KEMAS 12 (1) (2016) 76-89

Jurnal Kesehatan Masyarakat

http://journal.unnes.ac.id/nju/index.php/kemas

THE ROLE OF PUBLIC HEALTH CENTERS (PUSKESMAS)

AS THE GATEKEEPER OF NATIONAL HEALTH INSURANCE

Betri Anita, Henni Febriawati, Yandrizal

Faculty of Health Sciences, University of Muhammadiyah Bengkulu

Article Info Abstract

Article History: The percentages of referrals for the first level health facilities visits are coming from
Submited September 2016 the health center (Puskesmas) with 16.85% at the highest and from the practicing doc-
Accepted June 2016 tors with 12.45% at the lowest. The aim of the research is to examine the efficiency the
Published July 2016
promotion, preventive and curative care quality improvement. This study used qualita-
Keywords: tive exploratory design by case study approach. The collection of data was conducted
Management; Commu- through field observations, document observation and in-depth interviews. TThe in-
nity; Service; Gatekeeper formants consisted of 4 Head of Health Center/Puskesmas, 9 cadres of integrated guiding
posts (Pos Pembinaan terpadu /Posbindu) for Non-Communicable Diseases (NCDs), 9
DOI cadres of Integrated Service Post (Pos Pelayanan Terpadu/Posyandu), 33 participants of
http://dx.doi.org/10.15294/ the National Health Insurance and 23 people from community who have not joined the
kemas.v12i1.3933 national health insurance scheme. The results show that mini workshops are held every
month in preparing activities with a focus on the causes of most diseases in the previous
month. Posyandu may reduce morbidity rate on infants and pregnant women, Posbindu
for Non-communicable Diseases can prevent and control non-communicable diseases.
Quality of service can improve the perception of the quality of the service and can reduce
referrals to hospital.

Introduction cities in Bengkulu province. The number

The low quality, equity and affordability of JAMKESMAS participants who go to
of medical care are one of the problems of Puskesmas and are referred to M. Yunus
health development. The increasing health General Hospital in 2009 are about 9.2%, in
financing aspect will affect the quality, equity 2010 about 10.0%, in 2011 with 9.1% and in
and affordability of people to medical services 2011 by 9.8%. The Askes participants who are
wand affect the quality of human resources. civil servants in Bengkulu are 182,920 people.
Several factors that lead to an increase the From the number, there are 46,490 people who
health financing in Indonesia, among others use Puskesmas as first-level medical providers
are: 1) the demands for medical services both in (PPK I) in 2010 with the number of visits of
quality and quantity are increasing; 2) the rate 123,283 people (265.18%) and the referral
of inflation; 3) changing patterns of infection to number of 17,157 people (13.92%). In 2011,
chronic diseases; 4) changes in the pattern of there are 40,586 people with the number of
doctor-patient relationship because of demands visits of 149,487 (368.32%) and the referral
to the doctor / hospital; 5) the development of number of 20,133 (13.47%). In 2012, there are
medical technology; 6) changes in patterns of 45,960 people with the number of visits 141,876
health care toward specialist and sub-specialist (308.64%) and the referral number of 24,822
services. (17.49%). Based on the average percentage of
Bengkulu city is one of the districts/ visits in October 2014 to February 2015 in the


Correspondece Address: P-ISSN 1858-1196
Campus II University of Muhammadiyah Bengkulu E-ISSN 2355-3596
Jl. Rambutan Lingkar Timur Kota Bengkulu
Email : [email protected]
 KEMAS 12 (1) (2016) 76-89

city of Bengkulu, the highest average of 7.79%, health campaigns on alcohol abuse and
and the lowest in Head division of district with smoking.
an average of 5.39%. The average percentage of The disease prevention and control
referrals from the highest visit in Puskesmas can be done by empowering the public health
is 16.85% and the lowest at 12.455 Practice sector. Integrated Service Post (Pos Pelayanan
Physicians for the first-level of health facilities Terpadu/Posyandu) is one of the efforts
Branch Office of Bengkulu. Patients who are of health-resourced community (UKBM)
admitted to the hospital mostly say that they managed and organized from, by and with
are authorized to be treated/served at the the community in the implementation of
health center. Puskesmas is still authorized to health development to empower communities
treat but because of the limitations of medical and provide convenience for the public in
devices for diagnosis such as Rontgen, Labor, obtaining basic health services and accelerate
EKG do not exist, they are in difficult situation. the reduction in maternal mortality and infant.
Puskesmas as a gatekeeper or controlling the Some independent efforts done by community
use of participants of the National Health to improve health quality are done through
Insurance in Bengkulu can reduce the number some actions namely prevention programs,
of treatment visits to primary health care and disease control and disaster-emergency
hospitals by optimizing the promotion and mitigation program of “Desa Siaga”. The
preventive services. program implements several program such
National health insurance (Jaminan as (Posyandu), Caring Mother Movement,
Kesehatan Nasional-JKN) is organized under Nutrition Improvement, hygienic and healthy
the National Health Insurance Act No. 24 lifestyle (PHBs), mosquito larvae eradication
of 2011 on the Implementation of the Social (PSN), poskesdes and disaster emergencies.
Security Agency (Badan Penyelenggara Desa Siaga shows a condition where rural
Jaminan Sosial-BPJS). The purpose of National communities have the readiness of resources
Health Insurance is to enable the public to and the ability and willingness to prevent and
access quality health services. JKN aims to overcome health problems, disasters and health
provide basic needs for people in meeting a emergencies independently.
decent life for each participant and/or family The developing prevention and control
members. Some BPJS organizing principles of non-communicable diseases is a non-
include cooperation, mandatory participation, communicable disease guiding post (Pos
contributing fees based on a percentage of Pembinaan Terpadu Penyakit Tidak Menular/
wages / income, non-profit management and Posbindu PTM). This joint commitment of
mandate. The National Health Insurance began all elements of society who are concerned
in 2014 to achieve Universal Health Coverage about the threat of non-communicable disease
gradually. is channeled through Posbindu PTM. The
The catastrophic expenditure among development of Posbindu PTM is an integral part
other things is addressed for the treatment of the health care system based on the problems
of long and expensive non-communicable that exist in society and includes promotion
diseases (NCDs). The non-communicable as well as preventive and referral patterns.
disease impact from the contribution of risk Optimization of primary care to control and
factors include: 1) the cigarette / tobacco; 2) streamline the cost of hospitalization, and
an unhealthy diet; 3) the substance of alcohol; transportation, effective utilization of primary
and 4) the lack of physical activity. Non- care can streamline care services.
communicable diseases can be prevented by The function of public health-based
healthy behavior changes. The result of the efforts (UKBM) as Posyandu and Poskesdes
development of community empowerment is still limited, BOK is just a funding for
conclude that mere medication is not enough local governments in the implementation
to improve public health, therefore, prevention of preventive and promotion health efforts
is needed. Those preventive actions are for to continue, so that local governments have
example vaccination programs and public committed in utilizing BOK as effectively as

