Potential Improvement in a Portable Health Clinic for Community Health Service to Control Non-Communicable Diseases in Indonesia

Round 1

Reviewer 1 Report

The paper presents an adaptive and innovative approach: The Portable Health Clinic (PHC) which uses digital technology for telemonitoring and teleconsultation.  

Major comments:

The authors presented the PHC. The subject and the software are very interesting but some scientific aspects, like the novelty, the objective of the paper, the research question, the scientific gap, and the contribution must be clarified and improved.

The abstract is not according to journal guidelines. Please, rewrite it. (see https://www.mdpi.com/journal/applsci/instructions)

Abstract: The abstract should be a total of about 200 words maximum. The abstract should be a single paragraph and should follow the style of structured abstracts, but without headings: 1) Background: Place the question addressed in a broad context and highlight the purpose of the study; 2) Methods: Describe briefly the main methods or treatments applied. Include any relevant preregistration numbers, and species and strains of any animals used. 3) Results: Summarize the article's main findings; and 4) Conclusion: Indicate the main conclusions or interpretations. The abstract should be an objective representation of the article: it must not contain results which are not presented and substantiated in the main text and should not exaggerate the main conclusions.

Please, use the applied sciences template for word (also available on the above-mentioned website).

The current state of the research field should be reviewed carefully and key publications cited. Are there other software(s) that also do this?

The aspects related to the Informed Consent Statement are vague. Please, describe how it was done (for example, the first question in the Questionnaire) and how was taken the committee approval (number).

All figures must be mentioned in the text ("callout")

What is the scientific source of the algorithm that calculates the health risk based on 12 parameters? Figure 4: What is the scientific source?

Few scientific references.

The Results section presents Methodological aspects.

Conclusion: since the objective of the paper, the research question, the scientific gap, and the contribution were not clear, the conclusion is vague.

Minor comments:

Figure 5: The font size is too small (300% of zoom to read it)

 As the subject is interesting and has relevant social gain, I suggest the authors rewrite it in order to improve the scientific aspect and resubmit it.

Author Response

Response to Reviewer 1 Comments

 

Point 1: The paper presents an adaptive and innovative approach: The Portable Health Clinic (PHC) which uses digital technology for telemonitoring and teleconsultation. 

 

The authors presented the PHC. The subject and the software are very interesting but some scientific aspects, like the novelty, the objective of the paper, the research question, the scientific gap, and the contribution must be clarified and improved.

 

Response 1:

Thank you very much for your advice and correction. The Portable Health Clinic (PHC) is a community-based mobile health service equipped with telemonitoring and teleconsultation using portable medical devices and an Android application.

The objective of the paper is to assess the challenges and potential improvement of PHC implementation in Indonesia. The research question includes barriers and acceptance of health workers to the PHC implementation and the recommendation for sustainability and scale-up.

For the scientific gap, PHC application targeted the cadre to support the existing community health service. Many mHealth have been developed that are used by patients or health workers, while not many have facilitated cadre to conduct health examinations.

As telemedicine provides benefits for patients by saving costs, and travel time, reaching community with difficult access to health facilities, and reduces the contact of health workers with patients during a pandemic, some patient prefer to be visited by health worker directly. The novelty of PHC was not only allows telemonitoring and teleconsultation but also physical examinations carried out by cadres. We integrated the program with village health post, a community health service which already exist in Indonesia. This research give contribution in empowering and increasing community participation to improve public health especially control of Non-Communicable Diseases (NCDs). Digital health technology was expected to improve health service effectively and efficient.

 

Point 2: The abstract is not according to journal guidelines. Please, rewrite it. (see https://www.mdpi.com/journal/applsci/instructions)

 

Abstract: The abstract should be a total of about 200 words maximum. The abstract should be a single paragraph and should follow the style of structured abstracts, but without headings: 1) Background: Place the question addressed in a broad context and highlight the purpose of the study; 2) Methods: Describe briefly the main methods or treatments applied. Include any relevant preregistration numbers, and species and strains of any animals used. 3) Results: Summarize the article's main findings; and 4) Conclusion: Indicate the main conclusions or interpretations. The abstract should be an objective representation of the article: it must not contain results which are not presented and substantiated in the main text and should not exaggerate the main conclusions.

