Introduction

Unquestionably, the health sector has an important role in the development of a country and, in developing countries, this is especially true. Of paramount importance is the reliability of the work force in these institutions and one of the problems is the absenteeism and nonattendance of health workers, which is also a serious problem in Indonesia. Moreover, in the most recent research concerning health workers absenteeism in Indonesia, the country had a substantial 40 % absence rate, putting it on the high end of the scale for health worker absenteeism (Chaudhury et al. 2006). The study pointed out that the Indonesian health worker absence rate was the same with India. The 40 % absence rate is taken from public health centre, known as puskesmas in the Indonesian language. In the next section, we will explain in more detail the definition of puskesmas.

This chronic absenteeism is a handicap to the Government’s development planning, causing a waste of state funds and resources since the state has to pay for a service which is not provided, i.e. the recipients are being paid even though they are not working (Usman et al. 2007). Overall, the absenteeism adversely affects the health service, since those workers who do show up for work regularly will have an additional work load because their colleagues are absent (USAID 2012).

Apart from that, this non-attendance seriously undermines the whole system and, thus, can lead to a knock-on effect, e.g. the underprivileged cannot obtain proper treatment when they are ill, which causes them to miss work because they are continually sick and consequently do not have the means to provide the basic necessities for their families, ad infinitum, adding to the cycle of poverty. This absenteeism can be categorized as one of the main problems in development, as one scholar explained, “You can build schools and clinics and stock them with books, drugs, and equipment, but if the teachers, nurses, and other providers are chronically absent, these investment will be wasted.” (Abdul Latif Jameel Poverty Action Lab 2009).

The subject of health workers absenteeism has been a serious topic of discussion in recent years, and is mainly prevalent in developing countries in Asia and Africa some of which are India (Banerjee and Duflo 2006), Kenya (Goldstein et al. 2010), Bangladesh (Chaudhury and Hammer 2003) and Indonesia (Ramadhan 2013). This study was undertaken to define the rate of absenteeism in the public health care system, particularly that of the several public health centres in Bengkulu City the capital of Bengkulu Province, which is a province of Sumatera Island in Indonesia. In addition, we will attempt to determine the reasons this truancy occurs and define the pattern. The sample is taken by enumerators. We choose Bengkulu City for the study because the city has been categorized as better than average in terms of the ratio of urban health facilities to population, particularly for puskesmas (Community Health Centres) and midwives (World Bank 2008).

However, on the other hand, Bengkulu City is also considered as a city with a higher-than-average number of Malaria cases (BAPPENAS 2010). According to this data, it is has been postulated that there is a missing link somewhere in the sequence because of the fact that the health facilities are considered above average, which is not in line with the number of Malaria cases. We argue that the missing link is the continuing absenteeism of the health workers assigned to these facilities, consequently our team performed a research survey to ascertain this. This paper is a continuation of research of health worker absences in Indonesia (Ramadhan 2013) which discussed the determinant factors of teachers and health workers absenteeism in Indonesia.

Puskesmas overview

Puskesmas is an acronym for Pusat Kesehatan Masyarakat (Indonesian language) which means Community Health Centre in English; some people also refer to it as a public health clinic. Within the public health organizational structure, a puskesmas is classified as a technical unit of the Health Service Office at the district/city level. This office is in charge of organizing the primary health development efforts at the district/city level, while the puskesmas is responsible for the portion of health development effort required in the neighbourhoods at the sub-district level. The puskesmas facilities are the technical implementation units of the district/city Health Service Office.

These health centres are on the frontline providing healthcare service at the neighbourhood level mainly to those residents who lack the financial means to seek care from doctors and hospitals in the private sector. Ideally, there is one puskesmas per sub-district area, but if in one sub-district there is more than one puskesmas, then the responsibility is shared between these with attention to the integrity of the concept of area (rural/urban)

As the vanguard implementation unit of the health service, the puskesmas has an important role. One of its functions is intended to act as poverty eradication instruments. The idea being that the provision of free medical services to the disadvantaged poor will allow them to remain healthy and therefore be able to carry out their daily pursuits without being deprived of proper medical care because they cannot afford it. The prevalent policy of the majority of local governments subscribe to a no fee policy for services at the puskesmas in their area. Accordingly, the urban poor in these areas regularly avail themselves of the puskesmas medical services when they are ill, mainly because of their lack of additional income to seek medical help at an alternate (private) facility. This is where the system is at its weakest point and where the performance is most lacking.