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possible. The sufficient planning of action Based on the description of the

(POA) funds is really effective to improve background, researchers examine the efficiency
the health of the community, especially the of service through the increased role of
essential programs such as Desa Siaga which Puskesmas as a gatekeeper or controlling
has implemented various activities such as the participants using the National Health
Posyandu, Caring Mothers movement, nutrition Insurance in Bengkulu by reducing the number
improvement, and clean and health lifestyle, of treatment visits to primary care and hospitals.
Mosquito eradication nest, poskesdes and
disaster emergencies. Puskesmas can increase Method
the capacity of officers in identifying health This study used qualitative exploratory
problems in the community and developed design under the case study approach. The
standard operating procedures (SOPs) in the unit of analysis was conducted in Bengkulu
prevention and promotion health efforts at the Puskesmas with a focus on the social situation
health center level. where Puskesmas has the role as gatekeeper.
Based on Rikesdas 2013, healthy and Puskesmas is a health care facility that organizes
clean life behavior of people is still low. Bengkulu public health efforts and the first rate efforts
province population who smoke in 2013 is as of individual health, with more emphasis on
many as 37% of the population, members of promotion and prevention efforts to achieve
the household washing their hands as many as the highest degree of public health in the
34.5%. This generative disease conditions will working area. Puskesmas is one of the first-level
impose the implementation of national health health facilities in collaboration with the Social
insurance if promotion and prevention efforts Security Agency (BPJS) Kesehatan that serves
have not been done. Wrong dietary behavior in as gatekeeper.
Bengkulu Province is still high. The number of The informants were 4 head of Puskesmas
population eating less vegetables and fruit age that have the highest number of participants
above 10 years in 2007 is as many as 91.4% and of the National Health Insurance, 9 cadres
in 2013, there are 94.4% who eat less vegetables of Posbindu of Communicable Diseases, 9
and fruit and it can cause cancer. cadres of Posyandu, 33 participants of the
One strategy to improve health National Health Insurance and 23 people in
development is to empower and increase community who have not joined the national
the role of society, including the business. health insurance scheme. The informants were
The communities are given the facilities and in charge of activities as the health center or as
guidance in developing a body for the role, personal key. Participants of National Health
given the knowledge and skills to identify Insurance have not used Puskesmas as the
problems in their respective areas, to identify, first level medical facilities are the members of
formulate and resolve its problems on a priority Posbindu PTM. This study employed incidental
basis and the existing potential. In determining sampling technique to decide the participants
priority issues, planning, implementing, of JKN and the public.
monitoring and assessing the activities, people The research instruments used interview
need to be involved from the beginning. guidelines, primary data collection through
Potential community can be explored to the in-depth interviews, focus group discussions
maximum, so that solutions to problems more (FGD) and direct observation of secondary
effectively and able to guarantee the continuity data collected through observation documents.
of activities. Primary health care providers The collected data were the number of visits
in Bengkulu provide services to the general and referrals from Puskesmas, Puskesmas
public and participants of the national health planning, Puskesmas staff job descriptions,
insurance, the optimization of the primary Puskesmas existing equipment, documents
service control will be able to streamline the cost the implementation of GMP and Posbindu
of hospitalization, and transportation, effective PTM to determine what activities were
utilization of primary care can streamline care undertaken and the benefits to the community.
services. Observations used the check list to explore