 

Please, use the applied sciences template for word (also available on the above-mentioned website).

 

Response 2:

We have rewritten the abstract according to journal guideline.

 

Abstract: The Covid-19 pandemic has limited the routine community health services, including screening for non-communicable diseases (NCDs). An adaptive and innovative approach is needed through digital approach and health technology ecosystem. The Portable Health Clinic (PHC) is a community-based mobile health service equipped with telemonitoring and teleconsultation using portable medical devices and an Android application. This study aimed to assess the challenges and potential improvement of PHC implementation in Indonesia. The study was conducted in three Primary Health Centers, Mlati II in Sleman District, Samigaluh II in Kulon Progo and Kalikotes in Klaten in February-April 2021. In-depth interviews were conducted with 11 health workers and cadres. At the baseline, 268 patients was examinated then 214 patient successfully followed up until the third month. There were 32% patients required teleconsultations based on the automatic triage. Implementation challenges included technical constraints such as complexity of application, unstable network, and non-technical constraints such as effectivity of training, the availability of doctors and the workload at the Primary Health Center. The PHC was perceived as an added value for the existing community-based health services. The successful implementation of PHC is not only consider from technology but also related to human, organization and legality.

 

Point 3: The current state of the research field should be reviewed carefully and key publications cited. Are there other software(s) that also do this?

 

Response 3: Please provide your response for Point 2. (in red)

Digital health technology especially telemedicine was significantly adopted during the COVID-19 pandemic. Along with national blueprint for digital health transformation, PHC have been supported the government through the use of digital technology that enables remote services and the development of a health technology ecosystem with interoperability and integration as a goals. We were considering technical and non-technical aspects as enabler factors. There have been some applications develop to facilitate telemedicine between health facilities or between health provider and patient. PHC potential to be linked between the cadre and primary care, that do not exist in research location.

 

Point 4: The aspects related to the Informed Consent Statement are vague. Please, describe how it was done (for example, the first question in the Questionnaire) and how was taken the committee approval (number).

 

Response 4: Informed consent was obtained from all respondents involved in the study. The questionnaire for the patients consist of history of diseases and medication, health behavior, mental and cognitive assessment, then health examination. The interview guideline for health workers and cadres associated with perceived of usefulness, easy of use, privacy, resistance to use, social influence, perceived risk, trust, facilitating conditions, and technology anxiety. Inform consent along with the research proposal have been approved by The Medical and Health Research Ethics Committee of the Faculty of Medicine, Public Health and Nursing UGM before implemented the study. The approval reference number is KE/FK/1387/EC/2020.

 

Point 5: All figures must be mentioned in the text ("callout")

 

What is the scientific source of the algorithm that calculates the health risk based on 12 parameters? Figure 4: What is the scientific source?

 

Few scientific references.

 

The Results section presents Methodological aspects.

 

Minor comments:

Figure 5: The font size is too small (300% of zoom to read it)

 

The Results section presents Methodological aspects.

 

Response 5:

All figures have been updated and mentioned in the text. We revised the figure of PHC acceptance to enlarge the font size.

We add more scientific references especially in introduction, literature review, and discussion section.

The algorithm that calculates the health risk based on 12 parameters refer to Technical Instructions for Surveillance of Non-Communicable Diseases by Indonesian Ministry of Health.

The methodological aspects that previously write in results section such as the number of respondents relate to the response rate has been presented in materials and methods section.

 

Point 6: Conclusion: since the objective of the paper, the research question, the scientific gap, and the contribution were not clear, the conclusion is vague.

 

As the subject is interesting and has relevant social gain, I suggest the authors rewrite it in order to improve the scientific aspect and resubmit it.

