Comparative Overview of Urban Reproductive and Primary Health Care Systems

Dr. Gayl D. Ness

These three studies provide a number of insights into urban reproductive and primary health care in Asia. Most important is the positive finding of relatively well established programs and facilities for promoting reproductive and primary health care. All three cities do reasonably well in providing good, well used, and well regarded services. Moreover, they do this despite the fact that they remain relatively poor countries.

In this they all follow their countries' national policies. India was Asia's (and indeed the developing world's) leader in adopting a national program to limit fertility within marriage by creating a national family planning program as early as 1952. Thailand and Indonesia followed with firm policy decisions in 1970 and 1972. In addition all built relatively successful family planning programs that reached even the deep rural areas and the rural and urban poor. As a result all three have seen a dramatic decline in fertility and in both infant and maternal mortality.

In all three a determined national and local leadership was behind both the policy decisions and the effectiveness of program implementation. Political leaders spoke strongly in support of reproductive and primary health care and pushed for the allocation of public resources to them. In addition, all promoted the creation of effective programs for the distribution of these services. We can see the impact of this political and administrative leadership especially in Trivandrum, where the state government has always been considerably ahead of the rest of India in promoting human welfare, and an equal distribution of health and welfare services. The three also show certain distinctive characteristics that tell us much of the general problem and the specific solutions.

Trivandrum: exceptional gender equality

Perhaps the most striking case is Trivandrum, Kerala State in India. The state is below the national average in wealth, but is far ahead of the rest of the country in health and welfare. It is also quite remarkable in India for its high degree of gender equality. All of South Asia shows a much higher male dominance, for example, than does Southeast Asia or even Africa. The sex ratio (males per 100 females) in all India is 106, but in Kerala it is only 94.5; and in Trivandrum's slums it is even lower, 92.5. This is associated with the high rate of total and female literacy in Kerala, and an overall higher level of welfare than all India. In Kerala's slums it is also associated with a higher rate of female-headed households than we find in the wealthier parts of the city. The city's antenatal services are used by the great majority of both wealthier and slum women; most births are protected by institutional and professional services and postnatal immunization services are widely used. At the same time, poverty takes its toll with lower quality housing and lower nutritional levels than the more wealthy. What is striking, of course, is that although poverty lowers the quality of life of the poor, it does not lead to lower levels of primary or reproductive health care.

One area of concern, however, is the gender difference in reproductive health awareness. Women are well aware of all contraceptive services and of the health risks of unprotected sex. Unfortunately, males are woefully unaware of these risks, signaling a need for a more directed health education campaign. Overall, India has developed a good educational program aimed at curbing HIV/AIDS transmission, but it appears that the program is missing many males.

Surabaya: good services with gaps

Surabaya also shows a good availability of antenatal and birthing services, which are available to and used by the great majority of women. Postnatal and immunization, however, is somewhat lacking and needs to be improved. It is also notable that, while good birthing services are available and extensively used, there is still a significant minority of women who use traditional birth attendants. Again, this indicates an area in the system that needs strengthening. The Surabaya study also shows that typical infectious diseases such as diarrhea have become less common, due in part to better public health infrastructure. On the other hand, the high level of respiratory diseases indicates an environmental problem that may loom large in the near future. Although the authors do not emphasize this, the growth of automobile traffic in Surabaya has been very rapid, and one of the most serious consequences is reduced air quality, which is probably a major cause of this new disease pattern. This is an issue that will require other measures for environmental protection rather than the simpler extension or improvement of the reproductive and primary health care system.

Khon Kaen: second generation problems

Thailand is the most advanced of these three countries in both economic development and welfare, and this is clearly reflected in the study of Khon Kaen. Reproductive and primary health care services have been well developed, resulting is exceptionally low levels of infant (10.5) and maternal (80) mortality. Clinics and hospitals are widely available in the city and its surrounding rural areas; people use these services extensively and report being highly satisfied with them. The major problems now are what can be called second generation problems. The basic infrastructure to deal effectively with the traditional infectious diseases has been built and used. Mortality and morbidity have declined and the quality of life has increased dramatically. Now the city, and the country, faces a series of environmental problems that produce air and water pollution. These can increase specific illnesses and raise the public costs of providing a high quality of life.

More generally, all studies have pointed to strengths in the reproductive and primary health care systems. More importantly, however, they have pointed to specific weaknesses and problems that the systems can readily address.