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document and to investigate the measurement purpose of the analysis was to fit/match the
and inspection of Puskesmas planning. The available secondary data with the collected
interview was conducted to cadres to find out data. During the analysis in the field, data was
the implementation of GMP and Posbindu collected through interviews; investigators
PTM. The interviews which were conducted to immediately perform data analysis on the
the public was to know the health benefits by duties and functions of the health center and
joining Posyandu activities and Posbindu PTM the results of the interview, so that respondents
and to know the medical services provided by could be directed accordance with the purpose
Puskesmas. of research. The study immediately asked back
Researchers provided guidance to the so that answers can be targeted. The collection
cadres for the promotion and prevention of data using check list was to adjust or to
efforts to the people who came to Posyandu, review data in accordance with the purpose of
Posbindu PTM and Puskesmas. Counseling research.
was aimed to increase knowledge, attitudes After collecting the data, researchers
and behaviors to prevent disease. Counseling analyzed the collected data to determine
was done for 4 (four) months, at the time of whether the data had been fit for purpose.
counseling investigators conducted interviews Researchers performed data reduction, data
to determine whether during on month they presentation and deduction of tentative
went to Puskesmas and whether they are treated conclusion. Tentative conclusions would be
or referred to the hospital. matched with the purpose of research. To
The test of validity was done by four reinforce the results, researchers collected data
criteria: credibility, transferability, dependability from other analysis units, the result was the
and conformability. Credibility of this research same as the duties and functions of the previous
was ensured through triangulation of sources. Puskesmas, and then the researchers concluded
Transferability was conducted through the results.
writing detailed, clear and systematic reports Quantitative data analysis was done
on the implementation of research, so that it to see the trend in the number of visits and
could be trusted and applied in other places. referrals from month per month for 6 (six)
Dependability test was conducted by an audit of months. The results of interviews with people
the whole process starts researchers in deciding who visited Posyandu and Posbindu PTM to
problems / focus, entering the field, specifying determine whether during a year they had to be
the data sources and data analysis, testing the treated in the clinic, and during the treatment,
validity and compiling the data in a form of were they referenced or not.
research report. Conformability (certainty) The interpretation of data was compiled
in this study was conducted by examining the by the main tasks and functions of Puskesmas.
results of research associated with each process. An ongoing process involved continuous
At each stage of this research, analysis is carried reflection about the data, asking analytical
out toward the research purposes. questions, and writing a report throughout the
Qualitative data analysis consisted of study. The analysis of qualitative and quantitative
three steps interactive models. The component data was used to make interpretations and
of data analysis were 1) data reduction, to write reports. The analysis of collected
dealing with the selection process, focus, interviews and reporting note might eventually
simplification, abstraction and transformation be included as a narrative in the final report.
of data that appeared in the note of researchers The data analysis involved open data collection
or transcription; 2) data presentation, dealing by asking general questions and analysis of
with conclusion that could be deduced; 3) the information provided by the informants.
conclusion / inference, dealing with that Analytic differences depended on type of
verification studies. strategies which used common procedures
In doing pre-observation, researchers and submitted the proposed measures of data
collected before performing a secondary data analysis.
analysis of the activities in Puskesmas. The

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Results and Discussion health among others with schools to improve

The management implementation in student health through school health efforts
four Puskesmas, they have been implemented in (UKS) or with agriculture sector so that farmers
accordance with the guidelines and developed can use pesticides or organic fertilizer properly
in accordance with the conditions. The results so it does not cause disease. They also cooperate
of interviews in four Puskesmas can be seen with trustees of Family Welfare (Pembina
from the following results: Kesejahteraan Keluarga-PKK) districts and
One from four Puskesmas has limited villages to build healthy families by going the
time open enrollment at 7:30 a.m. Posyandu and Posbindu PTM. Puskesmas is held
to 11:00, and three Puskesmas open by the principle of areas integrating all available
until the service began 07.30- 13.30 resources such as cross-sector, community
according to the working hours.
leaders, community groups, families and
individuals in the working area of ​​Puskesmas.
Mini workshops have been conducted
every month with activities to evaluate Promotion and prevention programs on health
the activities of previous months and care are important to detect the health problem
plan activities of the current month. early, prevent and control diseases that exist in
The evaluation results are analyzed society. Puskesmas implementing promotion
to find the cause of the problem and and prevention efforts will be able to suppress
to plan the current month program as the rate of illness and the diseases can be
well as to find out the cause of most controlled and prevented.
diseases in the previous month (the Puskesmas management application
result of four Puskesmas). to perform the duties and functions of
implementing health policies is to achieve
Puskesmas have been implementing
the program of community-based development goals of health in the working
health efforts (UKBM). Puskesmas area and to support the realization of healthy
have not optimally involved the districts.
participation of Head of District, Head The tasks of Puskesmas are implemented
of Village, Chair of the Neighborhood by carrying out the community-based health
(RT) to mobilize communities to (UKBM) including: Posyandu, Posts Guidance
participate in the implementation of Integrated Non-Communicable Diseases
UKBM like Posyandu, Posbindu PTM, (Pobindu PTM), counseling Behavior on clean
Posyandu for elderly (the result of four and healthy lifestyle (PHBS), counseling in
Puskesmas).
the effort to improve the health of mothers
Cadres have helped to implement and infants in Posyandu, extension control of
UKBM but they do not help to evaluate non-communicable diseases in Posbindu and
the implementation of UKBM and counseling in Puskesmas to patients who are
report it to the health center and head waiting for treatment. According Ayuningtyas
of village (the result of four Puskesmas). (2014), the perceptions of midwifes in
Puskesmas who feel that the involvement of
Puskesmas is as an institution or a employee in Puskesmas is because they are not
work unit serving the district or rural area involved directly in the activities. Meanwhile,
for improving health services to people. The the heads of Puskesmas expect that the midwife
understanding of the Puskesmas is a functional coordinator should coordinate in advance
Health Organization directly under the with the entire midwife in Puskesmas. In
supervision of both the administrative and addition, some midwifes have the perception
technical aspects under Health department of that before doing routine and new work,
Regency / City (Saputra, 2013) head of health centers must provide advance
Puskesmas has the duty and responsibility directives. Meanwhile, according to the heads
for health oriented development with the of Puskesmas, the staffs already know so they
concept of territory. Puskesmas coordinates do not need to be given direction and guidance
with the relevant sectors to improve public in particular.

