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In early 1980s, the Study Group on Family Medicine (Indonesian Study Group on Family Medicine = ISGFM) was established. It gave additional training on Family Medicine especially in the principles of family practice. At the same time in a smaller proportion, clinical issues were also discussed in a seminar-like training given by the relevant specialists. It was quite successful to generate awareness among general practitioners in the importance of Family Medicine principles and their implementation. At that early time, to accelerate the dissemination, the ISGFM joined the WONCA world. In 1990, the ISGFM organised WONCA Regional Asia-Pacific Conference and the study group decided to change the name of the group to the “Indonesian College of Family Physicians” (ICFP). This is a milestone in the development of family practice in Indonesia. It took a long time to write a “standard training curriculum” to provide an accountable systematic training that can be audited appropriately. Medical doctors who have been passed the entire program will then be certified as “family physician”. In accordance wth the consensus in WONCA Regional ASPAC program and the help of the College of Family Physicians, Singapoe (CFPS), and in collaboration with Singapore International Foundation (SIF), several “Training of Trainers” have been conducted which results in the certification of 98 peoples to be trainers. Some of the certified trainers are now actively teaching or training other colleagues. This book will help trainers in such training to plan the training more effectively. Finally in 2002, the standard curriculum is finished and printed with the compliments of Indonesian Department of Health. It consists of four packages, those are: • • • •
Packet A Packet B Packet C Packet D
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Dealing with the Principles of Family Medicine Dealing with Managing the Family Medicine Practice Dealing with Medical Technical Skills and Care in Specific Situations Dealing with Applied Medicine in the Various Age Groups
To maximise the usefulness of this Primer, the topics have been arranged in line with the curriculum. Thus, you will find all the packets in similar sequential arrangement. This book is set in a practical layout that make it easy to follow the stream of learning. Both practitioners and trainers can use this book productively; practitioners can use it as quick reference in their daily practice and trainers can use it to plan the training programme for their trainers to reach the standard of competence. But, it has to be wisely used since this is only a handbook with limited contents. For further information you can read the current literature available at the end of each topic or chapter. No one is an island; your self help and efforts are needed to complete the content of this book. Acknowledgement is addressed to SIF who have encouraged us to finish and publish this book; and provide the financial supports as well. A lot of thanks are also addressed to the College of Family Physicians, Singapore especially to Associate Professor Goh Lee Gan who has helped wholeheartedly to finish this book. Dr Sugito Wonodirekso Wonca Country Representative, Indonesia Jakarta 12
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Edited by Goh Lee Gan Azrul Azwar Sugito Wonodirekso
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THE PRESENT STATUS OF HEALTHCARE SERVICES IN INDONESIA
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THE PRESENT STATUS OF HEALTHCARE SERVICES IN INDONESIA
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By Prof. Dr. Azrul Azwar MPH Chairperson, the Indonesian Association of Family Physicians H
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Outline National health development program Brief description of the country National health status Public health services Medical care services Financing of health services T
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The general objective of the National Health Development Program in Indonesia as stipulated in the National Health System is to provide a healthy life for all Indonesians. The specific objectives of the National Health Development Program in Indonesia are:
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To enable people to maintain their own health and live a healthy and productive life To promote an environment conducive to the health of the people To promote good nutrition among the people To decrease morbidity and mortality To promote a healthy and prosperous family life
To achieve these objectives, various healthcare efforts have been implemented, including among others, the strengthening of the healthcare delivery system as part of an overall health development program. This is being carried out both by government and the private sector. This paper aims to assess the present status of the healthcare services in Indonesia. BRIEF DESCRIPTION OF THE COUNTRY
