EPIDEMIOLOGICAL STRATEGIES IN PRIMARY HEALTH SERVICES

️
Innovation is the application of ideas or ideas, which are generated by creativity which
is a mental process and thought process. An innovation produces services or ways of
working that are more efficient (Setiawan, 1985). Decision-making based on evidence is an
idea, the result of creativity from experts in various sciences, including epidemiology. The
application of evidence-based decision-making to health service/program management is
an innovation in health care ( Budiarto , E. 2003).
Epidemiology is one part of public health science which is concerned with the
presence of diseases and other health problems in society (Bustan MN. 2002). According
to Rohtman , KJ. (2008) Epidemiology is an attempt to determine the distribution of
disease and how various factors cause the disease. Epidemiology has a role in the field of
public health in the form of: 1). Explain the magnitude of health problems and disorders
(including diseases) and their distribution in a certain population. 2). use essential
data/information for the purposes of planning, implementing programs, as well as
evaluating various activities in the community, both prevention and control of disease and
other forms as well as determining the priority scale for these activities. 3). determine the
various factors that cause problems or factors related to the occurrence of these problems
( Sutrisno , B. 2010).
In carrying out its role, epidemiology cannot be separated from its relationship with
other Public Health disciplines such as Public Health Administration, Biostatistics ,
Environmental Health, and Health Education/Behavioral Science ( Murti , B. 2003). For
example, the role of epidemiology in the health planning process. It appears that
epidemiology can be used in the planning process which includes selecting priorities,
setting goals, explaining activities, coordinating and evaluating.
In addition, in preparing a health education intervention, epidemiology can be used in
making an “Epidemiological Diagnosis” of the problem that requires the intervention. As
an example of its role as a tool for diagnosing public health conditions, epidemiology can
provide an overview or diagnosis of problems related to poverty (poverty) in the form of
malnutrition, overpopulation, low infant health, alcoholism, anemia, parasitic diseases and
mental health ( Lapu , 2009). ).
 According to Birwin (2018), health development aims to increase awareness,
willingness and ability to live healthy for everyone, in order to achieve the highest degree
of health both physically, mentally and socially through promotive , preventive, curative
and rehabilitative efforts. Humanity-based health development, community empowerment,
independence in a fair and equitable manner, through a life cycle approach.
Health development is carried out by taking into account population dynamics, disease
epidemiology, ecological and environmental changes, progress in science and technology,
and globalization. National development must have a health perspective, where every
public policy must pay attention to the impact of development on health. Health
development efforts are carried out by increasing: 1) Health efforts, 2) Health financing, 3)
Infrastructure, 4) Health human resources, 5) Pharmaceutical preparations and medical
devices, 6) Health management and information, and 7) Community empowerment
( Enjang I. 1979).
To fulfill access and health services towards universal health coverage, the
Government and local governments also support privately owned First Level Health
Facilities including: Primary Clinics , Doctors' Independent Practices and Dentists to act as
health service providers. To guarantee the quality of health services at the Primary Clinic ,
Doctor's Independent Practice and Dentist's Independent Practice, the private FKTP must
also meet standards and be accredited. One of the strategies taken to improve the quality of
services at the Puskesmas is to improve the quality of health human resources who provide
services at the Puskesmas, especially doctors through Specialist Education, namely the
Primary Service Family Medicine Specialist ( SP.KKLP ) which is supported by complete
infrastructure and medical equipment to support service .

METHOD
The purpose of this article is to show innovations in how epidemiological strategies
can be useful in primary health care. While the method of writing is done using content
analysis (Lapau , 2011) on the literature concerning health efforts, MDGs, epidemiology,
evidence-based decision making, decentralization of health services, higher education in
public health and health financing.

DISCUSSION
 In Indonesia to date, the rates of neonatal, infant and under-five mortality differ
between rural and urban areas, rich and poor, higher education and low education, and
among other provinces have not seen a significant decline. In addition, several non-
communicable diseases such as coronary heart disease, diabetes mellitus, several types of
cancer are also increasing. In fact, these deaths and diseases can be reduced if the primary
health services included in the Community Health Efforts (UKM) run well.
