Occupational Health and Safety in the World
Expansion of basic occupational health service through public health center: policy and practice from Indonesia
2024 年 6 巻 1 号 論文ID: 2023-0018-OW
詳細
2024 年 6 巻 1 号 論文ID: 2023-0018-OW
Indonesia is an archipelago nation that structures its health services through a stratified system. The public health center serves as the institution responsible for providing primary care services and undertaking various public goods initiatives, including promoting occupational health among workers in the informal sector. Integrated Occupational Health Services Post (Indonesian: Pos Upaya Kesehatan Kerja [Pos UKK]) is a community-based initiatives supported by public health centers that aims to address health-related issues among workers through a community participation model. Although the program appears to be well-suited to the country’s conditions, several challenges have emerged. This paper introduces the practical application of the program in the Province of Jakarta.
Basic Occupational Health Services (BOHS) is an application of primary healthcare principles tailored specifically for the occupational health sector. This concept was collaboratively developed by the World Health Organization (WHO), the International Labor Organization (ILO), and the International Commission on Occupational Health (ICOH), with the overarching goal of extending its services to all workers. The primary focus of BOHS is on preventive measures, encompassing health promotion, welfare, and workability, as well as the prevention of occupational diseases and accidents1,2). These services are particularly essential in countries and sectors where occupational health services are either nonexistent or extremely limited. The underlying premise is to establish a system that offers these services as a public good, grounded in national policy.
In this article, we delve into the policy and practice of BOHS in Indonesia, a country that leverages its existing networks of public health centers in each region to extend occupational health services to the informal sector.
Indonesia, an archipelago comprising over 17,000 islands, stands as the largest economy in Southeast Asia, boasting a Gross Domestic Product of over 1 trillion United States dollars3). The country derives its economic strength from a diversified portfolio that includes natural resources, such as oil and gas, coal, tin, copper, and gold, as well as the manufacturing, and service industry4). Currently, Indonesia is home to a population of more than 270 million people. Governed by a President, the country operates under a democratic system with parliamentary representation. Members of this parliament are elected from various political parties for 5-year terms. As the latest data in 2023, Indonesia is administratively divided into 38 provinces, each of which maintains a decentralized coordination with the central government5).
Health care system in IndonesiaIndonesia’s healthcare system is a hybrid model that incorporates both public and private providers and financing mechanisms6). The public system is administered in alignment with Indonesia’s decentralized governance structure, which delineates responsibilities across central, provincial, and district levels of government. At the central level, the Ministry of Health is responsible for managing tertiary and specialized hospitals, providing strategic direction, setting standards and regulations, and ensuring the availability of financial and human resources. Provincial governments oversee provincial-level hospitals, offer technical oversight and monitoring of district health services, and coordinate health-related issues across districts within their provinces. District or municipal government manages district or city hospitals and a network of public health centers (Indonesia: Puskesmas) and their associated subdistrict facilities. A variety of private providers also operate within this system, including a network of private hospitals and clinics, as well as individual doctors and midwives who are engaged in private practice at the community level.
Since 2014, the Government of Indonesia has implemented a social insurance program for healthcare and workers. This program is managed by two nonprofit government entities: the Health Insurance Agency (Indonesia: BPJS Kesehatan) and Workers Insurance Agencies (Indonesia: BPJS Ketenagakerjaan for general workers, Taspen for public servants, Asabri for military and police officers). The Health Insurance Agency pools contributions from members and allocates the funds to the healthcare facilities. Contribution to the premium is made in three ways: co-payment from public and private employers for entire family members; self-payments for the self-employed or those without employers, and government subsidies for economically disadvantaged individuals. As of July 2023, more than 90% of Indonesians were registered member of the Health Insurance Agency7).
