Let's close 2022 with optimism, hopefully the pandemic status of COVID-19 can be revoked in 2023. And we hope that the health transformation will increase Indonesia's health resilience.

We also hope that there can be a solution to the pros and cons regarding the Health Bill (RUU). Recently, there was a wave of protests against the Omnibus Health Bill, which was an initiative of the House of Representatives (DPR).

Several health and medical professional institutions, such as the Indonesian Doctors Association (IDI), the Indonesian Dentists Association (PDGI), the Indonesian Pharmacist Association (IAI), the Indonesian National Nurses Association (PPNI), the Indonesian Association of Medical Laboratory Technologists (Patelki) and the Indonesian Midwives Association (IBI) voiced their anxiety.

Iqbal Mochtar, PB IDI executive members (”Health Bill Controversy,” Kompas, 18/11/2022) and Sukman Tulus Putra, chairman of the Indonesian Pediatric Cardiology Association (“Revision of the Medical Practice Law between Essence and Urgency,” Kompas, 17/ 6/2022), explained how controversial the contents of the Health Bill were.

Among them is the secretive process, without socialization and without discussing it with medical and health professional organizations. All of a sudden, the draft was included in the House’s 2023 National Legislation Program.

This bill is very diverse in scope, many articles overlap and are controversial. One thing that has been highlighted is the large amount of authority of the Health Ministry, which is seen as crossing the line, and has cut the role and authority of the health professional organizations so that it marginalizes the role of civil society.

Meanwhile Judilherry Justam, deputy chairman of the Advisory Board of the IDI Executive Board 2012-2015 (“Should the 'Omnibus' Health Bill be Rejected?” Kompas, 7/12/2022), denied the allegation that the professional and community organizations were not involved. It was also revealed that the Omnibus Health Bill would actually revise and correct various overlaps, disharmonies and deficiencies in various laws in the medical and health fields.

We hope that this Health Bill does not coincide with Law No. 11/2020 concerning Job Creation, which was finally declared unconstitutional by the Constitutional Court after a judicial review.

This article does not discuss the above, but invites us to think about a more basic health agenda for 2023, namely accelerating equity in primary health care. There are many chronic problems that cannot be resolved yet, such as the high rates of stunting, tuberculosis, HIV and malaria infections.

In addition, non-communicable diseases such as chronic kidney disease, diabetes, hypertension, stroke and degenerative diseases, all consume enormous medical expenses, which is very burdensome for the government and the people. Affirmative policies are needed to accelerate equity and improve the quality of primary health services.

Primary health care gaps

We are familiar with community health centers (Puskesmas), a form of primary health care spread across each district, which is designed as a filter to reduce the accumulation of patients in hospitals (RS) in cities/regencies.

Mild illness, such as the flu without pneumonia complications, for example, is enough to be treated at the health center, given inexpensive generic drugs, without the need to go to the hospital, which costs a lot. Doctors who have just graduated are assigned to the Puskesmas to treat mild patients, while increasing their “flying hours” and skills. This is the basis of the health service equity policy which was quite basic during the New Order era.

Up until 2021, there were 10,260 health centers throughout Indonesia, but the distribution and quality of services is still unequal. In Yogyakarta, one district can have more than one health center, with good buildings, adequate doctors and health workers. Meanwhile in East Nusa Tenggara (NTT) or North Maluku, there are health centers that do not have doctors.

Based on data from the Health Ministry’s 2021 Health HR Information System (SISDMK), as much as 42.6 percent of Puskesmas in Papua do not yet have a doctor. In Maluku the figure is 23.0 percent. This is sad. Another example of the gap is the availability of essential medicines at the Puskesmas.

In 2021, the national figure reached 92.3 percent, exceeding the Health Ministry’s 2020-2024 target of 90 percent. In Maluku the figure is 63.4 percent. In Banten, which is very close to Jakarta, it is 72 percent.

Hospital limitations

There is a fundamental problem, namely the limited capacity of Puskesmas services. For a patient with a fracture (fractured or broken bone), the treatment involves an X-ray to see the position of the fracture then repositioning (restore or straighten the bone position) according to the indications.

It can be with or without pen installation and completed with spalk/cast dressing. This cannot be done in a community health center, even though medically speaking, the handling of fracture cases is actually quite simple and relatively easy.

There are many other simple medical treatments that cannot be handled by the Puskesmas, such as the simple handling of tropical diseases and infections. Because the Puskesmas is unable to resolve these simple cases, all are referred to hospitals in the city/regency until a backlog occurs. This has been going on for decades and there has been no adequate solutions.

The 2018 BPJS Kesehatan report notes that the number of referrals from basic health facilities (FKTP, Puskesmas) to the advanced referral health facilities (FKRTL, Hospital) in 2017 reached 18,891,657 referrals, with a ratio of 12.56 percent, an average of 1,574,305 referrals/month. In 2018, it increased to 24,331,172 referrals, with a ratio of 16.60 percent and an average of 2,027,598 referrals/month. This exceeds the 15 percent standard set by the BPJS Kesehatan.

