Integration of Traditional Medicine Services into Public Health Centers in Indonesia: A Qualitative Study

doi:10.21203/rs.3.rs-5291992/v1

Background: Many people are still using traditional medicine in various countries. This is a challenge for the government because they must effectively manage services, maintain quality, and protect patients. Integrating traditional medicine into public health centers provides safe and quality services. This study aimed to explore the perceptions and experiences of traditional medicine users and program implementers in Indonesian public health centers.

Methods: This study used an exploratory qualitative research design. Data were collected from program implementers and traditional medicine users. Data were collected through focus group discussions and in-depth interviews from March to June 2023. The study had 16 participants included 10 implementers in focus group discussions and six users in in-depth interviews. analysis with an inductive approach was employed.

Results: Three themes were identified, namely, user preferences for using traditional medicine, success factors of integration, and challenges for improvement of existing integration. Despite obstacles, many participants expressed their support for integration, particularly in terms of human resource readiness. Moreover, people tended to prefer traditional medicine services provided in public health centers over traditional healers because of individual belief, trust in the delivery services, and therapeutic effects.

Conclusion: The integration of traditional medicine services into public health centers is essential to provide easy access and preserve traditional health services that are in line with local wisdom, effective, and safe.

Integrative & Complementary Medicine

Integrated Medicine

Primary Care

Qualitative

Traditional Medicine

Public Health Center.

Traditional medicine is currently an attractive option for people who choose to live naturally. The traditional medicine used for health problems, such as chronic diseases, epilepsy, and wound healing, varies, such as herbal medicine, religious therapy or prayer, application of leaves on wounds, massage, juice, acupuncture, and cupping (1–4). People choose traditional medicine over conventional medicine for reasons such as being worried about the side effects of chemical drugs (5) and feeling tired of undergoing long-term treatment with no promising outcomes (6). In addition, people use traditional medicine to maintain health, particularly during the COVID-19 pandemic (7). Although traditional medicine is not covered by health insurance and various conventional medicines are available even in remote areas, many Indonesians still use traditional medicine.

The government has an important role in providing a healthcare delivery system for the public. Some countries adhere to a complete separation system between traditional medicine and conventional medicine. Some others integrate traditional medicine into conventional medicine; thus, traditional medicine will have a role as a complement or substitute for conventional medicine. For example, South Korea has separated the traditional medicine system from the Western medicine system, whereas Taiwan has a more flexible system, in which a Western medicine practitioner can obtain an acupuncture license and provide acupuncture services to patients (8). In Indonesia, traditional medicine is part of the national healthcare system. However, traditional medicine services at health facilities are not yet covered by national health insurance. The Indonesian Ministry of Health regulates the provision of traditional medicine. Traditional healthcare services provided in public health centers include four activities: (1) being responsible for the registration and licensing of empirical traditional health practitioners, (2) encouraging public empowerment for the development of traditional medicine, (3) building green open spaces, and (4) implementing traditional healthcare services in healthcare facilities. Among these four activities, the provision of traditional healthcare services in healthcare facilities is still not optimal. The lack of human resources remains the main problem in implementation because of the lack of clear guidelines for recruiting professional traditional healthcare providers in health service facilities. Currently, in the transition period toward an integrated service system, traditional healthcare in healthcare facilities can be provided by conventional health professionals who have undergone traditional health service training such as acupuncture, acupressure, and/or cupping, as stated in Government Regulation No. 103 of 2014 Concerning Traditional Healthcare Services, 2014.

A government pilot project on the integration of traditional medicine services into community health centers has been developed in Boyolali, Indonesia. It offers acupressure and cupping services as part of its traditional medicine services (9). This integration shows the success of the Ministry of Health’s program from 2020 to 2024. User experience and satisfaction are important factors in evaluating program improvement (10, 11). This study aimed to investigate user experiences of traditional medicine services at the public health center and explore the perceptions of traditional medicine program implementers about the integration.