Indonesia is the world’s largest archipelago, extending between two continents, Asia to the North and Australia to the South. It lies between two oceans, the Indian to the West and the Pacific to the East. The distance from the west to the east point of Indonesia is 3,200 miles, and the distance from the North to the South is 1,100 miles. The total area of Indonesia is 5,193,260 square miles, covering both land and sea territories. The total land area is an approximately 1,904,650 square miles, comprising 13,677 islands of which only 7.25% (992 islands) are inhabited. Almost 85% of the total land area is included in the five main islands, Kalimantan (the biggest), Sumatera, Papua, Sulawesi and Java. Because Indonesia lies along the equator, the climate is tropical, with high humidity, slight changes in temperature and heavy rainfall. Except at higher elevations, the temperature
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generally ranges from 20 to 30 Centigrade. Humidity ranges from 60% to 90%. Table 1 summarizes the physical features of Indonesia. Table 1. Physical Conditions of Indonesia PHYSICAL CONDITION
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Total area (sq ml) Land area (sq ml) Number of islands Number of islands inhabited Temperature (celsius) Humidity (%)
5,193,260 1,904,650 13,677 992 20-30 60-90
Indonesia gained its independence on August 17, 1945, after more than three and a half centuries of occupation by the Dutch and a further three and a half years by the Japanese. Indonesia is a republic, with a President as head of state, chosen by the People’s Consultative Assembly every five years. The capital city is Jakarta, situated on the island of Java. Administratively, Indonesia is divided into 32 provinces, each with a legislative council and headed by a Governor. The provinces are divided into Districts and Municipalities, each with a legislature and headed by a Bupati for the regencies and a Walikota for the municipalities. At present, there are 243 districts in Indonesia, while the total number of municipalities is 61. East district and municipality is divided into sub-districts, headed by a Camat, and is further divided by villages. Each village is headed by a Lurah and divided into hamlets which, in turn, are further divided by neighborhoods. The villages (except in the big cities), hamlet and neighborhood groupings are headed by elected persons who serve in a voluntary capacity. At present, the total number of sub-districts in Indonesia is 3,839 and the total number of villages amount to 65,554. Provinces, districts and municipalities are autonomous regions with administrative responsibilities. They have to finance public services, including the health sector, in their respective area of responsibility. The information about the administrative divisions of Indonesia, mentioned above, is summarized in Table 2. Table 2. Administrative Divisions of Indonesia ADMINISTRATIVE DIVISIONS
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Number Number Number Number Number
32 243 61 3,839 65,554
of Provinces of Districts of Municipalities of Sub-districts of Villages
The total population of Indonesia in 2000 was 203,456,005, making it the fourth most populous country in the world. The rate of population increase is 1.34%. The population distribution is uneven, with about 59.3% of the population live on Java Island, although Java occupies only 7% of the total land area. About 69.1% of the people live in rural areas, where health facilities and most other public infrastructure are unsatisfactory. 15
Indonesians are basically of Malay heritage and are divided into approximately 300 ethnic groups, about 360 languages and dialects. Islam is predominant religion and the national language is Bahasa Indonesia. Indonesia has passed law providing compulsory education for children. Primary school enrollment rate is 97%. It is estimated that around 15.9% of the population is illiterate. E
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The main occupation of majority of the people is in agriculture. The primary sources of government’s income are from export revenues of oil, LNG (liquefied natural gas) and lumber. The annual growth rate is running at an average rate of 4%, and the GNP per capita in 2000 is US$680. Information about the social and economic condition of Indonesia can be seen in Table 3. H
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Total population (millions) Rate of population increase (%) No. of people living in rural areas (%) Ethnic groups Moslem(%) Literacy rate(%) Primary school enrolment rate(%) Annual economic increase rate (%) GNP per capita (US$)
203.5 1.35 57.7 300 90 84.1 97 4 680
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NATIONAL HEALTH STATUS
Due perhaps to the fact that Indonesia is still a developing country, the present condition of Indonesian healthcare remains unsatisfactory although there have been major improvements compared to two decades ago. Various health indicators for Indonesia can be seen in Table 4. Table 4: Health Status Indicators for Indonesia INDICATOR/VARIABLE
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Infant mortality rate per 1000 live births Under five mortality rate per 1000 Maternal mortality rate per 100.000 live births Crude death rate per 1000 Life expectancy – male – female Low birth weight (%) Protein Calorie Deficiency per 100 Underfives Clean water supply per 100 population Latrines per 100 population Percentage EPI coverage
1993 1993 1993 1994 1993 1993 1993 1993 1986 1986 1993
58.0 81.0 425 6.0 60.8 64.6 15.0 40.0 30.0 37.9 93.6
