Volume 3, No. 9 September 2024 (1982-2000)
p-ISSN 2980-4868 | e-ISSN 2980-4841
https://ajesh.ph/index.php/gp
Implementation of Minister of Health
Regulation on
Immunization for Children's Right to
Health
Christy
Imelda Margaretha Mudrikah
Universitas
Islam Bandung, Indonesia
Email: cristyimelda09@gmail.com
ABSTRACT
The implementation of the Regulation
of the Minister of Health of the Republic of Indonesia Number 12 of 2017
concerning the Implementation of Immunization in the Context of Fulfilling
Children's Right to Health at Integrated Service Posts (Posyandu) in the
Cimandala Village area, Bogor Regency is the focus of this research to evaluate
the effectiveness of its implementation. This study aims to assess the extent
of the implementation of immunization policies in accordance with applicable
regulations and analyze the factors that affect immunization coverage in the
region. This study uses a descriptive approach with analysis of complete basic
immunization coverage data (IDL) and evaluation of the efforts of health
workers and health cadres in the implementation of immunization at Posyandu.
The implementation of the Minister of Health Regulation Number 12 of 2017 in
the Posyandu in the Cimandala Village area has not been optimal. Data shows
that IDL coverage is below the national target, which is 75.71% in 2021, 69.83%
in 2022, and 67.31% in 2023. Low IDL coverage contributes to the persistence of
immunization-preventable cases of diseases, such as tuberculosis, pneumonia,
and measles in children under 5 years of age. The efforts of health workers and
health cadres in the implementation of immunization have also not met
expectations, showing the need for improvement in the implementation of the
policy.
Keywords: Implementation
of Immunization, Integrated Service Post (Posyandu), Complete Basic
Immunization Coverage (IDL), Children's Right to Health
INTRODUCTION
Every human being has the right to an optimal
degree of health, and the state is obliged to uphold this right. The right to
health is a human right, in this case the right to an optimal degree of health.
In Indonesia, everyone has the basic right to feel safe from situations that
threaten their health and to receive health services. These unified rights form
the right to optimal health as a human right (Kurnia, 2007).
Article 28A of the 1945 Constitution of the
Republic of Indonesia states that every person has the right to life and the
right to defend his or her life. Article 28B paragraph (2) states "Every
child has the right to survival, growth and development and the right to
protection from violence and discrimination." (State, 2001). This
proves that anyone has the right to defend their life and it also applies to
every child to be able to grow and develop for their survival.
As a component of human life, the right to
health services has been recognized and accepted as one of the components of
human rights. The 1945 Constitution of the Republic of Indonesia, Article 28 H
paragraph (1), emphasizes the guarantee and recognition of the right to health
services. It states that every individual has the right to live in a good and
healthy place, to prosper physically and mentally, and to receive health
services. Health services are now a top priority as a result of the regulation (Ruslan
Renggong et al., 2021).
The country that announced its intention to
participate in child-related treaties or the Convention on the Rights of the
Child is Indonesia. Article 24 of the Convention on the Rights of the Child
states that states parties recognize the right of the child to the best health
status and ensure that no child's right to health services is violated. The
treaty consists of 54 articles. Countries participating in the KHA will also
seek to implement it in efforts to reduce newborn and child mortality, child malnutrition,
and the eradication of childhood diseases. Article 24 also states that parents
have the right to be supported in the use of knowledge about child nutrition
and health (Farid, 2003). The guarantee of children's right to health
is strengthened through Presidential Decree of the Republic of Indonesia Number
36 of 1990 concerning the Ratification of the Convention On The Rights Of The Child
(Supriyanta,
2023). The
Convention on the Rights of the Child correlates with the Law of the Republic
of Indonesia No.39 of 1999 concerning Human Rights where Article 52 paragraph
(2) states "The rights of the child are human rights and for their benefit
the rights of the child are recognized and protected by law even from the
womb". Children's right to health care is also mentioned in Article 62
"Every child has the right to obtain proper health care and social security,
in accordance with their physical and mental-spiritual needs".
Article 1 of Law No. 17 of 2023 on Health
states that all activities and/or series of activities designed to maintain and
improve the degree of public health in the form of preventive, curative,
rehabilitative, and/or palliative services must be implemented in an integrated
and sustainable manner. To protect children and infants from diseases that can
be prevented by immunization, Article 44 mandates that the national and local
governments provide comprehensive immunization to all infants and children. vaccination
of infants and children is the responsibility of the entire community and
federal, state, and local governments. In order for a child to live, grow and
develop to his or her full potential, Article 45 also mandates the government
to ensure that every newborn receives standardized health services. Article 46
describes the enforcement of children's health rights. This article states that
infants and children have the right to protection from acts of violence and
discrimination that could jeopardize their health, and governments, both
national and local, are obliged to ensure rights are implemented and offer
appropriate health services.
A child is any person who is not yet eighteen
years old, including children in the womb, based on Law of the Republic of
Indonesia Number 35 of 2014 concerning Amendments to Law Number 23 of 2002
concerning Child Protection (Bahroni et
al., 2019). Article 1 provides an explanation of this.
