Health developments continue to be improved by the government, especially in the border area, mainly directed at the area of eastern Indonesia. Health development activities towards the Universal Coverage 2019, with priority programs to achieve the expansion of health coverage, equitable access to health services, adequate health facilities in the border area, and to increase the promotive, preventive and disease mitigation (Ministry of Health 2010). Health development in particular on the border area, explicitly in the Decree of the Minister of Health of the Republic of Indonesia Number: 331/Menkes/SK/V/2016 about Health Strategic Plan 2005-2019 (Ministry of Health 2006).
The goals of health development are to facilitate the community in accessing health services and equitable distribution of qualified health services in the border area. In facilitating the access and equity of health services, the Ministry of Health has drawn up plans of action and development, namely: 1) Mobilizing and empowering communities in the border area, 2) Improving access of community in the border area to qualified health care, 3) Improving health care financing in the border area, 4) Improving the skill of health workers in the border area, 5) Increasing the availability of medicines and supplies and, 6) Improving the management of health centers in the border area, including surveillance system, monitoring and evaluation, and Health Information systems (Ministry of Health 2010).
West Kalimantan is one of the provinces in Indonesia which is directly bordering Sarawak Malaysia. The border areas including Badau, Puring Kencana, Senaning, and Entikong. The border area is a storefront of a country. Besides, the border area has geographically distant from urban areas, and have problems of road infrastructure and low economic levels. Another issue in the border area is the lack of availability of public health facilities, support, and health workers.
The National Health Insurance (in Indonesia, called Jaminan Kesehatan Nasional) began in 2014, held by the Agency for the Implementation of the Social Security (Badan Penyelenggara JaminanSosial /BPJS) and the enactment of Law No. 24/2011 about BPJS. The National Health Insurance gradually went toward Universal Health Coverage in accordance with the road map to Health Insurance in 2019 (GTZ, AusAID 2012). Generally, the purpose of the National Health Insurance is to facilitate a community for accessing health services and getting qualified health services. Universal Health Coverage is a very good thing but probably have some impacts. Unequal availability of health facilities, health workers and geographical conditions, caused a huge gap of qualified health services between provinces and the border area.
Ministry of Health develop an action plan to be applied in the field, such as increasing the skill of non-permanent health workers, giving permission to health workers to continue their study, and adding the availability of transportation in the border area (Ministry of Health 2010). In 2016, the Ministry of Health and Ministry of Utilization of State Apparatus and Bureaucracy Reform recruited the non-permanent health workers to become a civil servant to supply the needs of health workers in health centre in the border area (Ministry of Health 2015). However, it was not always accompanied by the readiness of health workers to be placed and serve in the border area.
Based on the situation, the authors are interested in conducting a study on the analysis of health policy in the border areas of West Kalimantan.
This research was a descriptive qualitative approach, aiming to analyze health policies in the border area including Badau and Puring in Kapuas Hulu District, Senaning in Sintang District, and Entikong in Sanggau District, West Kalimantan Province. This study was a literature review. The author performed the analysis of documents/policies, news, websites and any literature associated with the research topic.
3. Results and Discussions
Equitable health workers in the border areas
Equitable Health Workers in the Border often become a problem. This is due to the vast area of health centers in the border area so that the health workers are difficult to reach the community in its work area. The recruitment of health workers, especially non-permanent doctors, with a year contract period and its incentive pattern is not optimal yet, as well as health workers are still concentrated in urban areas (Dwiyanto 2011).
Health workers, especially civil servant doctors, as a head of the health center have larger duty and responsibility but they get less reward than the non-permanent doctor with less responsibility and less experience. Sustainability of the non-permanent doctors is a challenge since the contract period is only one year, thus affecting the management systems and affecting the quality of health services in health centers. Also, there are more health workers in urban areas compared to border areas. The low level of patient visits to health centers in the border area proved the difficulty for people to access health services because of a geographical location. Lack of transportations and low capability to pay for the cost of transportations also contributed to the low level of patients visit.