The primary cause of death in Indonesia since 1995 is cardiovascular diseases that now overtake predominant infectious diseases, reflecting the double burden faced today. 16
The pattern of death in Indonesia is still strongly related to general poverty, low income per capita, high rates of illiteracy and various socio-cultural factors. According to Household Health Surveys, the 10 leading diseases in the country are: acute respiratory tract infection, diseases of skin, diseases of teeth, mouth and gastro-intestinal tract, other infectious diseases, bronchitis-asthma and other disease of respiratory tract, malaria, nerve disorders, cardiovascular disorders, diarrhoea and tuberculosis. PUBLIC HEALTH SERVICES
The responsiblility for dealing with public health problem in Indonesia lies with the government. Following the basic principle of sound public health, public health services provision in Indonesia strongly encourages community participation through primary health care services. The main health body entrusted with carrying out public health services in Indonesia is the Community Health Center (Puskesmas), situated at sub-district level serving a population of about 30,000-40,000. There are over 7,000 such centers in the country by the year 2000. The Puskesmas render 6 basic services (health promotion, MCH/FP, CDC, Nutrition, Environmental sanitation, Curative care) and various developmental services according to local areas’ need. In most instances, a doctor, with a staffing between 8-32, consisting of nurses, midwives and other auxiliary personnel, heads each Puskesmas. In densely populated areas, there are Sub-Community Health Centers (Puskesmas Pembantu) at the village level, generally headed by a senior nurse or midwife, and operated under the supervision of, and linked to, the Community Health Center. At present, the total number of Puskesmas Pembantu in Indonesia is 19,977 To serve people who live in very remote areas, there are Mobile Community Health Center (Puskesmas Keliling), operated by and based at the local Puskesmas. The staff of Puskesmas Keliling consist of one doctor, assisted by two or three personnel, including nurses/midwives and a driver. At present, there are about 6,024 Puskesmas Keliling serving villages within the sub-district. To support the activities of the Puskesmas, the community health effort is organized in the form of the Integrated Services Post (Posyandu), located at the hamlet level. The responsible community institution to Posyandu is the village community resilience committee. The activities of each Posyandu, assisted and supervised by local Puskesmas staff, consist of five basic types of health services. These are: (i) MCH Services, (ii) Nutrition Services, (iii) Family Planning Services, (iv) Diarrhoeal Disease Control and (v) Immunization Services. At present, there are about 251,459 Posyandu registered in Indonesia. The position of the healthcare delivery system responsible for combating public health problems in Indonesia is summarized in Table 5. Table 5. Public Health Delivery System in Indonesia PUBLIC HEALTH DELIVERY SERVICES POINT
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Community Health Center Sub-Community Health Center Mobile Community Health Center Integrated Services Post
7,100 19,997 6,024 251,459 17
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In accordance with the principle of devolved autonomy, there are District Health Offices at the district level and the Provincial Health Office at the provincial level. The Ministry of Interior and the Ministry of Health at the national level coordinate the health offices that are directly under the coordination of the local government. V R E S E R A C H T L A E
The general rule is that the main function of the Ministry of Health is to provide conceptual guidance, technical guidance and material, as well as financial contribution and assistance to the local government district and provincial health offices. In brief, the organizational structure of the health offices in Indonesia is shown in below Table 6. H E H T F O S U T A T S
Table 6. Organizational Structure of the Health Offices in Indonesia. T N E S E R
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MEDICAL CARE SERVICES
The healthcare delivery system that is responsible for medical problems in Indonesia, in general can be divided into three categories: (i) primary medical care facilities, (ii) secondary medical care, and (iii) tertiary medical care facilities. In contrast to public health concerns which are under the government, the responsibility of the government is to encourage medical care services in Indonesia to have a considerable private sector involvement. Management of medical care services in Indonesia is therefore a shared responsibility between the public and private sectors. The primary level personal/medical care facility managed by the government is the Puskesmas assisted by the Puskesmas Pembantu and Puskesmas Keliling. Besides the 18
