The Jakarta Post
Soon after he took office in October 2019, Health Minister Terawan Agus Putranto highlighted the urgency for puskesmas (community health centers) to focus on preventing disease and promoting heath to help reduce the burden on the country's deficit-stricken National Health Insurance (JKN) program.
Only a few months later, community health centers across the country are doing both while conducting public health surveillance and providing treatment, but for a whole other reason: the COVID-19 outbreak.
Puskesmas staff are now expected to educate people on the disease, trace contacts, monitor suspected cases and administer rapid tests, all the while treating COVID-19 patients without sufficient personal protective equipment (PPE), risking greater exposure to the invisible threat.
"At first, we had to use thick [rain jackets and pants]. We had to maintain our distance, without physical contact with our patients," said general practitioner Christine Yulius, 40, the sole resident doctor at a puskesmas in Tasikmalaya, West Java.
It was only recently that PPE was distributed to the health center, although the supply did not include medical gowns or hazmat suits.
PPE shortages have also been reported at many puskesmas across the country, according to the Health Ministry's healthcare services director general, Bambang Wibowo.
Bambang said last week at a teleconference that amid the apparent "limited availability" of protective gear, community health centers were expected to use the equipment “efficiently [...] to save [the equipment] while being protected from the risks of COVID-19 exposure" amid their prominent role in Indonesia’s fight against the epidemic.
"Puskesmas have a very big and necessary role [...] from prevention to screening to response," he said.
With a population of some 267 million people across the vast archipelago, puskesmas had been the backbone of the national healthcare system even before the outbreak, dealing with the triple burden of disease: communicable diseases like HIV/AIDS, noncommunicable diseases such as diabetes and heart disease, and reemerging infectious diseases like malaria.
According to the Health Ministry's 2018 data, the country has 2,813 hospitals, some of which are currently overwhelmed by a surge in patients, and 9,993 puskesmas, many in remote coastal villages and inland regions.
Community health centers typically have a couple of general practitioners, at least one dentist, a few nurses and a midwife, and have limited facilities and equipment compared to hospitals. The data shows that 3,623 puskesmas also provide inpatient care.
Despite the long waiting time, people flock to puskesmas where they can seek free treatment for 144 types of disease and obtain hospital referrals if necessary under the JKN program. The national health insurance covers some 80 percent of the population, or around 222 million Indonesians.
The COVID-29 epidemic, however, has affected virtually every way puskesmas operate, particularly in regions that are now treating persons under monitoring (ODPs) and patients under surveillance (PDPs).
Medical staff have been split into teams for public education, contact tracing and patient treatment, while some puskesmas have set aside space in their limited facilities to treat COVID-19 patients in isolation from patients with other respiratory illnesses.
Several puskesmas doctors told The Jakarta Post that they were now prescribing medicines to outpatients based on their reported symptoms without a routine examination to avoid inhaling oral or nasal droplets, through which the coronavirus is transmitted.
In some regions, puskesmas periodically run posyandu (community health posts) to provide basic pediatric care, immunization programs, antenatal care, as well as health and hygiene programs. These posyandu and other public health programs have now been suspended to prevent large crowds that could help spread the virus.
A puskesmas doctor in Sidoarjo, East Java, who requested anonymity, told the Post that it had advised patients not to visit the centers unless absolutely necessary. This was not only to prevent transmitting the virus, but also because some medical workers had been reassigned to contact tracing and were thus unavailable to see patients.
Sidoarjo Health Agency's disease prevention and control head, M. Athoillah, who now heads the regency's 22-strong contact tracing team, said that it was not easy to trace contacts, and that involving puskesmas was central to approaching community leaders for better reach.
Athoillah said that puskesmas staff were expected to trace and monitor people who had been in direct contact with COVID-19 patients or who had traveled from regions with local transmission to prevent public panic. In some cases, the patients’ home addresses were inaccurate, owing to the stigma targeting people with COVID-19.
“The heads of neighborhood and community units [RT and RW] have become paranoid,” he said. “When residents return home from Malaysia or Japan, they ask us if they needed to report [them] to the police,” said Deborah Johana Rattu, who heads a puskesmas in Bandung, West Java.
“Our challenge is to for [grassroots] people to be on the same page in how they view COVID-19,” she said.
The social stigma surrounding COVID-19 has led communities to cast out medical workers from their midst and refuse the burials of people who had died of the disease in local cemeteries. Meanwhile, hoaxes and misinformation on the disease were circulating easily online, prompting the country's COVID-19 task force to counter the infodemic by sending messages asking the public to be accepting of these burials
The looming issue of mudik (exodus) has also raised concerns among puskesmas staff in smaller regions. If the government does not impose a domestic travel ban, the annual practice of people returning to their hometowns to celebrate Idul Fitri with their families could spread the disease even further.
Dina Nofitria, 36, one of two doctors at a puskesmas in Tulungagung, East Java, said that it was a challenge to maintain morale among fellow medical professionals, especially when dozens of doctors and nurses in other regions had died of COVID-19.
"Some asked for leave, when they were really just afraid. When any of us feel down, we like to lift each other up so we can brave this situation," she said.
Dina and other puskesmas staff are also tasked with monitoring ODPs and PDPs throughout the virus’ incubation period, which they try to do online to minimize physical contact.
With the heightened risk of exposure to the virus, Dina said she also had to maintain physical distance at home, including her 6-year-old child, who kept wailing, wanting a hug from her.