The sound of a baby crying cuts through the Waiwadan community health center (Puskesmas) in Adonara, East Flores regency, East Nusa Tenggara. Teresia Bo- lina quickly picks up her one-month old daughter and unbuttons the top of her blouse to breastfeed her. The baby girl, who has yet to be named, begins nursing, and the shrill wailing stops. Teresia has come to the Puskesmas for a routine check-up. Last December, she gave birth at the public hospital in Larantuka, the capital city of East Flores. She said she was referred to the hospital because it was too risky for her to deliver in the local Puskesmas, which lacks the necessary surgical equipment to handle problems that may arise. “A midwife from my village of Dusun Tiga accompanied me to the hospital,” the 32-year-old woman said.
On the day of her delivery, she was picked up by an ambulance and taken to a boat for the 20-minute ride to the city. Teresia said she was already in the second stage of delivery and was worried she might have to give birth on the boat. Another ambulance was ready to take her to the hospital when she arrived at the port. At the hospital, rapid action on the part of health staff allowed her to deliver the baby safely.
Yustina Benga, Teresia’s sister, was also referred to the public hospital after it became clear she would re- quire Caesarean section.“I thought I could deliver normally, but on the day, my blood pressure spiked to 220. The midwife (at the Puskesmas) immediately referred me to the hospital,” the 33-year-old woman said.
Six months later, she was back in the Larantuka hospital; her son had lost weight and was refusing breast milk. “I went back to the city and found out my son had an infection,” she said. Yustina stayed in the hospital for another two weeks.
Both Teresia and Yustina would not have received such service without the introduction of a new referral system that has created efficient communication between community health centers and the local hospital. Both women are participants of the free health care scheme run by the Social Security Management Agency (BPJS Kesehatan).
Teresia, who has three children, said the improvement in healthcare services was readily apparent. “Both the Puskesmas and the hospital closely monitor us to make sure my baby and I are healthy,” she added. Before, there was no coordination between the health center on the island and the public hospital in the city.
Patients often had to find their own transportation, which is hazardous for mothers on the cusp of delivery. With accreditation standards, however, all staff at Waiwadan Puskesmas have clear guidelines for providing healthcare services for the patients, and ambulances are now on call.
EAST Nusa Tenggara (NTT) is one of the provinces most in need of healthcare reforms. In 2012, the maternal mortality rate was 306 for every 100,000 live births, while the infant mortality rate was 45 for every 1,000 live births. Many suspect the higher-than-aver- age rates are due to a preference for home deliveries.
Susilowati, 36, the coordinating midwife for com- munity health centers in Adonara, said that tradition and culture were impediments to women seeking the health care they needed. “Especially the older generation, some of whom still don’t trust doctors or mid- wives to take care of their children and grandchildren,” she said.
Moreover, the lack of road access made it difficult for people to reach healthcare centers. Susilowati said there have been multiple cases when a mother was forced to give birth on the road or on a boat because they could not get to the hospital in time. She said historically, coordination between the Puskesmas and the hospital was lacking. “There were no clear guidelines on when we should refer a patient and not enough preventive measure for the mothers,” she said.
In 2014, with assistance from the Health Ministry and the Australia Indonesia Partnership for Health Systems Strengthening (AIPHSS), the East Flores Regency launched the new referral system. Prior versions of the system have been implemented elsewhere, but they found little success.
Yosep Usep Aman, the local health office chief, said capacity-building was necessary at the local Puskesmas—as it was for local health centers on many of the regency’s islands—because for many, it was the only accessible healthcare available. “We need the first medical treatments to be done at the Puskesmas, and only if patients need(second ones) they will be referred to the hospital,” he said.
Such a strategy is consistent with the National Health Insurance Program (JKN—Jaminan Kesehatan Nasional), which has been up and running since January 2014. The system is also managed by BPJS Kesehatan.
Under the terms of the program, patients must seek care at a Puskesmas or other primary care facillity. Upon examination, a referral can be made to send them to a higher-level facility for more advanced treatment.
The system is meant to avoid overcrowding at hospitals and to ensure the most efficient service.
The AIPHSS and the Health Ministry have held trainings to guide implementation of the referral system at the Puskesmas level. However, Yosep said even a well- run system would fail with the absencea of ample infrastructure in the villages. As such, the East Flores government decided to provide eight ambulances for 11 health centers in the regency, including the one in Waiwadan.
Today, the ambulance is available 24/7 for emergencies. On Adonara, the Puskesmas also cooperates with several boat operators to get patients to the hospital on the mainland. “Before that, it was quite hard for us to get a boat for a patient at midnight, for example,” Susilowati said.
Midwives at the Waiwadan Puskesmas and smaller healthcare posts in the village are also always on the ready. They are required to accompany patients with hospital referrals. “Many of the people here are not used to a hospital. They find it intimidating. So having someone from their village to assist them helps a lot,” Yosep said.
According to Susilowati, the women in Adonara Island now deliver births at a healthcare center. The maternal mortality rate on the island in 2015 has dropped to zero and complaints from patients on technical aspects have also decreased.
Standardization of the referral system was aided by the issuance of a regent regulation (Perbup) in May 2015. The regulation outlined guidelines and requirements for gaining accreditation. Accreditation is required for a Puskesmas to operate as part of the BPJS Kesehatan healthcare program.
Fitria Kasmin, 32, a staff worker at Waiwadan Puskesmas and coordinator for the accreditation program, said that dissemination regarding the accreditation scheme began in mid-2015. Facilitators from the health ministry and AIPHSS came to assist workers to meet the requirements. “By the end of last year, we submitted an official request to the local health office for our Puskesmas to be evaluated,” she said.
Fitria said it was challenging to meet the standards, mainly due to the limited resources at their disposal. Knowledge of how to meet certain requirements had to be gleaned from the Internet, she said. Fitria said sometimes she had to improvise solutions based on experience in the field. “If they (accreditors) think it’s alright, then we can go ahead and use it in our operation, but they can also make suggestions for improvement,” she said.
Puskesmas staff must now keep records of every medical procedure and employee meeting. Fitria said staff were by now accustomed to the changes and were happy to be providing better services. She said, in addition to Waiwadan, there were four other Puskesmas in the area currently in the accreditation program.
Accreditation and the introduction of referral systems are also taking place in the NTT regencies of Ngada, North Central Timor, and Southwest Sumba. Brigitha Binsasi, the head of a community health center in North Central Timor regency, said the guidelines in her area were the same. “We have a 24-hour emergency service and two ambulances that are always ready to transport a patient when they are referred to a hospital,” she said.
Zakarias Eduardus Fernandez, head of the North Central Timor health center, has committed to ensuring that improvements continue even after funding by the AIPHSS stops when the program life cycle ends.
Zakarias said he had allocated 10 percent of the regional budget to healthcare. “In the future, we will have better standards for providing healthcare and all of our Puskesmas will be accredited,” he said, adding that he hoped to have the task completed by 2020.
Photos by Amanda Siddharta (TEMPO)
Source: Tempo English Magazine