The government through Ministry of Health and Ministry of Research, Technology and Higher Education has opened a new program called Primary Care Physician (DLP) program. The government hoped that DLP program could improve the doctors’ quality in primary care, so it could suppress references to hospital, which is also related to community healthcare cost.
But in its implementation, this DLP program faces opposition, especially from the doctors as the subjects of the policy. In the viewpoint of Indonesian Doctor Association (IDI), DLP is illustrated as a mesure of covering the smoke without putting out the fire. It will be futile. Why? Because the problems of Indonesian healthcare are not only in the skills of doctors only but also on many factors.
There is a discrepancy on Law Number 20 of 2013 which categorize DLP as a new specialization in medicine. In the law, it is stated that DLP is a continuation of medical profession program and internship program which is equal with specialists. While in Law 29 of 2004 on Practices of Medicine, it is stated that doctors and dentists are doctors, specialists and dentist, and specialist dentist. There are no statements of DLP in it, so legally, there will be overlapping authorities and expertise between DLP and the existing doctors.
Second incongruity, currently there are 114,602 doctors (KKI data, October 2016) while the one who can open DLP program is only Faculty of Medicine (FK) with accreditation A, which means there are only 17 institutions out of 75 FK in Indonesia (excluding the newly established FK). So decades will be needed to DLP certified all the doctors to serve in primary healthcare service. It is excluding the annual 8,000 of doctors graduated every year. Even though the government is ready to fund the DLP program, it is still inefficient and might even burden the state.
ROOTS OF PROBLEMS
The society need to know that DLP was started from the government assumption that the high references to hospital was caused by low competence doctors. Doctor’s competence is indeed a factor but it is not the main issue faced by Indonesia now.
According to Hendrik L. Blum, Health Administrations Professor of University Of California Berkeley, there are four factors which affect human heath, environmental health, human behavior, healthcare service and genetic factor.
The first factor is environmental health. Recently House of Representatives (DPR) urged the government to strengthen clean water infrastructure. Based on BPPSPAM, there is only 50% of clean water from all water managed by PDAM. The rest is included in less healthy and dangerous when the human body composition is 60-70% water. Then there is also food problem. In Food and Agriculture Organization (FAO) report in 2015, they found that 37% or 7.6 million babies experienced stunting due to growth disorder caused by poor nutrition.
The fact shows that Indonesia has not been secured in terms of food. We still import rice, soybean, sugar and meat. The doctors feel concerned with this. It is still difficult to have access to clean water and healthy food for Indonesian daily life. Should the doctors get the blame when this condition causes chronic diseases which make higher references to hospitals?
Second factor is the human behavior. Available and complete health facilities, without being followed by human behavioral change is useless. The increasing cases of metabolic diseases like diabetes, stroke and heart are caused by unhealthy life styles. Life style with fatty food, smoking, alcoholic drinks, less exercises will trigger chronic metabolic diseases which cause more references to hospital as only hospitals have the equipments for the therapy.
The third factor is healthcare services. How excellent the doctors’ competence is, they still will not be able to handle the disease of their specialization well if the facilities and medications are not available. Have we observed the facilities in Puskesmas or primary healthcare services? Are the equipments and medications available so the doctors do not feel necessary to refer patients to hospitals? The fact shows uneven distribution of doctors. There are a lot of Puskesmas with no doctors. This should be the government priority. Rather than send doctors to DLP program, it would be better if the government facilitate and guarantee that this absence of doctors can be managed well.
The fourth factor is genetic factor. It is the smallest compared to other factors. But we should observe more, children born from parents with cancer have more risks to cancer even though it can be minimized by implementing healthy life style and early cancer detection. More people with genetic diseases will also affect the effort to improve health quality in Indonesia.
The government said that the difference of doctors and DLP doctors are on DLP doctors’ additional competences as they will be educated on family and public health. Hodgetss and Cascio have divided healthcare services into two, the community and individual healthcare service, where the community healthcare service are performed by public health experts and focused on how to maintain community health and prevent diseases.
So, why don’t we collaborate with Faculty of Public Health (FKM) to strengthen primary healthcare services? Why does the government establish FKM if their practitioners cannot support primary healthcare services? Doctors and public health experts also other health staff can work together to improve health of people at primary level.
Strengthening doctors’ competence in primary healthcare services is a must. The government needs to see this problem from upstream to downstream. FK institutions as the ‘factory’ of doctors have different qualities. Only 22.6% of them accredited A. The rest are B and C (KKI and BAN PT 2016). Kemenristek Dikti did not try to improve the existing FK qualities but opened eight new FK this year. The government needs to be more serious in improving qualities, not only focused on quantities. Excellent Faculty of Medicine (FK) will produce excellent and competent doctors.
IDI has more realistic suggestion. Indonesia is vast and diverse, so the need of medical competence is not ‘uniform’ yet. So for instance, DLP doctors in industrial regions will need different competence than the ones in coastal or remote areas. It will be more realistic if the competence improvement in primary services used “shopping” system in Professional Continuity Education Developmental Program (P2KB) as necessary. P2KB reinforcement will be more realistic.
All solutions provided, the rest is in the government’s commitment. There is a saying: “In the first half of our life we sacrifice health for money. In the next half we sacrifice money for health.” The infrastructure development is indeed important but do not forget to develop the human competence. (*)
Editor: Bambang Bes