|Year : 2019 | Volume
| Issue : 5 | Page : 1523-1527
Medical problem in Asia pacific and ways to solve it: The roles of primary care/family physician (Indonesia Xperience)
Retno Asti Werdhani
Department of Community Medicine, Faculty of Medicine Universitas Indonesia, Jl. Pegangsaan Timur No 16, Cikini, Jakarta Pusat, Indonesia
|Date of Web Publication||31-May-2019|
Dr. Retno Asti Werdhani
Jl. Sindang 2 No F1, Komp. Pertamina, Jati, Pulogadung, Jakarta Timur
Source of Support: None, Conflict of Interest: None
WHO reported that Environment contributed significantly as the causal of the disease in Asia Pacific. Indonesia is facing major health challenges, namely triple burden health problems, due to communicable diseases, non-communicable diseases and re-emerging disease. Primary care in Indonesia is conducted by Public Health Centers/Puskesmas and Primary Care Clinic covering around 86% of total health care facilities in Indonesia. Primary Care Physician plays important role as a gatekeeper and care coordinator. Primary care in Indonesia responsible for primary prevention and screening, should also be prepared to deal with various reasons for encounters of patient/community health problems, and conduct comprehensive management including referral management. It is therefore necessary to have teamwork with various health workers and patients/families at all levels of prevention.
Keywords: Challenges, health, Indonesia, primary care
|How to cite this article:|
Werdhani RA. Medical problem in Asia pacific and ways to solve it: The roles of primary care/family physician (Indonesia Xperience). J Family Med Prim Care 2019;8:1523-7
|How to cite this URL:|
Werdhani RA. Medical problem in Asia pacific and ways to solve it: The roles of primary care/family physician (Indonesia Xperience). J Family Med Prim Care [serial online] 2019 [cited 2019 Jun 20];8:1523-7. Available from: http://www.jfmpc.com/text.asp?2019/8/5/1523/259400
| Introduction|| |
WHO reported that Environment contributed significantly as the causal of the disease in Asia Pacific. Lack of safe drinking water and sanitation still the causal of the problem. Communicable diseases are still high in our region. Tuberculosis, HIV, Malaria, Dengue are still challenges in our country. Bad ventilation and sanitation in a dense environment can worsen the problem. While we are still fighting with communicable diseases, with the increase number of elderly and lack of healthy lifestyle, we are now and perhaps will be facing an increase number of non-communicable disease. Maternal and neonatal deaths due to lack of access and cultural issue are also a challenge for us. Issues like early marriage and early child bearing are some of the contributing factors.
| Situation in Indonesia|| |
Indonesia is an archipelagic country with an area of 1.905 million km 2, a total population of more than 261 million (no 4 in the world after China, India, and USA) and 68% of populations are productive age (15–64) years. We have more than 17.000 islands and 5 big islands (Sumatera, Java, Borneo, Sulawesi, and Papua). Indonesia consist of many islands and geographical challenges as well as risk of disaster and emergency situation. Java (the smallest among the 5 big islands) is burdened with 57% of total population, with an area only 7% of entire Indonesia land area.
Indonesia is facing major health challenges, namely triple burden health problems, due to communicable diseases, non-communicable diseases and re-emerging disease. Basic health research year 2018 shows the incidence of overweight, obesity, and central obesity increased compared to year 2013. The increase also occurred in cases of hypertension, diabetes mellitus, chronic kidney failure, stroke, and coronary heart disease. Tuberculosis and HIV are also become health problems that cause burden of infectious diseases in addition to increasing cases of non-communicable diseases.
Health services in Indonesia consist of primary, secondary, and tertiary care services. Primary care in Indonesia is conducted by Public Health Centers/Puskesmas and Primary Care Clinic covering 86% of the total health care facilities in Indonesia. Our Puskesmas/Public health centers are assisted by the village health centers that manage many community-based programs one of which is Integrated Health Service. Our secondary care is conducted by the hospital. Hospitals in Indonesia are divided into C-D type hospitals at the district level, B type at the provincial level, and A type at the national level. Among all doctors in Indonesia, 65% of them are primary care doctors. Primary Care Physician plays important role as a gatekeeper and care coordinator; however, we are still facing distribution issues. Urban is still favorite place to earn money.