provision of medical personal care, the Puskesmas also makes provision for public healthcare services in the community medical care facilities. The primary medical care facilities managed by the private sector vary. There are private midwives practitioners and private medical practitioners found in almost every part of the country. The number of private midwives practitioners in Indonesia is estimated to be approximately 34,000. Around 20% of the private medical practitioners are specialists, while the rest are general practitioners. Since most of the midwives and doctors are government employees, their private practice is usually conducted in the afternoon after the closing of government offices. In some places, although it is illegal, paramedics also have their own private practices. Most private medical practitioners in Indonesia operate their practices as a sole practice, although in the big cities there is now an increasing trend for group practices that become more popular. Other types of primary medical care facilities managed by the private sector in Indonesia are the MCH clinic and the polyclinic. These types of medical facilities are usually managed by midwives or nurses, although the responsible person for these facilities is still the doctor. Unfortunately, the actual number of private MCH clinics and private polyclinics in Indonesia is not available. Table 7. Situation of Private Medical Care Facilities in Indonesia (1993) TYPE OF FACILITIES Private Private Private Private
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midwife practitioners (estimated) medical practitioners (estimated) MCH clinics polyclinics
45,000 34,000 NA NA
The secondary and tertiary medical care facilities in Indonesia are located at hospitals. There are around 1,200 hospitals registered in the country, of which 404 hospitals are government or local government hospitals. The total number of beds available in all hospital is 111,460, which means that for every 100,000 people there are around 59.8 hospital beds available. In brief, the number of hospitals in Indonesia is shown in Table 8. Table 8. Number of Hospitals in Indonesia by the Year 2000 TYPE OF HOSPITALS Government Army State-Owned Private Total
NUMBER OF HOSPITALS
NUMBER OF BEDS
404 111 83 589
58,912 11,427 7,874 34,247
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Government hospitals are divided into five categories, namely the A, B, C, D and E type. Type D (with 25-100 beds) and type C (with 100-400 beds) government hospitals are considered to be secondary level medical care facilities in Indonesia. These hospitals are situated in the district capitals, of which there are 305 in the country. Type D hospitals are in transitional period and ought to be promoted to a type C hospital. Type C hospital are expected to be able to provide at least six major specialty services, namely internal medicine, pediatrics, obstetric and gynecology, surgery, radiology and clinical pathology. 19
Type B (with 200-500 beds) and the type A (with 100-400 beds) government hospitals are considered as secondary level medical facilities in Indonesia. Type B hospitals are located in the provincial capitals and are expected to be capable of providing a broad spectrum of specialist services, while type A hospitals are expected to provide a broad spectrum of sub-specialist services. At present, the total number of type B government hospitals is 23 and the total number type A government hospitals is 4. R
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Health Services in Indonesia are operated under a “fee for service” system. The number of people covered by health insurance schemes is still limited mainly to civil servants and some private employees. In brief, the number of people covered by health insurance schemes in Indonesia can been seen in the following table. Table 10. Number of People Covered by Health Insurance Schemes TYPE OF HEALTH INSURANCE SCHEMES
NUMBER OF PEOPLE COVERED
Government civil servant Private employee social security scheme Public health funded scheme Private health insurance scheme
15 million 2.5 million 14 million 1 million
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31 million
Annual health expenditure in Indonesia is still very low. It is estimated to be around 2.5% of GNP or about US$18 per capita, a level far under the WHO recommended expenditure level of at least 5% GNP. A big portion of total health expenditure in Indonesia comes from the people, whereas the contribution of government is only around 30%. The small contribution of government are utilized for all-line subsidy that creates unfair health financing for the poor. Most of private spending on health care is out-of-pocket, because 20
only around 20% are protected by various types of prepaid care. CONCLUSION
Indonesia still faces various health problems. To overcome these challenges, Indonesia has implemented, since 1969, a series of Five Year National Development Programs, including the National Health Development program. Significant progress has been achieved in health care sector, both in public health services as well as in medical services. The management of the healthcare delivery system in Indonesia is carried out both by government and the private sector, including some forms of public-private mix. The low level of health spending, the misdirection of government subsidies, and the big portion of population with out-of-pocket spending indicating low proportion of people protected by prepaid care, are challenges in that needs to be reformed gradually towards more fairness in health financing.
