What is the character of the reproductive and primary health care system?

What are the major health problems of the city?

How does the RPHC system affect the human health in the city�fs population?

What is the perception of the population being served?

How can the RPHC system be improved to provide better for the health of the city�fs population? Are there any plans to expand or improve the system? Are those plans derived from an understanding of both the health problems and how the system works to address those problems?

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1.3 Objectives

1.3.1. General Objectives

To develop a model of urban reproductive and primary Health Care system.

1.3.2. Specific Objectives

Examine the character of the reproductive and primary health care system

Examine the major health problem of the city

Examine the effect of the reproductive and primary health care system to the human health in the city�fs population

Examine the perception of the population being served

Improve the reproductive and primary health care system to provide the better health of the city�f population

II.Literature Review

2.1. A Conceptual Design of a Reproductive and Primary Health Care System

To develop a research design of this part of the RPHC system involves first the identification of a model of the system. After a model is defined, we can go on to propose ideas for operationalizing the model, or specifying the types of questions and respondents that should be included in the study.

One important caveat is in order at this time, however, and we shall repeat it throughout this statement. The model we propose will be a somewhat general one, and the specific questions or data gathering that operationalize the model are only suggestions. They outline a broad framework for research. But in each city, the general model must be adapted to specific local conditions by knowledgeable social and health scientists. That is, the research design is to be adapted to the local situation, not adopted for it. We shall return to this emphasis at many points.

The diagram below provides one way to think about a reproductive and primary health care (RPHC) system. The purpose of the diagram is to identify a possible system in which the political commitment of local authorities and the participation of local communities work together to design, maintain, and render services to obtain the best outcomes desired. It can thus help to guide research that will assess a reproductive and primary health care system, and identify point at which government policy or other interventions might help to improve the system.

This diagram is also distinctive in that it is designed to focus some attention to the political commitment, popular participation, and quality of care that a system provides to all participating partners and its users or clients. This is an issue that has often been neglected in health delivery systems, but is increasingly recognized as important for the overall success of a system (Simmons and Elias, 1994, Miller et all, 1997).

The following discussion provides some details on the elements identified in the system, starting with the outcomes, but them moving generally from left to right.

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Figure 1. Conceptual Diagram of a Reproductive and Primary Health Care System

The basic desired Outcome of the RPHC system is that every family and its members are being given proper health services so that they remain healthy. To measure whether the services reach the intended clients we should have proper prevalence measures. All these indicators should then be compared with various mortality and morbidity rates. The most basic mortality data are Infant and Maternal Mortality rates (IMR and MMR) that are especially useful in examining the large difference between rich and poor countries. For countries with highly productive economies and well-developed health delivery systems, more refined measures should be used. These should be decided upon for each individual case, but usually they will include rates of respiratory and gastrointestinal diseases, or in some cases of excessive environmental degradation, incidence of various carcinogens. In addition various measures of preventive care should also be noted. These include such things as the contraceptive prevalence rate (and one of its main outcomes, the total fertility rate) as well as rates of immunization for common preventable diseases.

Affecting these outcomes are two major categories of conditions: broad Contextual factors and more specific Program conditions. In the contextual factors there is another important distinction to be made, shown by the horizontal line in the lower part of the diagram. This divides two subsystems, which we call here the �gMedical Delivery System�h and the Public Health System. While a broad-based primary health care system would normally include both of these sub-systems, they are often separated by agency specialization, which requires deliberate strategies integrate them into an effective overall primary health care system. This specifically speaks to the �gintersectoral collaboration�h that is one of the main pillars of PHC movement.

The Contextual Factors include four sets of conditions. The Political administrative system includes the governmental system, the character of political power, the commitment of political leaders, and the aims or goals that the central political system embraces (Ness and Ando 1984). But it also refers to the administrative capacity to carry out and implement the goals that the government sets out. This set of conditions is addressed largely through qualitative analyses using expert or knowledgeable observers.

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The second of these contextual factors is the country�fs Socio-economic structure. This includes primarily the wealth of the country and the economic base of that wealth. But it also includes a more subtle set of conditions, such as the character of class divisions, the gap between the rich and the poor, and the extent to which the society can translate its wealth into human welfare. The latter can be assessed quantitatively by the UNDP�fs Human Development Index, and especially by the difference in the HDI and GDP ranking of any country (UNDP 1998). This is in large part reflected in the amount of resources a country allocates to health and other social services.

The third of the contextual factors is what we call the Community Structure and Commitment. This includes development of a community concern for public health measures, conditions of community organizations for primary health care, and how the community allocates its resources for primary health care. For the study envisioned here, the researcher could make use of secondary data available in the community, usually these data are of a more ethnographic or anthropological character.

A fourth contextual factors is what we call the Health Related Environmental Conditions. This includes a wide variety of conditions, but the most prominent will usually be air and water quality, sewage and waste disposal, and the treatment of hazardous wastes. For the study envisioned here, this set of conditions can be addressed with specific questions about environmental conditions and what government is doing about them. The outcome measures will include air and water quality, the quantity of water, and the infrastructure for sewage and solid waste disposal. It will also include where necessary both the policies and infrastructure for the management of hazardous wastes.

It is the Program Factors, however, that seem most amenable to direct policy intervention, and which can be a major focus of this study. These begin with what we call the RPHC Policy and Management System. In most developing countries government priority given to social services in general is the dominant force in shaping all of the program factors. It will be important to identify central government�fs aims in its primary health care system, and to assess the extent to which the government has the resources to implement its program. Specific questions on this issue are provided below. This system will be affected by a combination of the political administrative system, the socio-economic structure, and the community structure. For example, a strong and welfare-oriented government will decide on an effective RPHC system. At the other end of this political-economic spectrum, a weak and repressive political system will not give high priority to reproductive and primary health care. In addition, a wealthy economic structure will give the government more resources to implement that program, and, conversely, whatever the government does establish might be constrained by a very poor economy. Finally a community with a strong commitment to reproductive and primary health care will both push government to provide better services, and will take fuller advantage of whatever services government does provide.

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There are two parts of the RHPC delivery system that have in the past received a great deal of attention in research, data collection and policy formation: program and client characteristics. Program characteristics include the number, location, distribution and staffing of the clinics that provide the first line of contact between the population and government services. Also included will be clinic facilities, hours of operation, and scope of the treatments it provides. Client characteristics include a well-recognized set of conditions: age, sex, parity, health history, education, occupation, and where necessary, ethnic, regional or tribal identifications. These conditions are affected directly by the RPHC policy and management system, and in turn they affect the quality of care that the clients will receive. In addition an often unrecognized and less researched condition is the Community and Family Participation. This condition is less easy to quantify but is nonetheless a powerful determinant of how the delivery system works. A more open an egalitarian community structure with strong family ties and high female status will more easily take advantage of reproductive health services available. A closed and authoritarian community with low female status, or one atomized into conflicting elements will be less able to take advantage of services provided (Caldwell, 1986).

All of the conditions identified in the diagram can be further specified by questions and research methods that constitute the research design of this study. In what follows we suggest various types of questions and sources of information for all of these elements. But two things should be kept in mind, which we shall repeat for emphasis.

First, all of these conditions fit together, affecting and being affected by one another. They should be examined as parts linked to one another in an overall system. This is especially important for the design of interventions to improve any of the characteristics of the system.

Second, the specific questions to be asked and the specific sources of information will differ in all cases. Individual country study directors must decide what to ask of whom to develop an accurate picture of the reproductive and primary health care system, and a picture that can help government officials take practical steps to improve the performance of the system. Again, the design should be adapt to, not adopt for the in-depth study. Now, however, we must turn to those specific questions and make suggestions about sources and respondents.

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III. Reasearch Method

This research was done in two phases. These were, first, data collection that included quantitative data collection through the respondents who were drawn by sampling procedure, and qualitative data collection through in-depth interview that involved the chairpersons of governmental offices and the members of representatives of City of Surabaya. Second, Nominal Focused Group Discussion Technique (NFGDT). For more detailed information see Annexes 1 and 2.

3.1. Phase One of Research

3.1.1. Quantitative data collection

In Order to obtain the description of primary health care and reproductive health as an input material of NFGDT, a survey research was applied in this study.

3.1.1.2 Population, sample, and sample size

Population was defined as all households who lived in City of Surabaya.

Sample was defines as part of households who lived in City of Surabaya selected through sampling procedure.