Article 45 B paragraph (1) stipulates that the State, Local Government,
Community, and Parents have an obligation to protect children from activities
that endanger their health, development, and growth. Article 46 explains the
obligations of the State, Government, Local Government, Family, and Parents to
ensure that their offspring are protected from diseases that threaten their
existence or that result in disability.
This explains the importance of efforts to fulfill children's rights to
health so that children avoid disease for their survival. Efforts to fulfill
children's right to health can mainly be done by providing immunization.
Regulation of the Minister of Health of the
Republic of Indonesia Number 12 Year 2017 outlines the immunization policy. The
government states that immunization is the best way to avoid disease and
achieve the greatest degree of public health. Program immunization is an
immunization that must be carried out by someone as a member of the community
to protect the individual concerned and the surrounding community from diseases
that can be prevented by immunization. Immunization is an effort to increase a
person's immunity to a disease, so that if one day exposed to the disease will
not get sick or only experience mild illness. This is stated in Article 1.
The implementation of immunization is a
preventive health effort against a disease. An economical and successful early
prevention against infectious diseases is immunization. Immunization can stop
the spread of infectious diseases and protect recipients from dangerous
diseases (Prayogo et
al., 2016).
The implementation of immunization has also
been regulated by the local government so that children get their rights to
avoid infectious diseases as stated in the Bogor Regency Regional Regulation
Number 1 of 2022 concerning Communicable Disease Management where Article 5
states the types of infectious diseases and most of these diseases are directly
infectious diseases that are prevented by immunization. In the implementation
of infectious disease management, the active role of the community is required.
This is explained in Article 16 of the regulation.
Immunization reduces disease-related
morbidity, mortality and disability. Since 1956, Indonesia has conducted
immunization campaigns. To stop the spread of immunization-preventable diseases
(PD3I), such as hepatitis B, polio, measles, tetanus, and tuberculosis,
immunization activities were transformed into an immunization expansion program
starting in 1977. The Expanded Programme on Immunization (EPI), approved by the
World Health Assembly (WHA), marked the beginning of the World Health
Organization's (WHO) efforts to expand immunization programs worldwide.
Maternal and child health services, especially primary health care, will
benefit greatly from the inclusion of the EPI (Susanti, 2016).
Infants born between the ages of 0 - 28 days,
or babies born between the ages of 0 - 11 months, and toddlers or those born
between the ages of 12 - 59 months, are included in the age group called the
infant toddler period. Infants and toddlers experience rapid physical and
mental growth and development, so their health is very important to monitor.
Treatment and referral, nutrition, growth and development monitoring,
rehabilitation, long-term care for chronic or uncommon conditions, parenting
styles, fostering a safe and healthy environment, and immunization are aspects
of newborn and toddler health efforts (Ministry of
Health, 2023).
The purpose of immunization is to combat
infectious diseases and boost immunity. Public health is declining due to high
infant and under-five mortality rates in Indonesia. The implementation of a
comprehensive basic immunization program in infants and toddlers is one of the
efforts to overcome these problems. Immunization of children under five not
only helps prevent childhood illnesses, but also benefits society as a whole by
increasing immunity, or the body's resistance to certain diseases, and avoiding
widespread transmission. To maintain the decline in newborn and under-five
mortality rates, the Indonesian government continues to support these
immunization initiatives. However, parental resistance is still a problem for
the program.
Based on data from the Indonesia Family Life
Survey (IFLS) wave 5, which was conducted in 13 provinces between 2014 and
2015, the study examined the incidence of stunting, gender, child age, maternal
age, maternal height, immunization status, history of infection, and region of
residence of 1,048 children in the sample aged between 2 and 5 years. The
findings showed that the percentage of stunting was higher in children who were
not fully immunized (22.54%) compared to children who were fully immunized (13.82%).
It is possible that if nutritional intake is poor, children have a high chance
of contracting diseases in the first 1,000 days of life. Stunting can occur in
children who suffer from recurrent diseases that eventually interfere with
their growth and development. Stunting is 1.78 times more likely to occur in
children whose immunization status is incomplete than children whose
immunization status is complete. Stunting is less common in children who
receive vaccinations, and vaccinations contribute to reducing child mortality.
Timely immunization can reduce the risk of stunting in children, but delayed
vaccination can increase the likelihood of stunting. Efforts in overcoming the incidence of
stunting can be carried out by means of a pentahelix approach involving five
elements, namely policy makers (government), community leaders, educational
institutions, health services, and the media (Rachmiatie et
al., 2023).
Immunization of infants/toddlers in the first 1000 days of life is part
of the health services provided in an effort to prevent stunting in children.
The theme of World Immunization Week, which
takes place from 24-30 April 2015, is "Closing the Immunization Gap,
Vaccination for All". The World Health Organization (WHO) urges countries
to collaborate more closely to achieve immunization coverage goals. There are
many reasons for differences in immunization coverage between countries,
including lack of vaccine
and must be in accordance with statutory
regulations. In addition, in Article 32 before providing program immunization
services, health workers must explain about vaccination, including supply,
limited financial support, limited public awareness, and limited access to
health services. The implementation of immunization in Indonesia faces the
challenge of lack of information and public awareness. To spread awareness of
the importance of immunization, the government is increasing its health
promotion activities. The Ministry of Health has also collaborated with other
sectors to ensure vaccine availability, train health workers, and raise public
awareness through public service announcements and other media, in an effort to
ensure access to immunization services in hard-to-reach areas.