Our recent ministry of health data , showed a decrease malnutrition in children below 5 years of age, while at the same time there is an increase of obesity in the same age. According to WHO Global Tuberculosis Report 2018, Indonesia ranks second highest tuberculosis burden in the world. In addition, TB in Indonesia is also become the cause of top 4 deaths after cardiovascular diseases. TB has occurred mostly in productive age. As for HIV, the number of new HIV case findings was lowered in 2017. International Diabetes Federation data showed the number of people with diabetes mellitus in Indonesia ranked 7th highest in the world, with 2/3 of them do not know they have diabetes. Hypertension and Diabetes Mellitus is the most common non-communicable disease and top ten outpatient diseases in our primary care. The number of Infant mortality cases fell in 2016. Similarly, maternal mortality also dropped slightly in 2016. Our ministry of Health data  also showed Annual Parasite Incidence for Malaria, which in 2011–2015 has decreased number nation wide. In year 2018, the number of malaria elimination districts/cities was 254 of the 247 targets. However, the area of Papua (eastern part of Indonesia) is still a malaria endemic area, and therefore for anyone who will visit the Papua region must take malaria prophylaxis. Incidence rate of dengue fever disease tends to increase. This happens because of climate change and low awareness of maintaining environmental cleanliness.
| Primary Healthcare Services|| |
Modern medical services teamwork requires doctors with leadership competency. Primary care physician (PCP) must experience the stages of planning, organization, implementation, and evaluation in their daily practice. PCP is considered as one of the leaders of health system and we should provide leadership in healthcare delivery. Therefore, Primary Care Physician need to understand various aspects of socio-demographic phenomenon to create a bridge between people and health. Primary care physician become the forefront in all health efforts to ensure sustainable health management. In managing health problems, PCP must cooperate with various professionals both medical and non medical as well as patients and their families. Primary health care provides services from primary prevention until tertiary prevention, collaboratively. Not only responsible for primary prevention and screening, PCP should also be prepared to deal with various reasons for encounters of patient/community health problems, and conduct comprehensive management including referral management. It is therefore necessary to have teamwork with various health workers and patients/families at all levels of prevention.
Indonesia has government public health center (Puskesmas). It has been build as an implementation of Declaration of Alma Alta (1969), which mentioned the necessity of primary care in every country in the world. Puskesmas is a health service facility with a primary care-based service. They are functioning as a first contact and gatekeeper, open 24 hour, with priority on promotive and preventive efforts to achieve high degree of community health in its working area. This is still in accordance with Declaration of Astana (2018), which re-emphasize again about the importance of primary health care in global condition.
National wide, the standard working area of Puskesmas is within sub district area and is reinforced by village Puskesmas and mobile clinics as well as surrounding private health centers/clinic. The head of Puskesmas is PCP/Dentist, and helped by other personnel such as PCP's, Dentists, Midwives, Nurses, Pharmacist, Public health officer, Sanitarian, Nutritionist, Laboratory Analyst, Radiographer, and many others supporting personnel (administrative, medical records officers, etc.)
A Puskesmas is bound to serve around 30.000 residents with the scope of service both for community as well as individual health activities. With the increase number of our population, we are forced to strengthen ourselves not only our quality of work but also our infrastructure and transportation therefore we are able to give better services all over the countries up to remote area. Primary care clinic works together with Puskesmas to maintain community health in their working area. There have horizontal referral among themselves and join program together like resource sharing. Puskesmas/public health center is responsible for individual health activities with family medicine approach and collaboration with village and sub-district local government for community health activities. Primary care in our country is placed between community and secondary level. Our job is to maintain community health therefore there won't be high burden in upper level. This is the example of primary care as a bridge between community and other health facility.
Our primary care facilities work according to Ministry of Health (MOH) regulation. We have 12 actions that should be done and manage in primary care, which are:
- Antenatal care
- Normal birth delivery service
- Neonatal care
- Under 5 years old healthcare
- School age children healthcare
- Adolescent and reproductive healthcare
- Elderly care
- Diabetes mellitus
- Mental health
- Tuberculosis (TB)
The above actions are translated into 2 main activities in Puskesmas: in-door activities (representative of individual health services), and out-door activities (representative of community health services).