 

Response 6:

We have updated the conclusion including practical implication, future research, recommendations and the limitation of the research.

Conclusions:

Digital approach that allows remote services is potential to be used to improved health access and monitor the health status of vulnerable populations especially those who have been diagnosed with NCDs. The PHC support health data management at the community level. The PHC was perceived as an added value for the existing community-based health services that were conducted by Primary Health Center. Interoperability with medical records in Primary Health Care would be beneficial for the continuum of patient care. The successful implementation of PHC is not only considered from technology but also non-technical aspect related to human, organization and legality.

The limitation of this research is the scope of the assessment which is limited to health workers and cadres appointed for the implementation of PHC so that the perceptions obtained from this study have not considered the other aspects of service recipients. For future research, the feasibility of PHC can be analyzed in other health program or other areas with specific condition.

Author Response File: Author Response.pdf

Reviewer 2 Report

Potential Improvement of Portable Health Clinic for Community Health Service to Control Non-Communicable Disease in Indonesia

First. The idea of ​​the study seems interesting, different and even necessary.

Abstract

The abstract is too long and  unattractive, it should follow the solid scientific work structure, I suggest that it be restructured and shortened  in a way that includes the following clearly:

·         The contextualization of the study

·         The main objective

·         The justification

·         The sample used

·         The methods used

·         The main findings and conclusions

·         The novel contribution

Introduction

1.The introduction doesn’t flow well and needs to be more clear and straight to the point by justifying soundly on the main objective; to Control Non-Communicable Disease in Indonesia.  

2. What is the importance of this topic for Indonesia?

3. The order of the introduction could be this:

a) Importance and justification of the healthy, social and economic benefits of this topic in general and specifically in Indonesia which is under study.

b) The role of the country's government in promoting this field under study.

c) Presentation of the importance and necessity of the intention to undertake this study in this field.

d) Justification of why Potential Improvement of Portable Health Clinic for Community Health Service to Control Non-Communicable Disease in Indonesia is relevant and necessary and to be more specific of the justification of why The Portable Health Clinic (PHC) is important to undertake in this field.

e) State the method at the end of the introduction, as well as the study's novel contributions

Literature Review

The Literature section needs to be added as a separate headline , the authors must give an extensive background; it needs a comprehensive review to justify the proposed study.

 Literature section needs to be improved. The background section of the paper doesn’t demonstrate a clear relationship to the problem.  Not enough literature has been provided. The sources cited are not enough. The research gaps in the previous studies related to this topic were not explained clearly. Please address these issues

Methodology. 
1. The sampling process is not well described. Please explain exactly where were exactly the respondents? When the data were collected?

2. how many times the authors have visited such places? How did the authors contact the respondents?

 3.Explain how the depth interviews with 11 Primary Health Care workers and cadres consisting of 3 doctors, 3 nurses, 1 midwife and 4 cadres were conducted ?

4.What is the response rate? Does the authors' sample represent the population? Make sure whether the authors' sample can represent the population. the authors need to justify. 

5.The authors need to justify how the authors tested the validity and reliability should be at methodology section.  

6. some parts  should move to the Literature Review such as:

(Portable medical devices consist of anthropometric set (weight scales, microtoise, and metline), vital sign (sphygmomanometer, thermometer, and oximeter), peripheral blood tests kit (glucose, cholesterol, uric acid, and hemoglobin kit), urine examination sets (strips and urine pots), and personal protective equipment (PPE) (masks, hand gloves, hazard box, face shield, and hand sanitizer).

Results.

poorly presented

Discussions

1.The discussions are somewhat broad and general. I can’t see the clear explanation about this argument.

 

2.Some aspects of the discussion should be transferred to conclusion section or alone, and more clear. Such as: The limitation of this research, theoretical implication and practical  implication of the research.

 

The conclusions.

 Should be improved, including  a clear theoretical implication, practical  implication of the research, future research, recommendations  and the limitation of the research .