Study design and context

An exploratory qualitative research design was used because the experience and perception of the integration of traditional medicine services into public health centers has not been previously explored and is a novel insight that has not been clearly understood (12). This research was conducted at the Public Health Centers in Boyolali Regency from March to June 2023. Boyolali is the largest milk and beef producer on the island of Java. Boyolali is also listed as a production center for raw materials for the traditional herbal medicine industry. Several areas in Boyolali have ginger cultivation and traditional herbal medicine processing industries. The integration of traditional medicine services at a public health center in Boyolali is a model considered successful by the Indonesian Ministry of Health. Boyolali Regency has become an internationally achieving regency and its health campaign innovation received appreciation from the International Healthcare Innovation Award in 2020.

Data were collected through a focus group discussion (FGD) and in-depth interviews (IDIs). The researcher utilized the COREQ Checklist to ensure comprehensive reporting of qualitative research (13). FGD was used to identify the need for the integration of traditional medicine services into public health centers based on the perceptions of traditional medicine program implementers. IDIs were used to explore the experiences of users who received traditional medicine services at the public health center.

Samples and sampling procedure

According to the inclusion criteria of the implementers involved in the provision of traditional healthcare in public health centers, the purposive sampling technique was used to determine the sample invited to participate in the FGD. Ten participants involved in the FGD, consisting of the head of the health office (n = 1), head of the health resources division (n = 1), head of the human resources division (n = 1), traditional medicine services coordinator (n = 1), head of public health centers (n = 3), and conventional health professionals (n = 3).

The inclusion criteria for IDIs were patients who had used traditional medicine services at the public health center at least once. The users were randomly selected from data available at the public health center by the researcher and then invited to participate in an interview. The researcher and participants did not have any personal relationship; the participants could freely express their opinions and feelings according to the actual conditions. After receiving an explanation of the study’s purpose, process, and objectives, all research participants gave their written consent.

Data collection

FGD and IDI guidelines were used as the data collection instruments. All FGDs and interviews were audio-visually recorded. The first stage of data collection was to conduct face-to-face FGDs. The researcher started the FGD by asking some trigger questions regarding the participants’ opinions about the integration of traditional medicine services into public health centers, barriers, and success factors. The FGD was led by a researcher with expertise and research interest in traditional medicine and lasted for 90 min. The FGD was conducted through informal interactions and given sufficient time to encourage the participants of the FGD to feel comfortable, allowing them to freely express their opinions. The researcher was also assisted by an assistant researcher to make field notes. These field notes were used as a cross-correction of the audiovisual transcripts. The questions used to guide the FGDs are provided in Table 1.

Table 1

Trigger questions for the focus group discussion
Trigger questions
1. In your opinion, is it important to provide traditional healthcare in public health centers? Why? 2. Please explain the current conditions regarding the implementation of traditional medicine services. Do you think the program has been successful or not? 3. What factors support the success of the program? 4. What are the obstacles currently encountered in implementing the programs? In your opinion, how can we overcome these obstacles?

The second stage of the data collection was to conduct IDIs with users of traditional medicine services. As the interviewers, researchers have been trained in qualitative data collection and are experienced in conducting interviews. The researchers collected data via WhatsApp video calls that lasted approximately 45 min each. The interview guide was developed through an iterative process. Four questions explored the patient’s experience in using traditional medicine services in public health centers. These questions include positive or negative experiences, patient satisfaction, and the necessity and future expectation of the integration of traditional medicine services into public health centers (Table 2). Data collection through IDIs was stopped after data saturation. Interviews may be repeated with participants who need clarification of data. However, in this study, no interview was repeated.

Table 2

Interview questions
Questions
1. What is your experience in receiving traditional medicine services at the public health center? (positive/negative) 2. How satisfied are you with traditional medicine services at the public health center? Explain in detail. 3. Is it important for public health centers to provide traditional medicine services? Why? 4. Do you have any suggestions or hopes for improving traditional medicine services?

