Development and Improvement of Reproductive and
Promary Health Care System, Preliminary Action for City of Surabaya
I. Introduction
Reproductive health care and primary health care
are terms and strategies that emerged at different times in different
places. Primary Health Care (PHC) emerged first at the 1978 Alma Ata
WHO/UNICF conference (WHO/UNICEF, 1978). Reproductive Health Care
emerged at the Cairo International Conference on Population and
Development in 1994. Though their histories differ, they are close
together in espousing better, more thorough and more humane aspects of
a fundamental social service, that of promoting health. Thus they can,
and perhaps should, be examined together to understand how specific
social program can improve the quality of life.
For this research design, we first examine the meaning of the two
strategies, and then lay out specific suggestions for how the can be
assessed systematically. Our focus will be on urban areas, but the
proposed research design can be adapted to any administrative area or
terrain.
Primary Health Care (PHC) emerged as a blueprint for a new type of
health care system, especially for the Third World, which could provide
ghealth for all.h Involving a broad focus on human health that goes
beyond the narrow medical orientation that has come to dominate the
world, PHC aims to link health more closely to a countryfs economic and
social development program. As stated in 1978, PHC
gcforms an integral part of the countryfs health system, of which it is
the central function and main focus, and of the overall social and
economic development of
the community.h (WHO/UNICEF 1978).
In this sense, Primary Health Care has come to have both ideological
and practical aspects. It is built in part in opposition to what is
often called the western medical model that has developed a powerful
technology over the past century or more. That model is considered a
mechanical or engineering model, in which the body is seen as a machine
with parts that can break down or malfunction, and can be repaired or
replaced by technical experts. But that model is also considered
inappropriate for much of the poor world, where poverty and
malnutrition underlie much sickness and death, but are never seen as
part of the health problem. The western model also implies extensive
specialization, both within medical science itself, and between medical
and other sciences. This leads to a narrow definition of problems, as
when medicine fails to see poverty as a major source of disease and
death. It is, finally, a model that is closely associated with
inequality. The providers have all the power (and acquire considerable
wealth), imposing their own decisions and technology on users who are
considered mere passive recipients of care. This is a system that is
criticized for bypassing much of the worldfs poor.
Against this western model, PHC proposes a system that is closer to the
people served, and deals with them as human beings living together in a
community. The definition established at Alma Ata states that:
Primary health care is essential health care based on practical,
scientifically sound and socially acceptable methods and technology
made universally accessible to individuals and families in the
community through their full participation and at a cost that the
community and country can afford in a spirit of self-reliance and
determination (Declaration of Alma Ata, VI).
Social acceptability, universal accessibility, and
full participation are italicized to emphasize these distinctive and
unique aspects of PHC. From this definition, PHC is seen to stand on
three main pillars: participation, intersectoral collaboration and
equity. Individuals and communities must be actively involved in
promoting health. Medical and social sciences must be closely
interconnected. Good health and health services should be available to
all.
While this broad notion of Primary Health Care has some attractive
qualities as aims for the human community, there are problems with this
conception when we come to asking practical questions about a health
delivery system. There have been systematic attempts to assess national
health care systems to see how closely they come to the PHC model (Fry
and Harder, 1994, for example) but these appear extremely complicated,
and the connection of any specific dimension to actual indicators of
health is not clearly established. What measures of ehealthf are to be
used? What do ecommunity involvementf and eparticipationf mean and how
can we assess them? Furthermore, how do we assess their connection to
whatever health measure we choose to use? These are not mere pedantic
questions. They seek to understand how we can operationalize the PHC
concept to find how when we have more or less PHC. And they ask a most
fundamental question: is PHC in fact related to better human health? To
deal with these questions in any specific setting, we need a more
carefully constructed and precise concept, with more details of
connections, and more operational definitions. This is what we propose
for the AUICK In-depth study.
In order to examine Primary Health Care in Asian
urban settings, we propose taking a somewhat narrower view of the PHC
system. We begin with one basic aspect of PHC as defined at Alma Ata,
its front line character. PHC is considered gthe first level of contact
of individuals, the family and community with the national health
system bringing health care as close as possible to where people live
and work, and constitutes the first element of a continuing health care
processh (Declaration of Alma Ata, VI). In addition, we propose to
focus on two aspects that seem especially crucial, quality of care, and
people participation. While the PHC movement includes norms of good
service, quality of care as a distinctive measurable concept has
emerged and been developed more in the area of family planning and
reproductive health. In addition, focusing on people participation is
based on the recognition that people are both the means and the ends of
the service system.
Finally, however, in order to undertake a study that will have
immediate and direct practical applications, we propose to focus
primarily on the medical delivery part of the overall health system. We
also believe that it is both important and practical to ask questions
about the public health issues arising from environmental conditions.
