Primary Health Care Services During Pandemic

ABSTRACT


INTRODUCTION
The COVID-19 outbreak in early 2020 had a major impact on the health care system. The risk of exposure to SARS-Cov-2 makes patients change their use of health services and the implementation of health protocols during the COVID-19 pandemic experienced many changes caused by the risk of transmission. Some hospital services have to handle large influxes of patients, most of whom are being treated for COVID-19 (Pachetti et al. 2020;Purwito and Linggardini 2021).
In the context of this extraordinary health crisis, it is important to monitor, and measure changes in the use of non-hospital care to anticipate the possible consequences of these changes on public health, and to study how primary care is adapting to this situation by modifying their activities (Guagliardo 2021).
The Indonesie primary health care (Puskesmas) has made adjustments to health services since the start of the COVID-19 pandemic. The Puskesmas is the front guard in serving the health of residents in their area so that the Puskesmas never stops serving (Purwito and Nuntaboot 2018). With the current conditions, during the new habitual adjustment period, the Puskesmas staff have made changes to anticipate the potential for a resurgence of COVID-19 cases (Megatsari et al. 2019).
Almost all Puskesmas in this new order era provide health services by paying attention to the following matters: Puskesmas carry out prevention, detection and response activities to COVID-19 optimally, Application of Infection Prevention and Control (PPI) and strict physical distancing, Registration patients online/online to prevent queues at registration counters and shorten visits at ISSN: 2808-1021 Puskesmas, implementing service flow at the Puskesmas during the COVID-19 pandemic. A special examination room with good air circulation is used for examining patients with symptoms of ARI or other diseases that are easily transmitted by air.

RESEARCH METHOD
A qualitative research with phenomenological methods carried out using interviews, observation, FGD and documentation. Fifteen participants were Puskesmas health worker, patient and their family and village leader, the data analysis was carried out through the stages of data reduction, data display, and verification as well as drawing conclusions. Test the validity of the data is done by using the member check method.

RESULT AND DISCUSSIONS
There are 4 themes, the themes were analyzed based on the specific research objectives. The general research objective is for the health efforts provided by the puskesmas during a pandemic at the Sokaraja I Health Center.

Digital Health Care Service
The Puskesmas have been required to continue the services. Especially for, how to maintain or serve public health. During the pandemic, the work load of the health workers increased slightly, their tasks remained the same but the method was different, with online registration, online consultations and online education, therefore the Puskesmas was required an innovative approach.
"There are now so many people use it indirectly, yes, there is online registration, for example, consultations with health workers, patients can always go online." (P1) The activities such as health education are carried out using Whatapps group media for Posyandu cadres and the community. Posyandu cadres are assisted by the COVID-19 Task Force to provide education or outreach in various ways.
"Education by using flyers, leaflets on cell phones, or pictures we will distribute to the public later." (P1, P5).

Health Protocol Requirement
In addition to changes in the flow of services, health workers and visitors to the Puskesmas are required to implement health protocol (washing hands, wearing masks, maintaining distance, staying away from crowds, and reducing mobility) " There was indeed a change, the program has indeed decreased considerably, several programs have been delayed or temporarily stopped, the health workers in charge of the Public Health Efforts have been transferred to become the COVID-19 task force, because mass gathering activities are not allowed during a pandemic. It can be said that several programs were not carried out in accordance with their Standard Operating Procedures, while the Minimum Service Standards remained, the Puskesmas was required to meet these standards.
"In the beginning, yes, some were delayed, yes, especially the activities that gathered masses, such as the elderly Posyandu, Toddler Posyandu, that was also not allowed to have meetings and so on," (P1, P2). "So there have been a number of programs that have been delayed, for example the Childhood Immunization has gone into pending. Then for other prolanis programs like that, we have stopped looking at their faces."(P3)

The Task Force
During the pandemic the health workers responsible for carrying out the Public Health Effort program were transferred to become the village COVID-19 Task Force.
"Yes, because there are a lot of troops or employees and there are also a lot of areas. If you don't divide them up by region, they'll be dizzy too, so don't go back and forth." (P1)

