Diagnosing ills of low-cost health services<\/p>\n
The Use of Health Services in a Slum Area of North Jakarta
\nBy Charles Surjadi
\nEGC Publisher Jakarta, 1997
\n178 pp.<\/p>\n
JAKARTA (JP): With only 64 public hospitals serving the city's
\n9.8 million people, good quality health services at low cost are
\nhard to find.<\/p>\n
The government and city administration realize the gap between
\nservices of these facilities and those in luxury private
\nhospitals, but are handcuffed from building more hospitals by
\nfund limitations.<\/p>\n
This realization has not stopped concerted efforts to provide
\nhealth services for all Jakartans, 26 percent of whom live in
\nslum areas.<\/p>\n
On the national level, the drive has included the
\nestablishment of community health centers, or (Puskesmas),
\nimmunization drives for children under five years and the setting
\nup of monthly integrated health posts (Posyandu) for mothers and
\nchildren.<\/p>\n
These measures have won international recognition. In 1991,
\nPresident Soeharto received the World Health Organization's gold
\nmedal for the nation's efforts to achieve health for all by 2000.<\/p>\n
But the author of this work, an urban studies researcher at
\nthe Jakarta-based Atmajaya University, in 1989 explored
\nindications that the number of people actually using the low-
\ncost, nationwide services was relatively low.<\/p>\n
Charles Surjadi noted the infant mortality rate was still the
\nhighest among members of the Association of Southeast Asian
\nNations (four years after his study it remained at 63 per 1,000
\nlive births, still top in ASEAN).<\/p>\n
In efforts to reduce it, he writes that \"one of the objectives
\nof the government's current Five Year Development Plan, 1994\/1995
\nto 1998\/1999 is the provision of more equitable access to health
\nservices. Proof of access is the use of services\".<\/p>\n
He set out to determine the relevance of the latest data
\navailable, from way back in 1978, which showed only 13 percent of
\nurbanites utilized community health centers.<\/p>\n
\"Although almost every subdistrict has its own puskesmas,
\nstudies in Indonesia have shown that the percentage of sick
\npeople who use puskesmas facilities is less than the percentage
\nof sick people using private facilities,\" he writes.<\/p>\n
His study, conducted in the slums of Penjaringan and
\nPademangan Barat subdistricts in Penjaringan district, North
\nJakarta, involved in-depth research on 32 households.<\/p>\n
Change<\/p>\n
Conclusions were partly based on factors determining the use
\nof the community health centers and integrated health posts.<\/p>\n
Given the continuing lack of data on the subject, Charles'
\nwork should serve as an important contribution to improvement of
\nhealth services.<\/p>\n
Although eight years old, the findings are still relevant as
\nthere have been no significant changes in Puskesmas or Posyandu
\nservices.<\/p>\n
Respondents in Penjaringan perceived the quality of Puskesmas
\nservices as poor because of the long wait for treatment and
\noccasional use of non-medical personnel.<\/p>\n
Health workers were not fully to blame, the author believes,
\nas they were burdened by both regular and administrative duties.<\/p>\n
Only 30 percent of a doctor's time was actually spent on
\ncurative care per month, and a Puskesmas midwife was also
\nrequired to deal with administrative concerns.<\/p>\n
Jakarta administration data from 1996 appears to show this
\npattern of overburdened medical personnel continues. The city had
\nonly 565 general physicians, 104 specialists, 388 dentists and
\n1,125 nurses for its millions.<\/p>\n
Most Puskesmas doctors in Charles' study also balanced demands
\nof private practices, sometimes located close to the health
\ncenters, to supplement their poor government salaries.<\/p>\n
Charles proposes the government allow the doctors to open
\nprivate practices in the afternoon at the health centers, on the
\ncondition that a portion of the fees is allocated for the doctors
\nthemselves.<\/p>\n
He argues this would help overcome the need for extra income
\nand ensure availability of doctors at the facilities.<\/p>\n
Discriminatory<\/p>\n
