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urses, as health professionals, are on the front line of health care delivery in all countries. Since 1965 the International Council of Nurses (ICN) has celebrated International Nurses Day on May 12, which is the birthday of Florence Nightingale, the founder of modern nursing.

This year Nurses Day is themed '€œNurses: A Force for Change (Care effective, cost effective)'€ to credit their pivotal roles in the efforts to promote changes toward effective cost of health and quality of care.

Globally, the cost of healthcare is rising as a result of health technology advances and an increase in operational and maintenance costs of equipment. On the other hand, the instant lifestyle of urban people has led to chronic diseases such as stroke, diabetes and obesity.

A study by Chisholm and Evans (2010) found that the major causes of ineffective cost are overuse of brand-name medicines and underuse of generic products; overuse of supply and equipment, investigations and procedures; inappropriate or costly staff mix, unmotivated workers; inappropriate hospital admissions and length of stay; and poor quality of care. Learning from these findings, Indonesia'€™s health system needs to consider the use of available health resources in effective ways to achieve universal health coverage.

Primary Health Care (PHC) is the main key to provision of a healthy lifestyle and disease prevention. In addition, PHC should provide widely accessible and equitable health services for the community. Therefore, the heavy burden of a disease can be reduced, as it can get immediate treatment.

As agents for change, nurses have an opportunity to spark behavioral change by providing health promotion and disease prevention interventions. To realize this, however, they face many challenges, such as their deficits in numbers, competence and levels of welfare.

Today'€™s problem faced by nurses in Indonesia is workforce shortage. The World Health Organization (2006) states that in developing countries the progress of universal health coverage is delayed by the shortages in the health workforce of the right numbers, the right locations and with the proper skills to deliver a quality service to the entire community.

The result of nursing workforce shortages is overburdened nurses due to heavy workloads, which influences the quality of care for patients. The WHO recommended a minimum ratio of 50 nurses per 10,000 population. However, Indonesia Health Profile (2013) reported that the ratio only stood at 11 per 10,000 population.

 Worse, nurses in a developing country like Indonesia are still facing inadequate socio-economic welfare. There is no appropriate salary to reward nurses'€™ competence, despite their proper skills, to deliver advanced quality services

Nurses often work double shifts to get decent pay. The ICN (2015) reported that nurses often work for long periods under stressful conditions, which can result in fatigue, injury and job dissatisfaction. High quality care performances for patients are thus unlikely to be achieved. The ICN states that Positive Practice Environments (PPEs) need to be set to ensure the health, safety and well-being of staff, support quality patient care and improve motivation, productivity and performance of individuals and organizations. PPEs also aim to lower rates of absenteeism and turnover, and increase the morale, productivity and performance of staff.

Given the universal nature of health coverage, nurses work not only in hospitals but also in all settings of health services, including schools, work places, elderly homes, prisons and other places.

This means that cost of health care could be more effective if health promotion and disease prevention could be implemented more regularly and sustainably under the guidance of government and in collaboration with other health professionals as well as community partners.

Working together with other professionals is the key success to achieving a better health standard for the nation. Happy Nurses Day.
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The writer, who holds a Masters'€™ degree in nursing science, teaches at Saint Carolus School of Health Sciences, Jakarta.