Community health centers, which are at the front line of the nation’s primary healthcare services, carry a heavy burden.
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Kompas/Angger Putranto
Satrah, 87, is assisted by midwife Dayu Ummu Kholisyah, 44, who is visiting her house in Kertosari, Banyuwangi, on Monday (15/1). Since 2014, Puskesmas Kertosari has had a Fast Action-Response movement, which is a proactive effort to help residents at high risk of health problems.
JAKARTA, KOMPAS – Community health centers (puskesmas), which are at the front line of the nation’s primary healthcare services, carry a heavy burden. Apart from implementing fundamental health programs, puskesmas are also required to fulfill the minimum service standards as set by their regional heads. However, as a result of unequal distribution of resources, the capacity of puskesmas has also become highly imbalanced.
Indonesian Public Health Association (IAKMI) chair Ridwan Thaha said on Monday (15/1/2018) that puskesmas were required to implement numerous health programs. As the primary healthcare institute of the Healthcare and Social Security Agency (BPJS Kesehatan), puskesmas are required to achieve the target indicators of Commitment-Based Capitation. When the Health Ministry rolled out the Healthy Indonesia Family Program (PIS-PK), puskesmas health officers were encouraged to actively reach out to the public.
Health Minister Regulation No. 75/2014 on Puskesmas stipulates that each puskesmas must have at least one doctor or primary care physician, one dentist, one nurse, one midwife, one public health officer, one environmental health officer, one lab technician, one nutritionist and one pharmacist.
However, the reality in 2016 showed that 35.5 percent of puskesmas had an excessive number of doctors while another 24.6 percent did not have enough doctors. Moreover, 70.4 percent of puskesmas had too many midwives while 20.53 percent did not have enough midwives.
The Kenjeran Puskesmas in Surabaya, East Java, for instance, serves between 100 and 150 patients a day. It has three general practitioners, three dentists, eight midwives and five nurses. One doctor can see up to 100 patients in a single day. Of its six doctors and dentists, three are civil servants and three are on contract. [Should this be 10 patients instead? If one doctor can see 100 patients a day, serving 100-150 patients daily should be no problem.]
In order to reduce its workload, two additional puskesmas were established in the Bulak and Kedungcowek subdistricts. Each day, around 50 patients seek treatment at the two supporting puskesmas.
In Semarang, Central Java, Kedungmundu Puskesmas head Turi Setyawati said that the number of patients had been increasing since the National Health Insurance program was implemented. In one day, patient visits can reach between 200 and 250, an increase from 150 before. This is despite the fact that only six doctors, seven nurses and eight midwives are appointed to the puskesmas, along with four supporting puskesmas.
“Apart from taking care of patients, they also fill concurrent positions as puskesmas’ staff members, who often need to attend meetings with government agencies, as well as members of the community counseling team,” Turi said.
In Asmat regency, Papua, there has been enthusiastic public response for healthcare services at local puskesmas. However, the puskesmas do not have enough staff. With only one doctor and one midwife at each puskesmas, they have found it difficult to deal with the high prevalence of health problems in every district.
Puskesmas in densely populated areas also face problems. An influx of patients causes problems with family visits. Yuli Harida, the medical services head at Puskesmas Teluk Naga in Tangerang regency, Banten, said that up to 200 patients visited the puskesmas in a single day, excluding the under-5 children brought in for vaccinations.
Delayed aid
In order to align the puskesmas’ budgetary capacity, the government provides health operation assistanc (BOK) to cover non-salaried operational cost for promotions of preventive services, maternal and infant health, family planning (KB), nutritional counseling, vaccinations and environmental health. However, the BOK disbursement is often delayed. In Semarang, this has led to healthcare professionals using their own money toward promotional campaigns on preventive services and for preventive activities until the BOK fund is disbursed.
Sri Lestari, a medical doctor at Bandarharjo Puskesmas in North Semarang, said that the October-December 2017 BOK fund had yet to be disbursed. The puskesmas was eligible for receiving Rp 486 million (US$38,880) in BOK funds last year, and expected an increased BOK fund to Rp 592 million this year.
“The funds from the health agency is never disbursed on time. To address the problem, healthcare and puskesmas officers must chip in to pay for promotional and preventive activities. They will get their money back once the BOK fund is disbursed,” Sri said.
Rustam Effendi, the head of the Jabiren Raya Puskesmas in Pulang Pisau regency, Central Kalimantan, said that the BOK fund of the nearly Rp 400 million allocated to the puskesmas was often delayed.