Data analysis

The data were transcribed and then analyzed using a thematic analysis inductively. Two researchers (principal investigator and independent coder) read the transcripts to gain a better understanding. Important ideas were manually processed into codes, categories, and themes using Microsoft Excel. Data coding was conducted by the principal investigator and validated by an independent coder. If coding, determining categories, or themes were different, a joint discussion was held, and the principal investigator provided a more detailed explanation of the phenomenon or condition according to the context during the interview process and research context. After the discussion, the principal investigator and independent coder made an agreed decision. If both could not find an agreement, then an agreement was made by involving the supervisor in the discussion. After identifying the themes, the principal investigator conducted face-to-face member-checking with all participants, communicating whether the data findings were intended by the participants. All participants agreed with the findings. After completing all these processes, the final analysis was performed.

Trustworthiness

The researchers tested the credibility of the data by building a relationship and mutual trust with the participants; explaining the research objectives, informed consent, and importance of answering the interview questions as objectively as possible; and conveying that all the information obtained was kept confidential and used only for research. Interviews were conducted via WhatsApp Video Call to ensure good call quality, and the researchers told the participants to prepare a special time for the interview activities, prepare an Internet connection, and be in a comfortable and quiet place. The researchers also conducted face-to-face member-checking with all participants. Transferability criteria were met by selecting the participants according to the context and research topic. Dependability criteria were met through intensive discussions on the findings and data analysis with supervisors. In addition, confirmability criteria were met through peer review with expert researchers or a literature review.

Participant characteristics

Sixteen participants were involved, and no participants dropped out from the study; ten of them participated in the FGD as program implementer representatives, and six participated in the IDIs as service user representatives. Participant characteristics are presented in Table 3.

Table 3. Characteristics of the participants

Participant	Education level	Role in the research
P1	Complete Higher Education	FGD participant
P2	Complete Higher Education	FGD participant
P3	Complete Higher Education	FGD participant
P4	Complete Higher Education	FGD participant
P5	Complete Higher Education	FGD participant
P6	Complete Higher Education	FGD participant
P7	Complete Higher Education	FGD participant
P8	Complete Higher Education	FGD participant
P9	Complete Higher Education	FGD participant
P10	Complete Higher Education	FGD participant
P11	Complete Higher Education	IDI participant
P12	Complete Higher Education	IDI participant
P13	Complete High School	IDI participant
P14	Complete Higher Education	IDI participant
P15	Complete Higher Education	IDI participant
P16	Complete Higher Education	IDI participant

FGD, focus group discussion; IDI, in-depth interview; PHC, public health center.

Thematic findings

Three themes can be obtained from data analysis, which are described in detail below.

User preferences for using traditional medicine

This theme consists of several subthemes including individual belief, trust in the delivery of services, and therapeutic effects (Table 4).

Table 4

Themes, subthemes, and categories
Themes	Subthemes	Categories
User preferences	Individual belief	✔ Does not like taking medical drugs ✔ Tired of taking medical drugs ✔ Side effects of taking medical drugs ✔ Back to nature trends
	Trust in the delivery services	✔ Sterility of tools ✔ Certified healthcare provider ✔ Lower healthcare service costs ✔ Also receiving medical checkup services ✔ Service providers have a friendly, patient, and communicative attitude
	Therapeutic effect	✔ Cure disease ✔ Reduce pain complaints ✔ Reduce pain ✔ Increase body comfort

This theme illustrates the preferences of users who chose traditional medicine services over conventional medicine in public health centers. Here are some examples of user statements:

“I do not like medicine, so I prefer acupressure.” (P16/IDI participant)

“I do not get good outcomes with acupressure. I am more comfortable with authentic cupping (...); cupping is recommended by the prophet.” (P15/IDI participant)

“At the public health center, there may be a guarantee for sterilization of the equipment; (...) the needles are always changed. Second, there may be special training for the health personnel.” (P14/IDI participant)

The service was good. I was directed and taken to the acupressure clinic (...), and the service provider was also good, meaning that they were willing to provide consultation and answer questions, so patients are well-informed about their condition, you know.” (P14/IDI participant)

“I had pain from a pinched nerve in my waist (...) coincidentally. It was a bit difficult for me to sit down, but it turned out that after cupping, it improved.” (P11/IDI participant)

“Now many people start getting bored with modern medicine; they are looking for traditional medicine which they consider safer.” (P1/FGD participant)

Success factors of the integration

The success factors of the integration theme consist of two subthemes: benefits of integration and success factors. The Table 5 below illustrates the theme, subthemes, and categories of data processing results.