Patients at health centers also complained of limited opening
\nhours and little time devoted to medical-history taking,
\nexamination and advice.<\/p>\n
They perceived that health center staff gave special treatment
\nto their friends and relatives. Other complaints were that
\nmedicine was poorly packed and of inferior quality, and that
\nbuildings were in poor physical condition (e.g. rooms were too
\nsmall to accommodate all necessary treatments).<\/p>\n
In contrast, most respondents perceived services of private
\ndoctors as accessible; physicians were judged friendly, opening
\nhours convenient and good quality medicine was available.<\/p>\n
But costs of these services were beyond the pocketbooks of
\nmost respondents, who settled for treatment at health centers for
\nfees averaging Rp 1,000 per patient in 1989.<\/p>\n
Concerns over cost have not changed. Data from the Ministry of
\nHealth, released in Profil Kesehatan Indonesia 1996 (Health
\nProfile of Indonesia 1996), showed average spending of US$6.4 per
\nmonth on health services.<\/p>\n
Finances are among contributors to the practice of self-
\ntreatment, both in the use of traditional medicine and non-
\nprescription drugs.<\/p>\n
Knowledge<\/p>\n
Charles also found poor public knowledge of immunizations and
\nthe ages they should be administered, despite widespread
\ninformation at integrated health posts and in the mass media.<\/p>\n
Based on 1994 data from the National Bureau of Statistics, 80
\npercent of Jakartans listen to the radio and 93 percent regularly
\nwatch TV, both of which often carry public service announcements.<\/p>\n
And despite availability of information about immunizations at
\nPosyandu, Charles discovered services were sometimes unavailable.<\/p>\n
He reports that only 42 percent of under fives in his
\nhousehold grouping were fully immunized, and 16 percent had not
\nreceived any immunizations.<\/p>\n
Sixty percent of the children had been immunized at Posyandu,
\nwhile the Ministry of Health targets to reach 75 percent of the
\nyoung at these facilities.<\/p>\n
The health posts were also found to be ineffective in
\nincreasing the number of children completing the full set of
\nimmunizations, precisely because some were unavailable.<\/p>\n
Mothers unaware of the need for a full course often missed
\nthose immunizations only offered on particular dates.<\/p>\n
Forty percent of mothers perceived the quality of services at
\nthe health posts to be low. This was mainly related to the poor
\nattitude of Posyandu workers, inefficient organization of the
\nservices and resulting long waiting time, and the frequent
\nabsence of the midwives assigned to provide immunizations.<\/p>\n
Charles study found the midwives often arrived late, and did
\nnot bring vaccines because of lack of supplies or oversight.<\/p>\n
Occasionally, vaccinations for BCG against tuberculosis and
\nmeasles would only be administered if more than 20 children had
\nshown up.<\/p>\n
Officially free, the immunizations at both health centers and
\nhealth posts often required a \"voluntary contribution\" to the
\nstaff.<\/p>\n
Charles' findings are disheartening, particularly as little
\nseems to have changed in the ensuing years.<\/p>\n
Based on 1996 data, Jakarta has only 43 district and 265
\nsubdistrict health centers, and 14,371 Posyandu.<\/p>\n
In a staggering statistic, each subdistrict health center
\nshould serve more than 30,000 people.<\/p>\n
Charles offers recommendations for a better health future.<\/p>\n
He says the government should improve the management of
\nactivities and logistics at Puskesmas to facilitate their
\noperations.<\/p>\n
Aware that the staff has not got the time nor the skills for
\ncommunity mobilization, Charles urges them to join forces with
\nnon-governmental organizations in this drive.<\/p>\n
He concludes that more research needs to be done to determine
\nif these government services are really meeting the needs of the
\nneedy, the people they are designed to serve.<\/p>\n
-- Stevie Emilia<\/p>", "url": "https:\/\/jawawa.id\/newsitem\/diagnosing-ills-of-low-cost-health-services-1447893297", "image": "" }, "sponsor": "Okusi Associates", "sponsor_url": "https:\/\/okusiassociates.com" }