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FAMILY MEDICINE ORIENTED PRIMARY CARE
1 Vision Of Family Medicine Oriented Primary Care 2 Introducing Family Medicine To Health Care Systems
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VISION OF FAMILY MEDICINE ORIENTED PRIMARY CARE
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Associate Professor Goh Lee Gan Wonca Regional President, Asia Pacific R O E NI
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Outline Challenges in health care systems Meeting people’s needs Is family medicine the solution? Making things work – Towards Unity For Health Closing the financial gap — a 6-Strategy roadmap Where do we go from here
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The universal challenges to optimal health care delivery in health care systems are the result of the dream and reality struggle. The dream is the desire of the different stakeholders – policy makers, health professions, academic institutions, health care managers, and communities to meet their subsystem goals of quality and equity in each stakeholder’s perspective. The reality is that such a system will not be sustainable. The interim results are well-known: limited health budget, rapidly rising costs as more unprevented disease burden takes its toll, inequitable distribution of resources between need and want, and inefficiencies in delivery of care as different stakeholders work towards a subsystem optimum. The reality is the need for relevance and costeffectiveness. The solution – A balance is needed between quality and equity on the one hand and relevance and cost-effectiveness on the other hand. Various models have been introduced to find the balance – 1978 Alma Ata Declaration: Primary Health Care for All (WHO, 1978), Improving health systems: the role of family medicine (WHO Europe, 1998), and the WHO-Wonca vision of family medicine (WHO-Wonca Working Paper, 1994). To varying extent, some balance towards equity is being achieved. The lack of unity for health is now seen to be the cornerstone that the various stakeholders in the health care delivery system need to address – A new unity based on a common vision is needed. This has led to the WHO and Wonca working jointly towards unity for health in the WHO-Wonca TUFH (Towards Unity For Health) Project across the world. In this project, the primary care doctor has a role of bridging the different stakeholders to work toward a common vision for health care delivery.
MEETING PEOPLE’S NEEDS What do people need from the health care delivery system has been addressed in a WHO-Wonca Working Paper, “Making Medical Practice and Education More Relevant to People’s Needs: The Contribution of the Family Doctor”, the result of the 1994 Ontario, 24
Canada Conference and subsequently by WHO Europe in 1998 in its paper “Framework for Development of FP/GP”. Family Medicine, by the nature of its work and core values, can help health systems to meet people’s needs which are to: • • • •
Address common health problems Improve access to care and equity Integrate prevention and care, physical and psychological, acute and chronic diseases Collaborate and co-ordinate care with the health care team more efficiently and cost-effectively • Integrate care of individuals, families and communities.
IS FAMILY MEDICINE THE SOLUTION? Family medicine is the bridge and not the solution. The 1994 Ontario, Canada Conference Paper alluded to earlier had this to say: “To meet people’s needs, fundamental changes must occur in the health care system, in the medical profession and in medical schools and other educational institutions. The family doctor should have a central role in the achievement of quality, cost effectiveness and equity in health care systems.” The family doctor is a good bridge between hospital care & public health; he is able to help save costs through being a “five star doctor”, a model conceptualized by Dr Charles Boelen, a WHO staff who is now a healthcare consultant. The five star doctor is one who is: • • • • •
Care provider, Decision maker, Communicator, Community leader, and Manager of healthcare resources.
How does a family doctor (syn. primary care doctor, general practitioner) help to save costs? Some examples illustrate the possibilities: • Treatment of acute problems timely and appropriately, getting things right the first time – particularly in children and the aged – prevents death and disability. • Encouraging appropriate lifestyle to control chronic diseases will reduce disease burden and truly save costs to the individual, family, community, and nation. • Diet, exercise and weight control (DEW) – together they will prevent or reduce the prevalence of hypertension, heart disease, diabetes mellitus, hyperlipidemia and the downstream consequences from strokes, heart disease and the long term complications of diabetes mellitus. • Smoking – respiratory consequences of chronic obstructive lung disease, cancer of the lung and ischaemic heart disease are prevented or reduced. • Sexual behaviour – sexually transmitted infections including AIDs are prevented. 25
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How does working towards unity for health work? The common vision of reduction of disease burden, and promotion of health will place the use of limited healthcare budgets to achieve the greatest impact on health status. The activities among the stakeholders will not be divergent. There will be self-care by patients motivated to keep themselves healthy and to avoid unnecessary use of health resources; appropriate level of use of services and not more healthcare and in particular, hospital care; primary care doctors not just doing gatekeeping and the denial of care but to encourage the appropriate use of resources where appropriate. The outcome of such healthcare reforms in the minds of the stakeholders will be health systems that meet people’s needs.
