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Singapore International Foundation 2004
Published by
Singapore International Foundation
9 Penang road
#12-01 Park Mall
Singapore 238459
First Published June 2004
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording or otherwise, without the prior written permission of the
copyright holders.
No responsibility for loss occasioned by any person acting or refraining from action as a
result of the material in this publication can be accepted by the authors, sponsor or
the publishers.
ISBN 981-04-9688-5
Designed in Singapore by Onion Design Pte Ltd
Sponsored by the Lee Foundation Community Abroad Assistance Fund. This publication
is not intended for commercial sale.
3
CONTENTS
Foreword by Minister for Health, Indonesia
Message from President, Indonesian Medical Association
Message from Chairperson, Indonesian Association of Family Physicians
Message from Chairman, Board of Governors, Singapore International Foundation
Message from Chief Executive Officer, World Organisation of Family Doctors (Wonca)
PREFACE 10
SVO Specialist Team (Family Medicine) Project Leader and Wonca Regional
President, Asia Pacific Wonca
Country Representative, Indonesia
SECTION 1 HEALTHCARE DELIVERY SYSTEM IN INDONESIA 13
SECTION 2 FAMILY MEDICINE ORIENTED PRIMARY CARE 23
1. Vision of Family Medicine Oriented Primary Care
2. Introducing Family Medicine to Health Care Systems
3. A Training Programme for Indonesia
SECTION 3 PACKET A CONCEPTS OF FAMILY MEDICINE 41
1. The Central Values of Family Medicine
2. Personal Care, Continuing Care and Comprehensive Care
3. Family as a Unit of Care
4. Emergency Care, Housecalls and Home Care
5. Palliative Care
SECTION 4 PACKET B MANAGING THE FAMILY MEDICINE PRACTICE 77
1. Managing People & Resources
2. Managing Facilities & Utilities
3. Managing Information
4. Managing Finances, including Managed Care
SECTION 5 PACKET C MEDICAL TECHNICAL SKILLS & CARE IN 111
SPECIFIC SITUATIONS (A) PRACTICE SKILLS
1. The Consultation Process
2. Communication Skills
3. Counselling Skills
4. Changing Behavior
5. Disease Management Skills
6. Emergency Care Skills
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SECTION 6 PACKET C MEDICAL TECHNICAL SKILLS & CARE IN 167
SPECIFIC SITUATIONS (B) COMMON SYSTEMS
1. Fatigue 11. Vomiting
2. Weight Loss 12. Abdominal Pain
3. Fever 13. Skin Rash
4. Dyspepsia 14. Backache
5. Breathlessness 15. Joint Pain
6. Cough 16. Giddiness
7. Sorethroat 17. Headache
8. Chest Pain 18. Insomnia
9. Diarrhoea 19. Persistently Crying Baby
10. Constipation 20. Red Eye
SECTION 7 PACKET C MEDICAL TECHNICAL SKILLS & CARE IN 257
SPECIFIC SITUATIONS (C) SPECIFIC DISORDERS
1. Cardiovascular and Respiratory Disorders
2. Gastrointestinal Disorders
3. Renal and Hematological Disorders
4. Psychological Disorders
5. Skin Disorders
6. Bone and Joint Disorders
7. Nervous System, Eye and Ear Disorders
8. Nutritional, Metabolic and Endocrine Disorders
SECTION 8 PACKET D APPLIED MEDICINE IN THE VARIOUS 361
AGE GROUPS
1. Child and Adolescent Health
2. Womens Health
3. Mens Health
4. Health of the Working Adult
5. Elders Health
6. Public Health
SECTION 9 TEACHING FAMILY MEDICINE 477
1. Tasks of Teaching
2. Curricular Planning
3. Organising the Workshop
4. Giving a Lecture
5. Small Group Teaching
6. One-to-one Teaching
7. Formative and Summative Assessments
SECTION 10 ROADMAP OF FAMILY MEDICINE RESEARCH 501
5
FOREWRD
FAMILY MEDICINE ORIENTED PRIMARY CARE IN INDONESIA
I am pleased to write this foreword. Indonesia is a huge country sometimes referred to as
the country of a thousand islands. Making health care accessible and affordable is the
responsibilility and great challenge of any Government.
The solution lies in the development of a common vision amongst the various stakeholders
in Government, Professional, Voluntary and Private Sectors. The integration of health
promotion and disease prevention, cure and care services, as well as health care system and
health financing reforms are the operational aspects to the solution.
The present health care delivery system in this country has been built around the twin pillars
of public health and hospital specialist care. WHOs Health for All movement introduced
through the Alma Ata Declaration in 1978 created a paradigm shift of making primary care
the central focus of healthcare delivery for each country. This is the bridge between the two
pillars, which in my opinion would integrate the whole spectrum of health care. This bridge
is now strengthened by the development of Family Medicine oriented prmary care.
