Seeking the Road Map for a Healthy Indonesia
It is time for the Puskesmas to return to its basic functions, to interact optimally with the community outside the walls of the health center building to carry out health promotion and prevention programs.
Until the end of 2022, the health sector in Indonesia still faced a triple burden in the form of various disease problems or nutritional problems.
The burden of disease problems was, firstly, the existence of new emerging and re-emerging infectious diseases such as COVID-19. Second, infectious diseases had not been properly resolved. Third, non-communicable diseases (PTM) tended to increase every year, while the three nutritional problems (triple burden of malnutrition) were malnutrition, overweight and deficiency of micronutrients.
The two triple burdens above had an effect on the health status of the Indonesian people. The problem then was, to whom do the people of Indonesia convey their complaint about their fate and hope to be free from the bondage of these two triple burdens?
Of course, the answer to the above question lies with the government, specifically those responsible for dealing with public health problems. Next question, in what way? Is it enough with the six transformation programs in the health sector? Of course, this is not enough because it seems that the six transformations mostly focus on downstream, waiting for sick people to be served.
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Then, what about the upstream (program) and to whom will it be handed over? Upstream (programs) of the health sector are promotive-preventive programs, such as the availability of clean water, a healthy and clean environment, sanitation, improved nutrition, healthy behavior and of course immunization and vaccination. Therefore, in the writer's opinion, all the upstream and most upstream issues of public health are the main task of the government.
The 1945 Constitution has mandated that one of the objectives of forming the Republic of Indonesia government is "to promote public welfare". And "promoting public welfare" if translated to a practical level can be interpreted as "improving the health status of the Indonesian people".
The Constitution also stipulates: "The right to live in physical and spiritual prosperity, to have a place to live and to have a good and healthy environment and the right to obtain health services" (Article 28H Paragraph 1). Furthermore, "the protection, promotion, enforcement and fulfillment of human rights is the responsibility of the state, especially the government" (Article 281 Paragraph 4).
Therefore, if the government is serious about improving public health status and realizing the ideals of Healthy Indonesia, according to the writer, the government also needs to prioritize the concept of healthy thinking (a healthy paradigm) by prioritizing preventing healthy people from getting sick instead of prioritizing hospitals, medicine, laboratories, health equipment and technology, as well as the production of as many specialist doctors as possible.
System setup
Restructuring the health system is a discourse that is echoed almost every time by the new government.
And, indeed only the government has the power to do so even though in its implementation, it is sometimes just tinkering with articles of laws or statutory regulations, without being clear what the big concept is. There is no academic manuscript. Not infrequently the tinkering work ignores transparency and the need for community participation, especially the main stakeholders. Sometimes the main stakeholders are also involved at the end of the discussion, before it is passed into law.
Therefore, if the government is serious about restructuring the health system, it must first prepare the big concept and academic text in a transparent manner. We should involve the main stakeholders as well as all components of society with an interest in health and healthiness to design and formulate from the start. For example, if you want to reorganize health workers, involve health workers who are the main stakeholders.
Health workers really need to be reorganized, both professional and vocational workers. Likewise, health workers whose competence and authority are in the individual health sector (for curative and rehabilitative). Even health workers who are competent or choose to play a role in the public health sector should also be optimized to do so in the community.
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To the contrary, currently, health workers who have competence and authority in the individual health sector are also burdened with promotive-preventive programs in the community. Meanwhile, what should be the spearhead of the promotive-preventive measures in the community is fixed within the walls of the Puskesmas (community health center) building, which have been transformed into curative services.
As a result of the above disorganization, community entities outside the walls of the health center seem to have lost their way. They do not know what to do to maintain their health because the relationship between the community and the health center has been created as an individual relationship. The relationship between sick people (patients) and the place of treatment is no longer the link between the community and its health center.
In fact, in truth, the highest human right in health is "teaching every human being about the right to live a healthy life" and not treating them when they are sick. That is also the essence of the government of a country being formed, namely fulfilling the highest rights of the community. And this is also the essence of why a country establishes a health ministry, not a ministry for the treatment of sick people.
Professional division of tasks
The habit of ordinary people, when facing health problems, is always only focused on medical personnel. Looking for doctors, specialist doctors and hospitals, specialists are often given a dual role, as an "attack player" in the upstream sector as well as a "defensive" player in the downstream (defense) sector, acting as a promotive-preventive agent and downstream as a curative-rehabilitative agent. In fact, promotive-preventive should only be done downstream in the doctor-patient relationship.
Playing a dual role like this would make the doctor and the specialist feel overwhelmed and exhausted. Therefore, it is necessary to make a division of roles according to the competence of each health worker. Doctors should focus more on sectors where other health workers do not have the competence and authority to do so.
It is different if the doctor is appointed to become a public official, such as becoming the minister of health or the head of the health service. Of course, the consequence is that he/she has to change his/her way of thinking to prioritize upstream problems, in the public health sector, even though he/she is the best and only medical specialist.
Still fresh in our memories at the height of COVID-19, several specialist doctors said, "If the symptoms are mild, don't bring them to us; give them to us with severe symptoms."
This means that these specialist doctors are very aware that they are specialist doctors who work in the individual health sector (in the last sector). They really want to share tasks with other health workers, who work optimally in accordance with their competence and authority (severe and specific), which may not be imposed on other health workers.
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Besides, imposing most of the health problems on doctors, let alone specialist doctors, is certainly not right. It was as if all health problems would be borne by the medical profession. In fact, we all know that doctors and specialists are limited in number and production.
And, this can also lead to confusion in thinking when we talk about the health system. It should also be remembered that this country has graduated a large number of public health workers and graduates, health promotion experts, sanitation experts, nutritionists, environmental health experts and others, who can also work and share tasks and roles according to their competence and authority.
Puskesmas back to khittah
As part of public health efforts (UKM), it is time for the Puskesmas to return to its khittah (basic functions), back to its main role, which so far has been neglected: to interact optimally with the community outside the walls of the health center building to carry out health promotion and prevention programs.
Puskesmas need to teach people how to live a healthy life, exercise, provide clean water, improve sanitation, improve nutrition, prevent colds, prevent degenerative diseases and so on. To carry out this upstream role, health centers can join hands with health cadres, sanitation pioneer cadres, nutrition cadres, posyandu cadres and other health empowerment agents.
This task can only be carried out if the puskesmas is given space and also a large amount of money (budget). Without sufficient budget, the upstream program in the form of health promotion and prevention within the scope of public health efforts is unlikely to be of interest, let alone be successful.
There is still an opportunity for the government to make an effort, by changing the paradigm, reorganizing the system, dividing roles in a professional manner and returning the puskesmas as the spearhead of promotive and preventive programs in the community. Hopefully, with this endeavor, the road map for the ideals of Healthy Indonesia can be found again. Wallahu a’lam bisshawab (God knows best).
Zaenal Abidin,
Zaenal Abidin, Chairman of the PB Indonesian Doctors Association for the 2012-2015 period
This article was translated by Kurniawan Siswo.