In-door activities are provided for cure purpose. As for access issue, ambulance, and boat are also provided in each Puskesmas (depend on the geographical area), to support referral system. Out-door activities are conducted for promotive and preventive purpose in the form of health program. We have six basic Puskesmas programs, which are: health promotion, environmental health, infectious disease control, family and reproductive health, community nutrition, and non-communicable disease control. All of these activities are conducted in integrated, team based, and multidiscipline approach.
| Dealing With Health Challenges|| |
This is the example of TB-HIV program, which activities consist of:
- Active case finding and Screening
- Free Treatment (Fixed Dose Combination and Anti Retro Viral drugs)
- Monitoring and recording.
A person who has at least 2 weeks continuous coughing will have to perform an AFB test. If positive, they will be given a full free fixed dosed combination treatment. The patient's family will have to be screened. Home visit is conducted as a follow up action and/or identification of non-medical problem that might be a barrier for the treatment. HIV screening is performed to all TB patients. A pregnant woman is also has an obligation for HIV screening.
“Clean Friday Movement” has been done to eradicate the aedes aegypti mosquito larvae that become vector of dengue fever. The Cadres carry out the activity. They are checking and cleaning potentially mosquito-nest sites (water reservoirs). With a flashlight, the cadres conduct home visit inspections every Friday morning. Now we have a cellphone application, which can facilitate people in Indonesia to report if they found the mosquito larvae in their surrounding area.
For malaria eradication, we have program in primary care such as rapid diagnostic test, and if positive, we treat the case. We record the data and have the surveillance. For people who are at risk or will travel to endemic area, prophylaxis should be given before entering the area. We have mosquito net program, with the target of minimal 80% people who lives in endemic area must has mosquito net.
Non-Communicable Diseases control program (Prolanis) is a program which proactively implemented with integrated approach involving patients, health personnel and institution, as well as national health insurance institution in order to maintain the health of those who has chronic illness such as type 2 diabetes mellitus and hypertension to achieve optimal quality of life with effective and efficient health cost. The objective of the program is to gain well-controlled results on blood glucose and blood pressure according to related clinical guidelines as well as prevention of the complication occurrence. The targets of this program are all member of national health insurance who has type 2 diabetes mellitus and/or hypertension. The activities of this program include consultation, health education, treatment, home visit, and reminder for next visit, exercise as well as health status monitoring.
”KPLDH (Ketuk Pintu Layani Dengan Hati”/door's knock with sincere care) is the example of our proactive screening as well as care program. It is a team-based active health program, which provide a preventive and promoting as well as curative and rehabilitative if necessary. It was an initiative from Jakarta's Provincial Government therefore this program is still only implemented properly in Jakarta area. The team consists of PCP, nurse, and midwife. Their daily job is doing home visit to each house in neighborhood to perform health census, health education, health screening, and home care. After they collect the data, they will identify health problem that is unique to their work area. Each team will be challenged to develop certain innovation on how to manage/solve the health problem, and then execute directly towards community. Therefore, community will benefit from the program because the intervention is in accordance to their real problem.
The school health program activities are connected to teaching and learning at school, with integration between curriculum and healthy life style such as student and teachers reading the health report book for socialization and education on healthy life style, physical activity with stretching in the classroom, and student's training in schools as cadres. PCP and team from Puskesmas will visit the school once a month to have a screening and vaccination for school age as well as giving health education/training.
Mother and Child Health
The incidence of malnutrition in children in year 2018 decreased compared to year 2013 (19.6% vs 17.7). Likewise, the risk of chronic energy in productive women in year 2018 also lower compared to 2013. This can happen due to the role mother and child health program in which are part of basic six Puskesmas program with midwife, nurse, and doctors as the executors.
The mother and child health program in primary care activities consist of:
- Antenatal care
- Normal birth delivery by health personnel (only normal birth delivery that can be done in primary care with PCP and midwife)
- Family planning
- Neonatal care
- Healthcare for children under 5 year of age
- Growth monitoring
- Exclusive breast feeding, started with early initiation breastfeeding
- Iodine salt fortification program
- Sulfas Ferrous for pregnant mother and vitamin A for children
- Routine vaccination
- Vaccination acceleration if necessary
- Health promotion and community empowerment (posyandu/integrated health service and village alert).
Other community empowerment activity is Desa Siaga/Alert village. The objectives are village community awareness and responsiveness to health problems in their region, increased awareness, and public preparedness to the risks and danger to health and safety hazards, as well as increased ability and willingness of the community to help themselves in the health sector, independently. SIAGA is an acronym, which means: prepare, drop off, and take care. The villager communities are voluntarily make an inventory of their car/motor cycle that can be used for vehicle if someone in their village need to go/to be dropped off to health facility. They also have cadres, who have been trained for health education. They are also making an inventory of blood type of villagers for potentially blood donor if someone in their village needs one. Every month villagers usually have regular social gathering and money collecting for delivery savings/other health's need. All of the activities is endorsed and supervised by Puskesmas personnel.