The Health Insurance Agency allocates funds primarily in two ways, for primary service and referral service. Primary care facilities receive funding based on a capitation scheme, contingent upon number of registered members and the availability of services. Members can also choose and change their primary care facilities at their own choice. Each primary care facility should deliver comprehensive cares (promotive, preventive, curative and rehabilitative cares) and deliver more promotive and preventive cares than curative and rehabilitative. The agency employs a different approach for referral services in allocating funds. The funds are allocated based on diagnostic related groups through a system called INA-CBG. The Ministry of Health sets the cost of each clinical diagnostic at each hospital level. Reimbursement to referral service facilities occurs after an audit process conducted by the agency. Both primary and referral healthcare facilities must meet minimum criteria and pass an accreditation process to engage with the Health Insurance Agency. Members should follow the stratification of service for seeking healthcare, from primary to referral care service. For emergency conditions, members can directly visit emergency facilities at the hospital. There are some discussions about effectiveness of the systems and the implementation of qualified primary care services.
Workers insurance agencies provide services for both wage-earning and non-wage-earning employees, offering basic facilities, such as old-age security, death security, and employment injury security. Additional benefits, like pension and job loss security, are available to wage-earning employees based on their specific scheme. Premium contributions vary, with wage-earning employees co-paying with their employers and non-wage-earning employees making payments from their own pockets. While formal companies are mandated to register their employees with the Workers Insurance Scheme, informal companies are only advised to join the program.
Occupational health services in IndonesiaOccupational health services in Indonesia are legally mandated by Law no. 1 of 1970 concerning Occupational Safety8). Further detailed regulation was introduced through Government Regulation No. 88 of 2019, which focuses on various aspects of occupational health. According to this regulation, employers are required to provide four basic services in occupational health: disease prevention, health status enhancement, disease management, and rehabilitation. Employers have the flexibility to engage with various occupational health experts or facilities relevant to these services. However, the regulation does not specify standard types of experts or health facilities required, nor does it differentiate based on size of the company.
Public Health Center as a primary care services in IndonesiaAs previously noted, Indonesia’s healthcare system is stratified into primary and referral services6). Government-owned primary care services are provided through the Public Health Center, known locally as Puskesmas. In compliance with existing regulations and to fulfill the government’s obligation to offer the health program to the community, Puskesmas delivers a combination of private and public good services. In its capacity in private goods, as a primary care service provider, Puskesmas offers comprehensive care — including promotive, preventive, curative, and rehabilitative services — to communities. Accordingly, Puskesmas is staffed with medical doctors, dentists, nurses, and midwives to support these activities. Beyond individual care, Puskesmas also administers various public health programs, such as nutrition initiatives, chronic disease management, infection prevention, and other community health education efforts. For these undertakings, Puskesmas is supported by public health officers. Funding of these programs primarily comes from the district government, although some programs may receive support from the central or provincial government. Among these publicly funded programs is the provision of occupational health services targeted at informal sectors.
Role of public health center in delivering BOHSThe Government the Republic of Indonesia formalized the implementation of BOHS in public health centers through Ministry of Health Decree No. 100 year 2015, concerning integrated occupational health services post (Indonesia: Pos Upaya Kesehatan Kerja Terintegrasi [Integrated Pos UKK])9). The integrated Pos UKK is a community-based health service primarily aimed at informal workers. It mainly focuses on promotive and preventive measures, while offering limited curative and rehabilitative treatment. These services are coordinated with existing health promotion programs, such as infectious disease prevention, chronic disease management, nutrition initiatives, reproductive health, mental health, environmental health, and added specific activity related to early diagnosis of occupational disease and accident prevention, which done under supervision and coordination of Puskesmas. The day-to-day operations of integrated Pos UKK are managed by health cadres originating from the community of informal workers or other stakeholders intended to support the activities. The service is tailored for groups of informal workers engaged in similar occupational activities. A set of criteria must be met for the establishment of an integrated Pos UKK in the community:
1. Initiated by workers of informal sectors.
2. Workers should have similar occupational activities or job characteristics.
3. A minimum of 10 workers should be involved.
4. At least 10% of the total members should serve as health cadres.
5. A commitment to providing integrated Pos UKK services.
Although the integrated Pos UKK has independent activities, it requires support from Puskesmas for specialized services, such as disease screening, capacity building for health cadres, and medical referrals. Additionally, Puskesmas is responsible for monitoring activities, providing equipment if necessary, and reporting to the district government.