There are still some rumors about immunization
circulating in the community that become obstacles to immunization programs,
including breast milk, nutritious food, herbal supplements can replace
immunization, immunization contains dangerous chemicals that can damage the
brain, immunization contains haram substances, immunization can cause autism
and can even cause death due to Post-Immunization Follow-Up Events (KIPI).
In January 2019, WHO called vaccine hesitancy
a global health threat. In a three-year review (2015-2017) of the joint
WHO/UNICEF reporting form (JRF) completed annually by national immunization
programmes, more than 90% of 194 countries reported experiencing vaccine
hesitancy. The top three reasons for hesitation were:
1.
Security
risks and concerns
2.
Lack
of knowledge about the benefits of immunization
3.
Religious,
cultural and socioeconomic issues (Piot et al.,
2019)
It is for these reasons that more and more
groups of people are delaying or refusing immunization. The three cornerstones
of medical ethics are generosity, harmlessness, and justice (Sinaga, 2021). Given that children are not yet able to
voice their opinions, this has an impact on doctors who must always follow
their parents' choices. Even if it is wrong, parents will choose what they
want. Therefore, parents need to have accurate information to help make
decisions. Inaccurate information, especially regarding immunization safety,
will cause parents to have an unfavorable view of immunization as a whole. It
is important to clarify that there are more advantages to immunizing children
than disadvantages. Immunization can be seen as a long-term public health
investment (Ranuh et al.,
2017).
This is related to Article 30 of the Minister
of Health Regulation Number 12 of 2017 concerning the Implementation of
Immunization that health workers who have the competence and authority are
required to carry out program immunization services the type of vaccine to be
given, its benefits, the consequences of not getting immunized, the possibility
of KIPI and steps to be taken if it occurs, the next immunization schedule, and
the need for screening of immunization targets.
By explaining immunization to parents, it is hoped that they will be
aware and understand the importance of immunization for children.
To facilitate access to health services for
the people of Indonesia, the government provides Posyandu (Pos Pelayanan
Terpadu) which aims to provide immunization. Through community empowerment,
Posyandu aims to stop the increase in newborn and maternal mortality during
pregnancy, childbirth, and the postpartum period. Posyandu only provides
services once a month. The community can easily access Posyandu sites starting
from the village or kelurahan area to RT and RW.
The main key component of Posyandu that
determines whether or not activities are carried out is the cadre. Before
Posyandu is implemented, Posyandu cadres are tasked with preparing the
location, equipment and infrastructure and disseminating information to the
community. To create a health program in their community, cadres need to have
information and skills appropriate to their role. The low level of attendance
of children under five (toddlers) at Posyandu can be caused by a lack of
training and direction, which can result in a lack of knowledge about the
responsibilities of cadres as well as incomplete information and a lack of
cooperation between officers and cadres in carrying out Posyandu activities (Tristanti
& Khoirunnisa, 2018). So that it results in less running Posyandu
activities including in terms of immunization provision.
Immunization can prevent deaths from measles,
tetanus, diphtheria and pertussis each year in all age groups. About 2-3
million deaths can be avoided annually with immunization. However, 19.4 million
infants worldwide are not fully immunized. About 60% of these babies were born
in 10 different countries, including Indonesia (Kurniati,
2020).
The general description of the area of
Cimandala Village, Sukaraja Subdistrict, Bogor District is 316 hectares with a
population in 2023 of 28,779 people. The composition of the population based on
gender is 14,783 males, and 13,996 females, while the number of residents in
the age range of 0-5 years is 640. In addition, Cimandala Village also has 21
Posyandu.
Immunization coverage in the Cimandala Village
area from 2021 to 2023 has not reached the target because it is still below
90%. It can be seen that there are still cases that should be prevented by
immunization such as measles, pneumonia, and tuberculosis. These cases are
found in infants and toddlers who rarely or even do not get immunized at all.
This is different from the results of the
achievement of complete basic immunization in three other villages in Bogor
City, which are still close to Cimandala Village, namely Cibuluh village with
an IDL achievement of 95.3%, Tanah Baru 95.3%, and Cimahpar 94.3%.
Cases of diseases that could have been
prevented by immunization did not only occur in Cimandala Village, which has
many Posyandu, but also in areas with few Posyandu, although the number of
cases was not as high as in Cimandala Village, such as in Sukatani Village,
Sukaraja Sub-district, Bogor District. In 2021 to 2023, there were still cases
of tuberculosis and pneumonia. The immunization coverage in Sukatani Village is
higher than Cimandala Village, with 87% in 2021, 89% in 2022, and 91% in 2023.