A cluster random sampling was applied in which a RT (stands for Rukun Tetangga, asmallest group of households of regional system in Indonesia) as cluster unit. In the first step, a list of Kecamatan (sub district), Kelurahan (Village term for urban area), RW (stands for Rulun Warga, a collectionof RT), and RT was developed. The results were

Kecamatan :28 Kelurahan :163 RW :1281 RT :8358

Each Kecamatan, Kelurahan, RW, RT was numbered sequentially. A RT was considered as cluster unit, hence there were 8358 clusters In City of Surabaya. A fixed number of clusters were determined. These were 25 Clusters. By mean of systematic random sampling, 25 clusters of 8358 clusters were selected. The results

Table 3.1 List of Clusters

No.	Kecamatan	Kelurahan	RW	Rt
1.	Tandes	Bibis	1	1
2.	Benowo	Benowo	1	1
3.	Lakarsantri	Sambikerep	7	11
4.	Asemrowo	Asemrowo	7	1
5.	Genteng	Peneleh	3	5
6.	Tegalsari	Wonorejo	6	10
7.	Bubutan	Gundih	2	5
8.	Simokerto	Sidodadi	10	6
9.	Pabean Cantikan	Perak Utara	9	8
10.	Semampir	Pegirikan	11	9
11.	Semampir	Sidotopo	6	2
12.	Krembangan	Morokrembangan	7	4
13.	Mulyorejo	Tambak Wedi	2	2
14.	Mulyorejo	Tambak Kalisari	2	10
15.	Tambak Sari	Pacer Kemberg	7	10
16.	Gubeng	Gubeng	2	5
17.	Gubeng	Baratjaya	6	5
18.	Rungkut	Penjaringan Sari	4	9
19.	Sukolilo	Semolowaru	5	1
20.	Sawahan	Petemon	9	2
21.	Sawahan	Kupang Krajanl	6	10
22.	Wonokromo	Ngagel	2	6
23.	Karang Pilang	Karang Pilang	2	1
24.	Dukuh Pakis	Dukuh Pakis	6	1
25.	Wonocolo	Jemur Wonosari	5	10

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3.1.1.3 Variables collected

1. Client characteristics
a. Socio-demographic:	Age Sex Religion Ethnic/Tribe Education Occupation Marital Status Family income
b. Health Status:	Morbidity rate Type of disease
c. Family planning:	Type of contraceptives
d. Reproductive health Status:	Age at marriage Age at first pregnancy Age of the last child at last pregnancy Number of child Number of pregnancy Number of abortion Antenatal care Place of birth attendance Birth attendant
2. Health services conditions
Health services in Puskesmas (Community health center)	The Objective of visit Frequency of visit Health personnel who serve Length of examination Distance to Puskesmas Duration to approach Puskesmas Transportation used
Membership of health insurance Quality of health services in Puskesmas	Procedure of registration Convenience in waiting room Behavior of health personnel Clearness of direction in waiting room Length of waiting Hygiene of environment Services obtained by client Opportunity to explain the symptoms Type of services Open hour Tariff
Health facility	Type of facility Ability to pay Health personnel who serve Type of service Open hour Length of waiting

3.1.1.4 Instrument and method of data collection

A structured-schedule questionnaire through personal interview of respondents for collecting quantitative and a non-schedule questionnaire through in depth interview of informants for collecting qualitative data were developed. The interviewers were recruited from university graduates. They were in trained in 16 May 2001. Data collection was done from 18 may 2001 to 27 May 2001.

3.1.1.5 Data analysis

The raw data were edited and coded and they were in entered in a computer by mean of Epi Info Program version 6.4b then they were processed statistically by mean of SPSS for windows version 7.5. The data were presented descriptively in table & diagram.

3.1.2 Qualitative data collection

Information in the field obtained from the respondents about primary health care and reproductive health should be enriched with information about health services system obtained from the governmental executers and the services providers. Hence, an in-depth interview was done, the informants were:

1. Head of City Health Office Surabaya
2. Head of Regional Development Plan Board of Surabaya
3. Members of Regional Representative Board of Surabaya

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An interview was guided with the non-schedule questionnaire, and the following variables were collected:

1. Contextual factors
a. Political administrative system-	Governmental System The results of general election Political statement Environmental awareness Health budget Intersectoral/program cooperation Administrative capability Planning and Implementation Program priority Curative and Preventive Strategy Governmental awareness on Alma Ata Equity
b. Socio economics and health related	GDP Adequacy of health budget % health budget The role of health personnel on environmental control Adequacy of salary Double position of doctor Implementation PHC by community The role of community leader on planning and implementing PHC Ability to pay PHC
2. PHC policy & management system
Goal of PHC and RH Balance of prevention and curative goals People served by PHC Appropriateness and population and services target
3. Program characteristics Radio doctor: People Radio paramedics: People Access to obtain health facility Access to use health facility Adequacy Supervision
4. Community & family participation Number of community organization Number of community contribution Activity of community organization The role of community leader on community organization

3.2 Phase Two of Research

In this phase, the collection of expert opinion about primary health and reproductive health was done. The results were needed for constructing the model of primary health care and reproductive health 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
primary health and reproductive health. The technique used for collecting the opinions of experts was called Nominal Focus Group Discussion Technique (NFGDT). In order to obtain an optimum model, the following experts from various institutions were contacted that included:

1. University
2. Heads of governmental institutions
3. Heads of health institutions and their related institutions
4. Religious and community leaders

Based on criteria mentioned above, the informants were selected were:

A. City Level of Surabaya

1. Heads of Health office
2. Chairpersons of E Commission of Regional Representative Board
3. Heads of Social Affairs Office
4. Heads of National Family planning Coordination Board
5. Chairperson of Indonesian Medical Association
6. Chairperson of Indonesian Midwife Association
7. Chairperson of Indonesian Pharmacist Association
8. Chairperson of Indonesian Nurse Association
9. Head of Private Clinic of PUSURA
10. Chairperson of Islamic Community of Muhammadiyah
11. Chairperson of Islamic Community of Nahdlatul Ulama

B. Provincial Level of East Java

1. Head of Health Office
2. Chairperson of E Commission of Regional Representative Board
3. Head of Bureau of Community Welfare
4. Head of National Family Planning Coordination Board
5. Chairperson of Indonesian Family Planning Club
6. Chairperson of IKNI
7. School of Medicine, Airlangga University
8. School of Public Health, Airlangga University

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Collecting the expert opinion was done by mailing the summary results of phase one research to the experts who have been selected mentioned above. Mailing procedure is selected instead of group discussion since most informants were busy to be interviewed. Moreover, collection the expert opinion was done in three phases:

1. Sending the materials for expressing opinion and field information that spent one week.
2. All expert opinions were sent back as feedback that spent one week.
3. Model building based on expert opinion.

For more detailed information see Annex 2.

Three Levels of research effort

We can also suggest three different levels of research effort, depending on the resources available for the study in each city. The levels differ primarily in the sample of people who provide answers to the four questions. Before discussing these levels, however, we must make a distinction between informants and respondents, which also distinguishes two broadly different research methodologies.

Informants or Respondents There are two basic research strategies for asking people questions. People can be used as informants or respondents. These two ways also identify two broadly different research methods: anthropological or ethnographic research and survey research. Informants. In most anthropological research, people are used as informants. They describe conditions to the researcher, explain why things are they way they are, and explain the causal connections between conditions. This implies using a small number of people, sometimes only one major respondent and relatively lengthy interviews. It is the informant who explains causal connections. Respondents. In survey research, people are used as respondents. They respond to a relatively large number of highly standardized questions. Their responses do not include lengthy descriptions or explanations, rather they provide �gforced choice�h responses, such a �gagree or disagree.�h This implies a large number of respondents, use of statistical sampling techniques to select respondents and a fairly high degree of control of the interview process so that it is as much as possible the same for all respondents. The responses are then coded and quantified and the researcher uses methods of statistical inference to understand (or to �gguess at�h) causal connection

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The three levels of research effort involve different sets and numbers of informants or respondents. They are listed here from the most restricted to the most inclusive.

Political, community and technical leaders can be used to describe the system and its aims, the city�fs problems, and current plans or ideas for improvement. Political leaders would include the Mayor and possibly elected members of the city council if one exists. Community leaders would include the Chairmen of NGO and other Community Organizations, as well as religious leaders. Technical leaders would include the directors of the various parts of the health system. For example, this might include a medical director, a public health director, and a director of family planning. They would be interviewed at some length to have them describe the system, the city�fs health problems and ideas for improvement. The leaders should be asked about both the public and the private parts of the system

In this type of research, leaders are used as informants to describe the system and explain how it works. Questionnaires with standard closed choice responses are not used. Rather, the researchers use checklists of topics they wish the leaders to cover (identified generally by the boxes and arrows in the diagram). The method is more that of the anthropologist or journalist than of a survey researcher.
Researchers should examine others reports to determine if studies have been made of the health care system, and can include summaries of these studies in their report. In addition, the researchers should collect whatever objective data are available, including health system budgets, staff and facilities, mortality rates, causes of death, and incidence of major diseases. It would be most useful to collect data for at least the past ten years to note changes that are taking place.