References

References need to be updated  and Follow the style of the Journal

Others:
The paper has some editing issues. It needs proofreading.

 

 

 

Author Response

Response to Reviewer 2 Comments

 

Point 1: Potential Improvement of Portable Health Clinic for Community Health Service to Control Non-Communicable Disease in Indonesia

 

First. The idea of ​​the study seems interesting, different and even necessary.

 

Abstract

The abstract is too long and unattractive, it should follow the solid scientific work structure, I suggest that it be restructured and shortened in a way that includes the following clearly:

• The contextualization of the study
• The main objective
• The justification
• The sample used
• The methods used
• The main findings and conclusions
• The novel contribution

 

Response 1:

Thank you very much for an advise and correction. We have rewritten the abstract based on suggestion and suit with journal guideline.

Abstract: The Covid-19 pandemic has limited the routine community health services, including screening for non-communicable diseases (NCDs). An adaptive and innovative approach is needed through digital approach and health technology ecosystem. The Portable Health Clinic (PHC) is a community-based mobile health service equipped with telemonitoring and teleconsultation using portable medical devices and an Android application. This study aimed to assess the challenges and potential improvement of PHC implementation in Indonesia. The study was conducted in three Primary Health Centers, Mlati II in Sleman District, Samigaluh II in Kulon Progo and Kalikotes in Klaten in February-April 2021. In-depth interviews were conducted with 11 health workers and cadres. At the baseline, 268 patients was examinated then 214 patient successfully followed up until the third month. There were 32% patients required teleconsultations based on the automatic triage. Implementation challenges included technical constraints such as complexity of application, unstable network, and non-technical constraints such as effectivity of training, the availability of doctors and the workload at the Primary Health Center. The PHC was perceived as an added value for the existing community-based health services. The successful implementation of PHC is not only consider from technology but also related to human, organization and legality.

 

Point 2: Introduction

 

1.The introduction doesn’t flow well and needs to be more clear and straight to the point by justifying soundly on the main objective; to Control Non-Communicable Disease in Indonesia. 

2. What is the importance of this topic for Indonesia?
3. The order of the introduction could be this:
4. a) Importance and justification of the healthy, social and economic benefits of this topic in general and specifically in Indonesia which is under study.
5. b) The role of the country's government in promoting this field under study.
6. c) Presentation of the importance and necessity of the intention to undertake this study in this field.
7. d) Justification of why Potential Improvement of Portable Health Clinic for Community Health Service to Control Non-Communicable Disease in Indonesia is relevant and necessary and to be more specific of the justification of why The Portable Health Clinic (PHC) is important to undertake in this field.
8. e) State the method at the end of the introduction, as well as the study's novel contributions

 

Response 2:

We are grateful with the advice and updated the introduction section. Non-communicable diseases (NCDs) is one of the Primary Health Center’s priorities which need intervention through early detection of the risk factors, counseling, and regular monitoring. COVID-19 pandemic has had a serious impact on NCDs program. To overcome these challenges, create quality and easily accessible health services, and ensure resilience to health crises, an adaptive and innovative approach is needed through health technology.

The Portable Health Clinic (PHC) is a community-based mobile health service equipped with telemonitoring and teleconsultation using portable medical devices and an Android application. The PHC is important to empower the community in accessing health services. As telemedicine services, PHC provides benefits for patients by saving costs, travel time, reaching community with difficult access to health facilities, and reduces the contact of health workers with patients during a pandemic. PHC complements government programs for digital health transformation not only facilitate telemedicine between health facility or between health provider and the patient, but also between the cadre and patient. The novelty of PHC was not only allows telemonitoring and teleconsultation but also physical examinations carried out by cadres. PHC implemented in three Primary Health Center which have specific condition, one is rural with mountainous area, and the other relatively urban. Therefore, we conducted qualitative study to assess the acceptance, barrier and the potential improvement of PHC from health worker perspective to control NCDs and support the resilience of the health system. PHC is important to undertake in this field because it is possible to collect the data at community level.

