INTEGRATED TRADITIONAL HEALTH SERVICE DEVELOPMENT STRATEGY IN COMMUNITY HEALTH CENTER IN DENPASAR BALI
2
,
I Gusti Ngurah Alit Wiswasta
2
,
Ni Putu Pandawani
2
Abstract
Traditional Health Services (Yankestrad) is a development program that is a priority of the Indonesian government, and its existence is of sufficient interest to the public so that it needs to be developed to improve public health. Yankestrad can be combined with conventional health services to be implemented in an integrated manner in hospitals and in health centers. The purpose of this study was to evaluate the Yankestrad program in Denpasar Bali and develop strategies for the development of the Yankestrad Integration program at community health centers (Puskesmas) in Denpasar Bali. The method used in this research is descriptive qualitative using SWOT analysis. The results showed that the implementation of the Yankestrad Integration program in Denpasar City was categorized as sufficient. The dominant internal factor being the strength is that the vision and mission of the Yankestrad program has been stated in the strategic plan and trained and certified health workers, while the weakness is that the officers hold multiple programs so that they do not focus on providing services. The external factor, the biggest opportunity is community empowerment through independent care groups with the use of family medicinal plants (TOGA), and the biggest threat is that the community still tends to curative rather than preventive efforts and the community still sees Yankestrad as magical / mystical. Yankestrad Integration development strategy can be carried out by supporting an aggressive growth policy or a Streng Opportunity strategy, namely by taking advantage of opportunities to use their strengths for the sustainability of the program.
Keywords
Evaluation, Development Strategy, Traditional Health Services
INTRODUCTION
Traditional health services (Yankestrad) have been recognized for a long time and continue to develop according to technological advances accompanied by increased utilization by the community. In the international world, traditional health services have received attention from various countries. Meeting agreement According to Who (2008), the Congress on Traditional Medicine stated that safe and useful traditional health services can be integrated into the health service system and WHO encourages member countries to develop traditional health services in their countries according to local conditions. Basic health research data 2013, shows the proportion of households that use traditional health services is 30.4%, skills are 17.8% and ingredients are 49%, and this condition illustrates that traditional health services are in great demand for healing efforts. Based on data from the Bali Provincial Health Office in 2019, out of a total of 120 health centers in Bali, around 75% of the health centre (Puskesmas) have implemented Integrated Traditional Health Services, both inside and outside the building. The remaining 25% of Puskesmas have not provided integrated traditional health services. Bali Province consists of 9 (nine) regencies / cities, and in Denpasar City there are 11 (eleven) health centers implementing Traditional Health Service programs of varying quality, namely: good, moderate, and poor categories.
Some of the problems identified as hindering the progress of Yankestrad are that not all puskesmas have Independent Care Groups and have not been facilitated with permits, do not have a special room for Yankestrad. In addition, the Yankestrad service in the building is still constrained by the government's tariffs, so that there are still very few visits to the Yankestrad Polyclinic. On the other hand, there are still very few trained Kestrad officers, the lack of funds for the development of integrated Yanestrad services, as well as a lack of support from policy makers to implement the integration Yankestrad at the Puskesmas ( (, 2019) ).
Several efforts have been made by the Indonesian government since 2015 in developing traditional health services at Puskesmas. Among them are: (1) implementing the Independent Family Medicinal Plant Utilization (TOGA) and acupressure program with community empowerment, (2) increasing the capacity of health workers in acupressure skills, concoctions, and medicinal herbs, (3) Training for Fostering Facilitators Independent of Traditional Health through the Utilization of TOGA, (4) Capacity Building for Puskesmas Doctors in Medical Acupuncture and Herbal Medicine and (5) collaboration with Village Family Welfare Empowerment (PKK) in an effort to use TOGA. Through optimal integrated traditional health services, health problems in the community can be minimized and government goals can be achieved ( (Ministry & Health, 2018) ).
