Strengthening Indonesia’s healthcare as the first line of defense against Covid-19

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(illustration: IO/Design Team)

Lack of beds, PPE, medical personnel, the nation’s healthcare service struggle to cope with the pandemic 

IO – The COVID-19 pandemic sweeping across the globe today has had an impact on the health and non-health sectors. Countries across the world responded by issuing different policies in an effort to break the chain of transmission and minimize the damage caused to the economy. 

The resilience of our national health system is currently being tested in responding to the rapid escalation of COVID-19 cases which is already spreading to almost all corners of the archipelago. It has resulted in many deaths among the working-age population, including health workers who are at the forefront. The World Health Organization (WHO) reports that there are more than 22,000 medical workers across 52 countries that have been infected with COVID-19. It is also very concerning that a large number of healthcare workers in Indonesia have fallen victim to the pandemic, either becoming infected or dying. 

This has further led to the temporary closure of our primary healthcare system, such as Puskesmas (Community health clinic) and even auxiliary Puskesmas in several regions, to break the chain of virus transmission through healthcare facilities. 

According to several published studies, while a number of health workers have been infected by their family members, a majority contracted the virus at their workplace and from the community at large. This shows how weak our healthcare system really is, because many of them lack the necessary protection. 

In the early days of the pandemic, Indonesia was fumbling through its response to prevent further community transmission, with a number of healthcare facilities in the regional level quickly overwhelmed and availability of personal protective equipment in a dire state. Based on May 27 data from the Ministry of Health, the highest proportion of positive cases among health workers was found at the Dr. Kariadi General Hospital, Semarang, Central Java. In a letter numbered YR.03.03/III/III8/2020 addressed directly to head of health offices at the provincial and regency/city level, and directors of hospitals throughout Indonesia, Director General of Health Services Dr. Bambang Wibowo urged doctors and health workers to halt routine treatment, except in the case of emergencies. This instruction was aimed at curbing COVID-19 transmission. The general public were also advised to postpone treatment at hospitals if it is non-critical. 

Indonesia’s New Normal 

President Jokowi at a palace briefing announced, on June 15, that the Indonesian people must accept the reality that they must “live in peace” with COVID-19. Previously, the WHO had revealed that COVID-19 would not go away very soon. It means that we must learn to coexist with it. President Jokowi, however, stated that this does not mean that we are resigned to the situation. What he meant was that we must adjust or adapt to the new normal. Measures like wearing a mask, keeping our distance, and always washing one’s hands are part of the COVID-19 prevention protocol we must adhere to in our daily life. President Jokowi added that it is inevitable that we must change our lifestyles profoundly if we are to prevent the risk of infection. “It’s a must; that’s what many people call the new normal or the new order of life,” said president Joko Widodo. 

The definition of a new normal is a scenario to speed up the handling of COVID-19 in health and socio-economic perspectives. The Indonesian government has announced plans to implement the new normal scenario while taking into account epidemiological studies and regional readiness. 

WHO provides several recommendations to be followed by countries around the world in order to adjust to the new normal life, until a vaccine is found. First, countries must avoid creating circumstances that may increase transmission rate and geographical spread of the virus, to the maximum extent possible. Secondly, it is necessary to bolster the capacity of the health system to be able to respond to COVID-19-related services. Other measures include more robust surveillance to detect community transmission as early as possible, especially among at-risk groups, though testing, contact tracing, and quarantine. (covid-19.go.id Data, as of 14 June 2019) 

We know that some WHO recommendations on the new normal have not been met, as the spread of COVID-19 in the country is not yet fully under control, especially in some provinces. Thus, expect to see more government regulations in our daily life, meaning restoring the normalcy of life in a staggered manner, while at the same time adopting a watch-and-see approach on development in the field. 

The government’s steps to prepare for a new normal in dealing with the COVID-19 pandemic is not meant to put people’s health at risk but instead to make the community feel safer and become more productive. Therefore, health protocols remain strictly enforced. One of the main protocols is that people should stay fit and healthy by obeying health protocols, while still being able to work productively. 

New normal requires a change in behavior so people can continue carrying out their daily activities while adhering to health protocols in order to limit COVID-19 transmission. Health protocols that are often prescribed to include keeping a safe distance, wearing a mask, avoiding crowds and washing hands regularly. These habits constitute what many call the new normal. The new normal hinges on adjustment to a new pattern of life. This transformation is aimed at organizing life during the pandemic, which will be carried forward into the future until a vaccine is available. The question is, when will we have one? Most scientists believe that a coronavirus vaccine won’t be ready until the end of 2021. 

