Diagnosing ills of low-cost health services

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