 

Point 3: Literature Review

 

The Literature section needs to be added as a separate headline, the authors must give an extensive background; it needs a comprehensive review to justify the proposed study.

 

Literature section needs to be improved. The background section of the paper doesn’t demonstrate a clear relationship to the problem. Not enough literature has been provided. The sources cited are not enough. The research gaps in the previous studies related to this topic were not explained clearly. Please address these issues

 

Response 3:

We add literature review as the new section to give more extensive information about how PHC could overcome the problem. For scientific gap, PHC application targeted cadre to support the existing community health service. Many mHealth have been developed that are used by patients or health workers, while not many have facilitated cadre to conduct health examination.

 

Point 4: Methodology.

1. The sampling process is not well described. Please explain exactly where were exactly the respondents? When the data were collected?
2. how many times the authors have visited such places? How did the authors contact the respondents?

3.Explain how the depth interviews with 11 Primary Health Care workers and cadres consisting of 3 doctors, 3 nurses, 1 midwife and 4 cadres were conducted ?

4.What is the response rate? Does the authors' sample represent the population? Make sure whether the authors' sample can represent the population. the authors need to justify.

5.The authors need to justify how the authors tested the validity and reliability should be at methodology section. 

6. some parts should move to the Literature Review such as:

(Portable medical devices consist of anthropometric set (weight scales, microtoise, and metline), vital sign (sphygmomanometer, thermometer, and oximeter), peripheral blood tests kit (glucose, cholesterol, uric acid, and hemoglobin kit), urine examination sets (strips and urine pots), and personal protective equipment (PPE) (masks, hand gloves, hazard box, face shield, and hand sanitizer).

 

Response 4:

1. PHC in Indonesia was tested on a limited area at the Samigaluh II Health Center in Kulon Progo District Yogyakarta Province, the Mlati II Health Center in Sleman District Yogyakarta Province and Kalikotes Health Center Klaten District, Central Java Province in February - April 2021. Samigaluh is a rural area with hilly terrain, while Mlati and Kalikotes are urban areas. all patients were collected based on village health post schedule which was carried out at the village hall. If the patients were unable to attend, the health cadres would make home visits.

A qualitative study to assess the potential for PHC improvement was conducted through in-depth interviews using video conference in April – May 2022.

2. Monitoring by the authors were carried out online once a month by inviting PHC health worker from three Primary Health Centers, as well as field visits. There was a chat group to communicate between the author and health worker.
3. Indepth interviews were conducted using video conference in April – May 2022 regarding barriers and acceptance of health workers to the PHC implementation using Technology Acceptance Model, the recommendation for sustainability and scale up.
4. At the beginning of this activity, in February, 2021, ninety subjects were collected at Kalikotes Health Center, 83 subjects at Mlati II Health Center, and 95 subjects at Samigaluh II Health Center. A total of 268 subjects agreed to participate in this study. Respondents who were successfully followed-up until the third month were 214 subjects, consisting of 86 subjects at Kalikotes Health Center, 57 subjects at Mlati II Health Center, and 71 at Samigaluh Health Center (response rate 79,85%).

This participant represents the member of the village health post as population. All of the member have been included as a participants at the baseline.

5. To ensure the validity and reliability, the instrument has been piloted and all the reviewer has been trained.
6. We have moved some parts to Literature Review include the details of PHC box and android application.

 

Point 5: Results.

 

poorly presented

 

Response 5:

We rewrote and detailed the qualitative analysis of PHC acceptance from doctor, nurse and cadre’s perspective. The point of the result is factors that influence the acceptance of the use of PHC consist of technical constraints, non-technical constraints, perceived usefulness, perceived benefits, positive perceptions, risks of using, and support for the work environment. The potential improvement of PHC then was divided into a technical and non-technical (social) approach based on recommendation. For program sustainability, coordination with various stakeholders not only between PHC health worker is needed. To expand coverage, it is necessary to coordinate with the health office.