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The role of Puskesmas is highly dependent improve knowledge and skills of each person to
on management strategies for undertaking maintain health, recognize the disease and its
the task goals which provide community causes as well as to control and prevent disease;
empowerment and stakeholder encouragement e) reorienting health service, health concerns
to reduce morbidity and improve health. not only health services but also stakeholders
According to Dharmawan (2015), supervision to create policies of health promotion program
from the leaders is one of the factors in the by empowering people to control and improve
management system to provide assistance and the health of individuals. The emergence of
to direct subordinates so that subordinates have new challenges for the field does not negate
the ability to perform the job. Supportive and the relevance of the Ottawa Charter. On the
well-planned supervision is an important factor contrary, the Ottawa Charter strengthens
in the success of health programs, including in the notion for the field of health promotion
terms of recording and reporting to improve campaigns. It continues to confirm the vision,
data quality of midwife. Supervision from action orientation, and support the values that​​
Puskesmas leaders can improve performance comprise health promotion. Bangkok Charter
of the staffs so that they work better and for sustainability highlights the issue of health
focus on the target. Septyantie research result promotion focuses on the investment required
(2012) shows that the realization of BOK funds to meet the health challenges of globalization.
which focuses on health care for the increase WHO global health conference emphasizes
(promotion) and prevention (preventive) the special promotion measures to support the
programs can improve health care coverage and implementation of health promotion strategy
community participation in Nutrition KIA. and to close the implementation gap. Three
Most research on the gatekeeper has gaps identified for the implementation of
focused on health care utilization and costs, health promotion areas of concern are: the lack
while the effects on health outcomes and of evidence which is implemented in practice,
associated patient receive limited concerns. the lack of evidence the application of health
When considering the gatekeeper, policy impact in public policy, and the lack of sufficient
makers need to be aware of the limitations and capacity for health promotion practice in many
uncertainties. Future research should focus on countries (Potvin, 2011)
studying the effects on health outcomes and Primary health care in Australia is the first
patient satisfaction in the context of health level service that provides health services and
systems and managed care to ensure a strong systems with a trained workforce, consisting of
recommendation (Garrido, 2011). a multi-disciplinary team that is supported by
The Ottawa Charter identifies three basic an integrated referral system, giving priority to
strategies for promotion. Health advocacy those most in need; maximizing individual self-
creates the essential conditions for health, reliance, community participation and control,
enabling everyone to achieve the full potential and collaborative partnerships involving other
of their health, and mediation between the sectors to promote public health.
different interests in the community improving Puskesmas as a first levels health facilities
health. These strategies are supported by five is very relevant to apply the principles of Public
priority actions of areas as outlined in the Ottawa Health Care (PHC) to provide comprehensive
Charter for health promotion a) building heath services, namely: promotion, preventive and
public policy, to all sectors and stakeholders curative programs to maximize individual
levels in order to make the vision of health self-reliance, collaboration and partnership
policy; b) creating supportive environments for with other sectors for prevention and control
health, developing a network of partnerships of healthcare, support health systems, referral
to support activities that pay attention to the systems and health services. According to Rejeki
policy; c) Strengthening community action for (2012), community health centers/ Puskesmas
health through concrete and effective activities as a companion implement Desa Siaga Program
to strengthen community activities to achieve to provide good facilitation techniques that can
better health; d) developing personal skills, lead active Desa Siaga. However, the facilitation

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is done in the development of rural Puskesmas the community on the individual maximum
has not yet realized community development, independence and participation in the planning,
but more towards the social mobilization. organization, operation and control of primary
Puskesmas needs to seek techniques to be health care, making use of all the resources of
able to realize the implementation of the local, national and other available, purpose
community empowerment of Posbindu PTM to developed through appropriate education the
achieve early detection, prevention and control ability of communities to participate; f) must
of NCDs. be supported by an integrated, functional and
Puskesmas can perform individual mutually supportive referral systems, leading
services according to the Clinical Practice to improvement of comprehensive health care,
Guidelines for doctors in Primary Health and giving priority to those most in need; g)
Care Facilities including the guidelines for the depending on the local level and referral, health
management of the disease in primary care workers, including doctors, nurses, midwives,
based on the following criteria: a) the disease nurses and community workers that apply,
prevalence is high; b) the disease is a high as well as traditional practitioners as needed,
risk; and c) a disease requires high finance. trained socially and technically to work as a
Puskesmas that serves as an organizer of public health team and to respond to public health
health efforts and the efforts of individual needs; h) in need and promote community,
health can play an important role in early individual self-reliance and participation of
detection, prevention and control the disease cross-sectorial focus and involvement of the
in the community in their working area. This private sector.
health center functions in accordance with Puskesmas which is one of the first-
the Declaration of Alma-ata and functions level health facilities in collaboration with
of primary health care facilities in many the Social Security Agency (BPJS) Kesehatan
countries. Basic health services according to the plays an important role as a gate keeper for the
declaration of Alma-Ata (Gillam, 2008), are: a) function of carrying out the individual health
reflecting and evolving from the economic, and public health efforts. Puskesmas has many
socio-cultural characteristics of the country program types and the amount of power that
and society based on the application of relevant can exercise the functions of the Puskesmas.
research results, social services, biomedical and Gate keeping system is to give doctors a lot of
health and wellness experience community; responsibility to make sure to refer patients to
b) discussing the main health problems in the more specialized services when it is needed
community, providing promotion, preventive, and at the same time regulate the ability to
curative and rehabilitative services; c) involving recognize when they themselves can provide
at least: education concerning on prevailing adequate treatment (Pedersen, 2012).
health problems, methods of prevention and Puskesmas as a first-level health facility
control; promotion of proper food and nutrition; (FKTP)/primary provide services before the
an adequate supply of clean water and basic first or services referred to hospital. Puskesmas
sanitation; maternal and child health services, provides services to the public / participants of
including family planning; immunization the National Health Insurance are suffering from
toward the major infectious diseases; prevention infectious diseases and non-communicable
and control of locally endemic diseases; right diseases. Indonesia faces some challenges for
treatment of diseases and injuries; provision the effective implementation of the Universal
of essential drugs; d) involving, in addition to Health Coverage (UHC) in order to extend
the health sector, all related sectors and aspects the breadth, height, and peace of coverage,
of national and community development, particularly in addressing the condition of non-
especially in agriculture, animal husbandry, communicable diseases which are generally
food, industry, education, housing, public chronic in nature and require management of
works, communications and other sectors; patient case carefully from time to time, and
and requires the coordinated efforts of all the most cost effective targeted at primary care
those sectors; e) providing the promotion for level (World Bank, 2014).