Political, community and technical leaders PLUS system providers, especially at the primary care levels. System providers includes the medical and nursing staff at the primary clinics and lay workers, such as family planning workers, who link users with the system. In some cases, there are also education workers whose task is to increase the population�fs awareness of health issues and ways to improve their own health. Here a decision must be made about including the private part of the health care system. To reduce costs, it is best to focus on the public part of the system. Moreover, it is the public part of the system that is usually most amenable to change and improvement by government. Nonetheless, it must be recognized that a private system exists alongside the public system, and the relation between the two

At this level the number of respondents is expanded, with numbers determined by the resources available. Political and technical leaders are dealt with as above. They are used as informants, with open-ended interviews based on checklists of topics to be covered. System providers can be approached as respondents with standard questionnaires that will yield quantitative data for statistical analysis. Depending on the size of the system and the number of staff, it may be necessary to sample providers. If this is the case, the sample should include members of different parts of the system – such as medical, MCH, family planning etc. Clinics should also be selected to represent the different areas or neighborhoods of the city, with special attention given to including the range of economic conditions.

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Above PLUS System Users. In addition to political leaders and system staff, the clients or users of the system can be included if resources permit. This expands the research substantially, but it is especially useful to include the users and potential users of the system. Users can be sampled in a number of ways, but there are two common research tactics: exit interviews and area probability sampling. The simplest is to use what are called �gexit interviews,�h asking people who are leaving a primary health care facility to provide responses to a standard questionnaire. In addition to general background questions, respondents can be asked why they came to the facility, how far they traveled, how long they waited and what kind of care they received. They can also be asked for suggestions on how health care can be improved. (Suggested questions are shown below). Although exit interviews are the easiest and least expensive way to provide user views of the system, they typically miss what might be an important part of the population, those who use the system only rarely or not at all. If people do not use the system because they have had bad experiences with it in the past, the exit interviews miss this important information. The alternative to the exit interview is an area probability sample, with respondents drawn from households, selected by random sampling techniques. This will provide more information about the system, but it also greatly increases costs, and researchers may decide that the additional information to be obtained may not be worth the additional cost. This is a judgment that must be made locally.

Suggested questions and information

We can suggest types of specific information to be collected and questions to be asked by using the boxes of the above diagram. It is especially important for local researchers to view these as mere suggestions. Each situation will require the development of specific questions and data collection relevant to that situation. The questions listed are somewhat general. They will have to be shaped into specific formats depending on whether they are to be used as checklists for informants, or standardized surveys questions for respondents. Not all questions will be equally relevant in all situations, and other questions may have to the to local conditions, not simply adopted.

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IV. Results

4.1. Description of City of Surabaya

4.1.1. Geography

City of Surabaya is located on 07o12�f�f to 07o21�f�f South Latitude and on 112o35�f�f to 112o54�f�f East Longitude. The altitude is between 3 to 25 meters above sea level. The territory is bounded by Madura Strait in the North and East, District of Sidoarjo in the South, and District of Gresik in the West. This includes area of 32,636.6 hectares

4.1.2. Governmental system

The City Government is executed by a mayor (Walikota) assisted by a vice mayor (Wakil Walikota= Wawali). In doing internal affairs he is assisted by a City Secretary (Sekretaris Kota=Sekkota). In implementing the City Program, he is assisted by City Program Offices such as City Health Office for Health Program, City Public Work Office for Public Work Program etc. Head of the Office executes them. For planning the City Program he is assisted by Head of City Development Planning Board Bappeko). All assistants are responsible to mayor.

City of Surabaya is divided into five areas of assistant administration headed by a mayor assistant (Pembantu Walikota). These areas are North, East, South, West, and Central Surabaya. Each mayor assistant coordinates areas of administration called Subdistrict that is headed by a head of Subdistrict (Camat). However, each head of Subdistrict is appointed and responsible to mayor. Each Subdistrict is divided into areas of administration called Kelurahan that is equivalent to Village in a rural area. Lurah or Head of Kelurahan who is appointed by mayor is directly responsible to Head of Subdistrict. All staff in areas of administration is governmental officials. Each Kelurahan is divided into areas of neighborhood called Rukun Warga (RW) that is rather social institution than administration institution. It is headed by chairman of RW who is elected by members of households in RW. Unlike Lurah, he is not official of city administration. He does not receive salary, wage or any other incentive. Each RW is divided into areas of neighborhood called Rukun Tetangga (RT). It is headed by chairman of RT who is elected by members of households in RT. Hence, RT is the smallest area of neighborhood that coordinates households in doing social activity and he is the mediator between household and city government in doing community building and development.

4.1.3. Health system

City Health Office is a health organization in the level of City. It is headed by Head of City Health Office. He is responsible to mayor administratively and operationally since he executes the health program that involves people in the city. In the health policy and medical technique aspects he is built by Department of Health in National level. He coordinates and builds Puskesmas in serving health to community.

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4.1.3.1. Puskesmas

Puskesmas is a functional health organization unity as center of community health development that builds community participation as well as gives complete and comprehensive services to the people in the area where it works in the form of basic activity. The area where Puskesmas works is sub district or part of sub district. Density of population, the broadness of area, geographical and infrastructure condition determine the area of work. Puskesmas covers 30,000 people. For big city like Surabaya where the inhabitants are more than one million, the area of work of Puskesmas is Kelurahan. Puskesmas that is located in the capital of Sub district that has inhabitants more or equal to 150,000 is called Builder Puskesmas (Puskesmas Pembina) that coordinates Kelurahan Puskesmas and the center of referral services.

Supporting facility under Puskesmas is Assistant Puskesmas (Pustu), Mobile Puskesmas (Pusling), Village Midwives (BdD). A Pustu is a simple health services unit that support and assist Puskesmas in implementing its activity in small scale. The area of work of Pustu covers two to three villages that include 2500 inhabitants in outside of Java and Bali Islands, and 10,000 inhabitants in urban area like City of Surabaya. A Pustu is an integrated part of Puskesmas. A Pusling is a mobile health services unit equipped with a car or speedboat, health and communication instruments, and health personnel from Puskesmas. A Pusling support and assist Puskesmas in implementing its activity in the area under area of work of Puskesmas that has not yet been reached by health services. A village midwife will be placed to a village that does not have health services facility. She is provided with the building as village birth attendance cottage (Polindes), obstetric kit. She lives in this building. She serves 3000 inhabitants.

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4.2. The Results Based On Quantitative Approach

4.2.1.The Socio-demographic Characteristics of Respondents

Table 4.1 The Distribution of Age By Sex

Age (Year)	Sex				Total
	Male		Female
	freq.	%	freq.	%	freq.	%
0-4	228	8.9	2.9	7.8	437	8.3
5-9	244	9.5	230	8.6	474	9.0
10-14	221	8.6	223	8.3	444	8.5
15-19	274	10.7	321	12.0	595	11.3
20-24	241	9.4	317	11.8	558	10.6
25-29	252	9.8	247	9.2	499	9.5
30-34	217	8.4	233	8.7	450	8.6
35-39	184	7.2	237	8.8	421	8.0
40-44	181	7.0	200	7.5	381	7.3
45-49	161	6.3	147	5.5	308	5.9
50-54	132	5.1	108	4.0	240	4.6
55-59	80	3.1	66	2.5	146	2.8
60-64	69	2.7	65	2.4	134	2.6
65-69	38	1.5	34	1.3	72	1.4
70-74	33	1.3	20	0.7	53	1.0
75-79	9	0.2	10	0.4	16	0.3
80+	6	0.2	10	0.4	16	0.3
Total	2570	100.0	2684	100.0	5254	100.0

Figure 4.1 Population Pyramid by Age and Sex

Table 4.1. and figure 4.1. indicate the distribution of sample respondents by age in five-year interval and sex. The composition of population is determined by the development of birth, death, and migration rates in the past. Population pyramid mentioned in figure 4.1. shows small peak and narrow base. This figure expresses the general pattern of population with relatively high birth rate in the past. The narrow base of population pyramid is due to the decrease of birth rate within the last 15 years. This pyramid also shows the development of population from expansive pattern to constructive pattern during the last 15 years.