There are several reasons for this situation, e.g., unavailability of drugs, sub-standard facilities and health workers absenteeism being among these. One of the major causes for this condition is the fact that both the local and central governments allocate only a small portion of their yearly budgets to the public health sector. This policy results in a situation where many of the poor people do not receive adequate service at their local puskesmas.

To operate efficiently, each puskesmas must have an adequate number of doctors, nurses and paramedics to provide acceptable care to the population living in their sub-districts. Generally, the doctors in the puskesmas are general practitioners and dentists. However, in actual practise, there are no dentists and, in rural areas, they do not even have a general practitioner available but only a nurse and paramedic. This condition occurs because Indonesia has a shortage of doctors. The doctor shortage problem is an uneven redistribution of doctors; many doctors in Indonesia refuse to relocate to rural areas or small cities (World Bank 2008) because they prefer to work and reside in the large metropolitan areas.

The hours of practice at a puskesmas are on weekdays and they are closed on Sunday and public holidays, while Monday to Thursday, they are open from 7:30 AM–1:30 PM. On Friday, they are open from 7:30 AM–11 AM and on Saturday, they open from 7:30 AM–12:30 PM. In case of an emergency outside of these work hours, patients must go to a hospital. However, there are some types of puskesmas that are open 24 h that do accept emergency cases. These are referred to as nursing puskesmas.

In term of services provided, there are two types of puskesmas facilities, the basic version offers outpatient services only and the other, commonly referred to as a nursing puskemas, has beds and overnight facilities for patients. The latter are located in areas far from the city where there are no hospitals available, while the basic puskemas are located in the outskirts of the larger population centres. The nursing puskesmas, which serve as mini hospitals, can provide in patient services, but only in a limited capacity. These can normally provide inpatient services for no more than 4–6 patients. However, in the larger population areas, the number of beds available for inpatient services in nursing puskesmas can exceed this number.

Every puskesmas has a director. Normally, the educational background of the director is that of a doctor or they have a bachelor of science in public health. The doctor who becomes the director of a puskesmas has two jobs, whereby they function as a doctor, providing health care, while also attending to the administrative and clerical duties required by this position. This latter requirement can conflict with the doctor’s inpatient duties as he or she may have to attend to routine administrative meetings away from the puskemas at the local health office during working hours, thereby rendering him or her unavailable to treat patients during normal working hours, which contributes to a less than satisfactory job performance.

All of the puskesmas facilities provide maternal health services (prenatal and postnatal care), family planning services and vaccinations. The puskesmas facilities that are fortunate enough to have general practitioners and dentists in their staff can offer general health service and dental care service; however, in cases of serious emergencies, the patients are sent on to a local hospital for care.

The puskesmas is also encouraged to organize community health education to empower the community to maintain a healthy lifestyle and practice preventive measures to stay healthy. Moreover, a puskesmas has yet another task, which is new, which is to perform data collection of birth, mortality, family planning and disease in their area. The data report is then sent to the local government as one of the data sources for development.

In terms of salary, health workers in Indonesia are paid only a small amount. The medical doctor who is working for the government has a salary of only US$ 223/month (Ramadhan 2013), which causes the doctor to seek additional income via practicing in private facilities. The Indonesia Ministry of Health has allowed the doctor who has status as government employee to practice at private facilities as long as it does not interfere with health service in government facilities (Berman and Cuizon 2004). Although the salary is low, many health workers in Indonesia are willing to work as government employees, because doing so carries with it a pension, health insurance, security from being laid off and a broader working network.

Methodology of data collection

The research was carried out in Bengkulu City the capital city of Bengkulu Province, one of the provinces on the island of Sumatra in Indonesia. Bengkulu City is categorized as an urban area and is divided into nine sub districts or kecamatan in the Indonesian language. Every sub district has between one and three puskesmas facilities, comprising a total of 20. Using random cluster sampling, we sampled nine puskesmas facilities for this research, or in other words, we selected one puskemas for every sub district in Bengkulu City; and, one of the research samples is from that of a nursing puskesmas. As mentioned earlier, a nursing puskesmas is open 24 h and operates on an employee shift system according to the practice hours of the ordinary puskesmas. Thus, for this study, we counted only the health workers in the nursing puskemas whose shifts correlated with that of the practice hours of the ordinary puskesmas.