In line with the research conducted byRahmawati, Jati, and Sriatmi (2016) regarding the Analysis of the Implementation of Integrating Traditional Health Services at the Halmahera Public Health Center in Semarang City, the implementation of the integration of traditional health services has not been optimal. This is influenced by several factors, such as: insufficient number of trained human resources, inadequate regulatory support, the attitude of the implementer that has not supported program implementation, and the puskesmas does not have Standard Operating Procedures (SOP). The same thing is also found in research conducted byKristiana, Maryani, and Lestari (2015) in his research entitled Description of Traditional Health Service Implementation Using Herbal Medicine (Case Study at the Makassar Community Traditional Health Center (BKTM) and Puskesmas a Karanganyar) states that there is a need for legal rules in program implementation, monitoring, and evaluation of the Herbal Medicine Saintification program. not yet intensive. Likewise, Puskesmas in the City of Denpasar have implemented Yankestrad Integration but it has not yet been running well. Based on the description above, the researcher is interested in examining how the implementation of integrated traditional health services in the city of Denpasar with the aim of evaluating the implementation of the program, and obtaining a model for the development of integrated traditional health services (Yankestrad Integration) towards better services.
MATERIALS AND METHODS
|
No |
Criteria for Respondents |
Number of Respondents |
|
1. |
Program Holder of Public health Office Denpasar City |
1 person |
|
2. |
Head of Puskesmas I Denpasar Selatan |
1 person |
|
3. |
Head of Puskesmas 1 Denpasar Barat |
1 person |
|
4. |
Yankestrad Puskesmas 1 Denpasar Selatan program holder |
1 person |
|
5. |
Yankestrad Puskesmas 1 Denpasar Barat program holder |
1 person |
|
6. |
health workers trained in Yankestrad |
|
|
1 person |
|
|
1 person |
|
|
7. |
DPJP (Doctor in Charge of Services) |
|
|
Puskemas 1 Denpasar Selatan |
1 person |
|
|
Puskesmas 1 Denpasar Barat |
1 person |
|
|
8. |
Community / Patients in each Puskesmas |
|
|
Puskemas 1 Denpasar Selatan |
11 person |
|
|
Puskesmas 1 Denpasar Barat |
11 person |
|
|
Total |
31 person |
|
This type of research is observational, because data is obtained through observation and no treatment is carried out on research subjects during the study. The research design used is to use a combination of qualitative and quantitative methods. This research was conducted in the working area of Puskesmas I Denpasar Selatan and Puskesmas I Denpasar Barat, Bali province, with the determination of the research location carried out by purposive sampling with the criteria of Puskesmas that have organized an integrated Yankestrad, and already have trained health personnel. The time of research is in October-December 2020.
Data collection techniques and procedures were carried out through surveys and interviews, questionnaires, document review, field observations and Focus Group Discussions (FGD). The analysis technique used is descriptive qualitative analysis and SWOT analysis using the IFAS and EFAS matrices.
RESULTS AND DISCUSSION
Evaluation of the integrated strategic planning program at the health center in Denpasar City is still in the sufficient category, although from the context and input variables covering policies, infrastructure, human resources, and budget is good.
|
No |
Variable Assessed |
Score Obtained |
Highest Score |
Score (%) |
Category |
|
1 |
context |
12 |
15 |
66,67 |
Good |
|
2 |
Input |
15 |
20 |
75 |
Good |
|
3 |
Process |
45 |
110 |
40,91 |
Sufficient |
|
4 |
Product |
5 |
10 |
50 |
Sufficient |
|
|
total |
77 |
155 |
49,68 |
Sufficient |
This condition occurs because the determination of the implementation of the integrated Yankestrad service is adjusted to the existing schedule at the health center with the consideration of the availability of time and schedule from Yankestrad trained officers because they also have to carry out other health programs and not all patients have received socialization and want to take advantage of the integrated Yankestrad services at the Puskesmas.
