Ailing 'Puskesmas' need treatment before they can curb outbreaks

The Jakarta Post, Jakarta

Prevention is better than cure, according to the popular axiom.

The government, however, seems to believe the opposite as the Ministry of Health is allocating just 11 percent of its budget to community health centers (puskesmas), while giving three times that amount to hospitals.

Recent outbreaks of old diseases -- polio, dengue fever and malnutrition -- have been blamed in part on the erosion of puskesmas as the vanguard of community health care, due to a lack of funds following decentralization.

Minister of Health Siti Fadilah Supari, speaking about the polio outbreak and malnutrition cases, said many local administrations failed to provide the necessary money to keep the community health centers functioning healthily.

The central government appears to be following suit, allocating only Rp 342 billion earlier this year to assist the puskesmas, while setting aside Rp 901.7 billion for hospitals, which mainly play a curative role.

In the revised 2005 state budget, Rp 698.9 billion is set aside for puskesmas and Rp 3.256 trillion is earmarked for hospitals.

This same pattern is being followed in the allocating of the Rp 3.7 trillion health fund for the poor from the fuel subsidy cut. Only Rp 1.08 trillion of this money is being allocated for public health services at puskesmas, with the rest going to hospitals. This despite the fact that in most villages across Indonesia, distance is a serious barrier for people to get treatment at a hospital.

"We strongly urge the ministry to put the priority in its budget on taking preventive measures at the puskesmas level, instead of on curative measures (through hospitals)," House of Representatives Commission IX's health task force head, Mariani Akib Baramuli, said on Tuesday.

Last year, House Commission VII, which also oversees health, put preventive and educational measures at the top of its list of recommendations to the health ministry.

Puskesmas, a concept developed decades ago, emphasize preventive and educational measures. While hospitals are responsible only for their patients, puskesmas are meant to actively monitor health conditions in their respective areas, which average more than 10,000 people.

Besides serving as health centers, puskesmas also help to assure local development efforts encourage the populace to maintain a healthy environment, or at least to maintain conditions so they do not have a negative effect on the health of the local community.

Currently, however, due to insufficient operational funds, the 7,277 puskesmas nationwide are not playing a preventive role.

Health centers in most regions, except for Jakarta, have to pay money to local administrations, instead of receiving assistance funds from them.

A community health center head in West Java confirmed recently that the local administration, for which he works, demanded a yearly fee of Rp 69 million from the center. Only about 30 percent of this money is returned to the health center, which is barely enough to cover its operational costs.

The health center in question, located only a 30-minute drive from Jakarta, is forced to branch out to make extra money, including opening a telephone kiosk next to its building.

Puskesmas in remote areas face more problems than a lack of funds. "There are not enough doctors and medical workers willing to work at remote puskesmas," the health ministry's director general of community health, Azrul Azwar, told The Jakarta Post recently.

He said that because the government no longer made it compulsory for new doctors to serve in puskesmas, the number of volunteer doctors from Indonesia's 48 medical schools had steadily declined from an estimated 3,500 annually.

"As a result only 40 percent of puskesmas in the country are led by doctors. The rest are led by mantri (male nurses) or worse, district officers," Azrul said.

He suggested that incentives be given to young doctors to serve at puskesmas. In addition, the budget priorities of both the central government and local administrations is necessary.

Unless these measures are taken, many doubt the government's ability to create a "healthy Indonesia" by 2010.

If the puskesmas function as originally intended, fewer burdens would be placed on hospitals.

And why cure if you can prevent?