We chose the puskesmas for our research object because the puskesmas plays such an important role in terms of health services for poor people. Indonesian poor people often come to the puskesmas when they are ill; thus, the service of the puskesmas has become one of the main determinant factors in the eradication of poverty.

The total of health workers in our survey of these 9 puskesmas facilities was 20 doctors (general practitioners and dentists), 61 midwives and 76 paramedics. We used enumerators to survey all of the health workers over a total of ten visits at each facility. The survey was carried out during the period of July 2013 through October 2013. A more detailed representation is shown in Table 1 below.

Table 1 The health-worker distribution according to the surveyed puskesmas
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Data regarding the health worker’s absences in this research is based on physical verification, paper absence was not taken into account. In Indonesia, it often happens that the paper attendance list is fully filled, without any absence, even though in fact the person never comes to the office. The physical verification was done by counting the health workers individually in every puskesmas during our visits. The table indicates the actual absenteeism rates by percent.

We visited the subject puskesmas facilities unannounced at random times and only researchers and enumerators actually knew the schedule of the visits. However, we visited all nine puskesmas facilities on the same day to carry out research; sometimes they were visited once a week and sometimes twice a week. This method was implemented in order to obtain a true representation of the absence rates. Besides, using this survey technique, the researcher also interviewed the health workers directly to determine the reasons for the workers absenteeism. We also interviewed the puskesmas directors, the local health service officers and various patients. Apart from these research techniques, we also used observational techniques to study the phenomena at each subject puskesmas.

Results

In recent research investigating the problem of Indonesian health workers absenteeism, the data indicated that the rate of health workers absenteeism is 40 % (Chaudhury et al. 2006); however, it does not indicate whether the data was obtained from urban or rural areas or both. In this research, only data from the urban area of Bengkulu City was taken. Our survey concluded that the overall absentee rate of all the health workers surveyed was 23.4 %. However, it should be pointed out that our survey observed the absentee rate of the three different categories of health workers. We have indicated the different rates for each of these in Table 2.

Table 2 The absence list based on profession types
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Our survey indicates that doctors had the highest rates of absenteeism. This is because in every puskesmas, the number of doctors was only 1 to 3; thus, when the doctor was absent, the rate of absence was statistically high. For instance, supposing there was only 1 doctor assigned to a particular puskesmas, if the doctor was absent in one survey, the statistic would then report 100 % absence.

Our research team is of the opinion that where the rate of health workers absenteeism is above 20 %, this can be categorized as a warning light for the Indonesian development. The development of Indonesia in recent years has always accentuated the development of three sectors—health, education and infrastructure. However, if the absenteeism continues to appear at these high rates, this will no doubt have an adverse impact on the Indonesian development.

Absenteeism and working condition

One would surmise that a higher rate of health workers absenteeism may be related to working conditions, i.e. the worst working conditions having a higher percentages of absence rate. However, in our research, we did not find this to be the case. Please note the breakdown of absenteeism for each individual puskesmas in Table 3.

Table 3 The absence number based on each puskesmas
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Table 3 indicates the absence rate for each puskesmas sampled in the study. As can be seen, No. 5 has the highest non attendance rate. However, it should be pointed out that this puskesmas has some of the best facilities and working conditions. Additionally, they are located in an area with paved roads, the quality of the buildings and amenities are good. The puskesmas has three doctors, seven midwives and nine paramedics (see Table 1).

Conversely, No. 3 is located far from any paved roads and is accessible only by foot and motorcycle. Moreover, the building housing the puskesmas is a small structure located inside a general cemetery. However, this puskesmas has the lowest absence rate, particularly for midwives. Similarly, at puskesmas No. 9, the working conditions are also not very good, as it is small and crowded with patients. In addition, the building is cramped, dark, humid and stinks; however, it maintains a very low absence rate. Therefore, we can deduce from our data that there is not a strong relationship between absences of the health worker staff and the working conditions.

In line with the aforementioned, puskesmas No. 8 also has bad working conditions but it also has the lowest number of paramedic absences. Puskesmas No. 8 is a nursing puskesmas which means that it stays open 24 h/day to manage emergency situations such as traffic accidents. This facility is not equipped with an auxiliary power generator and on several occasions when power outages occurred, the staff had to stitch up traffic accident victims using a flashlight as their main source of illumination.

