Diagnosing ills of low-cost health services

The Use of Health Services in a Slum Area of North Jakarta By Charles Surjadi EGC Publisher Jakarta, 1997 178 pp.

JAKARTA (JP): With only 64 public hospitals serving the city's 9.8 million people, good quality health services at low cost are hard to find.

The government and city administration realize the gap between services of these facilities and those in luxury private hospitals, but are handcuffed from building more hospitals by fund limitations.

This realization has not stopped concerted efforts to provide health services for all Jakartans, 26 percent of whom live in slum areas.

On the national level, the drive has included the establishment of community health centers, or (Puskesmas), immunization drives for children under five years and the setting up of monthly integrated health posts (Posyandu) for mothers and children.

These measures have won international recognition. In 1991, President Soeharto received the World Health Organization's gold medal for the nation's efforts to achieve health for all by 2000.

But the author of this work, an urban studies researcher at the Jakarta-based Atmajaya University, in 1989 explored indications that the number of people actually using the low- cost, nationwide services was relatively low.

Charles Surjadi noted the infant mortality rate was still the highest among members of the Association of Southeast Asian Nations (four years after his study it remained at 63 per 1,000 live births, still top in ASEAN).

In efforts to reduce it, he writes that "one of the objectives of the government's current Five Year Development Plan, 1994/1995 to 1998/1999 is the provision of more equitable access to health services. Proof of access is the use of services".

He set out to determine the relevance of the latest data available, from way back in 1978, which showed only 13 percent of urbanites utilized community health centers.

"Although almost every subdistrict has its own puskesmas, studies in Indonesia have shown that the percentage of sick people who use puskesmas facilities is less than the percentage of sick people using private facilities," he writes.

His study, conducted in the slums of Penjaringan and Pademangan Barat subdistricts in Penjaringan district, North Jakarta, involved in-depth research on 32 households.

Change

Conclusions were partly based on factors determining the use of the community health centers and integrated health posts.

Given the continuing lack of data on the subject, Charles' work should serve as an important contribution to improvement of health services.

Although eight years old, the findings are still relevant as there have been no significant changes in Puskesmas or Posyandu services.

Respondents in Penjaringan perceived the quality of Puskesmas services as poor because of the long wait for treatment and occasional use of non-medical personnel.

Health workers were not fully to blame, the author believes, as they were burdened by both regular and administrative duties.

Only 30 percent of a doctor's time was actually spent on curative care per month, and a Puskesmas midwife was also required to deal with administrative concerns.

Jakarta administration data from 1996 appears to show this pattern of overburdened medical personnel continues. The city had only 565 general physicians, 104 specialists, 388 dentists and 1,125 nurses for its millions.

Most Puskesmas doctors in Charles' study also balanced demands of private practices, sometimes located close to the health centers, to supplement their poor government salaries.

Charles proposes the government allow the doctors to open private practices in the afternoon at the health centers, on the condition that a portion of the fees is allocated for the doctors themselves.

He argues this would help overcome the need for extra income and ensure availability of doctors at the facilities.

Discriminatory

Patients at health centers also complained of limited opening hours and little time devoted to medical-history taking, examination and advice.

They perceived that health center staff gave special treatment to their friends and relatives. Other complaints were that medicine was poorly packed and of inferior quality, and that buildings were in poor physical condition (e.g. rooms were too small to accommodate all necessary treatments).

In contrast, most respondents perceived services of private doctors as accessible; physicians were judged friendly, opening hours convenient and good quality medicine was available.

But costs of these services were beyond the pocketbooks of most respondents, who settled for treatment at health centers for fees averaging Rp 1,000 per patient in 1989.

Concerns over cost have not changed. Data from the Ministry of Health, released in Profil Kesehatan Indonesia 1996 (Health Profile of Indonesia 1996), showed average spending of US$6.4 per month on health services.

Finances are among contributors to the practice of self- treatment, both in the use of traditional medicine and non- prescription drugs.

Knowledge

Charles also found poor public knowledge of immunizations and the ages they should be administered, despite widespread information at integrated health posts and in the mass media.

Based on 1994 data from the National Bureau of Statistics, 80 percent of Jakartans listen to the radio and 93 percent regularly watch TV, both of which often carry public service announcements.

And despite availability of information about immunizations at Posyandu, Charles discovered services were sometimes unavailable.

He reports that only 42 percent of under fives in his household grouping were fully immunized, and 16 percent had not received any immunizations.

Sixty percent of the children had been immunized at Posyandu, while the Ministry of Health targets to reach 75 percent of the young at these facilities.

The health posts were also found to be ineffective in increasing the number of children completing the full set of immunizations, precisely because some were unavailable.

Mothers unaware of the need for a full course often missed those immunizations only offered on particular dates.

Forty percent of mothers perceived the quality of services at the health posts to be low. This was mainly related to the poor attitude of Posyandu workers, inefficient organization of the services and resulting long waiting time, and the frequent absence of the midwives assigned to provide immunizations.

Charles study found the midwives often arrived late, and did not bring vaccines because of lack of supplies or oversight.

Occasionally, vaccinations for BCG against tuberculosis and measles would only be administered if more than 20 children had shown up.

Officially free, the immunizations at both health centers and health posts often required a "voluntary contribution" to the staff.

Charles' findings are disheartening, particularly as little seems to have changed in the ensuing years.

Based on 1996 data, Jakarta has only 43 district and 265 subdistrict health centers, and 14,371 Posyandu.

In a staggering statistic, each subdistrict health center should serve more than 30,000 people.

Charles offers recommendations for a better health future.

He says the government should improve the management of activities and logistics at Puskesmas to facilitate their operations.

Aware that the staff has not got the time nor the skills for community mobilization, Charles urges them to join forces with non-governmental organizations in this drive.

He concludes that more research needs to be done to determine if these government services are really meeting the needs of the needy, the people they are designed to serve.

-- Stevie Emilia