IDENTIFICATION OF INTERNAL AND EXTERNAL FACTORS IN THE DEVELOPMENT OF THE YANKESTRAD INTEGRATION PROGRAM
Internal and external factors that are the strengths, weaknesses, opportunities and threats in the development of the integrated strategic planning program in the working areas of Puskesmas I Denpasar Selatan and Puskesmas I Denpasar Barat can be seen in Table 4; Table 3 .
|
Internal Strategy Factors |
Value |
Rating |
Score (Value x Rating) |
|
Strength: The vision and mission of the Yankestrad program is contained in the strategic plan of the Provincial Health Office, District Health Office and Puskesmas |
0,059 |
4 |
0,215 |
|
There are health workers who are Yankestrad trained and have certificates |
0,059 |
4 |
0,215 |
|
Human resources at the Puskesmas who are involved in the Yankestrad program receive training, seminars, socialization and or workshops on traditional health |
0,057 |
4 |
0,201 |
|
Continuous monitoring has been carried out from the city health office and the provincial health office |
0,053 |
3 |
0,173 |
|
There is an SOP for the implementation of Yankestrad Integration |
0,057 |
4 |
0,201 |
|
Yankestrad activities can be integrated with other programs at Puskesmas |
0,057 |
4 |
0,201 |
|
There is already a guidebook for the implementation of Yankestrad integration |
0,055 |
3 |
0,187 |
|
Recording and reporting of activities is carried out regularly |
0,055 |
3 |
0,187 |
|
Cross-sector support related to the Yankestrad program (PKK, Schools, Cadres) |
0,057 |
3 |
0,173 |
|
Total |
|
|
1,78 |
|
Weakness: Not all Puskesmas that organize Yankestrad integration have a decree |
0,053 |
3 |
0,173 |
|
The facilities and infrastructure at the Puskesmas for Yankestrad are incomplete |
0,055 |
3 |
0,187 |
|
Funding or budget is still limited |
0,055 |
3 |
0,187 |
|
Yankestrad trained officers hold a dual program so do not focus on giving Yankestrad |
0,057 |
4 |
0,201 |
|
Yankestrad trained officers are often transferred without replacements |
0,053 |
3 |
0,173 |
|
There is no clear financing regulation for integrated traditional health services in Puskesmas |
0,055 |
3 |
0,187 |
|
Yankestrad program managers are not Yankestrad trained |
0,049 |
3 |
0,148 |
|
Report content that changes frequently |
0,057 |
4 |
0,201 |
|
The flow of patient care is not clear |
0,047 |
3 |
0,136 |
|
Total |
|
|
1,59 |
|
IFE TOTAL SCORE |
|
|
0,19 |
|
External Strategy Factors |
Value |
Rating |
Score (value x Rating) |
|
Opportunities: Support from government and policy makers |
0,091 |
3 |
0,25 |
|
Policy from the central government with the discourse of traditional health programs as one of the criteria in the accreditation of Puskesmas |
0,091 |
3 |
0,25 |
|
The location of the Puskesmas area is quite wide but overall, it is easy to reach |
0,087 |
3 |
0,23 |
|
There is direction and tiered guidance from the Provincial and District / City Health Offices to program holders at puskesmas regarding Yankestrad Integration |
0,083 |
3 |
0,21 |
|
Community empowerment through Independent Orphanage Groups through the use of TOGA in their village |
0,099 |
3 |
0,30 |
|
The timing of the activities provided is adjusted to the schedule at the Puskesmas |
0,087 |
3 |
0,23 |
|
Kestrad program innovation by making snacks made from medicinal plants |
0,091 |
3 |
0,25 |
|
Until now, people at home are still using traditional medicine to treat minor complaints |
0,095 |
3 |
0,27 |
|
Total |
|
|
1,98 |
|
Threat: The development of technology and health information is increasingly sophisticated |
0,054 |
2 |
0,09 |
|
Not all patients are willing to take advantage of the integrated traditional health services available at the Puskesmas |
0,054 |
2 |
0,09 |
|
The skills to provide traditional health services at puskesmas can only be implemented on health workers with certain educational qualifications (health workers, doctors, nurses, midwives) and already have a certificate |
0,054 |
1 |
0,06 |
|
People still tend to do curative rather than promotive efforts |
0,062 |
2 |
0,12 |
|
The people's perspective on Yankestrad at the puskesmas is still on a mystical / occult pattern of thinking |
0,062 |
2 |
0,12 |
|
Total |
|
|
0,47 |
|
TOTAL EFE SCORE |
|
|
1,51 |
Based on the research results in Table 2 , it can be seen that the greatest strengths are: the vision and mission of the Yankestrad program, the availability of trained health workers with a score of 0.215, then HR involvement, the availability of SOP, and the integration of Yankestrad activities with other programs with a score of 0.201, and those who become the lowest strength is continuous monitoring from the provincial and city health offices and cross-sectoral support associated with a score of 0.173. Meanwhile, the main weakness of the Yankestrad integration program at Puskesmas I Denpasar Selatan and Puskesmas I Denpasar Barat is that the report content changes frequently with a score of 0.201 and the lowest weakness is that Yankestrad trained officers are often transferred without replacements.