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Primary care serves as the basis of a diseases at the primary health care providers
strong health system. However, it has long been in Puskesmas must be optimized, especially in
ignored in the United States, and the imbalance promotion and preventive programs to prevent
between primary care and specialist services and control non-communicable diseases.
exists there. The purpose of this paper is to Puskesmas must optimize human resources
identify evidence of primary care in the United and other resources to carry out the duties and
States and internationally with a focus on the functions of the health center so that it can
importance of primary care that is effective act as a gatekeeper in order not to burden the
in providing quality health care, improving National Health Insurance. Core functions of
health outcomes and reducing inequalities. primary care and public health is significantly
Developing countries, primary care has been very spacious (assessing the health needs of
shown to be associated with increased access the population, promoting and supporting
to health care, better health outcomes, and healthy lifestyles and behavior, supporting the
decrease hospitalization and use of emergency growth and development through the life cycle
room visits. Primary care can also help and promoting health and other vulnerable
diminishing the negative effects of adverse groups). They offer the opportunity to deepen
economic conditions on health (Shi L, 2012). the partnership between primary care and
The function of first contact Puskesmas population health. Without a mechanism for
is to ensure the continuity of participant the development of a truly integrated and jointly
visits whenever health problems occur so own plans and programs, primary care and
that the handling of the disease can run public health are unlikely to be able to address
optimally. Besides, Puskesmas must provide the fundamental challenges in preventing
comprehensive services mainly for health chronic diseases and reduce health inequities.
promotion and prevention, coordinate with It is widely recognized that addressing health
health care providers in order to give health inequalities in Australia requires action to
services to participants according to their address the social determinants at all levels
needs. The doctors are on duty to function as of the health sector in collaboration with the
regulators of services (care manager). Policy government, private sector, community groups
focuses on the issue of the readiness of the (Mark, 2012).
supply side of the perspective of assessing Health promotion is a social and political
the depth of the Universal Health Coverage process that is comprehensive, not only
(UHC) in Indonesia, especially in rural and necessary actions directed at strengthening
remote areas where most of the population is the skills and abilities of individuals, but
poor and nearly poor live and with a focus on also action directed changes in the social,
non-communicable diseases include diabetes environmental and health promotion so as to
mellitus (DM ), chronic cardiovascular alleviate the impact on the economy. Public
conditions, and chronic respiratory conditions and the individual health is a process that
at the primary level community care (PHC) in allows people to increase control over the
Indonesia. determinants of health and thereby improve
Using various sources of information their health. Participation is essential to sustain
including analysis of Rifaskes facility census health promotion action. The Ottawa Charter
in 2011, it shows that the ability of Indonesian identifies three basic strategies for promotion.
health system to provide effective coverage for Health advocacy creates the conditions
the non-communicable diseases throughout essential for health, enabling everyone to
Indonesia is still lacking especially for the achieve the full potential of their health, and
treatment of non-communicable diseases. mediation between different interests within
Therefore, it is required to have special efforts the community to improve health. Public health
to prevent and control non-communicable with regard to disease prevention and control at
diseases in order not to burden the National the population level through an organized effort
Health Insurance program (World Bank, that includes organizations, public, private and
2014). Health care for non-communicable individual. Contribution to public health comes