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Closing financial gap needs to be systems oriented. There are six strategies that need to be considered and implemented in parallel. Alignment of Vision – Strategy 1 • Work towards unity for health: work together for the benefit of all stakeholders. • Need for meetings and discussions on how unity for health can be achieved. • Work towards appropriate level of care – self-care, primary care, and hospital care (secondary care and tertiary care). • Deal with sub-maximisation of goals due to conflict of interests of carers between levels of care. The primary care doctor can play a 5-star doctor role here in reminding all stakeholders the ultimate goal of health care which is the reduction of disease burden and promotion of health. Set Quality Standards – Strategy 2 • Cost control without standards result in cutting of quality • Pay attention to outcome standards – examples are control of blood pressure, diabetes mellitus, obesity, lipid levels, and the levels of disability and mortality in the community. Reduce Unnecessary Expenditure – Strategy 3 • The easiest first to reduce expenditure will be to reduce variation of care – define best practice based on available standards. • Work towards standardisation of services with clinical guidelines – get a buy-in by stakeholders, publicise them, promote them, update them to keep them current. • Need the support of all – primary care doctor, specialists and patients. • Full payment or co-payment by users for non-essential expenditure is a useful cost control measure – need a political will to implement this. Training – Strategy 4 • Train ALL stakeholders on their unity role in the health care system. • How can they best contribute to close the financial gap must be the common vision. Pay Everybody Equitably– Strategy 5 • Poor payment results in cutting corners – this is the biggest reason for a failed primary 26
care healthcare delivery system – it becomes a system with the proverbial outcome of penny wise and pound foolish. • Payment may not always be in dollars and cents. • Recognition and mutual support for the mission of reducing the financial gap in the healthcare system are powerful incentives as equity in kind. Adequate funding for the primary care and prevention have big benefits in savings that has never been truly comprehended or never implemented because of lack of political will. • Premium or consultation fee has to be adequate – only then can unseen costs be controlled – e.g. unnecessary referrals, incomplete care, reluctance to use essential drugs. • Premium or consultation fee has to be adequate – only then will the optimal benefits of the GP be realised. • Prevention must have an adequate budget for training and implementation of patients and doctors – it is not free to the health care system. And it is a worthwhile investment for the healthcare system in the short, medium and long run. Financing system for the primary care doctor The important considerations for a managed care system are: • Adequate consultation fee for a visit. • Number of times per year which will depend on gender and age. • Medicine at cost plus 15%. Some formulas for managed care: • Acute conditions = [(Consultation + medicines + injections) X visits per year]/12 per month e.g. in Singapore NTUC pays [$20 + $5 + 2]X6/12 = $13.50 per head/year. • Chronic conditions = [(Consultation X average of 4 extra visits a year) + (medicines at cost plus 15% X12 months)]/12 per month. e.g. in Singapore NTUC pays ([$20 X 4] + [medicines at cost plus 15% X12 months]) /12 per month. Payment system for the primary care doctor can be a variety of methods depending on local factors and arrangements. Examples within the managed care system can be: • Once-off payments for more severe conditions requiring second line medicine – Example, Augmentin for a more severe cellulitis. • Minor procedures – Standardised fees will help to reduce variation of costs. • Fee-for-service – These require the support of the health care provider not to introduce unnecessary visits or be willing not to charge for visits where the patients is followed up for safety sake (there must be social capital in the community for this to work): Acute condition = $X for consultation & medicine Chronic condition = $Y for consultation & medicine Encourage Best Practice – Strategy 6 • Discussions and presentations on best practice will spread the best solutions to close the financial gap in health care. • The healthcare system may wish to consider the best stakeholders of the year award on best practice – policy maker, health professionals, academic institutions, health managers & insurance providers, communities – these will encourage best practice. 27
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• Get the message across that closing financial gap can only succeed if stakeholders are all working towards unity for health. • Organise discussion groups on how to close the gaps by the stakeholders. • Discuss on the funding for primary care and prevention.