The percentage of respondents under 15 years old is 25.8 % . This percentage is lower than that based on SDKI (Indonesian Health Demographic Survey) result in 1997 that was 34 %. This result is strongly related to age dependency ratio that might be a burden for productive age group. This ratio is 40.78 % that is lower than that based on SDKI result that was 79 %. The age median is 26.9 years old that means the age of respondents shifted to older age.

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Table 4.2 The Distribution of Religion and Tribe

Table 4.2. indicates that most respondents are Moslem (94,3%) and Javanese (74 %). The second largest tribe is Madurese (20,8%). In doing health and family planning services, the religion and tribe factors should be considered in selecting the appropriate approach such as IUD insertion among Moslem women, nutrition improvement among people from certain tribe who prohibits consuming certain food.

Table 4.3 The Distribution of Marital Status

Table 4.3. indicates that most respondents are married (49,8%). Only small percentage (0.3 %) of the respondents is divorced. This indicates that most respondents still appreciated marriage commitment.

Table 4.4 Level of Education By Age

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Table 4.4 indicates that the percentage of respondents who has completed senior high school is 25.3 %. Only 5.5 % of the total respondents have completed university. Most respondents of 20 to 40 years old has completed junior high school. Most respondents older than 40 years old only has completed elementary school.

Table 4.5 The Distribution of Work Force By Sex and Age

Table 4.5 indicates that the percentage of male respondents of 30 to 54 years old is higher than 90, while the percentage of female respondents of the same age is 40 %. The percentages of male respondents who work tend to increase from 15 to 49 years old, then they tend to decrease from 50 to older than 55 years old. The percentages of female respondents tend to be fluctuating, the highest percentage occurs in 40 to 44 years old (43.5 %).

Table 4.6 The Average Family Income/Month

Table 4.6 indicates that the mean of family income/month is Rp. 897.222, this figure is more than twice of regional minimal wage in Surabaya. This income ranges from Rp.60,000 to Rp. 7,500,000. This indicates that the respondents are heterogeneous in the social status and occupation.

4.2.2. Health Status

Table 4.7 The Distribution Of Sickness During The Last Two Weeks

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Table 4.7 indicates that during the last two weeks, the highest frequency of sickness occurs among people of 21 to 64 years old (2989 people), while the lowest frequency of sickness occurs among people of under one year old. The second highest frequency of sickness occurred among people of 6 to 15 years old.

Table 4.8 The Disease Pattern During The Last Two Weeks

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Table 4.8. indicates that upper respiratory tract infection is most prevalent among people of under one year old (68.1 %), between 1 to 5 years old (57.0 %), between 6 to 15 years old (54.6 %), between 16 to 20 years old (55.6 %), between 21 to 64 years old (46.1 %), and above 64 years old (23.5 %). Hence, upper respiratory tract infection is most prevalent in all ages. Diarrhea shows the second highest percentage among people of under one year old (21.3 %), and between 1 to 5 years old (19.6 %). Fever of unknown cause and diarrhea show the second highest percentage among people of 16 to 20 years old. Fever of unknown cause shows the second highest percentage among people older than 64 years old.

4.2.3.The Characteristics of Reproduction

Table 4.9 The Distribution of Contraceptive Use

Table 4.9 indicates that most respondents used injection as a contraceptive (22.9 %), while those who use pill constituted 15.0 % of the total respondents. The percentage of respondents who do not use any contraceptive is 46.3 %. Less people use vasectomy (0.5 %) and Condom (0.5 %).

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Table 4.10 The Distribution of Pregnant Woman and Abortion by Age

Table 4.10 indicates that the highest percentage of pregnant woman occurs among people of 25 to 29 years old (31.0 %), accompanied by people of 30 to 34 years old (29.8 %). Among youngest people of 15 to 19 years old, 20.2 % are pregnant. None of 45 to 49 years old is pregnant (0 %).

Table 4.11 The Number of Children Ever Born (CEB)

Table 4.11 indicates that the average CEB/female of people of 45 to 49 years old is 3.034. This can be considered as �gcomplete family size�h.

Table 4.12 The Average Age of Marriage, First Pregnancy, and The Smallest Child

Table 4.12 indicates that the average age at marriage is 19.7 years old. This age is higher that the age required for marriage by law. The average age at first pregnancy is 27.5 years old. The average age of smallest child when the mother is in last pregnancy is 3.9 years old. These conditions seem to be ideal for maternal reproduction health.

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Table 4.13 shows that Puskesmas is a health facility for antenatal care that is most often visited by the clients beside private midwives. Puskesmas is preferred because it is cheap. Private midwives are preferred because they are easy to access or close to client�fs homes. Private hospital is preferted because it gives good service, specialists are preferred because they give safe services, and General hospital is preferred because it has complete facilities. It is interesting that visit to TBA still occurs; there is reason that could explain it.

Table 4.13 The Health Facility for Antenatal Care

Facility	The Reason for Choosing Health Facility
	Easy		Cheap		Good Service		Complete Facility		Safe Service		Others		Total
	f	%	f	%	f	%	f	%	f	%	f	%	f	%
Community Health Center (CHC) Private Midwife Private Hospital Delivery Clinic Obstetrician General Hospital TBA General Practitioner Integrated Services Post Others	60 105 42 25 3 7 7 11 2 9	27.5 48.8 22.6 15.5 3.5 9.0 17.1 37.9 100.0 11.0	80 28 20 11 0 15 9 3 0 5	36.6 13.0 10.8 6.8 0.0 19.3 22 10.3 0.0 6.1	3 38 47 69 11 6 3 6 0 9	1.4 17.7 25.2 42.9 13.0 7.7 7.3 20.7 0.0 11.0	1 2 34 18 8 20 0 0 0 1	0.5 0.9 18.3 11.2 9.4 25.6 0.0 0.0 0.0 1.1	3 16 17 12 43 20 10 4 0 4	1.4 7.4 9.1 7.5 50.6 25.6 24.4 13.8 0.0 4.8	71 26 26 26 20 10 12 5 0 55	32.6 12.2 14.0 16.1 23.5 12.8 29.3 17.3 0.0 67.0	218 215 186 161 85 78 41 29 2 82	19.9 19.5 16.9 14.7 7.7 7.1 3.7 2.6 0.2 7.5

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Table 4.13. indicates that among 218 respondents who choose CHC for antenatal care, 27.5 % respondents choose it because it is easy to access, 36.6 % respondents choose it because it is cheap. Among 215 respondents who choose private midwives for antenatal care, 48.8 % respondents choose them because they are easy to access, 17.7 % respondents choose them because they give good services. Among 186 respondents who choose private hospitals for antenatal care, 25.2 % respondents choose them because they give good services, 22.6 % respondents choose them because they charge cheap tariff. Among 78 respondents who choose general hospitals for antenatal care, 25.6 % respondents choose them because they provide safe services and complete facility. Among 41 respondents who choose TBA (Traditional Birth Attendant), 24.4 % choose her because she provides safe services, and 17.1 % give reason that TBA is easy to access.

Table 4.14 The Distribution of Antenatal Services

Table 4.14 indicates that most respondents visit antenatal services when their ages of pregnancy are 1 to 3 months (72.4 %). Most respondents visit antenatal services more than four times (80.4 %). Most respondents have never been immunized with TT during they are pregnant.

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Table 4.15 of Last The History of Birth Attendance Child

*Community Health Center (CHC)

Table 4.15 indicates that most respondents choose private hospitals for attending birth of the last child (22.4 %), the second and third percentages are by birth attendance clinic (18.0 %) and private midwife homes (17.2 %). Births attended by midwives for the last child show the highest percentage (55.4 %).

4.2.4. The Condition of Health Services

Table 4.16 The Visit to Puskesmas

Table 4.16. indicates that most respondents have ever visited Puskesmas (63.4 %). This indicates that Puskesmas seems to be the good choice for people in the urban area like Surabaya particularly for those who have middle to lower social economic status. However, there are 35.9 % of the total respondents who have never visited Puskesmas. Probably they do not know about Puskesmas, they consider Puskesmas as Private Polyclinics or probably they do not like to visit Puskesmas because of its bad services.

