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Barriers and challenges for primary care service in the COVID19 pandemic

The COVID-19 pandemic is such a barrier for health systems around the world including Indonesia. Primary care is the first-line in controlling the pandemic at the community level, but there are many barriers and challenges faced by doctors during the service that are not fully recognized. This aimed to distinguish barriers and challenges in health centers and/clinics amid the COVID-19 widespread. This was qualitative study with a phenomenological approach. As much 44 health centers/clinical specialists interviewed in October 2020. Then, the data categorization method/coding and content analysis used. There were three themes related to the barriers and challenges confronted by specialists in health centers/clinics, specifically barriers and challenges based on service management, environment, and individuals. The barriers and challenges confronted are related to changes within the consultation flow, a diminished number of patient visits, limited supplies of personal protective equipment (PPE), patient states of mind and behavior within the confront of a pandemic, and progressively heavier burdens and duties for doctors. It is necessary to provide specific, valid, and right-on-target knowledge in improving community behavior in efforts to prevent COVID-19 infection and the government's important role to be more concerned about the future of health workers.


INTRODUCTION
On March 11, 2020 World Health Organization (WHO) has declared that corona virus is a global pandemic [1]. Coronaviruses (CoV) is the main cause of COVID-19 disease which is only discovered in 2019 in the province of Wuhan, China [2]. The status of a global pandemic that has been established by WHO indicates that the spread of COVID-19 moves fastly that almost no country in the world can ensure that it is protected from the corona virus [2]. In Indonesia, firstly, COVID-19 cases recorded on March 2, 2020 and reached 353,461 confirmed cases with 12,347 deaths as of October 17, 2020 [3]- [5] COVID-19 pandemic is such a barrier for health systems around the world including Indonesia. Primary care is the first-line in controlling the pandemic at the community level, but many barriers and challenges faced by doctors during the service process are not fully recognized [6]. Rapid increase of the need of care for people with COVID-19 is exacerbated by fear, misinformation, and restrictions of people movement and supplies that interfere with the delivery of front-line healthcare for everyone. If a pandemic situation requires a change in workload, then all healthcare workers have to work carefully and be supported

Service management
There are three issues that ended up barriers and challenges in service management. To begin with, the community finds it troublesome to carry out consultations due to restricted time and ways of communicating regarding the current widespread situation, which influences the diagnosis. Second, there is a change within the number of patient visits that has diminished, usually the effect of the pandemic which causes patients to be anxious to look for treatment straightforwardly. Third, implementing work programs is hampered because of the widespread situation, which makes it impossible to go directly to the field as presented in Table 2.

Environment
There are two issues that gotten to be barriers and challenges based on the environment. To begin with, amid the pandemic, the supply of PPE was exceptionally limited; this was since the PPE supply from the government did not have any result in an expanding required. Second, the facilities and infrastructure are still restricted so that the health protocol cannot be completely implemented as shown in Table 3.  The availability of PPE and its use during the COVID-19 pandemic PPE supplies are exceptionally constrained and don't meet standards [13] 1. The remote working area causes the distribution of PPE to be very limited 2. Doctors save on the use of PPE and pay their own costs to meet PPE shortages 3. The availability of PPE provided by the government is very limited but its use continues to increase. The use of PPE that is ineffective makes doctors uncomfortable using it [14] 1. Health facilities do not support 2. Doctors have to remove pairs of PPE so that the risk of being exposed to corona is very large Availability of facilities and infrastructure for primary services during the COVID-19 pandemic Limited facilities and infrastructure in primary services [13] 1. People in remote areas difficult to access the internet in order to conduct online consultations, and health facilities are still limited and less comprehensive 2. Availability and development of infrastructure that is not maximized, so that does not yet support communities to implement health protocols correctly

Individual/personal
From the results gotten, there are three issues that ended up barriers and challenges based on people/individual. To begin with, the psychological state and state of mind of the patient are related to the high level of anxiety and fear of the patient as a result of the pandemic circumstance. Second, the low level of education and the patient's economy make it troublesome to provide education. Usually due to the patient's low knowledge, so they are effortlessly impacted by scam information and distrust doctors. Third, the doctor's psychological condition gets to be irritated. This is because the burdens and duties confronted during the widespread are so overwhelming doctors feel on edge and stressed as shown in Table 4 (see in appendix).
According to WHO, Primary Health Care is an essential health service that held based on technology and practical procedures, in accordance with scientific principles and accepted by the society, which can be achieved by individuals and families in society by active role [5]. Primary health services will not be same in every region. This is due to differences in geographic and demographic conditions, regional and individual physical abilities, public health status and attention from local governments in health development on each region. From those several differences, those will be the focus of researchers to give further discuss about the barriers and challenges that occur in primary services during COVID-19 pandemic. Regarding to the previous research, researchers categorized barriers and challenges based on service management, environment, and individuals [16].