Table 5

Themes, subthemes, and categories
Themes	Subthemes	Categories
Success factors of integration	Benefit of integration	✔ Availability of alternative treatments ✔ Protect local wisdom ✔ Service innovation in public health centers ✔ Increasing the number of users of traditional health services
Success factors of integration	Success factors	✔ Funding and mentoring program ✔ Many herbal medicine users ✔ Regional regulation on traditional health services ✔ Good infrastructure ✔ Good acceptance from the government, providers, traditional healers, and public

A benefit of integrating traditional medicine services in public health centers was increasing the number of traditional medicine users by providing people with alternative health services in public health centers. As stated by one of the traditional health service users at the public health center, “I hope that all public health centers provide traditional medicine services, so there will be an increase in visits; there will be alternative treatments other than taking medication” (P11/IDI participant).

One of the FGD participants stated that integrating traditional medicine services is preserving local wisdom: “it is important to provide traditional medicine to protect local wisdom” (P2/FGD participant).

One of the factors supporting integration success is the support of the government in terms of finance or regulation. Some examples of participant statements are as follows:

“Boyolali Healthcare Office supports this traditional healthcare program by providing funding and assistance to traditional healers, so they have a license to provide traditional medicine services safely” (P1/FGD participant).

We are very grateful that there has been support from the Minister of Health Regulation, Government Regulations, and Governor Regulation, so the integration carried out in the community health center is legal. There are already traditional health service rates at the community health center” (P7/FGD participant).

Challenges for improvement of the existing integration

The third theme is about challenges for the improvement of the existing integration. This theme had two subthemes (Table 6).

Table 6

Themes, subthemes, and categories
Themes	Subthemes	Categories
Challenges and a need for improvement of existing integration	Barriers	✔ Competitions issues ✔ Health insurance does not cover services at acupressure clinics ✔ Human resource capacity and qualifications ✔ Time for services
	Program improvement efforts	✔ Integrating traditional healthcare services into all public health centers ✔ Providing traditional medicines that are easy to take ✔ Traditional health training for conventional healthcare providers ✔ Socialization of traditional healthcare services in public health centers ✔ Public education about the benefits of using traditional medicine ✔ Healthy lifestyle campaign (eating patterns, returning to nature, stress management, rest, and sleep patterns) ✔ Optimize various media for program socialization

Although traditional medicine services can be integrated in public health centers, some challenges remain, such as health insurance coverage and human resource capacity. Thus, improvements are needed in the future.

“Integration of traditional healthcare is quite necessary and important, but we must also pay attention to the resources (traditional medicine and its safety), in addition to policies (implementation, safety, and security), the issue of competition between public health centers, and empirical healthcare practitioners” (P6/FGD participant).

“In my opinion, what is lacking in the existing services is promotion, so perhaps promotion to the public needs to be improved” (P16/IDI participant).

The study generated several themes related to the integration of traditional medicine services into public health centers, including user preferences for using traditional medicine, success factors of integration, and challenges of improvement of the existing integration. In this study, the integration of traditional health services in public health centers was conducted through a traditional medicine polyclinic, in addition to other polyclinic services such as maternal and child health polyclinic, dental health polyclinic, and general medicine polyclinic. Traditional healthcare in Indonesia is developing rapidly, particularly after the issuance of a new omnibus health law (Law No. 17 of 2023). Previously, traditional healthcare only focused on promotive and preventive services; however, at present, this type of healthcare also covered curative services. Traditional health workers can provide services at healthcare facilities through traditional medicine polyclinics. In the absence of traditional health workers, conventional health workers who are certified in traditional health skills as stated in the Indonesian Minister of Health Regulation (Law No. 103 of 2014) concerning traditional medicine services can provide traditional medicine services in public health centers.