Based on the results of the research in Table 4 , it can be seen that the opportunities in the Yankestrad integration program at Puskesmas 1 Denpasar Selatan and Puskesmas 1 Denpasar Barat have the greatest opportunity value is community empowerment through independent care groups through the use of TOGA in their village with a score of 0.30. Whereas the main threat is that the community still tends to curative efforts rather than promotive and the people's perspective on Yankestrad at the health center is still on a mystical / magical pattern of thinking with a score of 0.12, while the lowest threat is the skills to provide services to health workers with qualifications certain education (health workers doctors, nurses, midwives) and already have a certificate with a score of 0.06.
SWOT ANALYSIS
The total score of each factor can be detailed as follows: 1.98 strengths, 1.59 weaknesses, 1.98 opportunities and 1.51 threats. The difference between the total score of the strengths and weaknesses is (+) 0.19, while the difference between the total score of the opportunity and threat factors is (+) 1.51. After obtaining this figure, the position described by point (x, y) is sought where the evaluation of the integrated yankestrad program at public health centers in Denpasar is in Quadrant I (as shown in Figure 1 ). The strategy that fits this quadrant is a strategy to support aggressive growth policies (Growth oriented strategy) or SO strategy, namely by having opportunities and strengths so that they can take advantage of existing opportunities for the advancement and goodness of future programs (Sumarto, 2009). The results of this study are in accordance with the results of (Siswanto, 2017) study entitled "Indonesian Traditional Health Development: Concepts, Strategies and Challenges", which states that the Indonesian traditional health situation has great potential and opportunity to develop Indonesian Traditional Medicine. The right strategy is through a "3P" approach (product, practice, and provider) which is carried out simultaneously.
Observing from the position of the Yanskestrad development strategy in the SO strategy, what needs to be implemented in the development of Integrated Traditional Health Services are: 1) Advocacy to policy makers for the development of the Yankestrad program by involving community participation through the Independent Care Group, and promotive and preventive efforts, 2) Conducting routine outreach / workshop / training to increase the knowledge and capacity of health workers in the Yankestrad program, 3) Implement policies, circulars and regulations of the Minister of Health optimally in the integrated head program, 4) Make maximum use of the support from the PKK, schools, cadres, and community leaders in the use of TOGA, 5) Increase the synergy between programs at the Puskesmas so that the Yankestrad program can be integrated, 6) Monitoring, mentoring and intensive monitoring of city and provincial health offices in efforts to develop the Yankestrad program, 5) Make a commitment with the head of the Puskesmas and other personnel involved in Yankestrad to implement it optimally, and Evaluating the SOP and Yankestrad service flow at the Puskesmas periodically and updating them if there are new developments following the guidelines and technical guidelines from the Ministry of Health.