Table 4. 17 Other Health Facilities Ever Visited by Respondents

Table 4.17 indicates that most respondents have ever visited GP (32.8 %). People in the urban area like Surabaya need the existence of GP as health provider in private sectors. Probably they prefer GP to Puskesmas since GP gives a good health service in which each patient is examined by GP not by a midwife or a nurse like in Puskesmas or Private Polyclinics. Usually patients from middle to lower social economic status feel satisfied when doctors not by midwives or nurses examine them. The second highest choice of health services is all day clinics (21.2 %). Now in Surabaya, all day clinics that serve patients in 24 hours grow rapidly. A patient can visit any time as he/she wants to visit, beside each patient is examined by a doctor, he/she receives drugs after examination. The patients prefer all day clinics to general hospital because of immediate services that is called one stop services. The third and fourth highest choices of services are general hospital (21.2 %) and private hospital (17.0 %). Probably the respondents chose general hospital because other health facilities did not have complete equipments and more sophisticated services.

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Table 4.18 The Reason to Visit Puskesmas

Table 4.18 indicates that most respondents visit Puskesmas for medical care purposes (62.3 %). Only 1.1 % of the total respondents visit Puskesmas for family planning purposes. When Reproduction Health Services to be attached to Puskesmas, an intensive socialization to people in the community should be planned properly.

Table 4.19 Distance, Time, and Transportation Used for Visiting to Puskesmas

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Table 4.19 indicates that most respondents live in the houses that are located in the radius of less than 3 kilometer from Puskesmas that can reached less than 15 minutes and they took a walk to Puskesmas (67.5 %). Only 1.3 % of the total respondents live in the radius of more than 7 kilometer from Puskesmas that can reach more than 30 minutes and they take public transportation to Puskesmas. In general, Puskesmas is an ideal health facility that is located close to the people in the community. Hence, Puskesmas seems to be accessible, feasible, acceptable, and accountable health facility in urban area like Surabaya. The problem is how to enhance the quality of services that meets the community demand.

Table 4.20 The Frequency of Visit to Puskesmas

Table 4.20 indicates that most respondents are seldom to visit Puskesmas (61.5 %), while 15.5 % of the total respondents always visit when they are sick. Moreover, 3.2 % of the total respondents visit Puskesmas once.

Table 4.21 The Health Personnel Serving in Puskesmas

Table 4.21 indicates that the doctors sometimes examine most respondents when they visit Puskesmas (42.5 %). Moreover, the doctors always examine 15.0 % of the total respondents when they visit Puskesmas. Furthermore, the midwives or nurses always examine 36.5 % of the total respondents when they visit Puskesmas. This fact conforms the results that explain that the preference of Puskesmas is low because midwives or nurses serve patients in spite of doctor.

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Table 4.22 The Duration of Medical Examination in Puskesmas

Table 4.22 indicates that most respondents explain that the health personnel examined them in less than 15 minutes (57.6 %). In point of view of efficiency, the examination by health personnel in Puskesmas is efficient. But in point of view of diagnostic accuracy, the results of examination by health personnel are questionable. Moreover, 33.8 % of the total respondents are examined within 15 to 30 minutes, while 8.6 % of the total respondents are examined in more than 30 minutes.

Table 4.23 The Membership of Health Insurance

Table 4.23 indicates that 47.4 % of the total respondents participate in various health insurance. Most of them who's insurance are covered by Social Insurance of Work Force (Jamsostek) (13.2 %). Most of them are categorized as workers not officials and their managers arrange their insurance through ASTEK Coy. (Work Force Insurance Coy.) Moreover, 8.3 % of the total respondents are governmental officials, hence their health insurance are covered by ASKES Coy (Health Insurance Coy), the agency under Department of Health. By law, all governmental officials are directly members of ASKES. Furthermore, 3.4 % of the total respondents are not governmental, hence, their health insurance are covered by various insurance agencies. Finally, most respondents are not covered by any insurance (52.6 %).

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4.2.5. Quality of Health Services in Puskesmas

The data about quality of health services in Puskesmas are obtained from interview by asking the procedure of registration, the convenience of waiting room, the attitude of health personnel to patient, the informative legend in waiting room, duration of waiting, the cleanness of environment, the availability of services, the opportunity in explaining health condition/symptoms, the opportunity in selecting alternative medication. The results of interview are scored and are presented from table 4. 24 to table 4.33.

Table 4. 24. Quality of Health Services in Puskesmas

Table 4.24 indicates that most respondents feel satisfied for health services given by health personnel in Puskesmas (61.9 %). Moreover, 33.0 of the total respondents feel moderately satisfied. Only 2.6 % of the total respondents feel unsatisfied for health services given by Puskesmas, and only 2.5 % feel very satisfied.

Table 4.25 Type of Services Provided by Puskesmas

Table 4.25 indicates that most respondents explain that Puskesmas is a place for medical care (93.1 %), immunization (76.1 %), family planning (73,2 %), dental care (72.6 %), and antenatal care (71.4 %). Only 23.1 % and 17.5 % of the total respondents respectively explain that Puskesmas is place for minor surgery and emergency unit.

Table 4.26 Time of Service in Puskesmas

Table 4.26 indicates that most respondents feel that time of service is moderate (78.0 %). Moreover, 21.9 of the total respondents felt that time of services is too short, while 0.1 % of the total respondents feel that time of services is too long.

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Table 4.27 The Tariff of Services in Puskesmas

Table 4.27 indicates that most respondents feel that the tariff of Services in Puskesmas is cheap (89.8 %). Moreover, 8.8 % of the total respondents feel that the tariff is very cheap, only 1.4 % of the total respondents feel that the tariff is expensive.

Table 4. 28 The First Visit to Health Services

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Table 4.28 indicates that most respondents explain that the first visit when they are sick was Puskesmas because it charges the cheap tariff (61.3 %), it is close to their homes (37.9 %). They choose GPs for the first visit when they are sick because they serve with complete facility (28.2 %) and convenience room (42.6 %), make them satisfied because they feel better, and are always available any time when they need them.

Table 4.29 Ability To Pay

Table 4.29 indicates that in average, the respondents are able to pay around Rp.13.615, -. However, several respondents are not able to pay the Puskesmas Tariff, that means they want to be free of charge, while several respondents are able to pay around Rp. 100.000

Table 4.30 The Health Personnel Who Served The Respondents

Table 4.30 indicates that most respondents are served by GP (84.7 %). Only 6.9 % of the total respondents are served by specialists. Moreover, respectively 5.8 % and 1.5 % of the total respondents are served by midwives and nurses.

Table 4.31 Type of Services Expected to be Available in Health Facility

Type of Services	Frequency	%
Medical care Antenatal care Immunization Dental care Family Planning Minor Surgery Emergency Services Others	1088 722 706 688 678 299 284 48	94.9 62.9 61.6 60.0 59.1 26.1 24.8 4.2

Table 4.31 indicates that most respondents expect that in each health facility, medical care is available (94.9 %), antenatal care is available (62.9 %), immunization services are available (61.6 %), dental care is available (60.0 %), and family planning services are available (59.1 %). Only respectively 26.1 % and 24.8 % of the total respondents expect that in each health facility minor surgery service and emergency service are available.

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Table 4.32 Time of Services Expected By The Respondents

Table 4.32 indicates that most respondents expect that any health facility opens 24 hours (41.0 %). Moreover, 36.9 % of the total respondents expect that any health facility opens in the morning and evening. Respectively 11.5 % and 10.5 % of the total respondents expect that any health facility opens in the morning, and in the evening.

Table 4.33 Waiting Time Expected By Respondents

Table 4.33 indicates that most respondents expect that the waiting time of service is between 15 to 30 minutes. Moreover, 36.3 % of the total respondents expect that the waiting time of service is less than 15 minutes, while 24.4% of the total respondents expect that the waiting time of service is more than 30 minutes.

4.3 The Results Based On Qualitative Approach

The structure of the model that will be developed depends on first, the form of services that are desired, second, the health personnel that are required, third, the status of employee, fourth, the origin of budget, fifth, type of services, sixth, the relationship with regional autonomic system, seventh, information system, and eighth, the relationship with various institutions.

First, the forms of services can be various level of community health center from third level such as Puskesmas Pembantu = Pustu (Assistant Community Health Center), to second level such as Puskesmas Community Health Center), and to first level such as Puskesmas Pembina (Builder Community Health Center), family physician, birth attendance hospital, reproductive health, Pos Pelayanan Terpadu = Posyandu (integrated services post), Balai Kesehatan Ibu dan Anak = BKIA (maternal child health clinic, private practice doctor, private practice midwife, polyclinic, and pharmacy.

Second, the health personnel can be, nurse, GP (General Practitioner), public health graduate, Diploma of nurse, Senior High School / Junior High School/ Elementary School, family welfare establishment (PKK) cadre, social worker, Diploma of Midwife, senior specialist, pharmacist, midwife, assistant pharmacist, prescription clerk, First and Third Diploma of Nutrition, Third Diploma of Environmental Health, dentist, Third Diploma of Pharmacy, assistant midwife, and home affairs clerk.