This study revealed that the integration of traditional medicine into public health centers has various benefits, such as the availability of alternative treatments, service innovation in public health centers, and an increase in the number of traditional medicine users. The integration of traditional medicine is a new option for users who do not like and are bored of taking chemical drugs because of the side effects and those who are seeking an alternative healthcare option that is back to nature. The use of traditional medicine as the sole treatment in Indonesia is still quite high (14). Another study in Indonesia on health-seeking behavior found that in the treatment process, most people prefer is to combine conventional medicine and traditional medicine (15).

The integration of traditional medicine has become a model of service innovation that is expected to improve the quality of health services in accordance with the preferences of Indonesians. It also enables the government to ensure the safe and standardized delivery of traditional medicine services. This is also in line with users’ preferences for utilizing traditional medicine in public health centers because of safety factors, competent service providers, adequate infrastructure, and guarantee of sterilization of equipment. Service safety is an important issue from the user’s point of view. Several studies have revealed quite worrying reported of adverse events in the use of traditional medicine. Several cases related to errors in the provision of traditional medicine have been reported. A study on adverse events in traditional medicine practices between 1999 and 2010 in Korea showed 9624 records of side effects; 522 of which were related to herbal medicine. Liver damage was the most frequently reported side effect. A total of 1389 records reported infections, pneumothorax, and burns. These side effects were associated with physical therapy (n = 285) or acupuncture/moxibustion (n = 1104) (16). Thus, to ensure patient safety, integrated traditional medicine inevitably must be implemented in public health centers.

Traditional medicine services consist of empirical, complementary, and integrated traditional medicine. An important issue in healthcare is patient safety and security. Pharmacovigilance is defined as “the science and activities concerned with the detection, assessment, understanding, and prevention of side effects or other drug-related problems.” Pharmacovigilance systems involve the systematic collection, aggregation, and analysis of suspected adverse drug reactions for signal generation (drug safety hazards), communication, and risk management. This also includes the promotion of safe and effective use of medicinal products. Pharmacovigilance aims to improve patient care and safety regarding medicine use and support public health programs by providing reliable and balanced information to assess the risk–benefit profile of medicines. Recently, its scope has expanded to include herbal medicine, traditional and complementary medicines, vaccines, and other health products. At present, pharmacovigilance includes issues beyond direct patient concerns, such as medication errors, lack of efficacy reports, and product quality assessments (17), and should be considered in the integration of traditional and conventional medicine in public health centers.

Traditional medicine is a cultural heritage in Indonesia that has been recognized as a form of local wisdom that needs to be preserved. Traditional healing systems are sociocultural phenomena. To study more deeply the customs and processing systems from the perspective of local communities, this traditional healing practice has also attracted the attention of anthropologists. This is known as ethnomedicine, which refers to traditional medical practices related to cultural interpretations of health, diseases, and how to treat and cure them (18). Local wisdom in the public in terms of treatment has various forms, such as ingredients, skills, or even thought processes. Among the Sundanese (West Java), several traditional medicines are used to cure diseases, for example, undur-undur to overcome asthma problems, cat’s whiskers for kidney problems, kabeling leaves for fever and chills, beruntus leaves for body odor, and cucumber, noni, young papaya, or mangala banana flower for hypertension (19). In Bitombang Tua Village, Bontoharu Subdistrict, Selayar Islands Regency, the people of Old Bitombang Village, Selayar Village (South Sulawesi), used 23 plant species with medicinal properties as traditional medicine. These species are divided into 18 families, and Euphorbiaceae family with three species is the most widely used. The leaves are the most widely used part of the plant (66%). In addition, local wisdom of using medicinal plants has three categories: (i) how to collect medicinal plant ingredients, (ii) how to mix medicinal plants, and (iii) when to consume medicinal plants (20). The preservation of traditional healthcare in our healthcare system is crucial, particularly in public health centers. These centers can make both individual and public health efforts by considering various factors. Despite modern advancements in medicine, the majority rely on traditional medicine. Public health centers must provide affordable and culturally suitable services. In general, people will feel comfortable if they can freely choose the treatment that suits their lifestyle (21), either traditional or conventional medicine, or choose the type of traditional medicine.