Related to the main theme of writing this
thesis, to the best of the author's knowledge there is no similar theme to the
research compiled by the author. The similar theme is the research on the
Implementation of Regent Regulation No. 5/2011 on the Provision of Complete
Basic Immunization as an Effort to Improve the Public Health Status in
Padarincang District. The study examines the implementation of the Regent's
Regulation in the Serang Regency area of Banten Province in providing
immunizations to children aged 0-11 months. Similar research is also found in
research on the Implementation of the School Child Immunization Month Program
to Fulfill Children's Human Rights in Obtaining Measles Disease Protection in
the Tegal City Puskesmas Region where the author only examines the
implementation of measles immunization in school children. Whereas in the main
theme of this thesis, the author conducted research on the Implementation of
the Regulation of the Minister of Health of the Republic of Indonesia concerning
the Implementation of Immunization at Posyandu in the Cimandala Village area,
Bogor Regency.
On the basis of the background description
above, the purpose of this study is to know and analyze. Implementation of Regulation of the Minister
of Health of the Republic of Indonesia Number 12 of 2017 concerning the
Implementation of Immunization in the Context of Fulfilling Children's Right to
Health. The benefits of this research are
RESEARCH
METHODS
This study uses a normative juridical research
method. In general, this method views the law as a system of norms or rules.
This approach focuses its study on law as a whole system involving legal
principles, legal norms, and legal regulations, both written and unwritten.
This research is descriptive analysis, namely describing the research object
and analyzing it based on the theory or opinion of experts. Providing real data
possible about individuals, situations, or other symptoms is the goal of
descriptive research.
RESULTS AND
DISCUSSION
Implementation
of the Regulation of the Minister of Health of the Republic of Indonesia No. 12
of 2017 concerning the Implementation of Immunization as an Effort to Fulfill
Children's Right to Health at the Posyandu in the Cimandala Village Area, Bogor
Regency
Health is a human right and one of the
elements of the welfare of every human being. Immunization is a health service
program that has been organized by the Indonesian government. Policies in the
implementation of immunization are listed in the Regulation of the Minister of
Health of the Republic of Indonesia No. 12 of 2017 concerning the
Implementation of Immunization (Khomariah et
al., 2018).
In the implementation of the Immunization
Program, the Central Government and Regional Governments are responsible for
the implementation of the immunization. This is mentioned in Article 12
paragraph (1). In accordance with these regulations, the implementation of
immunization in the Cimandala Village area, Bogor Regency can be carried out at
every Posyandu that has been prepared by the Government and immunization is
given free of charge. Furthermore, in Article 25, it is further explained that
the implementation of immunization programs is carried out using a family
approach to increase access to immunization services and can be carried out en
masse at posyandu. However, the results of the research through interviews with
parents and the observation of researchers in the field, there are still
parents who do not want to take their children to the Posyandu for
immunization. The non-fulfillment of children's right to health through
immunization in the Cimandala Village area, Bogor Regency is caused by several
factors, namely:
1. The level of parental knowledge about
immunization is still low.
Knowledge is the
result of knowing something, which is obtained after a person senses an object.
This sensing process occurs through the five senses of humans, namely sight,
hearing, smell, taste, and touch. According to Notoatmodjo, knowledge included
in the cognitive domain has six levels, namely:
a.
Know:
Recalling the material that has been learned before. At this level, a person is
able to recall specific information from the entire material that has been
studied or stimuli that have been received.
b.
Comprehension:
The ability to properly explain a known object and interpret the material
appropriately. A person who understands an object or material must be able to
explain, give examples, conclude, predict, and so on about the object being
studied.
c.
Application:
An application is the ability to use material that has been learned in a
real-life situation. It includes the application of laws, formulas, methods,
principles, and others in different contexts or situations.
d.
Analysis:
The ability to decompose materials or objects into components, remain in an
organizational structure, and still have a relationship with each other. This
ability can be seen from the use of verbs such as describe, distinguish,
separate, group, and so on.
e.
Synthesis:
The ability to connect parts into a new form of whole. This means compiling new
formulations from existing formulations.
f.
Evaluation:
Relates to the ability to provide justification or judgment of a material or
object. This assessment can be based on self-defined criteria or existing
criteria.
According to Mubarak, some of the factors that
affect a person's knowledge are:
a.
Education:
Education is guidance given to a person regarding something so that they can
understand it. The higher a person's level of education, the easier they will
be to receive information, which ultimately increases their knowledge. On the
other hand, low education can hinder a person's ability to receive new
information and values.
b.
Work:
The work environment can provide a person with experience and knowledge, either
directly or indirectly.
c.
Age:
As you get older, there are changes in a person's psychological and
psychological aspects. These physical changes generally include four
categories, namely changes in size, changes in proportions, loss of old
features, and the emergence of new features.
d.
Interest:
Interest is a high tendency or desire for something. Interest encourages a
person to try and delve into something, which ultimately deepens their
knowledge.
e.
Experience:
Experience is an event that a person has experienced in interacting with his
environment. Bad experiences tend to be forgotten, but if they are pleasant,
they will leave a strong impression and generate a positive attitude.
f.