The developement of a general practice/family medicine practice to meet the needs of
people has been taking place around the world in the last thirty years. This gathered
momentum with the formation of Wonca as the world forum for family doctors. General
practice/family medicine and its concepts are not new, but nevertheless require a
renaissance to bridge the twin pillars of modern public health and hospital specialist care.
Indonesia sees the need to develop its general practice/family medicine practice too. In this
context, I am pleased that the various stakeholders in healthcare delivery have got together
and with the fillip provided by the Singapore International Foundation and Wonca Family
Medicine leaders in this part of the world have begun to make an impact.
The gift of this Primer on family Medicine Practice from the Singapore International
Foundation will help to speed up the capacity building of our frontline doctors to provide
Family Medicine oriented primary care. I am told that it will be the forerunner of a Primer
written in Bahasa Indonesia by Indonesian Family Medicine leaders.
Finally. I must thank the Singapore International Foundation and through them, the Lee
Foundation who funded the printing of this project, the Family Medicine leaders in
Singapore and in this country, the various healthcare stakeholders for pursuing the vision of
Family Medicine oriented health care in Indonesia. May I wish you great success in this
journey into the future.
Dr Achmad Sujudi
Minister for Health
Republic of Indonesia
Jakarta
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MESSAGE FROM PRESIDENT,
INDONESIAN MEDICAL ASSOCIATION
The move to expand Family Medicine in Indonesia began in the early 1980s following a
decision made in the 1982 national meeting of the Indonesian Medical Association (IMA).
But over the last two decades, the development of Family Medicine in Indonesia has not
made significant achievements. The fragmentation in the development of Family Medicine
and the lack of resources in health care delivery system development are two main reasons
identified. The development of Family Medicine in Indonesia should be managed together
with the involvement of all stakeholders with the IMA playing an important role. Family
Medicine is now listed as a top priority programme of the IMA.
There are many things to do. This Primer on Family Medicine Practice as a product that
resulted from the technical cooperation between the Singapore International Foundation
(SIF) and the Ministry of Health Republic of Indonesia together with the Indonesian
Association of Family Physicians (IAFP), is one of the fundamental and strategic steps of
achievement.
On behalf of IMA, I express my appreciation and sincere gratitude to the SIF and the SVO
Specialist (Family Medicine) Team for their assistance in providing this Primer on Family
Medicine Practice as a part of an important phase in the development of Family Medicine in
Indonesia.
My heartfelt thanks go to the writers for their work that makes this book a very valuable
thing for expanding Family Medicine in Indonesia.
Professor Dr. Farid Anfasa Moeloek, Obgyn
President
Indonesian Medical Association
Jakarta
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MESSAGE FROM CHAIRPERSON,
INDONESIAN ASSOCIATION OF FAMILY PHYSICIANS
It was two decades ago when the Indonesian Medical Association (IMA) affirmed the need
for developing Family Medicine in Indonesia in the framework of restructuring the
healthcare system in Indonesia. But the situation at that time was different. Policies and
programmes were not suitable enough for the advancement of the Family Medicine. Many
fragmented efforts were made, but did not achieve good results.
The situation is changing today. Since 1998, following a Letter of Understanding between
the Ministry of Health Republic of Indonesia (MOH-RI) and the Singapore International
Foundation (SIF) Republic of Singapore, Indonesia has developed many programmes
designed to facilitate the development of Family Medicine in Indonesia. The SVO Specialist
(Family Medicine) Team, the MOH-RI together with the Indonesian College of Family
Physicians (now renamed by the Indonesian Association of Family Physicians) have
conducted training programmes for practitioners and trainers in Family Medicine, and
based on the above experiences, they have also developed this Primer on Family Medicine
Practice.
Within the context of overall development, and in line with the new national health system,
the development of Family Medicine is increasingly recognised as a major priority. With the
focus to develop Family Medicine, this Primer on Family Medicine Practice undoubtedly
reflects high interest that this vital programme takes off successfully.
On behalf of the Indonesian Association of Family Physicians, I wish to express my sincere
thanks to the SIF and the MOH-RI for their efforts to provide this book. It also conveys a
feeling of great hope and optimism that this book will bring improvement in the
development of Family Medicine in Indonesia.
Professor Dr. Azrul Azwar, MPH
Chairperson
Indonesian Association of Family Physicians
Jakarta
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MESSAGE FROM CHAIRMAN, BOARD OF GOVERNORS,
SINGAPORE INTERNATIONAL FOUNDATION
The Singapore International Foundation is pleased, through the SVO Specialist Team (Family
Medicine) Project, to be able to contribute to the development of Family Medicine oriented
primary care in Indonesia.