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Third, the status of employee can be permanent, contracted, honorary, and volunteer. An employee is categorized as permanent employee when the recruitment and appointment based on the national rule of employment under State Employment Administrative Board (BAKN). An employee is categorized as contract employee when the recruitment and appointment based on a contract agreement, she/he is called Nonpermanent employee (PTT). An employee is categorized as honorary employee when the recruitment and appointment based on local rule. An employee is categorized as volunteer when she/he joins with the institution voluntarily without any reward.

Fourth, the origin of budget can be cash from patient, can be from regional government, community fund, private fund, public health services insurance (JPKM), and costumer, central government, and domestic and overseas NGO.

Fifth, types of services can be MCH and reproductive health and family planning, immunization, medication including traditional medication, one day care (observation), emergency drug, popular disease prevention and care including surveillance, counseling including sex education and marriage counseling, nutrition, hygiene and sanitation, safe water supply, sex/special gymnastics, physiotherapy, infant massage, Pap smear, and home visit

Sixth, the relationship to regional autonomic system is characterized by

1. the budget does not fully depend on central government,
2. self reliance in determining policy,
3. implementing bottom up strategy by empowering community,
4. the target is addressed to the region that needs support,
5. equity in services,
6. low income people are insured their health,
7. no collusion, corruption, and nepotism by involving people openly and transparently,
8. establishment under City Health Office that is responsible to Governor through Provincial Health Office,
9. The Board of Inspector and Implementation Controller of PHC is needed, this board is related to profession practice, and the mechanism should be coordinated with profession organization,
10. no new institution, the existing institution is enhanced its capability,
11. health services are implemented freely and they may cooperate with any agency,
12. Regional government does public goods, while community is responsible to private goods that can be done by user fee, public health services insurance (JPKM), and private health insurance company.

Seventh, Information System makes

1. the coverage of Socialization is more extended,
2. communication and motivation are more frequently done,
3. there is a standardized index in the form of bulletin publication, periodic talk,
4. patient needs to obtain early information that is easy to understand,
5. open and simple administration system that is easily monitored and controlled by community
6. information technology, critical evaluation, and feedback are needed.

Eighth, in developing the relationship with other institutions the following points should be considered,

1. check the benefit technically,
2. coordination with other institutions is needed for handling the problem,
3. the relationship is needed particularly in the field of solution and fund,
4. the relationship with NGO/profession /community/private sectors (domestic/overseas),
5. build the club,
6. the relationship is particularly needed for developing health services in the future,
7. the relationship in the form of equal partnership (cooperation), and
8. enter the other governmental network (interprogram, intersector)

Based on Nominal Focused Group Discussion Technique (NFGDT), five alternative models show up as follows.

4.3.1 Alternative Model I: The Form of Services: PUSKESMAS

4.3.1.1 Type of Services

1. MCH and Reproductive Health
2. Medical Care
3. Immunization
4. Nutritional Improvement
5. Disease Prevention
6. Health Education
7. Hygiene and Sanitation

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4.3.1.2 Type of Personnel

4.3.1.3 Source of Budget

1. Direct (not submitted to regional cashier)
2. Health Insurance
3. Regional Government (Regional Budget)

City Health Office of Surabaya executes reproductive health to be integrated to MCH program so that its structure as section under division of family health (formerly was called MCH Section) based on new regional act.

The development of reproductive health can be done by enhancing the performance of reproductive health services in MCH Section, Puskesmas or in Reproductive Health and Family Planning Section, Division of Family Health, City Health Office, Surabaya and other innovative services programs. Right now the concept of primary health care (PHC) is being implemented. What is needed is to enhance the performance by implementing management function optimally so that the output and outcome will increase.

Figure 4.2 Management Information System of Primary Health Care/ Reproductive Health

The relationship with other institutions in the form of equal partnership by establishing cooperation that gives mutual benefit such as health organization in national and international level, NGO, other community and private organization. A health network that covers more extended target can enhance the relationship. An approach based on evidence research is needed to obtain the fund in order to assure executive and legislative sides in the level of city or district.

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4.3.2 Alternative Model II: Services: PUSKESMAS, MCH, Doctor Practices, Pharmacy Practices

4.3.2.1 The Form of Services: Puskesmas

4.3.2.1.1Type of Services

1. Medical cares, including traditional care
2. MCH and Reproduction Health
3.Immunization
4.Prevention and care
5.Enlighten

4.3.2.1.2Type of Personnel:

4.3.2.1.3 Source of Budget

1. Direct from patient
2. Regional Budget
3. Insurance

4.3.2.2 The Form of Services: MCH

4.3.2.2.1 Type of services:
1. MCH and Reproductive Health
2. Immunization
3. Prevention and care
4. Enlighten

4.3.2.2.2 Type of Personnel:

4.3.2.2.3 Source of Budget:

1. Direct from patient
2. Private
3. Insurance

4.3.2.3 The Form of Services: Doctor Practices

4.3.2.3.1 Type of Services

1. Medical cares, including traditional care
2. MCH and Reproductive Health
3. Immunization

4.3.2.3.2 Type of Personnel

4.3.2.3.3 Source of Budget

1. Direct from patient
2. Insurance

4.3.2.4 The Form of Services: Pharmacy

4.3.2.4.1 Type of Services

1. Modern and Traditional Drug, Medical Equipment, and Cosmetics
2. Enlighten

4.3.2.4.2 Type of Personnel

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4.3.2.4.3 Source of Budget

1. Direct from patient
2. Private
3. Insurance

4.3.2.5 The Form of Services: Midwife Practices

4.3.2.5.1 Type of services

1. Antenatal care and birth attendance
2. MCH and Reproductive Health
3. Immunization
4. Prevention and care
5. Enlighten

4.3.2.5.2 Type Personnel

4.3.2.5.3 Source of Budget

1. Direct from patient
2. Private
3. Insurance

4.3.3 Alternative Model III: The Form of Services: POLYCLINIC

4.3.3.2 Type of Personnel

4.3.4 Alternative Model IV: The Form of Services: PUSKESMAS, POSYANDU AND MCH

4.3.4.1 Qualification of personnel for Puskesmas

Type	Qualification	Status
Chairperson	BSPH	Permanent
Performer	Diploma of Nurse	Permanent
Assistant Performer	Senior High School	Contractual

4.3.4.2 Qualification of personnel for Posyandu

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4.3.4.3 Qualification of personnel for MCH

4.3.4.4 Source of Budget

Direct from patient

4.3.4 Alternative Model V: The Cumulative Model of Urban Primary Health Care

This model is a collection of all models that have been suggested by experts. This is the accumulation of alternative models I, II, III, IV. The center coordinator is Puskesmas particularly in reporting, mediating with City Health Office.

Figure 4.3 Cumulative Model of Urban RPHC

V. Discussion

5.1 The character of the reproductive and primary health care system

Government of Indonesia has signed the declaration of Alma Ata to achieve health for all in the year of 2000. As a consequence, those who signed this declaration should point out the keyword �g Primary Health Care (PHC) �g in the health planning. In Indonesia, to realize PHC, Department of Health through Provincial Health Office, District/City Health Office promotes the formation a community-based institution called PKMD (Pembangunan Kesehatan Masyarakat Desa or Village Community Health Development. In the beginning of the program PKMD were developed gradually in the rural areas such as Sub districts of Burneh and Kwanyar, District of Bangkalan (Kuntoro, 1980)

In the end of 1976, City Health Office of Surabaya promoted the formation of PKMD in the Kampong (Sub village) Bulak Rukem, Subdistrict of Semampir in the North of City of Surabaya. This Kampong was selected because it had rather rural characteristics than urban characteristics at that time this is the early form of PHC in City of Surabaya. The key persons who involved in this community institution were teachers, governmental officials who lived in this Kampong at that time. The reason of selection was these groups could be considered as reliable agent of change. The activity included health promotion to the households of the Kampong supervised and guided by the personnel of Puskesmas of Sub district of Semampir. Other activity was limited treatment of diarrhea by oral electrolytes and fever by antipyretic drug before being referred to Puskesmas. Puskesmas supplied these simple drugs. At the beginning, this community institution was supported by City Health Office of Surabaya through Puskesmas of Subdistrict of Semampir. At that time this institution was expected to be self-reliant after several years under building of Puskesmas. This community institution seems to be the first and the last one in City of Surabaya (Kuntoro, 1976)

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Today, the health facilities that can be considered as PHC because they are owned by community organizations or private sectors are polyclinics, MCH clinics, birth attendance clinics, traditional medicine clinics, and pharmacies. The Islamic Community Organization like Muhammadiyah, Nahdlatul Ulama have many health facilities in City of Surabaya. They charge the patients based on their social and economic conditions.