Community movement is a national movement initiated by our government, in the form of promotive and preventive efforts, without neglecting curative-rehabilitative efforts in promoting a healthy paradigm. The Movement of Health Living Community (Gerakan Masyarakat/GERMAS) is a systematic and planned action undertaken jointly by all components of the nation (health sectors and other sectors) with awareness, willingness and ability for healthy behavior to improve the quality of life. The implementation of GERMAS starts from the family, because the family is the smallest part of society that influence individual's personality. Family doctors/PCP must aware and promote these movements to all their clients wherever they are.
There are 7 movements that should be done by Indonesian society all together as part of GERMAS:
- Physical activity
- Fruit and vegetable consumption
- Routine health check up
- Environmental cleaning
- Clean toilet
- No smoking
- No alcohol.
| Current Development|| |
There are needs in primary care for continuous quality improvement. Our Ministry of health (MOH) gave a strategic policy, as guidance for primary care improvement, and also there will always be updates in knowledge and practice as a constant changes. Therefore, as practitioners, we should be aware of the plan, do, check, action approach in our daily practice. We should not be allergic to data; on the contrary, we should provide the data/innovation from the grass root as an input to the superior to make an alignment of micro, meso, and macro health system. This becomes our contribution to the reformation of health system and for the continuous improvement of our health service to patient and community.
Another challenges in health that need to be taken care of are:
- The necessity of public health intervention and medical services to be complementary to each other to ensure a continuity of care
- The neccessity of primary care as an effective referral back up at secondary level
- The neccessity of hospitals involvement in health promotion and disease prevention with patients and family members empowerment.
These challenges will lead us to create networking and academic health system.
To answer to the previous mentioned challenges, Universitas Indonesia has a brand-new university hospital, located in main campus in Depok. It has primary care unit to maintain the continuity of care. Primary care outpatient unit is the first entry, which is located in first floor of the hospital. We conduct health risk and initial nursing assessment to all new clients before patient sees the doctor. Back up referral from secondary care will be performed to help patient's monitoring and follow up. Family assessment and home visit will be conducted in certain cases especially chronic illness and/or cases, which will need family participation on their case management. There is primary care/basic health service unit in the hospital to ensure the continuity of care and a bridge between community and secondary of care as well as part of longitudinal integrated clerkship in community oriented medical education.
Since 2015, we have been developing a formal education for doctor who wants to have a career as primary care physician/family doctors; specialized in primary care practice. Initiated by our MOH to strengthen our primary care, and endorsed by WONCA, in 2016 we finally have our first formal post graduate education for doctors who wants to pursue their career as primary care physician/family physician. Hopefully this also become an answer of the health challenges that has been mentioned earlier because the work as primary care/family physician is not only as a practitioner, but also must be able to become a good team leader for patient and community. Therefore, there will need a special competency and skillful planner, organizer, executor, as well as evaluator for case management in primary care practice, especially for those who have passion for primary care and family practice development.
| Summary|| |
Learning from our experience, family doctors/PCP must have these abilities in order to face health challenges in our country:
- Has leadership capacity to become a good team leader and a good bridge between community and other health provider/facilities.
- Networking with other health personnel, supporting personnel, family member, and community
- Networking and joint cooperation with other specialist to ease consultation and referral system
- Proactive to the community to find the causal of health problem from environment and community point of view
- Give input to the head of health facility by providing evidence/data from your daily case/work; therefore, the guidelines will be in accordance with the patient/community needs as well as for quality improvement
- Regular monitoring and follow up of the client with the help of other team member/health provider
- Provide proper documentation for accreditation
- Self-awareness for life long learning as well as for our own health.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Health in Asia and The Pacific.
Ministry of Health Republic of Indonesia, Basic Health Research, 2018.
Ministry of Health Republic of Indonesia, Health Profile, 2017.
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Global Conference on Primary Health Care. Declaration of Astana, 2018.
Ministry of Health Republic of Indonesia regulation no 74/2014.
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Ministry of Health Republic of Indonesia regulation no 46/2016.
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