H

ealth is one of the human rights guaranteed by the Indonesian Constitution. Since 1968, the Indonesian government has had a concept to ensure those rights through the development of a primary healthcare system via Community Health Centers (CHC). As of December 2010, there were 8,967 CHCs, with 22,273 complementary centers in Indonesia.

Seeking medication is the main reason why Indonesians go to CHCs. If we ask what Indonesians see a CHC as being, the most common response is that it is a place to get medication. This perception is not totally true because a CHC is not only a curative site, but also a center for health prevention. The question is: Is it already functioning as a true health prevention and promotion center?

We can see how CHCs are not properly dealing with prevention from things like the maternal- and infant-mortality rates in Indonesia, which are still very high. According to data from the Indonesia Health and Demography Survey 2002-2003, the maternal-mortality rate (MMR) was 307 per 100,000 live births, which was still high compared to other countries in the region.

The infant-mortality rate (IMR) has declined from 68 per 1,000 live births in 1991 to 35 per 1,000 live births in 2002. But 60 percent of births still occur without assistance from health professionals. Why are the infant- and maternal-mortality rates still so high?

One reason is because there are still many deliveries assisted by traditional birth attendants. Research has stated that there are traditional acts that increase MMR and IMR, such as rubbing coconut oil on a pregnant woman’s vagina to ensure fast delivery, people not wearing gloves around the vagina and using non-sterile scissors to cut the placenta.

According to health researcher Linda Maas, one of the reasons why Indonesian people still choose traditional birth attendants is that there is no information about safe deliveries at the hands of health professionals, particularly from the CHCs that should be at the front-line in promoting of safe deliveries.

It is the one of the CHCs’ duties on the prevention and promotion. CHCs should promote that a doctor should attend childbirths. If people are afraid of the cost, CHC officials can inform them that the cost is covered by the government.

If we want to achieve better standards of healthcare, we need to revitalize CHCs as prevention and health-promotion centers. We can do this through improvements in CHCs’ budgets, paradigms and staffing.

Since the decentralization era, CHCs have been a technical unit below local government health agencies and no longer the domain of the central government. CHCs are funded by the local governments, so if the local government does not think that the health sector is a priority then the CHC will only get small budget.

The result is that many CHC’s preventive actions will be not working. New hope came in 2010 when the Health Ministry approved a new fund called the Bantuan Operasional Kesehatan (Health Operational Fund), which has been used to improve prevention and education programs in CHCs. The fund has been increasing each year, from
Rp 216 billion in 2010 to Rp 1,065 trillion in this year’s allocation.

Even with that budget, we still need a higher commitment from local governments to use the budget only for prevention and education programs. We also need a commitment from the central government to continue this program.

The CHCs main paradigm is mostly on the curative sector. It should be changed to prevention and education. The CHCs should be built from a prevention-basis, such as increasing the coverage of immunizations, promoting breast-feeding, improving mother and child attendance to integrated service posts (Posyandu), surveillance of nutrition programs to decrease the number of undernourished babies, raise awareness of clean and healthy lifestyles, prevent infectious diseases and educate people about HIV/AIDS.

In big cities, the centers should modify programs in order to get capture attention. For example, demand for HIV care and drug abuse programs have been met in Jakarta’s CHCs.

Another problem that needs to be tackled by the government is opinions of healthcare workers. Many still think of a CHC as a curative place.

They just want to see patients in the clinic and give them medication. It appears that they do not care that many of the diseases they see can be prevented, although they know that prevention is always better than the cure. We need to change that point of view, from the curative to the prevention paradigm.

CHC workers should have knowledge on health promotion and prevention, such as how to organize a health-promotion meeting, how to get support from local leaders in promoting healthy lifestyles and how to increase people’s awareness of living healthily. We can do this through training and the inclusion of more prevention and education policies in personnel education.

Making the paradigm shift toward prevention is not easy. We need to shift it gradually. If we want a healthy nation, we need more prevention and education programs in this country — and we can reach that through the revitalization of CHCs. Prevention is always better than cure, isn’t it?

The writer, a general physician, lives in Jakarta