The implementation of regional autonomy that has been launched since January 1, 2001 promotes health facilities owned by the government to be self-reliant in the near future. Health facilities that provide private goods should be self-reliant. Over years Puskesmas provides public goods. But in the near future as the local governmental budget is limited, Puskesmas is suggested to develop non-essential health services in basis of profit while essential health services are still supported by the local governmental budget. In this case community participation is needed to build Puskesmas to be self-reliant. Hence, Puskesmas may replace the function of PHC that no longer exists. Furthermore, any discussion about PHC should be connected to the role of Puskesmas in continuing the function of PHC.

Beside the description mentioned above, the early condition of PHC before being developed can be explained through two points, first, the components of PHC and second, the relationship between the existing PHC and other health institution. One of the components of PHC is MCH activity. It has been explained in table 4.15 that most birth attendance for the last child takes places in private hospital (22.4 %). Usually private hospitals are owned by the religious community such as Muhammadiyah, Nahdlatul Ulama for Islamic community, RKZ (Rome Catholic Hospital) for Catholic community etc. This is the form of community participation with self-reliant principle in providing health facility for the people in City of Surabaya. Birth attendance clinics that cover 18 % of birth attendance of the last child are also owned by private sectors and community organization. Most respondents prefer midwives to other birth attendants for their last children (55.4 %). For developing PHC, the role of midwives in MCH program should be considered properly. In table 4.16 although most respondents ever visited Puskesmas (63.4 %), however, about 35.9 % of the respondents who never visited Puskesmas should be taken into consideration in improving the health services of Puskesmas when it will be developed to be PHC in the future. Other component of PHC is Family Planning and Reproductive Health activity. In family planning activity, most respondents prefer injection to other contraceptives (22.9 %, more for detailed information refer to table 4.9). The second highest preference is pill that includes 15.0 % of he total respondents. In developing PHC these preferences should be taken into consideration. For reproduction health activity see table 4.10. The respondents who experience pregnancy for the last four months are 84 persons. Most of them are 25 to 29 years old (31.0 %) and 30 to 34 years old (29.8 %). These are the safe age groups for pregnancy in the point of view of reproductive health since the risk of pregnancy is low. However, about 4.8 % of the total pregnant women are 15 to 19 years old, the age in which the risk of pregnancy is high.

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The pregnant women who are older than 35 years old include 14.3 % of the total pregnant women. This age group as well as the youngest age group has the high-risk pregnancy. In reproductive health program these groups should be taken into consideration. Among respondents who are ever pregnant, 7.1 % respondents experienced abortion. One respondent of four respondents of 15 to 19 years old experienced abortion and one respondent of three respondents of 40 to 44 years old experienced abortion. The existence of abortion indicates unwanted pregnancy. A young respondent who experiences abortion indicates that her pregnancy is unplanned properly. This is a kind of bad reproductive health practice that should be avoided since it tends to increase maternal mortality. An older respondent who experiences abortion usually she gets difficulty in her reproductive health life due various factors such as a carier woman, a disturbance of reproductive organ, an unmatched couple. The urban area like City of Surabaya, PHC and RH should be developed by considering these complexities reproductive health experience.

The second point is the relationship between PHC and other health facility. Puskesmas is a functional organization unity in a sub district level or a kelurahan level that serves complete health services including MCH and RH. Right now this facility is owned by local government. The Head of Puskesmas is responsible to Head of City Health Office both administrative- operasional aspect and technically medical aspect. As long as Puskesmas serves public goods, financially it is responsible to national and local government. Until now private goods of health services has not yet been touched by Puskesmas. In City of Surabaya, these are managed by private clinics, private hospitals nationally and internationally. The relationship between private clinics, polyclinics, and laboratories in one side and City Health Office in other side is limited to permit arrangement and activity reporting. Private hospitals and pharmacies are under coordination of Provincial Health Office in permit arrangement and activity reporting. In the future this relationship should be improved. It should be extent to quality assurance and ethical problem.

5.2 The major health problems in the city

The rate of sickness among respondents of City of Surabaya during the last two weeks at time of study is 12.6 %. This finding is close to the rate of sickness among poor respondents in the same city (14.2 %), Districts of Sampang (11.0 %), Malang (14.2 %), Pasuruan (11.9 %), Nganjuk (13.0 %), Pamekasan (13.3 %), City of Blitar (13.0 %). These cities and districts are located in East Java Province. (Kuntoro, 2001). Moreover, the first highest rate occurs among children under one year old (33.6 %), the second highest rate occurs among children between one to five years old (30.9 %), and the third highest rate occurs among adults 65+ years old (20.4 %). These age groups are considered to be vulnerable. Hence, in developing PHC, the program of MCH and elderly should be the priority. Upper respiratory tract infection (URI) is prevalent among respondents in all age groups (50.4 %). The prevalence of URI among respondents of children under one year old is 68.1 %, children between one to five years old is 57.0 %. This finding is lower than the prevalence rate among children under five years old of poor people in the same city (96.3 %) (Kuntoro, 2001). Probably, when the result is adjusted to the social economic status (poor versus non poor), sub district, and time period, the result would be the same. The disease mentioned above seems to be related to the environmental condition such as bad housing, and poor knowledge of the disease, bad attitude and practice of living in health environment. Hence, in developing PHC in the city, the program of environmental sanitation should be taken into consideration.

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5.3 The effect of the reproductive and primary health care system to the human health in the city�fs population

Suppose that the existing PHC and RH care executed by Puskesmas and other health facility owned by community and private sectors has run since Alma Ata Declaration has been signed. Suppose that the portraits of family planning and MCH activities that has been collected could be considered as the effect of PHC and RH care system. The high percentages of respondents who use injection (22.9 %), and pill (15.0 %) indicate the respondents prefer the expensive cost to the cheap cost (see table 4.9) This results should be adjusted to the social economic status, and how they obtain these contraceptives (free of charge or not). When they pay for these contraceptives, hence, they are able to pay so that in developing PHC and RH, preference of costumer should be taken into consideration.

High percentage of the respondents of 20 to 34 years old who are ever pregnant indicates that most respondents are conscious to select the best age for pregnancy. They have practiced good reproductive health. The high percentages of 15 or 19 years old and 40 to 44 years old (see table 4.10) indicate that the practices of reproductive health among these age groups are poor. In developing PHC and RH these age groups should be taken into consideration.

Most respondents prefer private hospitals and birth attendance clinics to other health facilities in birth attendance (see table 4.15). These indicate that over years the implementation of PHC and RH make the respondents conscious to evaluate which health facility give good services and to decide where they have to go for birth attendance. Since midwives are the major preference for birth attendance, in developing PHC and RH they should be taken into consideration. Antenatal care is important to screen the high-risk pregnancy in order to minimize maternal and neonatal mortality. The pregnant women should follow the antenatal care schedule. Table 4.14 indicates that antenatal care among pregnant women of second and third semester are low (respectively 14.6 % and 1.2 %). These groups are critical. Hence, in developing PHC and RH the program of enhancing the antenatal care in all semesters should be prioritized.

5.4 The perception of the population being served

Ideally, each health facility should be close to the homes where people live. Most respondents take a walk when they visit Puskesmas (67.5 %) because the distance is less than 3 kilometers or they spend less than 15 minutes to reach Puskesmas. The concept of Puskesmas as the frontier health services and close to the community meets the expectation of the consumers. Most respondents who access Puskesmas say that the examination spends less than 15 minutes (see table 4.22). Usually people who are sick want to be served immediately with accurate examination. This is a matter of quality assurance needed by any consumer. Table 4.24 indicates that most respondents feel satisfied upon quality of health services in Puskesmas. In developing PHC and RH, satisfaction of consumer. Table 4.25 indicates that the consumers need Puskesmas that provides medical care, immunization, family planning, dental care, and antenatal care. Most respondents feel that the open hour from 8 to 12 daily is moderate time (78 %). However, 21.9 % of the respondents suggest Puskesmas to open longer. The tariff of health services is critical among consumers. They want health services that are cheap.