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from systems outside the formal health care Integrated Development of Non-
system, and the potential for cross-sectorial Communicable Diseases Post (Posbindu PTM)
contribution to public health is increasingly is an community empowerment organization to
recognized worldwide. The government’s role is control, prevent and control non-communicable
very important in influencing the health of the diseases. Puskesmas has implemented Posbindu
population which is not limited in the health PTM with the following results:
sector but also by the various sectors outside Puskesmas has implemented Coaching
the health system (Lakshminarayanan, 2011). Integrated Post for non-communicable
Desa Siaga is a condition of rural diseases (Posbindu PTM) which is
communities which has the readiness of assisted by cadres. Puskesmas as an
executor has not optimally involved
resources and the ability and willingness
the Head of district, Head of village,
to prevent and overcome health problems, Chair of the Neighborhood (RT) to
disasters and health emergencies independently. mobilize the community to participate
Puskesmas as a mentoring implementation of in the implementation of Posbindu
Desa Siaga has given supplies good facilitation PTM. The cadres have not carried out
techniques that can lead active participation of the evaluation of Posbindu PTM which
Desa Siaga. The facilitation done by Puskesmas is reported to Puskesmas and head of
has not realized community development, village to expect the feedback (results of
but more towards the social mobilization (Sri, four Puskesmas).
2012). The change or innovation policy with
Posbindu PTM in the region of four
adequate socialization needs to be followed
Puskesmas is held every month in
up. Socialization should be done in order to which the schedule is established by
concede equality and harmony in making Puskesmas. The implementation of
of a new policy such as rural / village / RW Posbindu PTM is informed through
Siaga. To be more easily understood by the the loudspeakers of mosques and word
local government, policies must be associated of mouth. Posbindu program is started
with the policy of community empowerment, with registration and then followed by
especially the strengthening of the capacity of measurement of weight, abdominal
villages and sub-level governments need to be circumference, moisture content, fat
integrated in the framework of the Ministry content and blood sugar, uric acid,
cholesterol checks (the interview three
at the national level within the framework of
PHC).
the development in strengthening of regional
autonomy (Darmawan, 2012). Posbindu PTM activity begins with
The supporting and hindering actors socialization and implementation of
to increase public participation in Manado measurement and inspection (result
and Palangkaraya show that basically the from one Puskesmas).
supporting and hindering factors are as follows:
a) local government leaders such as Head of The activities of the last medical
Village; b) religious and community leaders; examination and drug delivery to
c) Public Health Board / Puskesmas (PHC); d) members who indicated a particular
illness are referred to Puskesmas.
community; e) potential Organizations such
Posbindu PTM held at Puskesmas
as the PKK, BPD, NGOs, Youth, Religious yard is directly referred for treatment
Institutions and Custom Agency. Posyandu is to Puskesmas (Puskesmas one result).
one of the activities of primary health care by
the volunteer health workers to target infants, Monitoring and evaluation in general
toddlers, pregnant women and couples of has not been implemented, there is
childbearing age. Especially for Posyandu only a report from the health center
cadres, it is necessary to improve the skills of to the Department of Health (outcome
advocacy and negotiation periodically thus four Puskesmas).
more confident in carrying out development
activities. Posbindu PTM is a form of public

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participation in the activities of early detection, Posbindu PTM. Based on the results,
monitoring and follow-up of risk factors the examination is done directly by the
NCDs independently and continuously. This medical officer and there are referred
activity is developed as a form of early warning to the Puskesmas.
because almost all of the risk factors of non-
communicable diseases are asymptomatic. Posbindu PTM referral system supports
The general objectives of Posbindu PTM are comprehensive health care for people up to the
to create programs of prevention and control highest level of services. The benefit of Posbindu
of non-communicable disease risk factors for PTM is to serve as a community-based health
community-based participation through an efforts in which the targets / clients and
integrated, routine and periodic program. The empowered society should participate actively
specific objective include: 1) implementation in the activities and health programs. From
of early detection of risk factors for NCDs; the implementation of Posbindu PTM from
2) monitoring the implementation of non- registration until being registered as members
communicable disease risk factors; 3) the and finally they go home will be able to help
implementation of the follow-up of early Puskesmas detecting non-communicable
risk factors for NCDs. The goals in the diseases such as diabetes mellitus (DM),
administration of Posbindu PTM are divided high blood pressure, cancer and others who
into 3 groups of specific objectives, goals and continued with treatment can prevent and
objectives of the support. The approach to the control diseases that could reduce the level
three goals should be done in an integrated pain.
manner during the implementation process. The model of community empowerment
Posbindu PTM activities carried out by can be seen from the four domains of
the people in the city of Bengkulu based on development organizations which are formed
research by observing each activity include: based on the opinions and perceptions of
The Interviews to gather information about the community members: 1) activation of the
history of risk factors for non-communicable community; 2) competence in solving problems
diseases in the family and the participant, on their own; 3) ability of program management
physical activity, smoking, eating vegetables and 4) creation of supporting environment
and fruit as well as other information needed (Kasmel, 2011). Health promotion is most
to identify the health problems associated with often delivered through a top-down program
the occurrence of NCDs. This activity is done which is controlled by government agencies
when the first visit and periodically once a or non-governmental organizations (NGOs)
month after participants are registered. funded by the government. Government
Based on the results of the implementation policy (and resources) which sets the agenda
of Posbindu PTM, the interview of cadres to of health promotion difficult starts when it is
members Posbindu PTM new about family not met community concerns. The dependence
history of disease, individuals, smoking habit, on government funding of health promotion
the habit of eating vegetables, fruits and other has contributed to the dominance of the
activities. These results are recorded in the top-down style of programming. According
medical record of each participant. These to Pratamawati (2012), a proactive health
results would be the source of material when an paradigm as a model for health development is
individual go for counseling. expected to create self-sufficient communities in
The measurement abdominal maintaining health through greater awareness
circumference and body weight is on the importance of health promotion and
carried out by Kader. The measurement preventive action. Dengue fever prevention
of blood pressure, tension, simple lung program in this paradigm prefers the approach
function, blood sugar, cholesterol of promotion and preventive efforts including
and triglycerides is carried out by capacity building/health volunteers as the main
health personnel. Activity counseling entrance to improve understanding of the
and education is conducted by every epidemiology of this deadly disease.