Started in 1998, the collaboration between Family Medicine leaders from Indonesia and
Singapore seeks to introduce and reinforce the core precepts in the practice of Family
Medicine oriented primary care to stakeholders in the Indonesian health sector. Using the
approach of Training of Trainers to build capacity, our Singaporean volunteer team and its
Indonesian partners have worked untiringly at upgrading the skills and knowledge of
practising family physicians and trainers in the Universities.
Their steadfast efforts have paid off. There is now a perceptible acceptance and
implementation of Family Medicine oriented primary care by both Indonesian medical
educators and practising family doctors. Through the process of forming, storming,
norming, and performing, the Indonesian Association of Family Physicians together with
the Ministry of Health, have developed a four-packet Family Medicine oriented primary care
training programme. Packet A with its focus on imparting the concepts of family medicine
and Packet B that focuses on the management of services have been introduced. Packet C
that focuses on medical technical skills and Packet D that focuses on applied medicine in
the various age groups of the population are next to be rolled out.
To commemorate the successful completion of this significant partnership project, the
Singapore International Foundation is pleased to publish this book as a resource guide for
the development of the four packets of Family Medicine oriented primary care programme
in Indonesia. Together with our corporate partner, the Lee Foundation Community Abroad
Assistance Fund, we are honoured to present it as a gift to Family Medicine doctors of
Indonesia and their patients.
I also have the pleasure to record our thanks to Associate Professor Goh Lee Gan, his team
members and their Indonesian partners for not only putting this book together, but also for
demonstrating the rewards of bringing people from different communities and cultures
together to learn from one another in a spirit of mutual respect and growth.
Mr Barry Desker
Chairman, Board of Governors
Singapore International Foundation
Singapore
9
MESSAGE FROM CHIEF EXECUTIVE OFFICER,
WORLD ORGANISATION OF FAMILY DOCTORS (WONCA)
I am pleased to contribute a message to this Primer on Family Medicine Practice as the CEO
of the World Organisation of Family Doctors (Wonca). This Primer represents an important
step forward in the development of Family Medicine in Indonesia as well as a milestone in
the collaboration between the primary care medical professions of Indonesia and
Singapore.
Family Medicine is an important bridge between hospital care and public health. Countries
around the world have paid much attention to develop both hospital care and public
health. The missing link to a seamless system of care is the healthcare provider (the
vocationally trained Family Doctor) who is focused on the patient as an individual and as a
member of the family unit that he or she belongs to. It is therefore timely that Indonesia
sets its vision to develop this bridge.
Well-trained family doctors can help to save costs for the nation in three ways. Firstly, by
being judicious gatekeepers, they help to relieve the overloaded hospitals and reduce
ballooning hospital care costs. Secondly, the preventive focus of family medicine will help to
reduce the disease burden from chronic diseases like hypertension, diabetes mellitus and
the resultant complications of ischaemic heart disease, strokes, renal failure and blindness.
And finally, family medicine has the best chance among the stakeholders of healthcare
delivery to persuade all other stakeholders, namely, the policy maker, the healthcare
professional, the academician, the health care manager, and the community to work
together towards the unity for health (TUFH). The savings of healthcare costs are likely to be
substantial if each of the stakeholders pulls his or her weight in the same direction, instead
of different directions. This is the vision of TUFH as a collaborative project of Wonca and
WHO - working towards unity for health.
The Family Medicine programme in Indonesia is now gathering good momentum. It has
designed its curriculum of training consisting of four packets of modular Family Medicine
training programme. There are now some 89 trainers exposed to family medicine teaching,
thanks to the efforts of the Singapore International Foundation. And the universities in
Indonesia are now looking into introducing Family Medicine into its undergraduate
programme.
This Primer would have served its purpose if each copy is read and used extensively. It will
be a catalyst for more development in Family Medicine oriented primary care in Indonesia.
My best wishes in your future endeavours in the development of Family Medicine.
Dr Alfred WT Loh
Chief Executive Officer
World Organisation of Family Doctors (Wonca)
Singapore
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PREFACE FROM SVO SPECIALIST TEAM (FAMILY MEDICINE)
PROJECT LEADER & WONCA REGIONAL PRESIDENT, ASIA PACIFIC
This Primer on Family Medicine Practice is a milestone in the development of Family Medicine
oriented primary care in Indonesia. The knowledge base of Family Medicine is broad.
A Primer is a first book. It is a road map that has sufficient details, but without being
bogged down by minutiae.It is a starting point from which the reader will be directed to
further readings and the school of life to acquire the experiential skills of caring for patients
in the Family Medicine oriented way. The contents of this Primer has been organized with
the Indonesian Family Medicine Teaching Programme in mind namely, the four-packet
modular system.
