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I. INTRODUCTION Indonesia's Health Delivery System Before discussing the details of the Surabaya study, a word should be said about the organization of the Health Care system in Indonesia. At the city level, there is a City Health Office that is headed by Medical Professional appointed by and responsible to Mayor for administrative and operational matters for health policy and medical procedures, however, the Head is responsible to the Department of Health in the national level. The implementation of the health program at the community level is carried out by the Community Health Center, or Puskesmas (Suyono, 2002). The Puskesmas the center of the community health development program promotes and builds community participation as well as gives complete and comprehensive services to the people in the area. The area of the Puskesmas is a subdistrict or a part of the subdistrict. The density of population, the broadness of area, geographical and infrastructure condition determine the area of work. Typically a Puskesmas serves 30,000 people. For big city like City of Surabaya where the inhabitants are more than one million, the area of work of Puskesmas is the "Kelurahan." A Puskesmas that is located in the capital of the subdistrict that has inhabitants more or equal to 150,000 is called Builder Puskesmas (Puskesmas Pembina), which coordinates Kelurahan Puskesmas and is the center of referral services (Suyono, 2002). In implementing the health program, the Puskesmas is supported by a network including an Assistant Puskesmas (Pustu), Mobile Puskesmas (Pusling), and Village Midwives Clinic. (BDD). A simple health service unit under the Puskesmas that covers two to three villages is called a Pustu. This unit serves about 2500 inhabitant in Java and Bali islands or 10,000 inhabitants in urban areas like the City of Surabaya. This unit is an integral part of the Puskesmas. A mobile health services unit that is equipped with a car or speedboat, health and communication instruments, and health personnel is called Pusling. In remote areas that can not be reached by the formal health services, a Pusling replaces the function of Puskesmas. The government places a BDD in a village that does not have other health services. The BDD is provided with a building as a village birth attendance cottage (Polindes) where she lives and works. She is also equipped with obstetric kit. She serves 3000 inhabitants. II. METHODS AND MATERIALS This research was done in two phases. It began with a sample survey plus in-depth interviews with heads of governmental offices including service providers and elected representatives of City of Surabaya. Second, Nominal Focused Group Discussion Technique (NFGDT) [defined later] was employed. Phase one was designed to obtain the description of reproductive and primary health care as an input to the Focus Group Technique. The data collected included client characteristics, such as social-demographic condition, health status, family planning, and reproductive health status, and second, health services conditions such as health services in Puskesmas, membership of health insurance, quality of health services in Puskesmas, and health facility. In phase two, the collection of expert opinion about
primary health
care and reproductive health was done. The results were needed for
constructing the model of reproductive and primary health care (RPHC)
in the urban area. The results of the first phase research were sent to
the experts and then they were used to express their opinions about
RPHC. The technique used for collecting the opinions of experts was
called NFGDT. In order to obtain an optimum model, the following
experts from various institutions were contacted that included:
University faculty, heads of governmental institutions, heads of health
institutions and their related institutions, religion and community
leaders. III. RESULT AND DISCUSSION A. Health Conditions During the last two weeks, 12.6 % of the members of households in the study reported being sick. This was lower than that found by Kuntoro (2001) a year earlier, 14.2 percent. The highest percentage occurred among children less than one year old (33.6%). The second highest percentage occurred among children of one to five years old (30.9 %). The third largest percentage occurred among elderly people of 65+ years old (20.4 %) (Suyono, 2002). More detailed information is provided in table 1. These young and old age groups are categorized as vulnerable groups that should be taken into consideration in developing PHC in City of Surabaya. Child Care programs as part of Maternal and Child Health (MCH) program as well as a health for the elderly program should be included in PHC program. Table 1: People Reporting Being
Sick in the Past Two Weeks By Age
The most common reported illness was upper respiratory tract infection (50.4 %); fever of unknown cause showed the second highest percentage (9.5 %), and diarrhea showed the third highest percentage (7.6 %). These diseases are related to the behavioral and environmental sanitation aspects of people in the community. Hence, in developing PHC, health promotion and disease prevention should be included in the program in order to change health behavior towards good sanitation. In addition to infectious diseases, respondents reported non infectious diseases such as hypertension (3.2 %) and Diabetes mellitus (1,7 %), and CVA (1.2 %). (Suyono, 2002). B. Reproductive Health Condition Family planning is an important part of reproductive health. The rights of any couple to choose any contraceptive method and the family planning clinic they want should be considered in developing a RPHC program. Although the percentage of respondents who practiced family planning was higher than those who did not practice family planning (53.7 % vs 46.3 %), the latter should be taken into consideration if they did not want more children but were not using contraceptives. This has come to be known as the problem of unmet need. As to the methods used, most respondents used injection (22.9 %), or the pill (15.0 %). Other methods included tubectomy (6.7 %), IUD (6.7 %), implant (1.4 %), vasectomy (0.5 %), and condom (0.5 %) (Suyono, 2002). Table 2 shows the percentage of women who were pregnant and experienced abortion by age groups. Table 2. Pregnancies and
Abortion Among Women of 15-49.