People in border areas expect health workers from the health center to perform home visit or closer with them. Therefore, people tend to call the health workers, especially nurses and midwives, to come to their home because they consider the cost of calling the health workers to come to their house is same with the cost if they come to the health center. This situation showed that health workers are less useful in performing their duties. It is supported by research that conducted by Wasis et al. (2007), stating that 32.9% of working time nurses are not effective, while a midwife is approximately 43.09% work less effective (Wasis B, Agus, Ristrini 2007). Planning of health workers needs in the health center should be done with macro and micro level analysis. Macro-level analysis helps to know how many personnel needed while micro level analysis will determine the type of health workers that should be recruited (Rienke William 1998).
Health insurance system in the border area
The National Health Insurance (NHI) beginning in 2014 which was held by the Agency for the Implementation of the Social Security and the enactment of Law No. 24/2011 about BPJS. The NHI gradually went toward Universal Health Coverage by the road map to Health Insurance 2019 (GTZ, AusAID 2012). The general purpose of the National Health Insurance is to facilitate a community for accessing health services and getting qualified health services.
The results showed that the observation of one of the villages in the border area of a total of 50 families, only eight families who got the NHI freely from the government, in this case, was from BPJS. The results of the interview to the chief of the village found that the local community never got the socialization about health insurance from related parties. Therefore, the people in the border areas had not obtained the NHI equally. The NHI in the border areas would have an impact on the occurrence of health care disparities among regions in Indonesia, especially in border areas.
Basic health facilities and infrastructure in border area
Health infrastructure in the border area was inadequate, caused by the supportive infrastructure in a health center, such as laboratory, still incomplete and could not make the community satisfied. Besides, the medicine in the health center was incomplete and often out of stock. The result of observation showed that some tools in the health center, such as a sphygmomanometer, was not suitable to be used. Then, the emergency tools, such as oxygen tube, there was only one provided and often no oxygen inside.
This was supported with research conducted by Ristrini et al. (2004) and Handayani et al. (2006), showing that the medical equipment in the health center was still not sufficient. The number of emergency cases requires specialized equipment and skills, but in reality, it was still lacking. Because primary health center was the first provider to handle emergency cases, the provision of emergencies equipment should be available at all primary health care (PHC). Also, skills of health workers who are responsible at the health center should be improved (Hand et al. 2004; Ristrini et al. 2004).
Referral transportation in border areas
The referral transportation is very limited and costly, whether in land or river areas. At the primary health care (PHC), it only provided one ambulance. Use of referral transportation just was used when a patient required further treatment to the secondary level at the hospital which was located in the capital district. Patients who do referrals to hospitals were often not accompanied by health workers from health centers.
Integrated health care could address the problems of health care in border areas. The integrated health system is divided into two approaches: institutional approach and systemic approach (Anwar 1996). The contributors who can make integrated health care goes well was the government, technology, and transportation (Sheppard 2005). The government tried to solve the transportation problem to empower the community through a program named DesaSiaga. DesaSiaga is a village that has a readiness and ability to prevent and handle health problems (such as disasters and health emergencies) independently (Ministry of Health 2010).
4. Conclusions and Recommendations
• Health workers in the border area had not been able to provide optimal health service to the community.
• Health insurance in the border areas was not evenly distributed optimally.
• The availability of health care facilities and infrastructure in border areas was still not provided well.
• The referral transportation system in primary health care did not work properly.
• Increasing the number of health workers in the border areas and providing more intensive qualified training for health workers in border areas.
• Socialization about the NHI on communities in border areas should be implemented more intensive.
• The government should conduct fulfillment of the availability of facilities and infrastructure of health services in health centers in the border area, at least the same level as with the neighboring country's health services services by adding transportation health facilities in the border areas with the provosion of a referral transportations.