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Based on the interview to some people managed by cadres. The target is the whole
who do not utilize health centers as first-level community. Posyandu is one of UKBM managed
health facility says: and organized from, by and for the community.
I am not sick because it has become a In an effort to decrease the morbidity and
member of Posbindu PTM and follow mortality of infants and toddlers, birth rate
regularly every month. In Posbindu
PTM measurement, the blood tests in order to improve public health which has
and health area checked so that I can developed an approach to alignment which in
stay healthy. its implementation at the village level is done
through Posyandu.
Based on the above explanation, The targets of Posyandu are: infants,
concept development will look at the role toddlers, pregnant women, new mothers,
of stakeholders, the public, and cadres in postpartum and breastfeeding mothers and
identifying needs based on concerns of the spouses of fertile age. The objectives of Posyandu
community as a method of application to are: a) to reduce morbidity of mothers and
construct a model of empowerment Posbindu children; b) to accelerate the reduction of infant
PTM in the early detection, prevention and mortality rate (IMR), children under five and
control of non-communicable diseases can the birth rate; c) to accelerate the reduction of
prove reduce morbidity. maternal mortality (MMR), pregnant women
The implementation of Posyandu has and postpartum mothers; d) to accelerate the
been conducted in every Puskesmas. The staffs receipt of Small Happy and Prosperous Family
are more proactive in reminding cadres for Norms (NKKBS); e) to enhance the ability of
the implementation of Posyandu. Based on the communities to develop health activities and
results of interviews with health cadres in four other activities that support as needed; f) to
health centers, the result is as follows: increase the coverage of health services.
Cadres need to get refreshing
training because they have not The services held in Posyandu are for
received any training for quite babies and young children include:
monthly weighing and nutrition and
long time. The role of health care
health counseling, provision of nutrition
staffs in reminding the readiness of
help package, immunization and
Posyandu cadres for the next day monitoring of cases of flaccid paralysis
is very helpful (the results of four and early detection of growth and
Posyandu.). development, disease identification,
simple treatment and referral especially
The support from Head of district, for diarrhea, inflammation of the
Head of village, PKK, Chairman lungs (pneumonia ). pregnant mother
of RT rarely mobilize the include: prenatal care, feeding (PMT)
community to come to Posyandu. for maternal malnutrition or chronic
energy deficiency (CED), the provision
The implementation funding of
of iron tablet and iodine capsule and
Posyandu is the donation from
counseling about nutrition, maternal
BKKBN as one of the resources that health and safe delivery planning.
can move Posyandu (results from Mother postpartum / breastfeeding
one Puskesmas). include: vitamin A supplementation,
supplementary feeding (PMT),
Puskesmas staffs provide counseling postpartum care for mother and baby,
or examination, registration, iron tablet supplementation, family
weighing and other measurements planning services, and IEC / counseling.
done by cadres (results from four
Puskesmas) Posyandu developed in the initiative
of President Suharto in 1984. Posyandu has
Posyandu is a form of community been the pride of the people. Every month
participation in the health sector which is people flock to the Posyandu managed by

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community-based, led by cadres / health the implementation of the program at the same
volunteers who have received training from the time in the field of health. Puskesmas and
health department, providing health guidelines Posyandu services are spread to remote villages
for pregnant women and nursing mothers. In reduce infant mortality, controlling the spread
addition, Posyandu also gives vaccinations of infectious diseases, and improve public
and food supplements to infants and toddlers. health conditions.
Posyandu serves as early detection of cases of In particular, Posyandu becomes the
malnutrition and malnutrition in infants and of information dissemination about the
toddlers. The success of Posyandu makes some importance of family planning and health
countries adopt the concept of Posyandu and services before and after childbirth. Posyandu
instead, they are able to develop better than in teaches community on how to manage
Indonesia today. Posyandu participation shown nutrition, clean clothes, and healthy house
by the effect of mentoring and training learning (Shiffman, 2007). Hope is always there for
organization (LO) to the cadres except in terms new Health Minister to make a breakthrough
of the number registered in Posyandu cadres. to achieve the MDG targets and prepare the
The influence on mothers is reflected in different various efforts so that the people can live
proportions, as well as on the health service in healthy and make efforts in early detection of
Posyandu. The significant implementation can diseases. At the global level, a health problem
be seen from the monitoring of children growth has become a Global Health Diplomacy. The
between the intervention areas with control concept of community health development
areas (Aminuddin, 2011). refers to a healthy life without pain.
The results of research from Pratama Posyandu absolutely needs to be
(2007), still shows low ratings for the role of revitalized due to the following points which
participation (PSM) in accelerated of MMR and constitute the conception and thought at the
IMR decline in the form to provide counseling, time to develop Posyandu. Firstly, Posyandu
socialization and education to overcome the helps citizens to remain healthy so that
concept of “4 over and 3 too late” through the revenue could be used for other needs.
various activities such as teaching, social Reducing the dependency of citizens to the
gathering, consultation village and church National Health Insurance will save the use of
service. PSM activities are more in contributing the state budget. Secondly, the role of Posyandu
personnel, funds, facilities in the management is crucial when the availability of doctors
of the PSM such as Posyandu activities, village is still inadequate. Although the number is
medicine posts and Toga. PSM is concrete increasing, general practitioners do not spread
evidence by the public to the health sector, out evenly. Thirdly, Posyandu reduces excessive
especially in efforts to reduce maternal and dependence of society to the use of medicines.
infant mortality. Posyandu has demonstrated benefits
The benefits of Posyandu according to to the new era and can reduce morbidity and
Shiffman (2007), in the article “Generating mortality of mothers and children. Improving
Political Priority for Maternal Mortality health makes people healthy without pain. The
Reduction in 5 Developing Countries” success of Posyandu could reduce spending
published in the American Journal of Public on health care both by society and the state.
Health shows the success of the New Order Toddler weighing done by Posyandu aims to
government to reduce maternal and infant monitor developments, so that parents know
mortality and is encouraged by what he call as what to do if there is no increase in weight.
a “political entrepreneurship”. This means that Weight monitoring also aims to review
the President is the leader of the campaign, the conditions of children under five over
increases the budget to reduce maternal and the last month, the disease symptoms and
child mortality, and mobilizes provincial nutrition needs for the infants. Immunization
government and district / city to pay attention is an attempt to prevent diseases that can be
to the same problem. In the New Order era, prevented by immunization. Posyandu can also
Puskesmas and Posyandu become the spearhead provide guidance and counseling to maintain

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health of infants and mothers to stay healthy. Masyarakat, 7(2).