Absence tendencies

While conducting the research, we found that, at certain times of the day, the absence rates were substantially higher than others. Early in the survey we were conducting our visits early in the morning hours between 8:00 and 9:30 AM and the results were quite acceptable with a low absence rate. Later in the survey, we changed our procedure and started conducting our survey between 10:00 until 11:00 AM in all the puskemas, which produced some very different results with the absence rates being significantly increased. During this period, we found there were only a few health workers still on duty in the various puskemas facilities, and this situation held true for nearly every day we surveyed during these hours.

We analysed our data to determine the causes of these phenomena. We first reviewed the working hours, and information from local health service indicated that operating hours of the puskesmas are officially Monday to Thursday 7:30 AM to 1:30 PM, Friday 7:30 to 11:00 AM and Saturday from 7:30 AM to 12:30 PM (see section “Puskesmas overview”). According to this information, it should be that the puskesmas are not yet closed at 11 AM (except in Friday) and the health workers should still be offering their services. In actuality, it is only the registration desk that closes at 11:00 AM and the health care workers are supposed to remain on duty to treat the registrants who registered before the closing deadline from 12:30 or 1:30 PM, depending on what day of the week it is. It is apparent that the health workers are almost all leaving for the day between 10:30 and 11:00 AM instead of remaining at their posts to treat patients.

To further investigate the reasons for this practice, we interviewed the individual puskemas directors, all of whom gave similar answers. They confirmed that at 11:00 AM the patient registration desk is closed. It seems that the local managers and workers interpret this action to mean that after that time the puskemas is not required to provide any more services and any patient overflow will be treated the next working day. Because of this policy, the health workers for the most part start departing the puskemas after 10.30 AM as already indicated.

In our interviews with the puskemas directors, we also attempted to determine why such policies were prevalent in all the local puskemas. The answers to this question were various but the majority could not provide valid excuses why the majority of the health centre employees cut several hours off of what is already a short workday. The three most common responses were: they follow a policy to oversee only the patients who come before 11:00 AM, the supposed “official” close of registration; secondly, this policy follows that of the general hospital procedure by which the clinics are open for patients only from 7:30 to 11:00 AM; third, this policy is the convention of health workers of any puskemas in Bengkulu City and prevails at every puskemas in the province.

During our interviews, we also asked the puskemas directors what would happen if after 11:00 AM there was an emergency case in the puskemas such as an influx of patients from a major traffic accident. It should be noted that all puskemas facilities are equipped to manage light emergency cases such as first aid, wound stitching, etc. The response was that emergency cases were accepted until the puskemas official closing time. One cannot help but wonder how effective this policy can be if all the trained personnel have left the building by 11:00 AM instead of 1:30 PM?

To further seek answers, we went to the main Bengkulu local health service offices to interview the officers there and crosscheck the directors’ answers. To elaborate, the local health service office is a division of the local government and has the responsibility to supervise and set policy for all the local puskemas. When we asked the officials at the main office if they could clarify why such a policy prevailed, we were informed that the policy regarding the opening and closing times of the various puskemas facilities was managed by the directors of the individual puskemas. If the health centre manager deems closing the registration desk at 11:00 AM in his puskemas, the main office will not interfere. It should be noted that this 11:00 AM closing of the registration desk is not official policy, nor is it stated as such anywhere in the city regulations.

Other high truancy periods that we noted during our sampling were Saturdays. Based on our research, many of the health workers are absent on Saturdays which is considered by all the puskemas as a “shift” workday. This means half of the workers are allowed to take the day off, while the other half cover for them. We were not able to determine who established this policy or why. The main office of the local health service confirmed that this is not the official policy. We are of the opinion that these self-made procedures like the closing of the registration desk at 11:00 AM and subsequent short workdays is an inherently bad policy which does not take into account the needs of patients and the subsequent impact it causes to the public health system.

To reiterate, the closing of the registration desks and lack of on duty staff on Saturdays severely impacts the working hours and reduces the time the financially deprived poor are able to obtain basic medical services. The idea behind having these public health facilities available to the public is to aid in the development process in Indonesia and allow those who cannot afford to obtain services from private health facilities to remain healthy and pursue their dreams for a better life. If they are not healthy, they will not be able to provide for themselves and their family, thereby contributing to and maintaining a cycle of continued poverty.