 

Point 6: Discussions

 

1.The discussions are somewhat broad and general. I can’t see the clear explanation about this argument.

2.Some aspects of the discussion should be transferred to conclusion section or alone, and more clear. Such as: The limitation of this research, theoretical implication and practical  implication of the research.

 

Response 6:

We add more references to improve the scientific arguments.

The limitation and practical implication have been transferred to conclusion.

 

Point 7: The conclusions.

 

Should be improved, including a clear theoretical implication, practical implication of the research, future research, recommendations and the limitation of the research

 

Response 7:

We have updated the conclusion including practical implication, future research, recommendations and the limitation of the research.

Conclusions:

Digital approach that allows remote services is potential to be used to improved health access and monitor the health status of vulnerable populations especially those who have been diagnosed with NCDs. The PHC support health data management at the community level. The PHC was perceived as an added value for the existing community-based health services that were conducted by Primary Health Center. Interoperability with medical records in Primary Health Care would be beneficial for the continuum of patient care. The successful implementation of PHC is not only considered from technology but also non-technical aspect related to human, organization and legality.

The limitation of this research is the scope of the assessment which is limited to health workers and cadres appointed for the implementation of PHC so that the perceptions obtained from this study have not considered the other aspects of service recipients. For future research, the feasibility of PHC can be analyzed in other health program or other areas with specific condition.

 

Point 8: References

 

References need to be updated and Follow the style of the Journal

 

Others:

The paper has some editing issues. It needs proofreading.

 

Response 8:

We have checked the references follow the journal instruction.

The manuscript have been edited/proofread in Language Clinic for Editing and Consultation, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.

 

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Many of the questions from the previous review, the authors answered in the letter to the reviewers, however, these contents were not found in the text.

For example, the Scientific Gap, the objective of the paper, and the state-of-the-art.

Please describe this clearly in the text of the paper.

PHC showed results applied to Indonesia. The authors should also clarify whether it can be used in other locations, especially developing countries, or needs configurations or adaptations.

Author Response

Response to Reviewer 1 Comments

 

Point 1: Many of the questions from the previous review, the authors answered in the letter to the reviewers, however, these contents were not found in the text.

For example, the Scientific Gap, the objective of the paper, and the state-of-the-art.

Please describe this clearly in the text of the paper.

 

Response 1:

Thank you for the review, as we mentioned in the first response letter, PHC application targeted community health workers (health cadre) to support community health service as the extention of primary health center functon within their coverage area. However, the activity was distrurbed with COVID-19 pandemic that restricted any community based health services. We have reordered some point of introduction such as the benefits of telemedicine from last to the third paragraph. As the state of art, we mentioned in the third and fourth paragraph that telemedicine was significantly adopted during the COVID-19 pandemic. Telemedicine mostly conducted between health professionals or providers to patients for individual patient care. Along with national blueprint for digital health transformation, PHC used by health cadre has been supported the government through the use of digital technology that enables remote services and the development of a health technology ecosystem which integrated health data and health service application system.

In the last paragraph of introduction, we mentioned the scientific gap that many mHealth have been developed and used by patients or health workers, but not many have facilitated cadre to conduct health examination including at research locations. There was limited evidence how community health workers (health cadre) being involved in the monitoring of NCD within their community that directly link with primary health centers as part of coverage area. The novelty of PHC was not only allows telemonitoring and teleconsultation but also basic physical examinations and simple lab test carried out by health cadres to monitor through monthly community health service program.

Then we move the objective that implied in method before to the last sentence of introduction to assess the challenges and potential improvement of PHC implementation in Indonesia.

As showed in discussion, PHC contributed to empower and increase community participation to improve access of health service especially Non Communicable Diseases (NCDs). PHC is also a solution for community or patients who have low smartphone experience that facilitated by health cadres.