According to Ramadhani (Media Gizi Kesmas, 2020), this condition of referral overload is due to the nonoptimal role of the health center in carrying out its functions as gatekeepers. In particular, for the 144 diseases which are the competence of general practitioners that should be diagnosed and resolved at the health center. Of the 144 diseases, around 24 percent are still being referred to hospitals, so the workload and costs are increasing.

Why have the Puskesmas not been able to solve simple medical cases? First, standardized rooms and medical devices are not yet available. For example, data for the 2020 NTB Province shows that only 59.77 percent of Puskesmas have medical devices according to standard. This is actually not a difficult problem. With the 2023 State Budget of Rp 3.1 trillion and an allocation for the health sector of Rp 169.8 trillion, a program to gradually increase the availability of medical devices and Puskesmas rooms can begin.

Second, if the building and medical equipment are available, there must be doctors and medical equipment operators who are capable of handling them. This is a serious problem as the number of doctors is still limited. Currently there are 140,000 doctors who need to be given continuous training to be able to carry out medical procedures, which are currently held by specialist doctors.

Doctors at the Puskesmas so far are general practitioners who are still young, who are expected to handle initial treatments in a limited way. Beyond the limits of their abilities, the Puskesmas doctors will refer their patient to a hospital. If the distance from the Puskesmas to the hospital is very far, or if one has to cross an island, the patient's condition can become vulnerable. Treatment costs are expensive and pose a risk to patient safety.

The number of specialist doctors is also limited. The Health Ministry’s data shows that the proportion of medical personnel in Indonesia in 2021 will consist of 60 percent of general practitioners and 24.4 percent of specialist doctors.

As of Dec. 31, 2021, there are 141,946 general practitioners and 43,173 specialist doctors throughout Indonesia. This, too, is with unequal distribution. Only 40.4 percent of regions have basic medical specialists in internal medicine, obstetrics and gynecology specialists, pediatricians and surgeons.

Under these conditions, the target of placing more specialist doctors in each health center is a dream that is very difficult to realize. This is because our medical education has not been able to produce specialist doctors in large numbers in a short time.

Even if it could, this is also not an efficient and effective strategy. If our medical education system continues as it is today, the yearly increase in the number of specialist doctors will not be able to keep up with the demand, especially in relation to the geographical conditions of Indonesia which has thousands of islands.

‘Upgrading’ health centers and producing specialist doctors

There is a solution by slightly modifying the current system to develop a medical specialist education system, namely by providing and upgrading additional education for Puskesmas doctors.

To be able to perform minor medical surgeries, only 12 to 24 months of additional education is needed. For example, to be skillful at performing light surgery on broken bones, it may take only 6 to 12 months. In general, the point is that it only takes an additional two years of vocational education so that Puskesmas doctors are able to perform minor surgeries and handle simple medical cases.

After obtaining these additional skills, their qualification increases, by receiving a status as doctor with primary care skills. This way, there is no need to bring in specialist doctors to the Puskesmas, but it is enough to place a few general practitioners who have already obtained a skill upgrade.

The cost of upgrading to become a primary care doctor is not as expensive as the cost of recruiting a specialist doctor, so this program is realistic enough to run. If the Puskesmas can handle simple medical cases, this will reduce backlog and queues at the hospital.

Upgrading the Puskesmas along with medical devices and human resources will be very beneficial in areas that have so far been underdeveloped, such as most areas in eastern Indonesia, where the distance between the Puskesmas and the hospital can be very far and transportation conditions are also not ideal.

Next is the matter of accelerating the education of specialist doctors. So far, medical specialist education has been based on tertiary education and now produces 2,000 to 3,000 specialist doctors every year. At first glance the numbers seem large, but in fact the distribution is still unequal.

Sixty percent of regions do not yet have basic medical specialists, such as several provinces in the eastern region. To overcome this, it can be accelerated through breakthroughs in hospital-based educational models or community-based residency programs, as has been done in several other countries, such as the United States.

This hospital-based model will strengthen the university-based model to accelerate the addition of specialist doctors and improve distribution gaps, because graduates will be assigned to areas where there has been a shortage of specialist doctors.

This hospital-based specialist medical education is an affirmative program. It is necessary to harmonize cross-ministry regulations so that graduates have legality and are not too much different from graduates from the university-based model, although there are some differences in terms of completeness of skills and innovation.

If this program runs, the backlog of patients at hospitals can be reduced and the salary of Puskesmas doctors has potential to increase. So far, Puskesmas doctors are paid according to the BPJS standard, while specialist doctors in hospitals are paid with a higher standard. When doctors at the Puskesmas have been "upgraded" and can treat simple medical cases at the Puskesmas, it is only natural that the salary should also be increased, commensurate with the increase in their workload.

The accelerated affirmation program to produce hospital-based specialist doctors who accompany the university-based pathway will accelerate the equal distribution of primary health services in frontier, underdeveloped and isolated areas. We hope that the health transformation will increase Indonesia's health resilience.

Djoko Santoso
Professor of Medical Faculty, Airlangga University
Chairman of East Java MUI Health Board

This article was translated by Kurniawan Siswo