The operational funds for the integrated Pos UKK are generated from contributions by employer members, usually collected on a monthly basis. These funds are allocated for purchasing essential equipment, like blood pressure monitors and personal protective equipment (PPE), as well as supporting regular community health activities. At least one monthly meeting for health education is mandated, and additional health programs are supported by Puskesmas. Puskesmas should also schedule training activities for health cadres involved in integrated Pos UKK. A set of parameters is used to gauge the activity level of integrated Pos UKK as mentioned in Table 1.
| Parameters | Activities Definition | ||
|---|---|---|---|
| Active | Less active | Not active | |
| Health cadres | Minimum 10% from total workers | Available but less than 10% of total workers | Not available |
| Promotive & Preventive activities | Activities at least once a month | Activities once in 6 months | Activities less than once in 6 months |
| Equipment | Complete equipment | Incomplete/inadequate equipment | No equipment |
| Recording & reporting | Once a month | At least once in 6 months | Less than once in 6 months |
| Community sourced funding | Available | Available | Not available |
Apart from overseeing Integrated Pos UKK in their promotive and preventive activities, individual healthcare services are provided in coordination with Puskesmas, contingent on membership with the Health Insurance Agency and payment of monthly premiums. In cases where workers are classified as economically disadvantaged by the local government, premiums are subsidized. These workers can then access primary and emergency care services provided by Puskesmas and can also be referred to hospitals under the Health Insurance Agency scheme. Statistic data on the current number of Integrated Pos UKK are not available, but as of 2016, there were 1,610 such posts established across 32 provinces in Indonesia10).
Implementation of Pos UKK in Provincial Government of JakartaAs per statement from the individual responsible for overseeing Pos UKK within the Provincial Government of Jakarta, the capital has 181 active integrated Pos UKKs, catering to a diverse range of industries, such as fishing, farming, tofu making, and shoemaking. These units conduct various activities as delineated in Table 2.
| List of activities | ||
|---|---|---|
| Health promotion | 1. | Education on communicable and non-communicable disease |
| 2. | Education on nutrition and sports | |
| 3. | Education on healthy behavior | |
| 4. | Education on reproductive health and maternal health | |
| 5. | Education on environmental health | |
| 6. | Education and counseling in occupational health | |
| Preventive action | 1. | Identification of risk of occupational accident at the workplace |
| 2. | Identification of risk of health hazard at the workplace | |
| 3. | Demonstration the use of appropriate protective device | |
| 4. | Measuring bodyweight, height, and blood pressure | |
| 5. | Identification of dengue mosquito larvae in the workplace | |
| 6. | Activities done together with Puskesmas staffs (once a year): | |
| a. Early diagnosis on diabetes (blood glucose check) | ||
| b. Early diagnosis on hypercholesterolemia (blood cholesterol level) | ||
| c. Health screening (interview and physical examination) | ||
| d. Ferrous supplementation for pregnant woman’s workers | ||
| Curative action | 1. | Provide emergency tools kit and over the counter drugs. |
| 2. | Provide emergency care for wounds and basic life support and refer to Puskesmas for any medical treatment. | |
| Rehabilitation | 1. | Discussion with employer for some simple occupational health program to reduce impact for workers who already exposed to health hazard. This activity is supported by Puskesmas staff, such as: |
| a. Exposure to ergonomics hazard: intervention of lifting and handling objects and minibreaks | ||
| b. Poor indoor air: advise employer to improve ventilation within indoor air at workplace. | ||
| c. Waste: how to through waste properly follow government regulation | ||
To ensure the effectiveness of these community-based services, staff from Puskesmas offer annual training sessions to health cadres involved in the Integrated Pos UKK. These training sessions cover a wide array of topics including:
• General health education
• Occupational health
° Health and safety hazard
° Identification of hazard at the workplace
° PPE
• Basic emergency care
• Recording and reporting activities
The Provincial Government of Jakarta has adopted a strategy focused on the proliferation of the Integrated Pos UKKs across all sub-districts. While specific standardization criteria for the program’s implementation have not been established, the primary goal is to replicate the model wherever informal industry meets the existing criteria. The government has set a target to establish a total of 251 Integrated Pos UKKs, in alignment with the total number of sub-districts in Jakarta. Given the government’s sustained focus on expanding the reach of Integrated Pos UKK, coupled with ongoing training and diverse range of activities, these units within the jurisdiction of the Provincial Government of Jakarta can be classified as highly active.
