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COUNTRY REPORT 4 Public Health Services in Surabaya Municipality, Indonesia The following report is part of the Country Report of Surabaya City prepared by Dr. H. Widiharto, who participated in the 1st Study Course on Specific Fields of Urban Policy 1996 organized by AUICK. Dr. H. Widiharto is former chief of Surabaya Municipal Health Service and was in charge of all the health programs in Surabaya City. Now he is the Director of Subandi Hospital in Jember. 1. Introduction Surabaya is the capital city of East Java Province. The size of the area is about 290.44 square kilometers. The city is divided into five sub-urbans, headed by an Assistant Mayor. There are 28 districts (Kecamatan) and 163 sub-districts or villages (Kelurahan). At the neighborhood level, a head is locally elected among its 75 - 100 households members, known as R.T. Every 4 - 7 neighborhood units (RT) are coordinated by a Community Unit Organization (RW). Total population of Surabaya is approximately 3 million where one fourth are seasonal migrants. No less than 63 percent of these people live in dense settlements called Kampung which cover only 7 percent of the municipal area. Due to the KIP program that has been implemented since 1968, a lot of Kampung are no longer categorized as slum or squatter areas. People who need special attention in Surabaya city are the urban poor who are usually located in marginal areas or illegally occupied land without basic infrastructure. These people are subject to environmental and health risks deriving from overcrowding, lack of clean water and sanitary facilities, low level of nutrition, pollution, new communicable disease and accidents. Priority has been given to health programs targeting the most vulnerable group such as mothers and children under five years living under the poverty line. The urban poor population is estimated to amount to 28,220 or 1.04 percent of the total population who live in 13 of the 163 villages of Surabaya city. Various programs have been undertaken to alleviate poverty and its effect on health. 2. The Health System Referring to the National Health development policy, Surabaya Health Care Delivering systems have been developed through the Primary Health Care approach, accordingly the provision of essential health services have to be community based, include full participation and active involvement of the community and supported by inter-sectoral collaboration. The Indonesian health system is organized at various levels. At the level of the district or municipality, a district or Municipal Health Office is established by the Ministry Of Health and a district or municipal health service is operated by local government. The main functions of the district/municipal health service are to care for patients and examine specimens in the laboratory. Many of the patients will have been referred from the sub district level. In addition, the district/municipal health service carries out public health activities such as disease control, health education, and the training of health personnel. The district/municipal health office is mainly an administrative and supervisory body. It ensures that medical interventions reach the people who can benefit from them, especially high risk groups, and organizes public works aimed at improving environment hygiene and safety. Its responsibilities include village community health development, the management of drugs, man power, public information, planning, and general administrative work. At the village level, community health development is an integral part of overall village development under the umbrella of the Village Community Resilience Institute, which is the forum for all development activities requiring inter sector's cooperation. At least one health center and 3-5 sub centers can be found in every sub district. Their work involves case finding, treatment, immunization, environmental interventions and the teaching of healthy life styles. The activities of health centers are not only complete in themselves but also integrated with the village community and linked with all other kinds of health activities carried out in the community under the coordination of the Village Community Resilience Institute. The basic health services provided through health centers comprise maternal and child health, family planning, nutrition, environment health, the prevention and control of communicable disease, immunization, mental health, education, treatment, school health, public health nursing, oral and dental health, simple laboratory examinations, and the maintenance of records for the health information system. Health centers are the means of providing support, equipment, and supervision to sub center staff, private health practitioners, and village health volunteers. 