Thus we propose that both the medical delivery subsystem and the public
health subsystem of primary health care are areas in which systematic
research can yield very practical results.
Reproductive Health Care is a term that gained
widespread currency in the 1994 International Conference on Population
and Development (ICPD), held in Cairo, Egypt (Singh, 1998, Population
Council and PRB, 1999). The 1994 ICPD was the third in a series of
international conference launched by the UNFPA in its distinguished
tenure as the leading International Governmental Organization for
population issues. Like the preceding Conferences, this produced a Plan
of Action adopted unanimously by 180 countries.
But this Plan of Action differed considerably from those of the past.
It placed the status of women and the broad issue of reproductive
health at the center of the agenda. It
gwas a remarkable turning point in that governments formally recognized
that the health, rights, and well-being of the individual lie at the
core of sustainable development. Reproductive rights, including access
to quality reproductive health and family planning services, were
established as key to this consensus. (Population Council and PRB 1999,
p 1)
Many of the elements of reproductive health have received attention in
the past and have seen the development of useful operational
definition. Maternal and child health care, including immunizations and
nutritional services, are a core point of service. Major outcomes can
be measured in infant, maternal and child mortality rates. In addition,
there are family planning services, with data on the availability of
contraceptives, the contraceptive prevalence rates and the total
fertility rate as major measurable outcomes. Lying behind these
objective measures of outcomes are more subtle, but also more powerful
measures of political commitment and the willingness of governments to
do what is necessary to provide the good services that implement
reproductive health care.
Improve the reproductive and primary health care
system to provide the better health of the cityf 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
Systemh 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
collaborationh 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
countryfs 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 UNDPfs 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 governmentfs 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 choiceh 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 ath) 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.
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 07o12ff to 07o21ff South Latitude and on
112o35ff to 112o54ff 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.
To Top
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.
To Top
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.
To Top
Table 4.2 The Distribution of Religion and
Tribe
| Variable |
freq. |
% |
|
Religion
|
|
|
Moslem
Christian
Catholic
Hinduism
Buddhism |
4954
194
46
18
42 |
94.3
3.7
0.9
0.3
0.8 |
|
Tribe
|
|
|
Javanese
Madurese
Foreign descent
Others
|
3889
1094
63
209
|
74.0
20.8
1.2
4.0
|
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
| Marital Status |
freq. |
% |
Not yet married
Married
Divorced
Widower/Widow
|
2447
2617
18
172
|
46.6
49.8
0.3
3.3 |
| Total |
5254 |
(100) |
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
Age Group
(year)
|
Level of Education Completed |
Total |
| No Education |
Elementary School |
Junior High School |
Senior High School |
University |
0–4
5–9
10–14
15–19
20–24
25–29
30–34
35–39
40–44
45–49
50–54
55–59
60–64
65–69
70–74
75–79
80+
|
437(100.0%)
474(100.0%)
236 (53.2 %)
18 (3.0 %)
15 (2.7 %)
21 (4.2 %)
27 (6.0 %)