Barriers and challenges based on management service
According to Ministry of Health Republic Indonesia, management is a series of processes consisting of planning, organizing, implementing and controlling (Planning, Organizing, Actuating, and Controling) to achieve goals/objectives effectively and efficiently [17]. Another definition of management according to Luther Gullick is a field of science that attempts to systematically understand why and how humans work together to achieve goals [18]. Meanwhile, according to Daviddow and Utal, service can be defined as any business that enhances customer satisfaction [19]. When viewed from the opinion of experts, it can be concluded that service management is an effort that goes through a systematic process in achieving goals effectively and efficiently. Effective in this case means that the expected goals can be achieved through the implementation process which is carried out properly and correctly and with quality, based on the results of a situation analysis supported by data and accurate information (evidence based). Meanwhile, efficient means how the health care utilizes available resources to be able to carry out health efforts according to standards properly and correctly, so as to realize the performance targets that have been set. However, the current global pandemic situation has resulted in several health efforts being made unable to meet standards so that the predetermined performance targets cannot be achieved.
Based on the collected data from the results of interviews with doctors who served in primary care, they express about what are barriers and challenges in providing health services in a pandemic situation. One of the barriers and challenges that occur is the difficulty in consulting with patients, this case is related to the anamnesis and physical checking that cannot be done holistically and specifically. There are some factors that support in this case, limited time for consultation, and the implementation of social distancing, so that it is limited for doctors to perform anamnesis procedure and physical checking which one of the references becomes for a doctor in making a diagnosis.
The changes that occur are not only have an impact on the consultation but also on the implementation of existing work programs in primary services. Based on the answers taken from the interview data, the doctor said that in current pandemic situation, some work programs in primary services have been hampered, some even have to be stopped. In line with that, there is also a decrease in the number of patients visiting health centers and clinics. This is also caused by pandemic conditions that make it is impossible or even limited activities such as visits to residents' homes, schools and offices.
Based on the comparison of the results of this study with the Ministry of Health's regulation number 75 of 2014 concerning Community health centers, which states that health centers have the task of implementing health policies to achieve health development goals in their working areas and the function of organizing first-level Public Health Efforts (Upaya Kesehatan Masyarakat (UKM)) and Individual Health Efforts (Upaya Kesehatan Perseorangan (UKP)) in their working areas has not been fully fulfilled, this is based on the limited that made as a form of control of a pandemic condition that impact on service management [17].
Primary level of health facilities is gatekeepers in health services in the era of National Health Insurance, meaning that the authority to decide which patients can be handled completely or which patients need to be referred is in the hands of primary health facilities. Various challenges have been encountered in the effort to maximize the function of the gatekeeper in providing complete services, one of that is the limited availability of PPE and its use [20].
PPE supplies have been provided by each office in a region to be allocated for each health service. However, the problem is that its availability is not sufficient for the need which is certainly increasing every day. From the results of this study, it found that some doctors in primary care complained about the limited availability of PPE. Many of them have to spend personal funds to meet the need of PPE and some doctors even have to save on use of PPE. This is certainly caused discomfort among doctors who are struggling to provide services during a pandemic. In addition, some of the existing facilities and infrastructure in primary services are not supportive.
Barriers that occured in this study is similar with the barriers that occurred in previous studies regarding the limited supply of PPE. Emanuel et al said that since early 2020, US has experienced a severe shortage of the personal protective equipment (PPE) needed by health workers in order to fight against COVID-19 pandemic [21]. There are four possible factors that are being the main causes behind the limited supply of PPE. First, there is a large demand shock triggered by the need for the health care system and panic market behavior depletes PPE supplies. Second, the government failed to maintain and distribute domestic supplies. Last, major disruptions to the global PPE supply led to a sharp decrease in PPE supplies. Market and government failures make procurement of PPE by hospitals, health care providers, businesses, individuals and governments to be competitive and expensive in terms of time and money [22].
From previous studies, it was said that the main factor of the caused of structural weakness in the health care system was the wrong budget method used by the hospital. 26 Based on a statement from the occupational safety and health administration (OSHA) organization, which obliges employers to provide PPE to health workers free of charge [23], [24]. The ideal PPE budgeting method would certainly align the interests of employers, healthcare workers and patients with the need for effective and efficient care facilities that are safe for all [25], [26].