Time without absence

Considering our discussion in the last section, there are several times that health workers are absent. In this research, we also found two cases when the absence rate of health workers is zero percent; thus, all of the health workers were in the office. The first case is payday for the health workers, whereby it is the custom in Indonesia that public worker’s salaries are paid manually and not through payroll/transfer in the bank. Therefore, during these periods all of the health workers are present in their puskemas facilities. This is also true during periods when the main office carries out their scheduled working evaluations of the facilities and the staff. The local health service office, as the puskemas supervisor, periodically executes working evaluations at the puskemas facilities. They check the health workers’ absence rolls, medicine stocks and other puskemas facilities. During these periods we found that all health workers were present in the puskemas.

Sanctions for health workers

It is health service office policy that those workers who have a high rate of truancy are subject to sanctions from the office. Considering the fact that almost one quarter of the workers we surveyed were chronically absent, it would seem that the rates should be significantly lower if they were subject to disciplinary action. From our observations we determined that the workers pay little heed to these sanctions since they are never enforced in most cases. However, in fact, we found that the health workers are still concerned about being sanctioned. For instance, the puskemas directors requested we not name their puskemas in our research report because they were concerned that if their puskemas had a high absence rate they might be penalized by their supervisors in the local health service office.

The type of penalty from the local health service for the puskemas directors who do not perform well are warnings which can, in disproportionate cases lead to a demotion (the puskemas director is reduced to the status of ordinary staff). If the puskemas staff does not perform well, they will receive sanctions from the director of the puskemas in question. The forms of the sanctions are initially warnings which can lead to the worker being transferred out to another puskemas. According to interviews with puskesmas directors, we were told that what usually happens is that the director sends a request to the local health service office to transfer the health worker who is not performing well, from their facility into another facility; however, after waiting for months, there is usually no reaction from the local health service office. It is difficult in Indonesia to suspend or terminate the services of a non-performing public servant with a permanent employment status. We argue that this is one of the strongest reasons the health workers are frequently absent from their posts.

If a robust sanction policy was in place for health workers who break the rules, there would be a stronger adherence to the rules, but this does not appear to be the case with the subjects we sampled. The enforcement policy is slack and penalties are almost non-existent—only when the health workers are persistently absent do they get light reprimands such as verbal warnings from their supervisor. Should the situation persist, they are then called in for more verbal warnings and if the situation continues for a period of time, the puskemas director will submit a negative report to the local health service office regarding the conduct of the health worker.

Based on our interviews with the local health service, they maintain that they make unannounced visits to random puskemas to check the attendance of the staff. Admittedly, they often come at times when only a few of the health workers are present for duty in many of the puskemas. Accordingly, they record the names of absent health workers and send the reports to the local government office which manages all affairs concerning local government employees. However, there is rarely if any action ever taken from this office to penalize the offending employees or reduce the absence rates.

Temporary employee versus permanent employee

As mentioned earlier, it is not easy in Indonesia to suspend or terminate the services of non-performing public servants who have attained the status of permanent government employees. According to our research, there are two types of employees in the puskemas we surveyed, either permanent or temporary. All doctors in puskemas facilities are classified as permanent government employees, while some of the midwives and paramedics are classified as temporary employees.

Based on our studies, the temporary employees in the system are usually more hard-working than permanent employees, most probably due to their employment status. Every year, the temporary employees are evaluated by the local government as their employer. If the local government finds that they do not perform well, their contracts will not be extended. On the other hand, all doctors employed in the puskemas are permanent employees, but these individuals have the highest absence rates (26.5 %). The reason for this could be that the MDs are paid only small salaries and usually they all are also employed at private health facilities from which they derive the major share of their income (Ramadhan 2013).

Further to this problem, most puskemas facilities have an overstaffing of midwives and paramedics which contributes to the absence problem because such an excess of employees in this category has a tendency to promote the dependence of the less diligent workers on the conscientious and hard-working ones. The tardy health workers deem that they do not need to come to the office when the diligent one is already at the office. What would happen in the case that the diligent health workers also do not come to the office? Supposedly, people will not get any health service.