Dharmawan, Y., Wigati, PA., Dwijayanti, F. 2015.
Conclusion Kinerja Petugas Dalam Pencatatan dan
Puskesmas can be divided into two Pelaporan PWS KIA di Puskesmas Duren.
categories namely: first, the center of health Jurnal Kesehatan Masyarakat, 10(2): 210-
care promotion and prevention targeting 217.
communities and individuals; second, health Garrido, MV., Zentner, Buse, R. 2011. The effects
centers as primary individual health care center of gate keeping: A systematic review of the
literature. Scandinavian Journal of Primary
where the role of Puskesmas as gatekeeper. The
Health Care, 29: 28–38.
integrated couching post non-communicable Gillam, S. 2008. Is the declaration of Alma Ata still
diseases (Posbindu PTM) is a form of public relevant to primary health care?. BMJ 336
participation in the activities of early detection, Kasmel, A., Andersen, PT. 2011. Measurement
monitoring and follow-up of risk factors NCDs of Community Empowerment in Three
independently and continuously. Posyandu Community Programs in Rapla (Estonia).
actively plays as role of community participation Int. J. Environ. Res. Public Health, 8, 799-817
in the health sector which is managed by health Lakshminarayanan, S. 2011. Role of government
cadres targeting the whole community. in public health: Current scenario in India
Posyandu as the first level of health care and future scope. Journal of Family and
Community Medicine, Vol. 18 (1) : 26-30.
providers (FKTP) has the function of improving
Mark, F., Harris, MF., Harris, E. 2012. Partnerships
public health through promotion, preventive between primary healthcare and population
and curative community empowerment which health: preventing chronic disease in
will be able to decrease the number of hospital Australia. London. Journal of Primary Care,
visits and referrals to hospitals. Posyandu must 4:133–7
optimize the implementation and scope so Pedersen, KM., Andersen, JS., Søndergaard, J. 2012.
that Posyandu and Posbindu PTM can detect, General Practice and Primary Health Care in
prevent and control the disease from spreading. Denmark. JABFM, 25: 34-38.
Potvin, L., Jones CM. 2011. Twenty-five Years After
Acknoledgement the Ottawa Charter: The Critical Role of
My highest gratitude is addressed to Health Promotion for Public Health. Can J
Kopertis Region II which has funded this Public Health, 102(4): 244-48.
research through DIPA Directorate of Research Pratamawati, DA. 2012. Peran Juru Pantau Jentik
dalam Sistem Kewaspadaan Dini Demam
and Community Services, Directorate General
Berdarah Dengue di Indonesia. Kesmas,
of Higher2015. I also extend my big appreciation Jurnal Kesehatan Masyarakat Nasional, 6 (6)
for the Chief of Medical Officer of Bengkulu, : 243-248
Head of Puskesmas Bengkulu City, Posyandu Rejeki, LS., Hasanbasri, M., Sanjaya, GY. 2012. Peran
and Posbindu PTM Cadres who are willing to Puskesmas Dalam Pengembangan Desa
become informants in this study. Siaga di Kabupaten Bantul. Jurnal Kebijakan
Kesehatan Indonesia, 1: 154-160.
References Saputra, RF. 2013. Studi Tetang Pelaksanaan Program
Aminuddin, Zulkifli A., Djafar N. 2011. Jaminan Kesehatan Daerah (Jamkesda) di
Peningkatan Peran Posyandu Partisipatif Puskesmas Sidomulyo Kecamatan Samarinda
melalui Pendampingan dan Pelatihan Upaya Ilir Kota Samarinda. eJournal Administrasi
Pemantauan Pertumbuhan dan Masalah Negara, 1(1): 41-55.
Gizi Balita di Bone, Sulawesi Selatan. Jurnal Septyantie, UP., Cahyadin, M. 2013. Hubungan
Kesehatan Masyarakat Nasional, 5(5). Antara Realisasi Dana Bantuan Operasional
Ayuningtyas, D, Rezeki, SP.,. 2014.Kualitas Kesehatan Dengan Indikator Gizi KIA di
Lingkungan Kerja dan inerja Bidan Kabupaten/Kota Provinsi Jawa Tengah
Puskesmas dalam Pelayanan Kesehatan Tahun 2012. Jurnal Kebijakan Kesehatan, 2
Ibu. Kesmas. Jurnal Kesehatan Masyarakat (4): 215-221.
Nasional, 8 (6): 265-271. Shi L, 2012. The Impact of Primary Care: A
Darmawan, ES,. 2012. Mengukur Tingkat Focused Review Hindawi Publishing
Pemberdayaan Masyarakat dalam Sektor Corporation Scientica. Volume 2012,
Kesehatan. Jakarta. Kesmas. Jurnal Kesehatan Article ID 432892, 22 pages http://dx.doi.

88
 KEMAS 12 (1) (2016) 76-89

org/10.6064/2012/432892 Puskesmas dalam Pengembangan Desa

Shiffman, J. 2007. Generating Political Priority Siaga Di Kabupaten Bantul. Jurnal Kebijakan
for Maternal Mortality Reduction in 5 Kesehatan Indonesia, 1 (3): 154-160
Developing Countries.Framing Health World Bank. 2014. Supple Side Readiness for
Matters, Peer Reviewed American Journal of Universal Health Coverage : Assessing the
Public Health, 97 (5). Depth of Coverage for Non-Communicable
Sri, LR, Hasanbasri M., Yoki, GS. 2012. Peran Diseases in Indonesia. www.worldbank.org.

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