Barrierss and challenges based on individuals
COVID-19 pandemic is a global threat that is currently being an attention in every country. The government's strict movement restrictions to reduce the spread of COVID-19 are likely having a negative impact on people's mental health [13], [27]. By this research, a pandemic situation as now becomes a burden to societ that gives the rise to psychological disorders in terms of both patients and health professionals. From the patients' point of view, they feel anxious about coming to a health check directly to a health service such as a clinic or health centers. This is because of the perspective of the society who is afraid to come and have a direct contact with health services because they feel that the risk of being exposed by COVID-19 is very large. In addition, there is a lot of information that is not known about its truth, which actually makes people being more depressed and stressed [28]. This is influenced by the low level of public education, so it is very easy to be influenced by the wrong information. The good knowledge, precise, valid can improve one's behaviour [29]- [31].The role of a doctor here is needed so much in terms of education to provide more knowledge and improve the public mindset about the stigma of corona. However, if it is seen from a doctor's point of view, this certainly becomes a big burden and responsibility. In this case, doctors have to be more active in providing counseling or educating to society and be more objective so as not to be led by opinions from the uncertain information. In addition, doctors' responsibilities are also exacerbated by increasing of working hours in several health centers so that it is not only mental but also physical burden.
The results of the findings in this research are also in line with previous studies, that uncertainty health situation and its development and consequences can lead to mental disorders such as stress, excessive anxiety, and depression. Overall, these results highlight the enormous psychological impact of the COVID-19 pandemic on the population [29]- [32]. Besides, there are some opinions from previous research which suggests that frontline healthcare workers are generally vulnerable to the emotional impact of a pandemic situation. In this study, four manifestations of psychological distress were identified among health workers, namely fear, anxiety, frustration, and anger [16], [15], [33]. In this case, there are many factors triggered, for example, frustration is caused by the increasing working hour that makes doctors have to work longer than usual with more cases of disease handled.
The large number of COVID-19 incidents is accompanied by extensive information about this disease, but there is still a lot of disinformation and misinformation in the society which lead to excessive panic and refusal to follow government recommendations [29]. As on March 2020 to 6 April 2021, The Ministry of Communication and Informatics (Kemenkominfo) recorded 1,513 hoaxes spread on various social media platforms related to disinformation about the corona virus (COVID-19) [34]. The amount of information is supported by the development of the internet and the ease of access to information at this time. This circulating misinformation can affect people's knowledge, so that it can have an impact on people's behavior. The decisions and choices taken are mostly based on information from the internet, especially social media [29]. Therefore, the provision of knowledge provided by education is very useful in relation to complete unequal level of education among the society and a good communication strategy can help people prevent COVID-19 [26], [35]- [37].

CONCLUSION
The problems that are barriers and challenges faced by primary care physicians during the pandemic such as there was a decrease in the number of patient visits, inadequate health facilities, and the psychological condition of both doctors and patients becomes disturbed. It is necessary to provide specific, valid, and right-on-target knowledge in improving community behavior in efforts to prevent COVID-19 infection. In addition, the important role of the government to be more concerned about the future of health workers is needed.  N2  N3  N4  N5  N6  N7  N8  N9  N10  N11  N12  N13  N14  N15  N16  N17  N18  N19  N20  N21  N22  N23  N24  N25  N26  N27  N28  N29  N30  N31  N32  N33  N34  N35  N36  N37  N38  N39  N40  N41  N42  N43  N44   Male  Female  Female  Male  Female  Female  Male  Female  Female  Female  Female  Female  Male  Male  Female  Female  Female  Female  Male  Male  Male  Female  Female  Female  Male  Male  Male  Female  Male  Male  Female  Male  Female  Male  Male  Female  Female  Female  Female  Male  Female  Female  Female  Female   53  24  35  24  32  38  24  27  32  25  24  27  35  25  24  24  40  32  27  59  30  28  25  27  45  27  26  23  32  24  34  56  50  30  24  46  24  25  23  24  25  33  24  27