31 ( 7.4%)
33 ( 8.7%)
18 ( 5.8%)
24 ( 10.0%)
19 ( 13.0%)
28 ( 20.9%)
19 ( 26.4%)
17 ( 32.1%)
10 ( 38.5%)
6 ( 37.5%)
|
-
-
188 (42.3%)
154 (25.9%)
81 (14.5%)
93 (18.6%)
116 (25.8%)
127 (30.2%)
137 (36.0%)
122 (39.6%)
94 (39.2%)
56 (38.4%)
58 (43.3%)
39 (54.2%)
23 (43.4%)
12 (46.2%)
8 (50.0%) |
-
-
20(4.5%)
275(46.2%)
95 (17.0%)
72 (14.4%)
76 (16.9%)
88 (20.9%)
91 (23.9%)
60 (19.5%)
46 (19.2%)
26 (17.8%)
29 (21.9%)
6 (8.3%)
5 (9.4%)
2 (7.7%)
2 (12.5%) |
-
-
-
148 (24.9%)
335 (60.0%)
239 (47.9%)
185 (41.1%)
143 (34.0%)
86 (22.6%)
87 (28.2%)
55 (22.9%)
30 (20.5%)
12 ( 9.0%)
5 ( 6.9%)
5 ( 9.4%)
1 ( 3.8%)
- |
-
-
-
-
32 ( 5.7%)
74 (14.8%)
46 (10.2%)
32 ( 7.6%)
34 ( 7.6%)
21 ( 6.8%)
21 ( 8.8%)
15 (10.3%)
7 ( 5.2%)
3 ( 5.7%)
3 ( 5.7%)
1 ( 3.8%)
- |
437
474
444
595
558
499
450
558
421
308
240
146
134
72
53
26
16 |
| Total |
1433(27.3%) |
1308 (24.9%) |
893 (17.0%) |
1331 (25.3%) |
289 (5.5%) |
5254 |
To Top
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
| Age Group |
Sex |
Total |
| Male |
Female |
| No of People |
No of Worker |
% |
No of People |
No of Worker |
% |
No of People |
No of Worker |
% |
15–19
20–24
25–29
30–34
35–39
40–44
45–49
50–54
55+
|
274
241
252
217
184
181
161
132
47
|
37
130
204
203
180
178
160
123
39
|
13.5
54.9
81.0
93.5
97.8
98.3
99.4
93.2
83.0
|
321
317
247
233
237
200
147
108
37
|
38
119
101
92
85
87
46
44
8
|
11.8
37.5
40.9
39.5
35.9
43.5
31.3
40.7
21.6
|
595
558
499
450
421
381
308
240
84
|
75
249
305
295
265
265
206
167
47
|
12.6
44.6
61.1
65.6
62.9
69.6
66.9
69.6
56.0 |
| Total |
1689 |
1254 |
74.3 |
1847 |
620 |
33.6 |
3536 |
1874 |
53.0 |
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
Mean
Median
StandardDeviation
Minimum
Maximum |
897,222.4
650,000.0
781,650.6
60,000.0
7,500,000.0 |
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
| Age Group (year) |
No of People |
No of Sick People |
% |
< 1
1 – 5
6 – 15
16 – 20
21 – 64
65+
|
140
392
931
635
2989
167
|
47
121
97
45
317
34
|
33.6
30.9
10.4
7.1
10.6
20.4 |
| Total |
5254 |
661 |
12.6 |
To Top
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
| Type of Disease |
Age Group (year) |
Total |
| <1 |
1-5 |
6-15 |
16-20 |
21-64 |
65+ |
| f |
% |
f |
% |
f |
% |
f |
% |
f |
% |
f |
% |
f |
% |
Upper Respiratory Tract Infection
Fever of Unknown Cause
Diarrhea
Hypertension
Muscular Disturbance
Tension headache
Typhoid Fever
Alimentary Tract Disturbance
Allergy and Skin Infection
Diabetes Mellitus
Dental Infection
Gastritis
Bronchial 0sthma
Cerebrovascular 0ccident
Eye Infection
Others |
32
2
10
0
0
0
0
0
1
0
0
0
0
0
0
2
|
68.1
4.3
21.3
0.0
0.0
0.0
0.0
0.0
2.1
0.0
0.0
0.0
0.0
0.0
0.0
4.3
|
69
14
20
0
0
0
2
1
2
0
2
0
0
0
2
9
|
57.0
11.6
16.5
0.0
0.0
0.0
1.7
0.8
1.7
0.0
1.7
0.0
0.0
0.0
1.7
7.3
|
53
19
4
0
1
0
5
3
5
0
2
0
1
0
2
2
|
54.6
19.6
4.1
0.0
1.0
0.0
5.2
3.1
5.2
0.0
2.1
0.0
1.0
0.0
2.1
2.0 |
25
4
4
0
1
0
3
3
0
0
0
0
0
0
2
3 |
55.6
8.9
8.9
0.0
2.2
0.0
6.7
6.7
0.0
0.0
0.0
0.0
0.0
0.0
4.4
6.6 |
146
19
10
18
13
16
6
7
7
10
7
8
5
7
2
36 |
46.1
6.0
3.2
5.7
4.1
5.0
1.9
2.2
2.2
3.2
2.2
2.5
1.6
2.2
0.6
11.3 |
8
5
2
3
4
2
0
1
0
1
0
0
2
1
0
5 |
23.5
14.7
5.9
8.8
11.4
5.9
0.0
2.9
0.0
2.9
0.0
0.0
5.9
2.9
0.0
15.2 |
333
63
50
21
19
18
16
15
15
11
11
8
8
8
8
57 |
50.4
9.5
7.6
3.2
2.9
2.7
1.2
2.3
2.3
1.7
1.7
1.2
1.2
1.2
1.2
9.7 |
| |
47
(7.1) |
100.0 |
121
(18.3) |
100.0 |
97
(14.7) |
100 |
45
(6.8) |
100 |
317
(48) |
100 |
34
(5.1) |
100 |
661
(100) |
100 |
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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
| Type of Contraceptive |
Frequency |
% |
Injection
Pill
Tubectomy
IUD
Implant
Vasectomy
Condom
No Contraceptive
|
245
161
72
72
15
5
5
496
|
22.9
15.0
6.7
6.7
1.4
0.5
0.5
46.3 |
| Total |
1071 |
100 |
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 %).