Culture:
Culture in the surrounding environment affects knowledge. For example, if an
area has a culture of maintaining environmental cleanliness, then the
surrounding community tends to have an attitude to always maintain cleanliness.
The level of
knowledge of parents about the importance of immunization is still lacking
because they have never found out about the importance of immunization and its
impact if it is not given. Most of them also rarely see news in print,
electronic, and social media, so the information they get about immunization is
very lacking. The experience of several parents who have immunized their
children but AEFIs such as fever or pain leave a negative impression of immunization
(Malasari,
2019). The culture of parents in the past who never
immunized also influenced the mindset of parents of babies/toddlers so that
they felt that immunization was not so important for children's health.
2.
Lack
of parental awareness of children's growth and development.
In Article 25 paragraph (3) of the Regulation
of the Minister of Health No. 12 of 2017 concerning the Implementation of
Immunization, it is stated that one of the places where the immunization
program services are carried out en masse is carried out at the posyandu.
Posyandu which is a health facility that has been provided by the government
provides health services every month through activities that aim to monitor the
growth and development of babies/toddlers as well as a place to carry out
immunizations. However, it is very unfortunate that based on data in the field,
there are still many parents who do not take advantage of the Posyandu
facilities. This can be seen in the data on Posyandu visits that are not in
accordance with the number of targets. Posyandu growth and development
monitoring activities are carried out free of charge, including in terms of
immunization. This is stated in the government policy in the Minister of Health
Regulation No. 12 of 2017 in Article 28, namely local governments, both districts
and cities, are responsible for preparing operational costs for the
implementation of immunization services at Puskesmas, Posyandu, Schools, and
other immunization service posts.
Although the health services carried out at
the Posyandu are carried out for free, the enthusiasm of parents to come to the
Posyandu is still low. This shows the lack of awareness of parents of the
importance of children's right to health services for the growth and
development of children (Pratiwi, 2020).
Human rights are basically a set of provisions
or rules aimed at protecting citizens from possible oppression, restriction, or
reduction of freedom by the state (Pratiwi, 2020). This means that there are certain
restrictions imposed on the state so that the basic rights of citizens are
protected from abuse of power.
Newborn children are protected by
international human rights arrangements by the United Nations. The preamble to
the United Nations Declaration implies that humanity has an obligation to give
the best for children. All parties agreed that the role of children is the hope
of the future. "My son is the most precious to me and my son is the spirit
of my life." Children have an existence as a human being that encompasses
the whole of life and humanity.
One of the rights
of children protected by the state and regulated in the applicable law is
health and from the ten principles contained in the Declaration of the Rights
of the Child states that children have the right to adequate nutrition, proper
housing, recreation, and health services. Families, especially parents, have an
important role in carrying out their obligations by bringing children to get
immunized at health facilities provided by the government as stipulated in the
Regulation of the Minister of Health Number 12 of 2017 concerning the
Implementation of Immunization. From the perspective of health science,
children from birth to the age of five are very vulnerable to various diseases,
so immunization is very important as a prevention of infectious diseases by
providing vaccines to build immunity to these diseases.
Indonesia
participates in the Convention on the Rights of the Child, which states that
participating countries must recognize the right of the child to the best
health status and ensure that no child's right to health services is violated.
This is stated in article 24 of the Convention on the Rights of the Child.
There are 4 principles contained in the KHA, namely: Non-discrimination, Best
interest of the child, Survival and development of children, and Respect for
children's point of view.
One of the principles that is
considered an important feature of the rule of law according to "The
International Commission of Jurists" is that governments must respect the
rights of individuals. For example, when a child is entitled to health services,
the government is obliged to provide such facilities for all children in
Indonesia. Another principle of the concept of the state of law is that the
state must obey the law. To carry out this principle of the state of law, it is
necessary to have positive law enforcement.
Good governance is generally carried out with
government principles. Since Indonesia adheres to the concept of a welfare
state, the government is responsible for the general welfare of citizens. The
government's activeness in pursuing public welfare must always be based on the
principles of good governance.
Law functions as a social control of the
government, namely as a social rule and process that seeks to encourage
beneficial behavior and prevent harmful behavior. To obey the applicable law,
legal awareness is needed so that the public understands the existence of laws
that regulate various kinds of regulations. According to Soerjono Soekanto,
there are four requirements for legal awareness, namely: must be aware of
knowledge of the law, understand the law, be aware of obligations to others,
and accept the law.
3.
Religious
Factors
The hampered implementation of immunization in
the Cimandala Village area, Bogor Regency is influenced by religious factors,
where there are rumors that the vaccine used for immunization is not halal for
followers of Islam. There are still some families who remain steadfast in not
wanting to immunize their children because their previous parents also did the
same thing, namely not giving immunizations.
Maqashid sharia is the goal that will be
achieved by the determination of sharia and the secrets placed by Allah as the
Maker of the Most Wise Shari'a in every law in order to provide benefits for
human life in this world and the hereafter. Human benefits consist of 3 types,
namely: daruriy, hajiy, and tahsiniy.