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INTRODUCING FAMILY MEDICINE TO HEALTH CARE SYSTEMS: SINGAPORE, INDONESIA, MYANMAR
Associate Professor Goh Lee Gan Wonca Regional President, Asia Pacific Outline The Singapore Experience The Indonesian Experience The Myanmar Experience Critical success factors in the introduction of family medicine Syllabus for family medicine training Five tasks in training
THE SINGAPORE EXPERIENCE Critical Success Factor in Introducing Family Medicine into the Singapore Health Care System: Link Up with Stakeholders • Ministry of Health wanted a vocational training programme; is supportive. • College of Family Physicians, Singapore saw the opportunity to promote Family Medicine through Wonca. • The University had sympathetic supporters on adoption of Family Medicine as a discipline. • An external change agent was available. In Singapore’s case, a Family Medicine expert was invited to meet up with the various stakeholders to discuss the place of family medicine, training requirements and organizational matters. • The Hospital specialists were convinced of the importance of well-trained primary care doctors who were individually willing to contribute their efforts towards training the doctors. Sequence of developments • 1988: pilot Family Medicine programme – hospital rotation programmes and polyclinic posting as pilot vocational training programme. 28
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Grad Dip In Family Medicine This programme grew out of the recognition that the MMed (Family Medicine) – 3 years (Programme A) & 2 years (Programme B) – may be too demanding for many family doctors. Accordingly a Grad Dip Family Medicine was created and launched in 2000. To date, the programme is in its third year and we have 70 doctors who have graduated. Grad Dip Family Medicine components: • 2 year-course • Same modular course for distance learning as the MMed (Family Medicine) course (2 years) • Quarterly tutorial (not weekly & monthly as for MMed (Family Medicine). • Own clinical practice or hospital work or Government outpatient clinic. • Simpler exam – 100 MCQ & 10 KFP (3 hours), 10 OSCE based on GP clinical scenarios (each 9 minutes).
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THE INDONESIAN EXPERIENCE The introduction of family medicine in Indonesia as family medicine oriented primary care has three reasons to make it succeed: • There is a critical mass of primary care leaders, university teachers, and insurance providers, as well as Ministry of Health primary care leaders who have been exposed to the concepts and understanding of the role that family medicine can play in the health care delivery system. • Indonesian needs family medicine oriented primary care doctors to be effective gate keepers in the health care delivery system. • The project between Singapore International Foundation (SIF) & Indonesian Ministry of Health allowed the transfer of skills and knowledge on the organization and development of a family medicine programme. What were done right • Time and efforts spent to foster a common vision of the various stakeholders in health care delivery on the place of family medicine primary oriented care resulted in good acceptance of the discipline. • TOT as the transfer of knowledge created a critical mass of committed primary care leaders to spearhead the development of family medicine in the postgraduate and also in the undergraduate level. • Attention to syllabus and content of family medicine will ensure that the family medicine programme is built on a focused knowledge and skills base.
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The Stakeholders who are positive for its introduction are: • Ministry of Health • Indonesian Association of Family Physicians • Indonesian Medical Association • Universities • Ministry of Education • Insurance providers
THE MYANMAR EXPERIENCE • Invitation of Singapore Medical Association and Myanmar Medical Association (MMA) was the entry point for in-depth introduction of family medicine learning and teaching strategies into Myanmar. • Reason for entry of family medicine into Myanmar Health Care Delivery System – GP as primary care provider is recognized to be important. Prior exposure of medical leaders to the concepts and the role of the family doctor is again important. • Family Medicine Workshop & interaction with MOH & MMA as the means to transfer of technology. Knowledge Transfer Activities • The Myanmese medical leaders met their counterparts from Singapore and discussed the tasks of organizing a family medicine programme, syllabus and teaching methods. Myanmar has since developed its course and implemented it. • Demonstration of a GP Clinical Teaching Session (Small Group) was done in Yangon. • Clinical Short cases sessions were conducted jointly with the Myanmese hospital specialists for the primary care doctors from Singapore and Myanmar. • Visit by Family Medicine programme director designate to Singapore to study training implementation details in greater depth.
CRITICAL SUCCESS FACTORS IN THE INTRODUCTION OF FAMILY MEDICINE Some Observations There are common important milestones in introducing Family Medicine into health care systems in Singapore, Indonesia and Myanmar. These are: • Adequate presentation to stakeholders on what Family Medicine can contribute – important not to over-promise. • Explanation, discussion and involvement of stakeholders in the planning and local development is an important factor. • External help in developing the curriculum, teaching methods, TOT ideas, and organization of the training programme expedites the implementation of the training programme. In the case of Singapore, Australia and UK provided the external help. Suitable Programme For Rapid Development The experience from Singapore and Myanmar suggests a Diploma in Family Medicine as 31