It has been written in English because it is the fastest way to get the body of knowledge
together in the time available. Hopefully, it can be translated and expanded to meet the
needs of the family doctors as time goes on. As has been pointed out by my colleague Dr
Sugito whom I have worked closely in this SIF project, the content is likely to change over
time as knoweldge and care situations change. It would then be time to write a new Primer,
this time in Bahasa Indonesia.
Thanks are due to my many colleagues and friends in Indonesia who have been the
fountain of strength and source of encouragement that made the effort of producing this
Primer meaningful. In particular I would like to thank Professor Azrul, Dr Widyastuti, Dr
Sugito, Dr Lucky, Dr Nitra, Dr Dhanasari, Professor Asiniati, Dr Donald Padede, Dr Erna
Mulati, Dr Trisa Wahjuni Putri, Dr Zulnilda, Dr Yulherina and Dr Ferlindah for their unstinting
support, encouragement and hospitality. I hope I have not missed out anybody.
Thanks are due to my many friends, my colleagues in the Family Medicine world and the
Wonca world both in Singapore, Philippines, Australia and beyond as well as my colleagues
in the hospital specialities in Singapore for their written resources. To each of them, too
many to mention by name, I gratefully acknowledge the resources used.
I would also need to thank the Chairman and Director of the Singapore Volunteers
Overseas (SVO) Programme in the Singapore International Foundation for the opportunity
to lead this Family Medicine Project with the Ministry of Health in Indonesia. In particular, I
would like to thank the many SIF staff, both present and past, all of whom I have great
satisfaction in working with. They are Ms Lee Mui Ngah, Ms Coleen Beck, Ms Rosemary
Chng and Ms Lydia Ang. Grateful thanks are due to Mr Tan Beng Seng and his staff from
Onion Design Pte Ltd who have worked hard to get this Primer out of the press within the
really narrow margins of time that I have given them. I must not forget to thank Lee
Foundation Community Abroad Assistance Fund who have generously sponsored the
printing of this Primer.
Associate Professor Goh Lee Gan
SVO Specialist (Family Medicine) Team Leader
Wonca Regional President, Asia Pacific
Singapore
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PREFACE FROM COUNTRY REPRESENTATIVE WONCA, INDONESIA
The principles of Family Medicine, albeit in parts, have long been implemented in
Indonesia and could be in any other countries as well, Most general practitioners, since the
early years of medical education, namely, during their undergraduate schooling and
training, have been introduced to the practice of medicine in the family doctors way. In my
opinion, Family Medicine is the generic of medicine and family doctor is the generic of
medical doctor. Since specialties are in fact the branches of medicine, they are also the
branches of Family Medicine. This rationale implies that the practice of medicine, in any
specialty and general practice is included, there should be the learning of the principles of
Family Medicine. This is the only way to establish an effective and efficient health care
delivery system that leads to quality health care. Family Medicine oriented health care
service in not only primary care but also secondary, and tertiary care is considered
fundamental. This becomes the unifying aspect of health care - a service delivery that pays
attention not only to cure but also prevention; a service that is more than caring for diseases
in disordered organs.
Community oriented medical services instead of individual, family, and community
oriented medical services has been introduced for long time in many countries including
Indonesia in accordance with WHO policy. Indonesian undergraduate medical teaching
has been set to produce doctors who will deliver community oriented medical services;
most of the graduates will then work in a community or public health centres (PHC)
provided by government. As a consequence individual and family oriented medical
services, and the other Family Medicine services especially the coordinative and
collaborative cares is not given enough emphasis. District oriented PHC have been
established throughout the country and they effectively provide community oriented
health care services; they do fortunately make available individual medical care as well. In
the meanwhile, most general practices are held by solo practice general practitioners
who are formerly, during their undergraduate education, conditioned to deliver
community oriented health services. However some general practitioners naturally apply
family practice principles in serving their patients although not in the complete setting of
Family Medicine oriented practice. Thus, in my opinion, instead of entirely new medical
entity, Family Medicine is an attempt to go back to the origin of medicine. It is a
renaissance of medicine and is welcomed.
The other problems in Indonesia are the large number of private and new state faculty of
medicine with varying quality of training, which in turn produce a large number of new
medical doctors each year with varying quality of professional skills. The standardization of
competence and services is therefore mandatory. In addition, by the emergence of Family
Medicine as a new paradigm in providing quality medical services, addditional and
conditional training to be a family physician or family doctor, must be considered
obligatory. This book will be very useful in providing the beginning of such standardization
and additional training.
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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 Dealing with the Principles of Family Medicine
Packet B Dealing with Managing the Family Medicine Practice
Packet C Dealing with Medical Technical Skills and Care in Specific Situations
Packet D 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
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Edited by
Goh Lee Gan
Azrul Azwar
Sugito Wonodirekso
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