One of the reasons for this overstaffing is because every year the local government opens up the recruitment for new employees for temporary and permanent status. One reason for this over-recruiting is because it offers an opportunity for the local government employees to obtain bribery money from candidates applying for government employment (Ramadhan 2012). Overstaffing of employees (see Table 1) is present in all puskemas facilities surveyed in this study. Every puskemas has only one to three patient examination rooms yet, for each puskemas in the survey, there are more than four midwives and paramedics.

The reasons for absence

As previously mentioned, we found many reasons for health worker absenteeism without leave, with most of them starting to leave the puskemas at 10:30 AM, which effectively gives them only a 3-h working day. In this section we will define what constitutes a legitimate absence.

When we carried out the survey, we found that there are mostly three reasons given by the employees for their absences. The first are absences validated with an official letter giving the employee permission to be excused from their duties. This type of absence includes the health workers who are granted normal leave due to them as part of their employment contracts, such as maternal or annual leave or illness backed up with a letter from the doctor. During the period of this research, we encountered two health workers who were absent on their annual leaves and three health workers who were absent performing their religious duties, specifically they were on a pilgrimage to Mecca performing the Haj. In Indonesia, where the majority of the population is of the Islamic faith, this type of leave is considered as official and there is a government regulation that supports this. This religious leave is extra leave excluding the annual leave. In Indonesia, health worker has 12 days for annual leave. This amount of annual leave is the same in all industries in Indonesia because Indonesian regulation obliges companies/organizations to give a minimum of 12 days for annual leave.

The second is absence due to work requirements without a written excuse. This means that the health workers are absent because of work-related reasons which are not accompanied by an official letter. During the period of this research, we found that the puskemas directors were often not in the office and the reason given for their absence was that they were called to a meeting at the local health service office. Upon cross checking the information with the local health service office, we were informed that there were regularly scheduled meetings several times a month with the puskemas directors. We found that this situation occurred quite frequently. We are of the opinion that these meetings, which are always held during the operation hours of the puskemas, disrupt the work flow of the health services. A good many of the puskemas directors we sampled are doctors (general practitioners or dentists) and some of the puskemas have only one doctor. When the doctor is absent, it disrupts the health services of the unit. This will be examined further in the following section.

Another situation where a health worker’s absence without an official letter occurs is when some of the health workers in the puskemas leave their posts to provide services at a posyandu. A posyandu is another feature of the government public health system and is an integrated service post for children, babies, pregnant women and elderly people. This is a monthly health service which provides health and well-being services to the hamlets and surrounding communities in the vicinity of the puskemas. The posyandu is managed by community volunteers and is supported by the puskemas close to their locations. The puskemas health workers, once a month, come to the posyandu to provide vaccinations, food supplements and provide other health services. These posyandu are not located in the puskemas facilities but are located in the surrounding hamlets. The distance between the posyandu and puskemas varies between 300 m up to 1 km in urban areas. However, in rural areas, the distances between posyandu and puskemas are usually in excess of 1 km. In every puskemas area, there are anywhere from three to five posyandu facilities. In any given month, the health workers (doctors, midwives and paramedics) must be away from their duties at the puskemas at least three times a month to service these facilities.

Since midwives and paramedics are overstaffed, this does help ease the requirement to provide services at both locations at the same time. Usually the services of midwives and paramedics in the puskemas can proceed normally even though some of them must leave the puskemas premises to provide services at the posyandu. Unfortunately, this overstaffing is not the case for the puskemas doctors because the doctor staffing levels at most of the puskemas facilities are severely limited. If the puskemas only has one doctor, this doctor has to be absent from the puskemas while he/she is at a posyandu. As mentioned earlier the absence of the doctor from the puskemas tends to detract from the quality of the services there.

Another reason for absences without an accompanying letter is when the health workers have to leave the puskemas to help a patient deliver a baby at the patient’s home. It is common in Indonesia, particularly in villages and small cities that birthing takes place in the patient’s home. In the course of our research, we found that on occasion the puskemas midwives and paramedics have to be absent from the puskemas for this reason.

Apart from the official reasons, the health workers we surveyed also were absent for other, albeit unofficial, reasons. In this category, the main cause was that the workers often left their posts to pick up their children at school. In Indonesia, children who are in kindergarten and grades 1–3 only study at school until the hours of 10:00–11:00 AM; hence, one of the main reasons for a lot of the employees leaving the puskemas shortly after 10:00 AM.