The benefits that are daruriy consist of five things, namely: hifzud-din
(maintaining religion), hifzun-nafs (maintaining the soul), hifzul-'aql
(maintaining the intellect), hifzun-nasl (maintaining offspring), and
hifzul-mal (maintaining property). Hifzun-nafs, which means to preserve the
soul, means to maintain one's right to live, be safe, and be honorable. This
means that every human being has the right to survive and one of them is by
preventing diseases for survival through immunization. Immunization aims to realize benefits, namely the creation of
a healthy generation, a strong generation, immune from various diseases, and
this is also in line with the principles of maqashid sharia to maintain the
sustainability of descendants (hifzun-nasl).
Islamic teachings strongly encourage their
people to always maintain their health, which in practice can be done through
preventive efforts so as not to get sick and seek treatment if sick in order to
regain health, namely by immunization. Based on the Fatwa of the Indonesian
Ulema Council No. 4 of 2016 in the legal provisions, it is stated that
immunization is basically allowed (mubah) as a form of effort to realize
immunity and prevent the occurrence of certain diseases. Immunization with
illegal and/or unclean vaccines is not allowed except in the following
circumstances:
1)
Used
in the condition of al-dlarurat or al-hajat;
2)
No
halal and holy vaccine ingredients have been found; and
3)
There
is information from competent and trusted medical personnel that there is no
halal vaccine.
In the event that an unvaccinated person will
cause death, severe illness, or life-threatening permanent disability, based on
the judgment of a competent and trusted expert, then immunization is legally
mandatory.
4.
Cultural
Factors
Law as a social norm reflects and concretizes
the values that apply in a society. To realize the desired social values, the
rule of law is needed as a tool. To understand the relationship between law and
the socio-cultural values of Indonesian society, it is necessary to pay
attention to the outlook on life of the Indonesian nation, most of whom still
live in the countryside. Indonesians feel themselves as part of the environment
and behave accordingly.
Rejection of immunization is one of the
consequences of the socio-cultural values that apply in a society where there
are still Indonesian people who think that the administration of herbs such as
honey or propolis can replace immunization and is more efficacious to increase
the body's immunity, and compare with previous parents who can live a healthy
life without immunization. This is what happened to several parents of
babies/toddlers in the Cimandala Village area, Bogor Regency, so that they did
not want to take their children to the Posyandu for immunization.
Immunization is one of the programs in an
effort to fulfill children's right to health, and has been regulated in the
Regulation of the Minister of Health No. 12 of 2017 concerning the
Implementation of Immunization, but based on observations in the field, the
implementation of the regulation has not gone well at the Posyandu in the
Cimandala Village area, Bogor Regency. This is because there are still parents
who do not participate in the immunization program and do not take advantage of
the facilities that have been provided by the government, namely the Posyandu
as a place to get the immunization.
The implementation of immunization in the
Cimandala Village area, Bogor Regency has not been carried out properly because
based on the results of the study, complete basic immunization coverage data
was obtained which is still below the national target of RPJMN 90% and there
are still cases of diseases that can be prevented by immunization (PD3I) such
as measles in 3 children in 2023; pneumonia in 7 children in 2021, 25 children
in 2022, and 22 children in 2023; then tuberculosis in 6 children in 2021, 15 children
in 2022, and 18 children in 2023.
This is due to the fact that in practice there
are still parents who do not carry out their responsibility to provide
immunization to their children as a right that should be obtained by children
in an effort to prevent the occurrence of a disease as stated in the Regulation
of the Minister of Health Number 12 of 2017 concerning the Implementation of
Immunization Article 1 "Immunization program is an immunization that is
required for a person who is part of the community to protect him and the surrounding
community from diseases that can be prevented by immunization".
Efforts
of Health Workers and Health Cadres Towards the Implementation of Immunization
as the Implementer of the State's Obligation in Fulfilling Children's Rights to
Health at Posyandu in the Cimandala Village Area, Bogor Regency
The obligation to protect requires, among
other things, that the state enact legislation or take action to guarantee
equitable access to health care and services related to third-party providers;
ensuring that the privatization of the health sector affects the accessibility,
acceptance, and quality of health services, goods, and services; regulating the
marketing of health supplies and medicines by unaffiliated parties; and
ensuring that physicians and other health professionals adhere to ethical
standards, knowledge requirements, and educational standards (Supeno, 2013).
States are required to meet their commitments
by implementing laws that recognize the right to health in national political
and legal systems and by adopting national health policies that include
comprehensive strategies for achieving the right to health. Public health
infrastructure must provide health services, including immunization programs
against infectious diseases.
The right to health in all its forms and at
all levels contains important and interrelated elements. Its proper application
depends on the specific circumstances of a country, namely:
1.
Availability
Cimandala
Village already has 21 Posyandu that can be used as a place to provide
immunization to infants and toddlers.
2.