Moreover, the expected healthcare system provides satisfaction to the users. Satisfaction with services is an important indicator because user satisfaction is often linked to organizational performance. Variables that influence service satisfaction include responsiveness, empathy, guaranteed certainty, rates, service benefits, service promotion, and ease of service access (22, 23). In this study, users expressed satisfaction with service delivery, treatment outcomes, and service providers. Service providers who provide comfort to patients will improve the patient’s recovery, as the study observing the interaction of doctors and patients showed that a smile and friendliness can promote patient recovery (21). The use of traditional medicine can improve the user’s health in general. Studies have proven that patient satisfaction with the outcomes is the main variable that encourages someone to use the service or recommend it to others (24, 25).

However, this study has weaknesses because of the lack of government policy in implementing integration; financial challenges because the National Health Insurance Scheme does not cover herbal medicines, weak advocacy, and research opportunities; and the lack of training for conventional health practitioners in herbal medicine (26). The obstacles conveyed by the research participants are also nearly the same, particularly the availability of traditional health workers. In Indonesia, traditional healthcare providers are supposed to be provided by traditional health workers; however, their availability is limited. To address this issue, medical professionals are trained in traditional medicine practices such as acupressure, cupping, and herbal medicine. Ensuring continuity of care is an important aspect of the provider’s role. Patients who have received satisfactory care have praised culturally proficient nurses who are better equipped to understand and assess their cultural values (27).

This study has limitations, including the possibility of selection bias by randomly selecting interview respondents, even though data saturation was achieved. This random technique enabled us to miss respondents who had richer experience in using traditional medicine services. In addition, the concerns of patients who did not use traditional medicine services were not addressed in the study. Their statements may indicate the reasons why traditional medicine has not been an option, which needs to be considered in the development of an integration program. Future studies should aim to increase the number of participants by not using random sampling techniques to overcome this issue. In addition, further research can be conducted to explore the effectiveness of traditional medicine in treating specific diseases.

The Boyolali district of Central Java has achieved notable success in integrating traditional medicine into its public health centers. This promising program serves as an exemplary model for other public health centers throughout Indonesia to adopt. By integrating traditional health clinics into existing public health centers, progressive and effective healthcare services that can have a positive effect on communities worldwide can be introduced. Let us work together to transform healthcare and enhance the wellbeing of millions.

FGD

focus group discussion

IDI

in-depth interview

Ethics approval and consent to participate

This study was reviewed and approved by the Medical and Health Research Ethics Committee (MHREC), Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada–dr. Sardjito General Hospital Indonesia with number KE/FK/1334/EC. All Participants provided written consent to participate in this study.

Consent for publication

Not applicable

Availability of data and materials

Not applicable

Competing interests

The authors declare no competing interests.

Funding

This research was funded by Pekalongan University.

Authors’ contributions

SMY had a significant role in conceptualizing, designing, analyzing, and interpreting the data, as well as drafting the article. RSP, EM, and YM contributed substantially to the data analysis and provided critical revisions for important intellectual content. SSW assisted with data collection, analysis, and interpretation. Lastly, all authors were involved in evaluating and approving the final version of the manuscript.

Acknowledgments

The research team would like to express their gratitude to Universitas Pekalongan, the Head of Boyolali District Health Office, and all participants for their support in conducting this research.

Authors’ information

^{1, 5}Nursing Department, Faculty of Health Sciences, Universitas Pekalongan, Central Java, Indonesia

²Doctoral Program of Medical and Health Sciences, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia

^3*Department of Health Behaviour, Environment and Social Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia

^4*Community and Mental Health Nursing Department, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia

⁶Department of Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia

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Integration of Traditional Medicine Services into Public Health Centers in Indonesia: A Qualitative Study

Status:

Version 1

Abstract

Background

Methods

Study design and context

Samples and sampling procedure

Data collection

Data analysis

Trustworthiness

Results

Participant characteristics

Thematic findings

User preferences for using traditional medicine

Success factors of the integration

Challenges for improvement of the existing integration

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1