Protocol
An evaluation of the referral systems at community health centres in remote, border and island regions of Indonesia: a research protocol
AUTHORS
Meistvin Welembuntu1,2 Masters Degree, PhD Student * 
Martina Sinta Kristanti3 PhD, Senior Lecturer and Supervisor
Yodi Mahendradhata4 PhD, Professor and Supervisor
AFFILIATIONS
1 Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
2 Health Department, Politeknik Negeri Nusa Utara, Tahuna, Indonesia
3 Department of Basic and Emergency Nursing, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
4 Department of Health Policy and Management, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
ACCEPTED: 15 August 2025
Early Abstract:
Introduction: Indonesia comprises of 16,771 islands, including 111 small islands and atolls. The Indonesian government has established community health centres, known as puskesmas in Indonesian, to provide health services to the entire populations of the country, including those in remote areas. In 2014, the government of Indonesia introduced a national health insurance system with the goal of providing equitable access to healthcare for all citizens. However, not all health issues can be managed by these community health centres, necessitating a referral system to more advanced health care facilities. This study aims to evaluate the implementation of the referral system by community health centres in small island areas, with a view to addressing a research gap on this topic.
Methods: This implementation research explores the challenges associated with the referral system using the intervention mapping approach. This approach involves six stages: (1) needs assessment, (2) change matrix development, (3) devising strategies to optimise referrals based on practical theories, (4) programme preparation, (5) adoption and implementation planning, and (6) evaluation planning. The target population will comprise patients, health care workers at community health centres, and various other stakeholders. The study is to be conducted on three small islands in Sangihe Islands Regency, North Sulawesi Province: Nusa Tabukan, Marore, and Kahakitang.
Results: The evaluation of the referral programme addresses the gap in the implementation of referrals from community health centres on small islands, providing valuable information for the government and policymakers regarding healthcare delivery in hard-to-reach and remote areas.
Conclusion: The study’s results are expected to offer valuable insights into systematic research processes and provide recommendations for interventions designed to improve the referral system from community health centres to regional hospitals.
Keywords: implementation research, islands, primary health center, referrals, remote area.