J

akarta, with more than 10 million inhabitants, is one of the largest urban areas in the world. Of course, Jakarta has a lot of problems, and health care is one of them. Jakarta, despite having 341 community health centers (Puskesmas) and more than 4,000 integrated health service posts (Posyandu), is still battling preventable diseases.

According to data from the Jakarta Health Agency in 2007, the incidence rate for dengue hemorrhagic fever (DHF) was the second-highest among diseases in Indonesia, with 227 cases per 100,000 people, plus diarrhea, which affected more than 200,000 people per year.

The number of fatalities caused by Avian influenza was higher in Jakarta than anywhere else in the country from 2005-2010. Unfortunately, the ratio between Puskesmas per 100,000 citizens is still very low, at 3.55. The burden on Puskesmas is too heavy, with one puskesmas having to provide care to 30,000 Jakartans.

What Jakartans can learn from these cases is that preventive action is far more important than a
merely curative one. Preventive action means sowing the seeds in a clean environment and healthy lifestyle.

According to the 2010 National Basic Health Survey, residential areas in the city that are categorized as healthy constitute only 66 percent. So, Jakarta still has a lot of breeding places for microbes.

In the case of dengue fever, preventive action can be taken by intensifying the government-initiated 3M program (destroy the mosquitoes’ larva-breeding sites, clean water sources and place unused sacks that can contain
water underground), search for the Aedes aegypti larva, and clean the environment. Meanwhile, with diarrhea, hygienic water sources and improved garbage disposal would help to provide a solution for its prevention. In the
case of Avian flu, segregating poultry from human residential areas is one of the key preventive actions.

It is not only incidences of infectious diseases that are on the rise, however. Some preventable diseases relating to lifestyle choices, and degenerative diseases, are also rising in number.

According to Health Ministry data, the mortality rate from degenerative diseases increased from 49.9 percent in 2001 to 59.5 percent in 2007.

The common causes of mortality in Jakarta are stroke, followed by hypertension, diabetes and cancer. Degenerative diseases are triggered by risk factors, such as smoking, an unhealthy diet, low physical activity and a generally unhealthy lifestyle.

According to the 2007 National Basic Health Survey, the prevalence of people in Jakarta who smoked every day was 24 percent with the majority of smokers being in the 15-19 age group, while 93.6 percent of Jakartans had low consumption rates of fruit and vegetables, and 48.2 percent of them took little physical activity.

The increasing number of degenerative diseases will eventually lead to a lack of productivity in the city. For people with these diseases, curative treatments take a long time and cost a great deal of money. For the government, it will require an even larger health budget as the majority of patients come from low economic households, meaning that their health expenses need to be covered by the government.

The solution is for people to adopt healthy lifestyles and the Jakarta administration can help promote this by making city parks comfortable for people to jog; build more sport centers; restructure slum areas; increase taxation on fast food and cigarettes; strengthen the non-smoking regulation; and promote health screening for those people at high risk.

With the rise of degenerative and preventable infectious diseases, Jakarta needs more preventive health and health-promotion programs. One of the solutions could be via family doctors.

The idea is to improve the role of general physicians in Jakarta’s Puskesmas by becoming family doctors. With more than 900 general practitioners in puskesmas across Jakarta, the government could set up a pilot project of the family-doctor program.

According to the theory behind this program, one doctor takes care of several families in one area and he receives grants to implement preventive program in that coverage area.

The more people in his area that become sick, the fewer grants the doctor will receive the following year.

The family doctor is in charge of health prevention programs, such as immunization, health screening and environmental health.

This program would result in more family doctors going to the grass roots and implementing a variety of health preventive measures.

But the concept will not work if the referral and health-payment systems in this city remain untouched. The referral system should be regulated so that in non-emergency situations, a patient should first see his or her
family doctor.

If the doctor sees that the patient should visit a specialist doctor at the hospital, the doctor will submit a letter of referral to the hospital in question. This program would eventually reduce unnecessary visits to specialist doctors.

With regards to health payments, all Jakartans should receive an insurance card. Impoverished people’s insurance contributions are covered by the government.

If they go to a public hospital, hospital officials will take the insurance card and a referral letter. In non-emergency situations, the insurance card will not be valid if there is no referral letter accompanying it.

To implement better preventive action, the Jakarta administration should raise its health budget. Right now, Jakarta’s health budget is only Rp 2.4 trillion (US$256.8 million) per year, which is a mere 8.6 percent of Jakarta’s total provincial budget.

According to the Health Law, a province’s health budget should be 15 percent of its total budget. From Jakarta’s current health budget, the budget for preventive action amounts to only Rp 150 billion. Therefore, the Jakarta government should increase the health prevention budget.

With 675,000 Jakartans on national health insurance and 340,000 of the city’s residents on Jakarta’s provincial health insurance, the budget should also be allocated to the poor.

Now, Jakartans are awaiting the gubernatorial election, in which six pairs of candidates are competing. It is a welcome sign that the candidates have vowed to increase the city’s health budget to more than 10 percent and allocate more of the budget toward preventive health.

It will surely not be an easy task to change the approach of the current health program to adopt a preventive direction, but focusing on preventive action can both improve the health of Jakartans and help control health-care spending.

The writer is a physician in Jakarta.