Accessibility
In
the implementation of immunization in the Cimandala Village area, Bogor Regency
which was carried out at the Posyandu, the babies and toddlers who came were
given the same health services without any form of discrimination. Posyandu
locations have also been spread across every RW and have been equipped with
anthropometric equipment to monitor the growth and development of babies and
toddlers. The drugs used for immunization have been provided by health workers
and immunizations are given free of charge. The dissemination of information
about the implementation of the Posyandu has been carried out by health cadres
and heads of RTs, RWs and PKK RW groups in the Posyandu area, but there are
still people who do not want to come to the Posyandu to provide immunizations
to their children due to the lack of correct information about the
immunization.
3.
Acceptance
Immunizations
that will be given to infants and toddlers who come to the Posyandu must be
approved by the parents or guardians of the babies and toddlers. But
unfortunately there are still parents who do not allow their children to be
immunized.
4.
Quality
In
the implementation of Posyandu activities, there are health workers from the
Cimandala Village Health Center as well as health cadres who are local natives
and have been fostered before. The medicines given for immunization at the
Posyandu were obtained from the Bogor Regency Health Office which has been
clinically tested and BPOM.
Article 30 of the Regulation of the Minister
of Health Number 12 of 2017 concerning the Implementation of Immunization
explains that immunization program services are carried out by health workers
who have competence and authority in accordance with the provisions of laws and
regulations.
The implementation of immunization at the
Posyandu in Cimandala Village, Bogor Regency was carried out by one health
worker and five health cadres who had received training as Posyandu health
cadres. The implementation of the Minister of Health Regulation Number 12 of
2017 concerning the Implementation of Immunization at Posyandu in the Cimandala
Village area, Bogor Regency has not gone well, this is due to the lack of
people using Posyandu to get immunization so that immunization coverage data
does not reach the national target and there are still cases of diseases that
can actually be prevented by immunization. For this reason, more optimal
efforts are needed by health workers and health cadres as implementers of
immunization at the Posyandu so that efforts to fulfill children's right to
health through immunization at the Posyandu can run well.
Based on Law of the Republic of Indonesia No.
17 of 2023 concerning Health, it is stated that health workers are any person
who devotes themselves to the health sector and has a professional attitude,
knowledge, and skills through higher education which for certain types requires
the authority to carry out health efforts.
Health workers play an important role in
improving the quality of maximum health services to the community. The goal is
to increase people's awareness, willingness, and ability to live healthily, so
that an optimal degree of health is achieved. This is considered an important
investment in the development of socially and economically productive human
resources and as one of the elements of general welfare. In the implementation
of immunization, health workers can make the following efforts:
1.
As
a motivator
This means that health workers
can provide counseling to parents during the implementation of posyandu about
the importance of immunization and the steps that need to be taken when AEFIs
occur. In addition, health workers can attend community meetings to provide
education and encourage mothers to immunize their children to prevent various
diseases. According to Notoatmodjo, a motivator is someone who provides
motivation to others. Motivation itself is the urge to act to achieve a certain
goal, the results of which are manifested in behavior. Therefore, health
workers as motivators can provide encouragement to others to act to achieve
certain goals that are reflected in their behavior. A health worker must be
able to provide motivation, direction, and guidance to increase the awareness
of the motivated party in order to achieve the desired goal. In this context,
health workers must play a role as a motivator to increase parents' awareness
of the importance of immunization.
2.
As
a dynamizer
Health workers provide information about
immunization for toddlers through collaboration with posyandu cadres and the
village government. As dynamists, health workers must be able to communicate to
convey messages or stimuli to others, so that they can move and cooperate to
achieve goals.
3.
As
an Innovator
Health workers can act as agents of change for
individuals, families, groups, and communities, especially in changing
behaviors and lifestyles related to health improvement and maintenance. In
carrying out their duties as agents of change, health workers must provide
assistance, awareness, and encourage groups to recognize the problems they face
and develop their potential to solve these problems.
4.
As
a Facilitator
Health workers must act as facilitators in
providing immunizations to toddlers during every visit to the health center.
According to Sardiman, the role of the facilitator does not only take place
during the meeting or counseling process, but health workers must also be able
to provide a special time and place when patients want to ask more in-depth and
closed questions. As such, facilitators must be skilled in integrating three
important things: facilitation optimization, time provisioning, and participation
optimization. Health workers must be able to be companions in a forum and
provide opportunities for patients to ask about things that are not understood.
Based on the results of the research, so far
the efforts that have been made by health workers at the Posyandu are only to
provide explanations about immunization to parents before injecting
immunization into their children. Before immunization, health workers give an
explanation of the type of immunization, benefits, side effects that may occur
after being given, and the next immunization schedule. Health workers did not
provide special explanations or counseling regarding immunization to all
parents who came to the Posyandu.
In accordance with Article 44 of the
Regulation of the Minister of Health of the Republic of Indonesia No. 12 of
2017 concerning the Implementation of Immunization, the community, including
the private sector, can participate in the implementation of immunization in
collaboration with the government, which can be realized through: community
mobilization; socialization of immunization; support for the facilitation of
the implementation of immunization; participation as a cadre; and/or
participate in monitoring the implementation of immunization (Wirasmi et
al., 2022).