 

Point 2: PHC showed results applied to Indonesia. The authors should also clarify whether it can be used in other locations, especially developing countries, or needs configurations or adaptations.

 

Response 2:

We stated in the conclusion that PHC can be used in other locations, especially developing countries who has similar approach of empowering community health services (health cadre) to improve health status in their own area/village. We mentioned in the literature review that most developing country, health cadre were the core component in the Primary Health Center system. Information and communition technology is additional tool to enhance the health cadre to monitor health status in their community. Infrastructure such as internet access, smart phone or tablet, electronic medical recods in the primary health centers are recommended to be in place to ensure seamless interconnecting of community health services under the primary health center program. The successful implementation of PHC should be supported non-technical aspect such as competency of human resource, organization and legality.

 

 

Author Response File: Author Response.pdf

Reviewer 2 Report

Potential Improvement of Portable Health Clinic for Community Health Service to Control Non-Communicable Disease in Indonesia

Abstract

The abstract is good now

Introduction

1.The introduction has improved, but it  needs to be more ordered

2. Could you please move the benefits of  Telemedicine in  The last paragraph to the first or second paragraph.

 

Literature Review

The Literature section  has  improved, but it  still needs more  updates. The background section of the paper needs to explore the  relationship to the problem and enough literature needs to be provided to explain the problem .

Methodology. 
fine

Results.

fine

Discussions

Fine .

 

The conclusions.

Fine

Author Response

Point 1: Introduction

1. The introduction has improved, but it needs to be more ordered
2. Could you please move the benefits of Telemedicine in The last paragraph to the first or second paragraph.

 

Response 1:

Thank you for the review. We have reordered some point of introduction such as the benefits of telemedicine from last to the third paragraph, following from state of the art, scientific gap, and the objective of research.

As the state of art, we mentioned in the third and fourth paragraph that telemedicine was significantly adopted during the COVID-19 pandemic. Telemedicine mostly conducted between health professionals or providers to patients for individual patient care. Some references mentioned telemedicine for specific diseases. Along with national blueprint for digital health transformation, PHC used by cadre has been supported the government through the use of digital technology that enables remote services and the development of a health technology ecosystem which integrated health data and health service application system.

In the last paragraph of introduction, we mentioned the scientific gap that many mHealth have been developed and used by patients or health workers, but not many have facilitated cadre to conduct health examination including at research locations. During the pandemic health professional prioritized the COVID-19 patients that seems to neglect the chronic diseases patients. The health cadres play a significant role on monitoring the chronic diseases patient surrounding their area. To fill this gap, the PHC has been introduced to support health worker to monitor chronic diseases patient within the NCD program carried out by cadres. Therefore, the objective of the research was to implement the PHC, assess the challenges and potential improvement to deal with endemic conditions, control NCDs and support the resilience of the health system.

 

Point 2: Literature Review

The Literature section  has  improved, but it  still needs more  updates. The background section of the paper needs to explore the  relationship to the problem and enough literature needs to be provided to explain the problem.

 

Methodology.

fine

Results.

fine

Discussions.

fine

The conclusions.

fine

 

 

Response 2:

We added some literatures in the first and second paragraph to explain the gap in implementation of mobile technology for health cadres or community health workers. In some developing countries including Indonesia, primary health centers has central role to implement community-based health program such as maternal and child health, school health, immunization, reproductive health and non-communicable disease screening. Health workers are limited, especially in remote area that has shortage of health professional who are willing to stay in the outreach area. Therefore the health cadres or community health workers play significant role in supporting the health program implementation such as monthly health post at village or sub-village level whitin the primary health center coverage area. The health post normally facilitated by the community (health cadres) where a health worker visits and provides basic services for under-five, eldery or reproductive health. The activities considers as routine activities, but the implementation of mobile health for the health cadre were still limited. The PHC and the mobile apps was potential to integrate primary health center and the existing community-based health service.

 

Author Response File: Author Response.pdf