Another unofficial reason for some of the truancy takes place around the holiday period. We found when we carried out the survey after the Eid holiday (this is a major holiday for Muslims and equates to Christmas in the non-Muslim world), there were several puskemas that were closed, even though we carried out our survey during the normal weekdays working hours. These puskemas were supposed to be open but had an announcement posted on the gate of puskemas that they were closed due to Eid day events which take place after the primary holiday when the Muslim residents traditionally mingle with each other. Officially, these meetings were not supposed to be held on weekdays and it interrupted the health services at the puskemas.

Doctor absences at the puskemas

As was mentioned previously, the doctors we surveyed had the highest rates of absence. Based on our research, we felt the quality of the services was impaired although the health services still proceed even though the doctors are absent. The patients are handled by the midwives and paramedics. The senior staff member from the midwives group at the puskemas assumes the role of the supervisor for all health services at their puskemas while the doctor is not in the office.

The danger of allowing the midwives and paramedics full control over handling the patients at puskemas without supervision from a medical doctor leaves a potential for a possible medical mismanagement by the staff. The midwives and paramedics might find themselves in a position where they are not capable of handling the situation in a medical emergency. Unfortunately, since the absence rate of doctors is high, this condition often occurs. We interviewed the heads of puskemas concerning this condition. We asked what is the standard response in the case where the midwives and paramedics are faced with a life-threatening situation which they are not capable of handling and there is no doctor in the facility. The reply from the director was that they all have a standard operational procedure when this situation arises, and that is that the midwives and/or paramedics will handle the patient as long as they are able based on a “standard operational procedure”. When the situation becomes critical and they consider themselves unable to provide adequate care as per this procedure, they will send the patient to the emergency unit of a general hospital. However, when we asked to see the documentation outlining this “standard operational procedure”, they could not produce it.

Patient’s comments regarding absences

When the senior qualified health workers are absent, the patients are the parties who are directly disadvantaged since it could deprive them of receiving proper health services. We carried out random interviews with several patients at various puskemas facilities asking them what are their perceptions of the care they receive when the senior health workers (doctors) are absent? Is it acceptable to them if they receive treatment from midwives and/or paramedics when the doctor is absent? All the patients answered in the affirmative that they were content with treatment from the midwives and paramedics and surprisingly some of the interviewees stated that they preferred this way rather than treatment from the doctors. It would appear that the patients have become accustomed to be treated by midwives and paramedics. However, a smaller amount of patients still preferred to be treated by the doctor on duty.

Conclusions

The puskemas system in Indonesia has an important role in terms of poverty eradication. They are the front line of health services in particular for the poor and disadvantaged. The financially deprived always use puskemas facilities when they require medical treatment because the puskemas will give them free health services. We are of the opinion that these individuals deserve quality healthcare by attentive health care professionals. If the health workers who are supposed to provide these services are derelict in their duties and are frequently absent from their posts, this does not allow the government to provide satisfactory health services to its citizens. Unfortunately, our research showed that the rate of health workers absenteeism at the puskemas facilities we surveyed is quite high. This obvious flaw in the Indonesian government health services system is a formidable challenge to the government’s ultimate goal, which is to eradicate poverty.

The caveat to this research is that we only carried out the survey in an urban area. There are rural areas in Indonesia and the Bengkulu Province where the health workers absences might even be higher than in urban areas. Our team plans to undertake a survey of rural health workers absences for our next research project.

Our recommendations are that, primarily, an improvement of health worker supervision is necessary. We argue that if the local government can provide proper supervision of the health services in these areas, the absence rate can be significantly reduced; secondly, the improvement of health worker allowances is necessary to motivate them to provide a good performance. However, any augmentation of allowances should be done on a merit-based system. The health workers who perform well deserve to have their allowances improved and vice versa for the health workers who show a bad performance. Third, a moratorium on the recruitment of new midwives and paramedics within the puskemas system needs to be considered. As we mentioned earlier, Bengkulu City has an overstaffing of midwives and paramedics. What the situation in the rest of Indonesia is, we are not aware, but we feel it is not beneficial to the health services in Bengkulu. If in the future, Bengkulu City requires new midwives and paramedics, we feel it is better to have an open recruitment policy for temporary employees.