One thing that we cannot deny is that medical doctors in Indonesia have done so many things, particularly those who work in the field of primary health care. They have been assigned to work in isolated areas at the borders, at the corners of this country. In slum villages and remote islands at the borders.
They live and work in places which are unfamiliar for the majority of people in this republic. Their presence is only noticed by the small communities where they live. There are no news about them, No exposure in the mass media, No stories on facebook. No stories on Kompasiana. The communities also have no access to share stories to the high officials of this country, about the brave doctors they respect so much.
They have no access to internet. Even if they do have access, they may not have the capacity to share the stories to their fellow citizens in the urban areas. They exist in the district capitals as mere statistical figures. The head of the district office would mainly count the number of community health center (puskesmas) present in meetings. It does not matter who represents the puskesmas. It could be the midwife, the nurse, the environmental health staff member. It could be anybody. The district office would probably only ask why the doctor is absent, when they come to the district health meetings once every few months.
Whoever comes to the district meetings may have journeyed from far away. Sometimes they need to leave one day earlier as they have to pass though muddy pathways. Sometimes they also have to journey during midnight passing through forests.
Do not ask about how they are being paid. By the old system, many of them only receive their basic salary plus a minimal number of honoraria for health programs at the puskesmas. Sometimes they would have to save small change to buy premium gasoline, which unfortunately can also be expensive. How sad.
Now medical doctors are paid by using the capitation system. The more doctors there are, the higher would the capitation payments be. Often times they would be the only doctor available at the primary health care unit, as many doctors are reluctant to serve in remote areas. The capitation system thus makes their payment become much lower. This is not in comparison with their work load. The fewer doctors there are, the more heavier would the work load be, with less payment, which does not really make any sense.
But the communities usually do care about them. They would bring fruits and gifts for the doctors. What kind of gifts? Bananas, sweet potatoes, palm sugar, chicken….. Praise God.
In such a difficult situation with heavy work load, they still work hard. Threats of malaria become very common. Also typhoid fever, not to mention diarrhea. Surprisingly, they all survive, and once in a while one of them gets exposed in the mass media. But even if he or she is exposed, very rarely is the root of their problems in primary health care being mentioned. After the doctor returns to the city and works in a hospital, all those matters are once again forgotten. Like a heavy rain leaving no remains are all.
The other problem we have now is that there is little progress in achieving our health indicators. We need health reform, and so the officials in the capital city would start to organize symposia, seminars, focus group discussions and meetings, resulting in recommendations that we need to improve everything, and more budget is needed. A higher budget for health system reform particularly for primary health care is then proposed.
Unfortunately and sad enough, the medical doctors become victims again. Those working in primary health care are considered less competent, less capable, and need improvement. Ironically, those who mention these facts are often those who had experience working as a doctor in primary health care. They are the experts who have been trained with excellence, through a competence-based educational program. The systems which they developed have been denied by the experts themselves.
Then a remedy is mentioned to deal with all these problems. Doctors need to be trained again with a new system of excellence. Everything is instant in this country, like “magic water” with can instantly cure all problems. Here is the instant cure for our health system reform; train the doctors again. Aduh, where should I put my face now? This is really embarrassing. Using magic water to cure the problems in our health care system.
Within the present condition, what if we send our distinguished, honorable, important high-level officials from the grand building in at Jalan Rasuna Said, Jakarta (the Ministry of Health) to remote areas? This will still not solve the problem. They may be persons of high competence with great expertise, but they themselves will create more nuisance. Someone would need to hold their umbrellas, hold their shoes, drive their cars, as they are unable to walk by foot. Ironically they act as if they are the ones who own the cure to solve all health care problems in this country.
Stop seeking for instant cure to solve health care problems in this country. It is not that simple. If our health budget is still low and if we still do not give high priority to health in order to increase the quality of our human resources, then nothing will be solved.
However much you want to improve the quality of human resources in primary health care, or however much you place experts in the primary health care settings, even competent professors, it will still not solve anything. The easiest way is to work in close proximity with them. Accompany them in the remote puskesmas for three months. Live with them. Then you will know what their issues are. It probably will have nothing to do with competency.
Do not just visit puskesmas in urban areas. You already know who works there. You will see they have adequate facilities. They can still dress up nicely. But do not forget how many patients will they treat per day. Ask a public health expert to treat patients in a big city. I am sure they will all give up.
You may accuse them for so easily referring patients. You may say they are less competent. I am worried that if you go there and see the crowd of patients in the waiting room, you will die with shock. If there are 100 patients, I am sure you would not be willing to treat all of them. And if you become the urban puskesmas doctor, I may be worried that would easily say: just refer them to the nearest hospital.
I am sure you are not the type of people who seek for instant cure for your illnesses. Those people who do that will usually seek instant cure because they cannot afford much. Are you also able to find the roots of our health care problems? It would be much too easy to say that puskesmas doctors are only able to refer patients. Much too easy to say they are less competent. Much too easy to say that the solution is to increase their competency through further training. Stop your instant mode of thinking!
I am capable enough to address this as I had worked long enough in a primary health care system. The puskesmas I used to work at was made out of rotten wood and rusty metal roof. But it was awarded the provincial championship twice. I have also been a model doctor (dokter teladan). The Puskesmas is the champion of the province. Please do not think I am making things up.
Give appreciation to the primary health care doctors. They have done enormous things for this country. Stop thinking that they are the cause of the bad quality of our health care system.
The author worked in primary health care for seven years in a remote area. Now he is a general surgeon sub-specializing in vascular surgery at Cipto Mangunkusumo Hospital.
Article is generously translated by Danny Yatim from Angsamerah Associates.