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Most respondents feel that the tariff of Puskesmas is cheap. This is the reason why health insurance among medium to low class of community is not effective. Puskesmas can maintain cheap tariff because it is subsidized by the government (Thaha, 2002) The respondents want the health facility that is cheap like Puskesmas, has complete facility like GP, has convenience room like GP, is close to the home like Puskesmas, makes satisfied like GP, is always accessible any time like GP. Hence, PHC and RH that will be developed should be as good as GP and as cheap as Puskesmas.

5.5. Improving the reproductive and primary health care system to provide the better health of the city�fs population

In improving PHC and RH several factors have been discussion in point 1 to point 4. The previous conditions indicate that there no PHC that meets exactly the definition of PHC based on Alma Ata Declaration. Only modification of PHC that has been adjusted to the condition of Indonesia. The best structure of PHC and RH should be appropriate to the need of health delivery system in Indonesia to obtain health for all and also the demand of people in the community as consumers. When Puskesmas and other health and health related facilities can be considered as the existing PHC and RH care system, the structure of PHC and RH in City of Surabaya should be adjusted to the health problem of urban area, and reproductive behavior of urban area. The health problem of urban area is dominated with the diseases related to the environment of urban area. The reproductive behavior of urban area is dominated with the demand of health facility that is cheap, complete, convenient, and accessible with assurance of quality of care. This condition may affect the form of services such as Puskesmas or other better health facility, the health personnel to be involved, the status of health personnel, the origin of budget, type of services, the relationship to the city government system, the information system, relationship with other institution. Based on survey, in-depth interview, and NFGDT that involve people in the community who represent the consumers, health and governmental institutions related to the implementation of health program, and the opinion of the experts, five models come up. These are first, Puskesmas, second, System Compound of Puskesmas, MCH, Doctor and Pharmacy Practices, third, Polyclinic, fourth, System Compound of Puskesmas, Posyandu (Integrated Services Post), and MCH, and fifth, Cummulative Model of Urban Primary Health Care and Reproductive Health, this is compound of four models.

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VI. Conclusion and Recommendation

6.1. Conclusion

6.1.1. The Character of the reproductive and primary health care system

The reproductive and primary health care system is in the form of Puskesmas owned by government, MCH clinics, birth attendance clinics, polyclinics, pharmacy owned by community organization and private sectors. For births, most respondents prefer private hospitals (22.4 %), birth attendance clinics (18.0 %), and they prefer midwife as birth attendant (55.4 %). Most respondents ever experience pregnancy in age group of 25 to 29 years old (31.0 %) and 30 to 34 years old (29.8 %). Abortion occurs among respondents of 15 to 19 years old (25.0 %) and 40 to 44 years old (33.3 %). Most respondents use injection (22.9 %) and pill (15.0 %) for family planning activity. Most respondents do antenatal care during the first trimester (72.4 %) Only 1.2 % do antenatal care during the third semester.

Puskesmas is owned by government and it depends on regional budget. It is responsible to City Health Office. Private clinics (MCH clinics, birth attendance clinics, polyclinics) are under City Health Office in permit arrangement, monitoring and reporting. Private hospitals and pharmacies are under Provincial Health Office in permit arrangement, monotoring and reporting.

6.1.2 The Major health problem of the city

The sickness is prevalent among individuals under five years old (64.5 %) and 65 years and older (20.4 %). They are included the vulnerable people in the community. Upper respiratory tract infection is the disease that is prevalent among all age group (more than 45 % for all age groups). The second disease is diarrhea it showed more than 15 % among child under five years old. Hypertension is prevalent among people of 65 years old and over (8.8 %).

6.1.3 The Effect of RPHC system on the human health in the city�fs population

About 53.7 % of the respondents are protected by various contraceptives. About 25 % of respondents 15 to 19 years old and 33.3 % of respondents 40 to 44 years old experience unsafe reproductive health. Less respondents do antenatal care in second and third semester, hence, they experience unsafe reproductive health.

6.1.4 The Perception of the population being served

Most respondents prefer cheap tariff like Puskesmas, complete, convenience, and easily accessible health facilities like GP.

6.1.5 Improving RPHC system to provide better health of the city�fs population

Five models come up after NFGDT, these are, first Puskesmas, second, Puskesmas-MCH-Doctor and Pharmacy Practices Compound, third, Polyclinics, fourth, Puskesmas-Posyandu- MCH Compound, and fifth, Cumulative Model of Urban Reproductive and Primary Health Care System.

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6.2. Recommendation

6.2.1. The Model of Midwife Practice.

When this model will be selected, several remarks should be taken into consideration such as:

1. By regional autonomy, everything will be arranged by District/City Authority
2. Regulation related to profession (Doctor/Pharmacist Practices) to be coordinated with Profession Organization
3. No more new institution, but to enhance the function of existing institution
4. The role of other institution as donor agency

6.2.1. The Model of Polyclinic

When this model will be selected, several remarks should be taken into consideration such as:

1. The relationship between Primary Health Care and Reproductive Health Model and Regional Autonomy
2. Organization: Joint with an organization under City Health Office
3. Balance: By considering reproduction health services it is expected that the baby born has good quality of life (mental, physical, intelligent aspects) so that good human resources can be produced that can be used for developing the region in regional autonomy era
4. Controlling Collusion, Corruption and Nepotism (CCN): By involving community in solving the health problem, an organization can perform better control function so that CCN can be avoided.
5. Develop MIS that is easy to understand by people in the community so that it is easy to implement without moral risk.
6. The outsiders should be involved in developing the form of services and the type of services in the future.

6.2.2. The Special Model of PHC and RH in the urban area
When this model will be selected either in the form of services of Puskesmas or Posyandu or MCH, several remarks should be taken into consideration such as:

1. Reproduction Health becomes the part of Primary Health Care in which the execution is under District/City Health Office. Then it is responsible to Governor through Provincial Health Office.
2. It is required to establish Inspector and Controller Board of PHC Implementation
3. Management Information System can be developed by bulletin publication, periodic and continuing talk
4. Relationship with outsider such as NGO, Profession Organization, Social Organization.

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VII. References

Caldwell, John, 1986, �e Routes to Low Fertility in Poor Countries �g, Population and
Development Review, Vol. 12, No. 2 pp. 171-220

Fry, John, John Horder, 1994, Primary Health Care in an International Context, (London:
The Nuffield Provincial Hospital Trusts)

Kuntoro, 1976. Personal Experience in Developing Community-Based Health Supporting
Organization, Bulak Rukem, Subdistrict of Semampir, City of Surabaya

Kuntoro, 1980, Penelaahan Kegiatan PKMD, UKS dan Dukun Bayi di 4 Pedukuhan di
Wilayah Kecamatan Burneh dan Kwanyar Kabupaten Daerah Tingkat II
Bangkalan, Tim Pelaksana University Study Universitas Airlangga.

Kuntoro, 2001, Studi Longitudinal Evaluasi Pelaksanaan Program JPS-BK di Propinsi
Jawa Timur, Jakarta, Direktorat Jenderal Bina Kesehatan Masyarakat Departemen
Kesehatan RI.

Mac Donald, John J., 1993, Primary Health Care: Medicine in Its
Place. (London: Earthscan Publications, Ltd.)

Miller, Roberta et al., 1997, The Situation Analysis Approach to Assessing Family
Planning and Reproductive Health Services, (New York: The Population
Council)

Ness, Gayl D., and Hirofumi Ando, 1984, The Lands is Shrinking: Population Planning
In Asia, (Baltimore: Johns Hopkins University Press)

Population Council and PRB, 1999, A Guide to Research and Findings on the Cairo
Consensus, Cairo Plus Five, 1994-1999, (New York: The Population Council,
and Washington DC: Population reference Bureau)

Razak, A.R., Husni Mu�fadz, 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.

Singh, Jyoti, 1998, Creating a New Consensus on Population, (London: Earthscan Press)

Simmons, Ruth and Christopher Elias, �gThe Study of Client-Provider Interactions:
A Review of Methodological Issues�h, Studies in Family Planning, Vol. 25,
No. 1(New York: The Population Council)

UNDP, 1998, Human Development Report, (New York:UNDP)

WHO/UNICEF, 1978, Primary Health Care: The Alma Ata Conference, (Geneva: WHO)

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VIII. Annex 1

Annex 1. Flow of Urban RPHC Model

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IX. Annex 2

1. General explanation (macro) of the problem area, then focused on more micro problem related to the objectives
2. Questionnaires are distributed to the participants to collect their opinions individually
3. Each participant answers the questionnaires confidentially and collected by a facilitator
4. The facilitator lists all opinions on paper (without identification) and distributed to all participants
5. Free discussion among the participants moderated by the facilitator
6. Repeat step 1 to step 5 several times until no change of opinions

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