The government has issued the COVID-19 Prevention and Control Guideline in Office and Industrial Workplaces to support business sustainability during the pandemic. It is expected that the business community and workers can follow these guidelines, so that they can significantly contribute to the reduction of transmission, considering the large population of workers and their high mobility. Furthermore, people’s interactions generally take place at the workplace. 

The state of healthcare facility in Indonesia 

According to data from the Health Ministry, nurses comprise the largest group of medical personnel (143,821), followed by general practitioners (12,329), medical laboratory specialists (10,701), specialists in internal medicine (2,690) and lung specialists (807). Currently, there are 755 COVID-19 Referral Hospitals across Indonesia. Based on the results of the 2019 research on healthcare facilities, conducted by the Health Ministry’s Research and Development Department, it was found that 7.5% or 742 Puskesmas are yet to have general practitioners. 

Around 29,900 ventilators are needed for COVID-19 designated healthcare facilities, but only 8,400 units are available, as of March 2020. There are only four provinces with ventilators numbering over half than what they need, namely, North Kalimantan (72.7%), Bangka Belitung (69.8%), Jakarta (55.9%), and West Sulawesi (51.6%). On the contrary, the availability of ventilators in other provinces ranges between 20-30%. 

The ratio of hospital beds in Indonesia is 1.2 per 1,000 population, which means that on average there is only one bed per thousand people. Jakarta has the highest ratio (2.24), followed by North Sulawesi (2.1), East Kalimantan (1.84), and Yogyakarta (1.82). The smallest ratio is found in West Nusa Tenggara (NTB) with only 0.71. This means that NTB only has 71 beds per 10,000 population. 

These facts indicate that the state of healthcare service in Indonesia, when measured against facilities and workforce, is still very limited, far from being sufficient to cater to the needs of local communities in a pre-pandemic situation, let alone during COVID-19 era. 

Challenges faced by Indonesia’s healthcare facilities in New Normal 

At the onset of the pandemic, the handling of COVID-19 as an Emerging Infectious Disease (EID) was more focused on hospitals. But with the rapid increase of cases, more hospitals are designated as referral hospitals, in addition to the rapid construction of emergency hospitals. Central and local governments would definitely be limited in their ability to provide COVID-19 referral hospitals, which beg the question: To what extent can referral hospitals able to accommodate and manage COVID-19 cases? 

The government must start thinking about steps to treat COVID-19 patients while still serving non-coronavirus patients and keep the risk of infectious transmission as minimal as possible. Undeniably, healthcare services in the new normal era will be starkly different from a pre-coronavirus situation. Among other things that need to be considered are preparations in anticipation of the possibility of a second wave, considering the risk of community-wide transmission is still high. In this respect, healthcare facilities need to have clear emergency protocols in the event there is a need. 

Healthcare facilities, comprising hospitals and Puskesmas, must implement strict health protocols for all visitors, from patients, patients’ families or companions to hospital workers. The health protocol includes compulsory use of masks for all visitors, physical distancing practice, to rapid health screening such as temperature measurements, physical checks, and interviews about health conditions and history of contact with high-risk areas or people. There must be separate entrances and special wards, and hospital staff must wear personal protective equipment according to standards set by the Health Ministry. 

As a Primary Healthcare facility, the Puskesmas plays a crucial role in breaking the chain of transmission at its early phase, because of its extensive network in each district and embodiment of regional-based healthcare. In the COVID-19 era, Puskesmas needs to make all possible efforts in preventing and limiting transmission. Although this is currently a priority, it does not mean that Puskesmas can neglect other services that are part of its core function as the first level community and individual healthcare efforts as stipulated in Health Ministry Regulation No. 43 of 2019 on Community Health Centers. 

Telemedicine 

General public anxiety in visiting hospitals during the COVID-19 pandemic has also become a problem of its own, when someone has a medical problem but is afraid of being infected when seeking treatment from hospital. Therefore, telemedicine is now one of the more popular methods used by the community to avoid contact with hospitals. Public interest in using applications that offer health consulting services or online doctor consultation has increased dramatically during the outbreak. Based on a report by the Minister of Health at the Limited Cabinet Meeting on April 6, the users of telemedicine apps have reached 15 million people. Some of the most popular telemedicine apps are Alodokter, Halodoc, SehatQ, Klikdokter, Yesdok, Doktersehat, Dokterpedia, Maudok and more. 