3.Health's objective and policies The citizens of Surabaya are very much heterogeneous, there exists urban society, rural society and the traditional society. In order to achieve the goal of Surabaya in the future, the development must also promote the quality of the citizen, their discipline and other motives that could bring success in developing the city. As far as the cultural development is concerned, the kampung is still needed, because the kampung society is usually the traditional society. Kampung takes part in preparing people from rural areas (which is the product of the urbanization), to become urban people. Since urbanization was the product of imbalance in the inter-regional development, then development of the surrounding area of Surabaya, i.e. Mojokerto city, Bangkalan city and Sidoarjo city (known as Gerbang Kertasusila), must also be a major priority. In recent years Surabaya has expanded very quickly. Surabaya has been developed as a modern city, a center of industry, commerce and maritime industries, as well as education. Consequently, Surabaya people are subject to "modern" risk, while the "conventional" risk hasn't yet been left out. Unfavorable environments, urbanization, poverty and other modern risk factors arise from changing behaviors, and exposing people to the health hazards of industry need serious consideration. Prevention and control of communicable disease are directed towards the achievement of an objective i.e. to decrease morbidity and mortality due to communicable disease and to avoid unnecessary suffering and economic losses. At present the diseases threatening Surabaya citizens are diarrhea, Dengue Hemorrhagic Fever, as well as new communicable diseases (such as AIDS). Most child preventable diseases such as Tubercles, Diphtheria, Pertussis, tetanus, Polio and Measles are successfully controlled by immunization and are no longer a threat to Surabaya people. Various health programs have been drawn up while keeping in line with the policy and developmental directions of public health (which is aiming to facilitate the attainment and maintenance by the individual of a standard of health that will enable him to lead an economically and socially productive life). In developing objectives for each program in Surabaya city, care has been taken so that these objectives will fall within the broader objectives of national health development. There are five objectives of the city health development, namely: 1. The improvement of the communities' ability to help themselves to be healthy. 2. The improvement of the environment so that it can no longer threaten the health of the people. 3. The improvement of community nutritional status. 4. The reduction of morbidity and mortality. 5. The development of small, happy and prosperous families. In the second long term health development special emphasis has to be given to the development of human resources. To ensure health services reach all Surabaya citizens, high priority is directed toward underprivileged urban people. 4. Implementation of Municipal Health Program Health services are provided through Health Centers, Sub Health Centers, Mobile Health Services and Policlinics as well as Hospitals supported by private agencies such as medical practitioners and community participation such as Posyandu (Integrated Health Post). In Surabaya city there are 47 Health Centers, 57 Sub Health Centers and 28 Mobile Health Services. Although the ratio of Health Center and Sub Health Center to Surabaya population are a little higher than expected (1 : 56,728 and 1 : 46,775) it doesn't mean that the availability of health services is low. Coupled with health services by private clinics and other health service units run by other agencies, the availability of health services is very high. (Ratio of health service unit to population is 1 : 8947). Health facilities available in
Surabaya are as follow:
The development in primary health care approaches has been accelerated by the establishment of integrated health posts (Posyandu) in the villages, staffed by health professionals and village health volunteers working side by side. These posts are opened to the public at least once a month. Health services for infants and children under the age of five are provided by these posts include growth monitoring by weighing, the provision of supplementary foods, basic immunizations, the treatment of disease (especially diarrhea diseases) and the health education of mothers, health services for pregnant and lactating mothers and eligible couples cover nutrition, disease prevention (including tetanus toxoid immunization), treatment, the provision of contraceptives, and health education for individuals and groups of people. When the health post is not operating, village health volunteers deliver essential health care where it needed, they have to help people on the spot. Every post belongs to the village in which it is located, not to the government, making each a forum created by the community for its own benefit. To support development of Posyandu the PKK (Women Family Welfare Movement) has started to develop a system of care based on 10 families (Dasa Wisma). PKK, an abbreviation of Pembinaan Kesejahteraan Keluarga, was officially recognized in December 1972 as a nation wide movement and it was not until 1983 that this movement was included in the Guide Lines of State Policy (the GBHN). Through the establishment of integrated health posts and development of the ten families systems of care, the idea of health for all is becoming a reality in Indonesia. Surabaya citizens through PKK are always encouraged to take part in every health development program. These village health