In this study, the evaluation of the Kestrad program refers to the theory of the CIPP evaluation model proposed by Stufflebeam & Shinkfield (1985) in Arikunto (2009), which states that the evaluation results will provide alternative problem solving for decision makers. The CIPP evaluation model in the evaluation of the implementation of the Yankestrad Integration program consists of 4 (four) evaluation components, namely, context evaluation variables, input evaluation variables which include the availability of human resources, infrastructure, budget and SOP / rules, process evaluation variables, and product evaluation variables. These four variables must be implemented simultaneously because each other has a close relationship. The results of the evaluations that have been carried out at two health centers, namely Puskesmas I Denpasar Barat and Puskesmas I Denpasar Selatan, show that the context variables and input variables from program implementation are categorized as good, while the process evaluation and results are in the sufficient category. It can be concluded that the evaluation of the Yankestrad integration program in the city of Denpasar is included in the sufficient category (51.67%), meaning that the Yankestrad integration program in Denpasar City has not been running optimally so that it has not had a significant impact on improving public health. This is also in line with research conducted byRahmawati et al. (2016) which states that the implementation of the integration of traditional integrated health services in Puskesmas has not been optimal. The results of research conducted by MMuslyati and Rahayu (2018) state that there is no protection for consumers as recipients of traditional health services, there are still deviations from traditional medicine actors, and do not have SOPs, are problems that need to be addressed in Yankestrad.
Internal and External Factors Determining the Implementation of the Yankestrad Integration Program Based on the analysis results, the dominant internal factors in the Yankestrad integration program are: already stated in the vision, mission and strategic planning of the provincial and district health offices; The Puskesmas has been supported by the availability of health workers who have been trained and have certificates. The disadvantages are: the manager holds multiple programs resulting in large workloads, unclear service flows, and frequently changing report content. The biggest threat is that the community still tends to curative rather than promotive and preventive efforts, and the public's view of Yankestrad is still on a mystical / magical mindset with a value of 0.12. Based on the results of the SWOT analysis, the Yankestrad program development opportunities should be directed towards community empowerment. This can be done by promoting the Yankestrad program to villages and reactivating the Independent Care Group in the village by involving the PKK and the Dasa Wisma group. The same research results were obtained from research conducted byUmamah, Suparwati, and Wigati (2017) that traditional health services have great potential in the future. Socialization and promotion need to be increased to change the mindset of the community towards traditional health, open people's insights that the integration of traditional and conventional health care is a combination of traditional and conventional health care with a clear legal basis, and recognized by the government and supported by its development to preserve the local wisdom of the Nusantara culture through traditional medicine. safe, and in accordance with the law.
Based on the results of the evaluation on the standard results / products of the Yankestrad integration program at the Puskesmas, it is included in the sufficient category with a value of 40% at Puskesmas I Denpasar Barat and 50% at Puskesmas I Denpasar Selatan. So that overall in Denpasar City, the results of the Yankestrad integration program in the health center were included in the sufficient category (49.68%), where of the two Puskesmas that were observed had not been able to implement all indicators of traditional health services. All of them have their respective limitations and shortcomings, need to be addressed and solutions found so that they can achieve the program output. This is in line with the results of research byRahmawati et al. (2016) which states that the implementation of the integration of traditional health services at the Halmahera Health Center has not been optimal, the facilities and infrastructure for integrating traditional health services are incomplete, low budget support, trained health workers, as well as a small budget so that support from the government is urgently needed. For the continuity of the development of this program, it is necessary to formulate a strategy and planning that is always based on the evaluation results that have been obtained.
CONCLUSION
The integrated yankestrad program at the Puskesmas in Denpasar city is in a sufficient category, and a strategy that can be applied in the development of Yankestrad is to support an aggressive growth policy (Growth Oriented Strategy), namely by maintaining opportunities and strengths so as to increase the progress and sustainability of the program. Through the Yankestrad integration program, it can assist the community in health recovery efforts as alternative medicine and supporting therapy. Community empowerment through traditional health independent care groups in villages will be able to assist the community in maintaining their health independently through the use of TOGA.
ACKNOWLEDGMENTS
Our gratitude goes to the research supervisors, respondents, managers of Puskesmas I Denpasar Selatan and Puskesmas I Denpasar Barat, and managers of the Yankestrad program at the Denpasar City Health Office.