Telemedicine refers to long-distance health service through the use of communication and information technology that can provide health care solutions for remote areas where health facilities are inadequate. Telemedicine (also known as telehealth) is part of the drive to implement electronic health (e-health). The government, through the Health Ministry, has issued Health Ministry Regulation No. 20 of 2019 on the Implementation of Telemedicine Services Among Healthcare Service Providers as an effort to accomplish safe, quality, non-discriminatory and effective telemedicine services as well as prioritizing patient’s interests and safety. 

Technology can serve as a bridge between health services and procedures. The growing popularity of telemedicine can become the solution to ease access to health services ,as well as a breakthrough in health services in a New Normal era. This application can connect patients with doctors, so they don’t have to meet in person, effectively reducing the risk of transmission. Telemedicine can be a health solution in the future. In fact, the World Health Organization (WHO) has its own special digital health department. 

In Indonesia, the use of telemedicine can overcome a number of challenges in providing equitable access to health, such as geographical constraints, uneven distribution of health workers and the lack of health facilities in hard-to-reach areas. However, while sophisticated, there is one thing that telemedicine cannot do, namely, a physical examination by a doctor. This sometimes result in the doctor being unable to provide a definitive diagnosis when having a virtual consultation using this technology. At most, the doctor will only provide a tentative diagnosis, accompanied by other comparable diagnoses. This is understandable, considering that the process for establishing a diagnosis is multi-layered, with steps that sometimes also need to be accompanied by various examinations. The absence of a definitive diagnosis also results in doctors being unable to dispense prescriptions for specific drugs to alleviate or cure an illness. 

Although there are still pros and cons surrounding this technology, telemedicine is the product of an inevitable technological progress. Regulations from the doctors and users sides are still being deliberated, to find a middle ground that can benefit both parties. Going forward, the use of telemedicine will continue to be developed, not as replacement for in-person visits to doctors, but more as a companion to increasingly better, more efficient, and more appropriate healthcare. 

A health paradigm 

Health paradigm is a holistic perspective, mindset, or health development model aimed at improving, maintaining and protecting health. Beyond healing the sick or restoring health, this paradigm encourages people to be more independent in staying healthy through a higher awareness of the importance of health services that are, by nature, promotive and preventive. In dealing with the COVID-19 pandemic, it is not only focused on handling cases, but also on community empowerment in order to break the chain of transmission by voluntarily and obediently following health protocols set out by the government, namely, to use masks, diligently wash one’s hands with soap and flowing water and staying at home. 

The role of first-level healthcare facilities during the COVID-19 pandemic is very important (especially the Puskesmas) in the prevention, detection and rapid response to control COVID-19 infection. Puskesmas must be able to manage and utilize their resources effectively and efficiently in breaking the chain of transmission, both at the individual, family and community level. Puskesmas also has an equally important role in realizing community independence through community empowerment in effecting behavior change at the individual and community level. This can be done through risk communication and awareness raising activities. 

Collaboration with cadres, community and religious leaders, local organizations, healthcare groups, and other stakeholders to improve literacy and encourage groups/individuals/ family to live a clean and healthy lifestyle to prevent the spread of COVID-19 is of significance to provide an understanding to the general public and intersectoral parties on how to break the chain of transmission, as this should be a shared responsibility on the part of society, community leaders, the health sector and the government, at both local and national levels. 

In the advent of a new normal, we must be able to adjust to the implementation of health protocols in our daily lives. And we should start by changing our mindset from “sick” care to “health” care paradigm as it aims to create a healthy society, by paying keen attention to policies that are preventive and proactive in nature, as well as providing support and resource allocation to protect the healthy and treat the sick. There is a pressing need for health promotion and disease prevention at the community level. (Tince Arniati Jovina) 

Tince Arniati Jovina is a policy analyst at the Department of Research and Development of the Health Ministry of Indonesia, Tince Arniati holds a Master’s degree in Public Health from the Faculty of Public Health, Universitas Indonesia. She is writing for the Independent Observer.