In the National Health System (MOH, 2004) written two health efforts, namely
Community Health Efforts (UKM) and Individual Health Efforts (UKP). SMEs consist of
three strata, namely the first strata, second strata and third strata. The first strata of SMEs
have 3 functions, namely:
1. Center for driving health-oriented development
2. Center for community empowerment in the field of health and
3. Primary health care center- peripheral health service unit at the puskesmas.
Primary health service units that are included in the first strata of UKM and
implemented at the puskesmas level at least consist of:
1. services include health promotion, maternal and child health and nutrition
improvement
2. Preventive services including family planning, environmental health and disease
control
3. Curative health services that only include simple treatment.
Primary health services included in the second strata of SMEs can be explained as
follows: The person in charge is the district/city health office which is supported across
sectors. Its functions include managerial functions including planning, and controlling, as
well as supervision and responsibility in the implementation of health development, and
technical functions which consist of 7 activities as mentioned above.
Primary health services included in the third strata of SMEs are located at the central
level as follows: Directorate General of Community Health Development Ministry of
Health is managed by health promotion, maternal and child health and nutrition
improvement. At the National Family Planning Coordinating Board (BKKBN) family
planning is managed. At the Directorate General of Disease Control and Environmental
Health, Ministry of Health, disease control and environmental health. At the office of the
State Minister for the Environment, environmental health is managed and at the
Directorate General of Medical Services, treatment is managed.
 Since 2000 the Millennium Development Goals (MDGs) have been announced (
Lapau , B. 2011 ), namely:
1. Eradicate extreme poverty and poverty
2. Equitable distribution of basic education
3. support gender equality and women's empowerment
4. Reducing child mortality
5. maternal health improvement
6. Combating HIV/AIDS, malaria and other diseases
7. Ensuring environmental sustainability
8. global partnership for development.
If the 8 objectives of the MDGs are considered, then the MDGs number 4, 5 and 6 are
related to the health sector. Primary health services in the MDGs are nutrition, maternal
and child health services, eradication of infectious diseases, especially TB, malaria and
HIV/AIDS, clean water and essential medicines . However, primary health care activities
should not only focus on the MDGs which are international programs, we should not be
careless about other infectious diseases, non-communicable diseases and other health
programs ( Hardisman , H. 2009 ). Thus supporting the MDGs is only part of the goals that
must be achieved by health services, although it may be a priority. The purpose of a
program is to overcome the problem situation through the determinants or factors that
relate or influence the problem situation. Thus, to achieve a primary health care program
goal, including the MDGs, it is necessary to include epidemiology ( Azrul , A. 1999).
Epidemiology is a science that aims to diagnose public health problems, identify the
natural history and etiology of disease and provide information that can be used for the
management of health services/programs (Lowe and Kostrzewski , 1973). For these three
objectives, there are two epidemiological strategies, namely epidemiological surveillance
and epidemiological research. Both surveillance and epidemiological research are activities
of collecting, processing and analyzing data to produce information and subsequently
produce information as evidence. The difference is that surveillance is a routine activity,
while research is carried out when there is no or less information from the results of
surveillance (Bustan, 2006).
Decision-making based on evidence is a scientific approach, especially epidemiology (
Gerstman , 2013) which is applied in health service management as an innovation. In this
case, the system approach in health services/programs is carried out as follows:
 Input → Process → Output → Effect → Impact
Inputs are resources (human labor, facilities/logistics and money for financing) needed
so that system processes (activities) can run directly so that the resulting output can be
measured immediately. Effects are people who can accept or reject health
services/programs and the impact describes the health status of the community as measured
by mortality, disease rates and/or numbers (Morton, 2003). If the community rejects the
service system/program, then the output target may not be achieved. If the community
accepts it, then the output can be achieved and the impact is likely to improve.
As above, the epidemiological strategy, either surveillance or epidemiological
research, carries out activities for collecting, processing and analyzing data so that
information is generated. If you want information to be used as evidence, four activities are
needed, namely relevance, coherence, population context, geography and management
cycle. Relevance answers the question of whether the indicators in output, process, input,
effect and impact are related to each other. Coherence answers the question of whether the
relationship always occurs according to time and place. Population context and answers the
question of whether the information generated is useful for certain population groups and
geographies ( Lapau , B. 2013) . The cycle answers the question of whether the
information generated is useful for planning, monitoring and inquiry.