Herd Community Effort
District Health Office was holding training for new programs related to the pandemic. The Puskesmas were ordered to send their members as Vaccinator Training. This training is expected to increase the competence of health workers in dealing with a pandemic.
"Since the vaccination has started continuously, so it's starting to normal, since the PPKM level has dropped, right, we can meet face to face." (P3) "Anytime something is detected, we immediately do a screening." (P3)

DISCUSSIONS
Health services are one of the components in the national health system that have direct contact with the community. Law Number 36/2009 concerning health, explains that the definition of a health service facility is a place used to carry out health service efforts both promotive, preventive, curative and rehabilitative carried out by the government, local government and/or the community (Megatsari et al. 2019).
Public services are very important and must be considered by the government because they meet the needs of many people (Marshall et al. 2009). In addition, public service is also one of the components in the problem of people's welfare. Public services must be carried out properly because those who enjoy this policy are all Indonesian citizens. Highlighting certain issues facing public service innovation, and we see that innovation in this field is very diverse (Kementerian Kesehatan Republik Indonesia 2020).
In the context of a health crisis it is important to monitor, and measure changes in the use of non-hospital care to anticipate the possible consequences of these changes on public health, and to study how primary care is adapting to this situation by modifying their activities (Marston, Renedo, and Miles 2020).
Obtaining this information in real time is essential to ensure that health authorities can respond quickly and adapt their response and related interventions as closely as possible to this dynamic situation (Guagliardo 2021).
Primary health services are basic routine health services whose needs will continue to exist in the community, in this context is the Puskesmas. The Puskesmas has the task of carrying out health development in its working area (Hasanah, Dai, and Sari 2021). The health services provided by Pusksmas are; Essential Public Health Efforts and Primary Health Efforts. The health services referred to include immunization, examination of pregnant women, treatment of patients with TB, HIV and chronic diseases (Insani;and Purwito 2020).
Efforts to adapt health services at the Puskesmas have been implemented since the start of the COVID-19 Pandemic. The Puskesmas is the front guard in serving public health in its area so that the Puskesmas never stops serving the community both inside and outside the building. At this time, in the period of adapting to new habits, many changes have been made to the Puskesmas services to anticipate the potential for a resurgence of COVID-19 cases (Sari 2020).
In addition to services in virtual form, direct services to the community must still be carried out by fulfilling the health protocols that have been set, for example providing hand washing equipment, checking temperatures before entering the Puskesmas, limiting the number of visitors/guests in the waiting room according to the number of seats available until it is enforced. partitions to limit contact between patients and health workers in each service section (Megatsari et al. 2019).
Puskesmas in this new order era provide health services by paying attention to the following matters; a) carry out prevention, detection and response activities to COVID-19 optimally, b) implement infection prevention and control as well as strict physical distancing, c) online patient registration to prevent queues at registration counters and shorten visits, d) ensure implementation of the triage process is always carried out correctly and adjustments to the flow of services, e) a special examination room with good air circulation is used for examination of patients with symptoms of ARI or other diseases that are easily transmitted by air, f) management of non-emergency cases, including diseases chronic disease is supported by the use of information and communication technology, g) monitoring/supervision of health conditions with mild symptoms is carried out online, and h) program services are regulated by regulation on certain days or separated places. The steps mentioned above were carried out as an effort to prevent transmission of COVID-19 so that patients can still have their health checked safely and comfortably at all Puskesmas (Harper et al. 2020;Hasanah, Dai, and Sari 2021;Rokhman and Purwito 2021).

CONSLUSION
During the COVID-19 pandemic Puskesmas experienced changes caused by the risk of transmission. The Puskesmas play importance role to response and provide the services at the same time. The main service for Individual and community has change but individual health services program remains the same in principle, while public health services (UKM) have many changes including as a task force for COVID-19 at the subdistrict level.
Puskesmas as a provider of primary health services has a significant role as the front line of services COVID-19 and play a role in prevention, detection and response. In addition, the Puskesmas continues to pay attention to the need for non-COVID-19 health services and ensures that essential health services can still be accepted by the community so as not to cause new health problems.