volunteers or village health workers are selected and paid by the community. These people are trained to perform simple health related activities. The number of community health workers (Cadre) in 1994 is 15,379 people (0.5 percent of Surabaya's population) in which 68.5 percent (10,539 cadre) are very active. The community health worker from the PKK is a cornerstone of the primary health care approach. The existence of the family welfare movement ("PKK") in each village and neighborhood makes it easier to implement many community health development activities. There are various cadres engaged in health development such as Posyandu ("Integrated Health Post"), PSN ("Cleaning Breeding Places of Mosquito"), UKS ("School Health"), screening of high risk mother, etc. Community participation in financing health services is also considered very decisive, therefore the ability to participate and to manage the health insurance scheme has been enhanced. There are health insurance schemes for school groups, self employed workers, and the village community health development. Consequently, to reach the grass root levels, the PKK is utilizing the Government's structure. The basis of PKK activities is at the village level, where PKK is one of the nine partners of the village Community Resilience Body (LKMD), administratively under the Directorate of Rural Development, and the Ministry of Home Affairs. The chairman of PKK Board is based on functional appointments, i.e. in the hands of the wife of the highest local government authority, while the rest of the board members are from local prominent men and women. The Mayor's wife is acting as the chairman of the PKK Board at the municipality level and like-wise at the sub district and village level. There are PKK motivators at the respective levels, who function as facilitators, motivators, monitors and supervisors of PKK's activities at the level below. Because of this structure, PKK has an effective line of supervising and implementing units, from national level down to village level. PKK is a voluntarily movement and although its motivators are women, or housewives, who voluntarily contribute their time and energy for the welfare of the community, men are also involved. The achievement in
implementation primary health care in
Surabaya Municipality are as follows:
5.Future issues of health and welfare In the future Surabaya will still need to be developed as a centre of industry, commerce, maritime industries and education. It is expected by the year 2000, that economic growth will reach 8.1 percent. New housing will be set up in the west and east part of Surabaya city, so as to reduce density in the centre part of Surabaya. Development of very low price houses (RSS) will be prioritized to accommodate poor urban citizens. Walk up flats will also be built, the water supply network will be expanded to reach every household under the auspices of the World Bank. Population expansion will be continue to be targeted to reach zero population growth, through family planning programs. In the second long term development era, in which industries will have been given high priority, work-related health issues will be a major focus. Additionally, diseases transmitted by vectors such as dengue hemorrhage fever will still be a threat for Surabaya citizens. Migration of people to Surabaya city to seek jobs, which can not be avoided, will bring about typical problems such as unemployment, poverty, over crowding etc. Since industry has been developed, air pollution as well as water pollution will be challenges to overcome. Uneven distribution of health facilities will again render an impact on family health. By the year 2000 the population of Surabaya will reach 3,052,648 and the population growth will achieve 1.47 percent in 1998. Among them, 11.32 percent are children under 5 years. With the standard of one maternity clinic for 10,000 people, Surabaya will need about 200 more clinic (compared with 103 clinics in 1994). To ensure health services reach all Surabaya citizens in the year 2005 the hospitals will need 9000 beds, twice the total bed capacity nowadays. By increasing the health status of Surabaya citizens, the elderly group of people will increase and this will cause another health problems in the city. Rapid and easier transportation between countries make the prevention of communicable diseases such as HIV/AIDS more difficult. 6. Conclusion 1. Surabaya developed very fast and consequently, bears both traditional health risks coming from urbanization, poverty, unhygienic environments and overcrowding, along with modern health risks from industries and globalization. Under these circumstances, Surabaya will require appropriate strategies and technologies to overcome these risks. 2. The primary health care approaches which have been implemented in Surabaya have become the key to success in achieving the objective of the health development of Surabaya municipality. - Surabaya: 29 November 1996 Table 1:Dengue Hemorrhagic
Fever in Surabaya
Table 2:Coverage of Clean
Water & Sanitary Facilities
Table 3:Coverage of Maternal
and Child Health Care
Table 4:Coverage of
Immunization
Table 5:Coverage of
Nutritional Improvement
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