One of the data inputs at the national level in 3 provinces in the Province of NTT, Bali
and Lampung, shows that the financing of public health programs ranges from 2.9% to
12%, while the costs for individual health programs range from 32.1% to 66.6 %, then the
cost of building expansion ranges from 28.8% to 55.7%. It is clear that financing for
primary health services in terms of prevention and promotion is far less than curative
services. Experience in Denmark dealing with salmonellosis with investigations towards
prevention is much cheaper than experience in the United States which treats salmonellosis
with only curative methods ( Sardjana , 2007).
Evidence-Based Decision Making (PKBB) in the management of health
services/programs is difficult to do nationally based on basic data and information from
districts and provinces. Therefore, PKBB needs to be carried out at the district/city health
office, puskesmas and hospitals. PKBB at the district level aims to:
1. Intensify the implementation of health programs
2. improved health management
3. do partnerships for the success of point one and point two
 In the framework of item one , sub- disciplines are needed epidemiological
surveillance and operational research, while in the context of item two , strategic
management and quality management/audit sub-disciplines are needed ( Timrmeck , 2005).
To achieve the three objectives above, at the district/city health office level, it is necessary
to form a District Management Epidemiology Team (TEMK) that works as follows:
1. Provide skills to district health office staff, puskesmas and hospitals to plan and
implement epidemiological surveillance and conduct research
2. Coordinate the activities of interpreting information into evidence that can be used
by the head of the district/city health office for decision making in order to
formulate strategies and operations that are advocated to BAPPEDA, DPRD, and
across sectors
3. assist the head of the district health office to monitor and assess health programs
At the puskesmas level, a Puskesmas Management Epidemiology Team ( TEMPus )
was also formed whose function was to interpret information into evidence for decision
making by the head of the puskesmas for planning, monitoring and health
services/programs. Until now, almost all district/city health offices and puskesmas have
not had TEMK and TEMPus . To fill a position in TEMK, it requires staff with a master's
qualification in public health, specializing in management epidemiology, and for TEMPus ,
a public health graduate with an epidemiological specialization is required ( Zulfitri , R.
2017) .
At this time in Indonesia there have been around 150 to 160 public health
undergraduate study programs that do not have an epidemiological management
specialization and less than 10 public health master's study programs, only 2 with an
epidemiological management specialization. Although too many public health study
programs have been established, with the decentralization policy, regional leaders who
appear to have appointed officials in health agencies who are not qualified in the health
sector.

CONCLUSION
1. Health problems that should be addressed with primary health services have not
shown a downward trend.
2. Government policy in planning health services seems to depend on international
encouragement alone, has not used epidemiology in the context of decision making
 that is integrated with science related to management and communication/advocacy
to address health problems
3. Although there are already many established and high schools related to public
health, the ability of graduates to make decisions based on evidence, thus enabling
the management and management of health services can overcome diseases that
should be overcome by primary health services.
4. With the decentralization of health services, local governments have all-in-one
power, including health officials who have health expertise, who do not understand
preventive and promotive health services so that primary health services are
neglected.
5. The government's attention and commitment to primary health services has not
been optimal. This can be seen in the lack of funding for primary health services
and public health education.
MEANS
1. In order to make a strategic plan for primary health services including health
services included in the MDGs as a priority starting from the central, provincial and
district/city levels, for which health workers are needed who can utilize
epidemiology and knowledge related to management and advocacy as well as
substantive sciences that relevant, so that evidence-based decision-making can be
generated, which in turn can lead to efficient and effective advocacy and
management of primary health care
2. Conducted on the curriculum of educational institutions that carry out public health
learning aimed at obtaining information in order to develop a competency-based
curriculum so that graduates have relevant technical skills and can work together in
teams to improve basic health services for evidence-based decision making
3. The government and the executive review existing laws or regulations concerning
the powers of local governments which, if necessary, can be carried out by scholars
who have relevant health expertise in implementing quality, effective and efficient
health services.
4. The executive and executive governments need to pay attention and commitment to
the development of public health science so that it is useful in primary health
services in the form of making laws or regulations that support education and
subsequently public health services.
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