Among 1702 women 15 to 49 years of age, 84 were pregnant (4.94 %). The highest percentage of pregnant women occurred within age 25 to 34 years old (10.53% and 10.73 %). The percentage pregnant among older high risk women (35+ years old) was 5.3 %. The percentage of young high risk women (< 20 years old) was 1.25 %. Although the percentages were relatively low, these age group should be the target of RH program. Antenatal care should be intensified for these age groups in order to minimize maternal and neonatal deaths among them. Six women experienced abortion (0.35 %). One woman of 15 - 19 years old experienced abortion as well as a woman of 40 - 44 years old (Suyono, 2002). The reason for abortion was not stated. Abortion that occurs among young age group seems to be related to very young marriage, in which the woman does not yet feel prepared to be a mother emotionally and physiologically. These should be avoided when a healthy reproductive life is desired. Abortion that occurs among women over 35 years old seems to be related to a desire to have no more children. In both cases, this may indicate some weakness in the family planning program in bringing information and services to these age groups. In developing a RH program, attention should be given to young married and older high risk women. Regular antenatal care is the best way to
detect high risk pregnancies so that more effective preventive measures
can be taken. Regular postnatal care is also important, especially
since it includes the basic immunization that prevent neonatal
mortality. Table 3 shows antenatal activity among our respondents. Table 3: Antenatal Care (%) by
Stage of Pregnancy
The great majority (72 percent) of women in and around Surabaya received antenatal care during their first trimester; almost 90 percent received care within the first or second trimester. This indicates that the primary and reproductive health care system is reaching the great majority of family at right time. Table 4: Health Facility and
Attendant used for Births
* Puskesmas, or community health
center
About two-thirds of women report using a protected facility for their births. It appears that the choice of facility is governed in part by availability, in part by past experience, and in part by the advice of family and friends. This suggests that the PRH Care program should pay some attention to both consumer preference and the communication network that influences health care choices. Still on the positive side, the great majority (79 percent) report using a "qualified" professional attendant. This is another indication of the considerable success of the Indonesian Health and Family Planing Program. Still 16 percent of the women report using a Traditional Birth Attendant, and this is in Indonesia's second largest city. Over the years TBAs have been seen as major cause of maternal and neonatal mortality since they often use procedures that are unhygienic. Table 5: Tetanus Immunizations
Received
Table 5 indicates a weakness in the reproductive health program. Even though the great majority of women received antenatal care, the postnatal appears to be lacking. As many as a third of women report no tetanus immunization for their children; adding to this the "unknown," may indicate that well over half of the children are unprotected. Obviously the primary and reproductive health care program needs to put greater emphasis on postnatal care. IV. THE FUTURE MODEL OF REPRODUCTIVE AND PRIMARY HEALTH CARE SYSTEM The experts who participated in Nominal Focused Group Discussion recommend the Cumulative Model of Urban Reproductive and Primary Health Care (URPHC). This model places the Puskesmas as coordinator and builder of five types of services: Doctor Practices, Pharmacy Practices, Polyclinics, Integrated Services Post (Posyandu), and MCH Services. The Puskesmas coordinates recording and reporting related to services that involve people in the community where it works. This is the part of health information system. This information should be reported to City Health Office, which will be the coordinator and builder of all Puskesmas located in the City of Surabaya. The network of this model is presented in the following figure.  Figure 7. The Cumulative
model of URPHC
The pharmacy, doctor, and MCH practices, and the polyclinics can be owned by private companies, community organizations or individuals. They can raise funds from the stock market when they are private companies, or from members of community organization or from their own pockets when they are individuals either through JPKM (Community Health Insurance) membership as mentioned by Razak (2002) or direct payment. Most pharmacy and doctor practices are already owned by individuals. Most polyclinics and MCH services are owned by community organizations such as Muhammadiyah, Nahdlatul Ulama, Catholic, and Christian congregations. The Posyandu is created by regional governments, and are managed by cadres in the Kelurahan /Village; it is supported by Puskesmas personnel. The future model is not real PHC as stated by Alma Ata conference. The definition should be adjusted to the current condition in the community. As City of Surabaya is growing up rapidly to be a big city, the life styles of the people change, reproductive health demand also changes. Hence, URPHC System should adjust to these changes. People of City of Surabaya need RHC and PHC services that are easy to access at any time, considerably cheap, complete, and should be done by experts with required standards. This is the challenge for all components of the City of Surabaya in realizing URPHC System. All components that include regional government, regional representatives, community organizations, private companies, and individuals should work hand in hand in developing URPHC system towards better reproductive health.
V. CONCLUSION AND RECOMMENDATION It is recognized that upper respiratory tract infection and diarrhea are prevalent in City of Surabaya, They are related to behavioral and environmental sanitation of the people. Injection and pill are the preferred contraceptive methods. Most pregnant women receive antenatal care during the first trimester, but postnatal care and immunizations need greater emphasis. Midwives are still preferred by women for birth attendance, but some attention should be given to the issue of traditional midwives; they should receive some training or people should be discouraged from using them. Based on focus group discussion A Cumulative Model of Urban Reproductive and Primary Health Care system has been recommended by the experts. It is recommended that the model that has been selected to be launched in an international seminar in City of Surabaya in order to assure that the Mayor of City of Surabaya will implement the program. REFERENCES Kuntoro, 2001, Studi Longitudinal Evaluasi Pelaksanaan Program JPS-BK di Propinsi Jawa Timur, Jakarta, Direktorat Jenderal Bina Kesehatan Masyarakat Departemen Kesehatan RI. Razak, A.R., Husni Mu'adz, Kuntoro, Sudiro, Susilowati, 2002, Alternatif Pelayanan dan Pembiayaan Kesehatan yang Berkelanjutan Bagi Keluarga Miskin, Pelajaran Dari Pelaksanaan Program JPS-BK 1999-2001, Policy Paper, Jakarta, Badan Penelitian dan Pengembangan Departemen Kesehatan RI. Suyono, H.H.., H. Sunarjo, H. Kuntoro, H.H. Suparto, Budiono, P. Lestari, 2002, Development of Reproductive and Primary Health Care System, Preliminary Action for City of Surabaya (Indonesian Report). WHO/UNICEF, 1978, Primary Health Care: The Alma Ata Conference, (Geneva: WHO) |
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