Community involvement serves as a cornerstone in the operation of Integrated Pos UKK for BOHS among informal sector workers in Indonesia. Given budgetary constraints on the government side, this collaborative approach communal resources for program implementation. The recruitment and training of health cadres from among the informal sector workers further enhances this participation. These cadres then deliver services within their communities, aided by regular supervision by Puskesmas. Additionally, community financial contributions, agreed upon by informal sector employers themselves, underpin the sustainability of Integrated Pos UKK.
Public and private goodsThe Indonesian healthcare system faces challenges when solely relying on either employer-provided or government-provided services. Employer-provided services, often impractical due to financial constraints and lack of coordination channels, leave much to be desired. On the other hand, government services through Puskesmas focus more on general healthcare rather than specialized occupational health. Therefore, a blended approach that integrates both public and private goods and services emerges as the most pragmatic solution, although it necessitates community financial participation due to limited public funds.
Creating an entity: The role of Integrated Pos UKKTo formalize this multi-stakeholder initiative, the entity of Pos UKK is crucial. It serves both as a recognizable brand and as a mechanism for legal funds collection, stakeholder coordination, and regulation under government laws.
Evaluation in the implementation: The Jakarta caseThe Provincial Government of Jakarta presents a case of effective BOHS implementation, attributed to its relatively ample resources. However, the focus seems to be more on replication across sub-districts rather than quality assurance. Moreover, while brief and qualitative reports exist, there is a lack of detailed, regularized reporting from each Integrated Pos UKK to Puskesmas, indicating a need for improved supervision.
Strengths and limitationsThe Indonesian model’s strength lies in its community-government partnership and the organizational structure facilitated by the Integrated Pos UKK entity. However, the system’s efficacy is contingent on both government policy and community interest. Should either falter, the program’s existence becomes precarious. Therefore, continuous government promotion of occupational health awareness remained essential.
Lesson learned from IndonesiaIndonesia’s approach to implementing BOHS, particularly its community-government partnership and organizational framework, could serve as a valuable blueprint for other developing, large-scale countries. However, the specific strategies for cultivating such partnerships may vary, contingent on local policies and stakeholder dynamics.
Indeed, the Integrated Pos UKK serves as a bespoke solution for BOHS among informal sector workers in Indonesia. Its customized nature allows for better stakeholder engagement, facilitating more community-centric approach that is vital for success public health program, especially in developing nations with limited resources. However, its effectiveness is highly reliant on localized efforts and resources, necessitating strong supervisory and evaluative systems for sustained success. Therefore, ongoing commitment from both government and community stakeholders is crucial for refining and scaling the program.
The authors would like to thank the staff at Puskesmas Johar Baru and Puskesmas Cilincing, Provincial Government of Jakarta, Indonesia for providing data on their activities. The author used ChatGPT 4.0 and Grammarly for the English proofreading of the final draft.
None declared.
NA and KM, study design; NA and BP, data gathering and discussion; NA, draft of manuscript; All authors have reviewed, edited, and approved the final manuscript.