Health cadres are the spearhead of the
implementation of Posyandu in the community. Health cadres have the task of
managing the implementation of Posyandu, starting from the preparation,
implementation and post-implementation of Posyandu every month. The
requirements to become a Posyandu cadre are to come from local community
members, be able to read and write Latin letters, be interested and willing to
become a cadre, be willing to work voluntarily, and have the ability and free
time. A cadre must also have the necessary knowledge and skills in accordance
with their duties in order to develop health programs in their village. For
this reason, before becoming a health cadre, training is carried out first
until finally given authority by the local village government to become a
health cadre. Health cadres who are indeed local indigenous people are obliged
to mobilize parents to bring their children and immunize them at the Posyandu.
The success of posyandu
activities cannot be separated from the efforts and hard work of cadres who
voluntarily manage posyandu in their respective regions. Cadres have an
important role in supporting the success of immunization, namely:
1. Helping to record the targets
of the immunization program (infants, toddlers, elementary school age
children).
2. Mobilizing parents and targets
to come to immunization service sites.
3. Helping to prepare immunization
service sites and waiting rooms before and after injections at posyandu.
4. Regulate the flow of
immunization services.
5. Help record targets who have
been immunized.
6. Recording infants or children
who have not been immunized and visiting the parents or families of the infants
or children.
7. Visiting parents or families
who have never taken their child to the immunization service site.
8. Report to the officer if a
Post-Immunization Adverse Event (AEFI) is found.
Cadres play a role as a liaison
between the community and the government. The success of government programs,
especially immunization programs, is highly dependent on the role of cadres.
Therefore, the role of cadres as data collectors, movers, implementers, and
motivators in increasing immunization coverage at posyandu greatly affects
public health activities, especially basic immunization. If the role of cadres
is good, then mothers will be more motivated to take their children to posyandu
for immunization. Thus, a cadre must be able to provide information,
motivation, appeals, and counseling to the community so that they are more
active in bringing their children for immunization (Kusuma
et al., 2021).
The health cadres in the
Cimandala Village area are five people in each Posyandu. In the implementation
of Posyandu activities, the cadres occupy positions in accordance with their
respective duties in accordance with the 5 table services in the Posyandu. In
the implementation of Posyandu immunization, there is one cadre who helps
health workers to carry out immunization services, namely at table five. The
provision of information about immunization is carried out by cadres at table
four where the health cadre is in charge of providing information to parents
who come to the Posyandu about child growth and development, providing
additional food to children, and immunization.
In article 46 of RI Law No. 35 of 2014
concerning Amendments to Law No. 23 of 2002 concerning Child Protection, it
explains the obligation of the state, government, family, and parents to ensure
that their offspring are protected from diseases that threaten their existence
or cause disability. In an effort to prevent diseases that can actually be
prevented by immunization, cooperation between the government and families is
needed so that the implementation of immunization runs optimally. For this
reason, it is necessary to approach parents to increase their awareness in
immunizing children.
The efforts of health workers and health
cadres as implementers of immunization at Posyandu have not been carried out
optimally because there is no direct approach to parents through special
counseling regarding immunization.
Based on the results of research and
observations of researchers in the field, several obstacles in the
implementation of immunization in the Posyandu in the Cimandala Village area
are as follows:
1.
Lack
of parental knowledge about the benefits of immunization, its impact on health
if not done, as well as the side effects or AEFIs of immunization.
2.
Lack
of awareness of parents regarding monitoring their children's growth and
development.
3.
Issues
and myths about immunization related to the halalness of the vaccine
ingredients used and myths conveyed by previous parents to their children and
grandchildren so that they refused immunization.
CONCLUSION
Based on the results
of research on the Implementation of Regulation of the Minister of Health of
the Republic of Indonesia Number 12 of 2017 concerning the Implementation of Immunization
in the Context of Fulfilling Children's Right to Health at Integrated Service
Post (Posyandu) in Cimandala Village area, Bogor Regency, several things can be
concluded. First, the implementation of the Regulation of the Minister of
Health of the Republic of Indonesia Number 12 of 2017 related to the
implementation of immunization in order to fulfill children's right to health
at Posyandu in Cimandala Village, Bogor Regency, has not gone well. This is
based on field data showing that there are still people who do not use Posyandu
health facilities to immunize their children, so that the coverage of complete
basic immunization (IDL) is still below the national target, which causes cases
of diseases that can actually be prevented by immunization. The achievement of
IDL in the Cimandala Village area in 2021 reached 75.71%, in 2022 it was
69.83%, and in 2023 it decreased to 67.31%. The coverage of complete basic
immunization, which is still below 90%, has led to the emergence of cases of
Immunization Preventable Diseases (PD3I) such as tuberculosis, pneumonia, and
measles in children under 5 years of age. Second, the efforts of health workers
and health cadres in the implementation of immunization in Posyandu in
Cimandala Village, Bogor District, still do not meet expectations so that the
implementation of the Minister of Health Regulation No. 12/2017 related to the
implementation of immunization has not run optimally. Therefore, more optimal
efforts are needed from health workers and health cadres regarding the
importance of fulfilling children's right to health.
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Copyright holder: Christy Imelda Margaretha Mudrikah (2024) |
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First publication right: Asian Journal of
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