To Top
Table 4.10 The Distribution of Pregnant Woman
and Abortion by Age
| Age Group(year) |
Pregnant Woman |
Abortion |
| freq. |
% pregnant woman |
freq. |
% abortion among pregnant woman |
15 – 19
20 – 24
25 – 29
30 – 34
35 – 39
40 – 44
45 – 49
|
4
17
26
25
9
3
0
|
4.8
20.2
31.0
29.8
10.7
3.6
0
|
1
2
1
0
0
1
0
|
25.0
11.8
3.8
0.0
0.0
33.3
0.0 |
| Total |
84 |
100.0 |
6 |
7.1 |
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)
| Age Group (year |
Number of Female People |
Number of (CEB) |
average CEB/female |
15 – 19
20 – 24
25 – 29
30 – 34
35 – 39
40 – 44
|
321
317
247
233
237
200
|
25
109
257
439
561
574
|
0.078
0.344
1.040
1.884
2.367
2.870 |
| 45-49 |
147 |
446 |
3.034 |
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 sizeh.
Table 4.12 The Average Age of Marriage, First
Pregnancy, and The Smallest Child
| Variable |
Mean |
Standard Deviation |
Minimum |
Maximum |
| Age at Marriage |
19.7 |
4.1 |
10 |
38 |
| Age at first Pregnancy |
27.5 |
6.2 |
13 |
44 |
| Age of Smallest Child at Last Pregnancy |
3.9 |
3 |
1 |
21 |
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.
To Top
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 clientfs 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
| Variable |
Frequency |
% |
|
Age of Pregnancy
|
|
|
1 – 3
4 – 6
7 – 9
Unknown |
831
166
14
136
|
72.4
14.6
1.2
11.8 |
|
Frequency of Visit
|
|
|
> 4
< 4
Never
Unknown
|
922
100
50
75
|
80.4
8.7
4.4
6.6 |
|
Status of TT Immunization
|
|
|
Once
Twice
Never
Unknown
|
124
395
447
181
|
10.8
34.4
39.0
15.8 |
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.
To Top
Table 4.15 of Last The History of Birth
Attendance Child
| Variable |
Frequency |
|
|
Health Facility
|
|
|
Private Hospital
Birth Attendance Clinic
Private Midwife Home
General Hospital
Puskesmas*
Others
|
257
206
197
102
98
287 |
22.4
18.0
17.2
8.9
8.5
25.0 |
|
Birth Attendant
|
|
|
Midwife
Obstetrician
TBA
General Practitioner
Others
|
635
185
184
85
58 |
55.4
16.1
16.0
7.5
5.0
|
*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
| |
Frequency |
% |
Yes, in Surabaya
Yes, outside of Surabaya
Never
|
727
8
412 |
63.4
0.7
35.9 |
| Total |
1147 |
100.0 |
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
| Health Facility |
Frequency |
%
|
|
GP
|
593 |
32.8 |
All Day Clinics
General Hospital
Private Hospital
Specialists
Midwives
Nurses
Alternative Medication
Others |
383
308
231
86
74
46
32
55 |
21.2
17.0
12.8
4.8
4.1
2.5
1.8
3.0 |
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.
To Top
Table 4.18 The Reason to Visit Puskesmas
| Reasons |
Frequency |
% |
Medical Care
Immunization
Dental Care
Antenatal care
Family Planning
Health Certificate
Consultation
Others
|
453
28
23
13
8
5
3
194
|
62.3
3.9
3.2
1.8
1.1
0.7
0.4
26.6 |
| Total |
727 |
100.0 |
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
Distance
(in kilometer) |
Time
(in minute) |
Transportation |
| Take a Walk |
Becak
(Tricycle) |
Motorcycle |
car |
Public
Transportation |
Total |
| |
|
|
|
|
|
|
|
|
|
|
|
| >7 |
< 15
15 - 30
> 30 |
3
1
0 |
1.0
0.3
0.0 |
0
0
0
|
0.0
0.0
0.0
|
1
4
1 |
0.6
2.3
0.6
|
1
0
0
|
16.7
0.0
0.0 |
0
2
1
|
0.0
2.6
1.3 |
5
7
2 |
0.7
1.0
0.3 |
| 5-7 |
<15
15 - 30
> 30
|
0
1
0
|
0.0
0.3
0.0
|
1
7
2
|
0.6
4.2
1.2
|
3
12
2
|
1.7
6.8
1.1
|
1
1
0
|
16.7
16.7
0.0
|
5
11
2
|
6.6
14.5
2.6
|
10
32
6 |
1.4
4.4
0.8 |
| 3-<5 |
< 15
15 - 30
> 30 |
0
3
1 |
0.0
1.0
0.3 |
8
17
2 |
4.7
10.1
1.2 |
15
12
0 |
8.5
6.8
0.0 |
1
1
0 |
16.7
16.7
0.0 |
7
15
1 |
9.2
19.7
1.3 |
31
48
4 |
4.3
6.6
0.6 |
| <3 |
<15
15-30
>30 |
203
77
12 |
67.5
25.6
4.0 |
94
35
2 |
56.0
20.8
1.2 |
44
80
2 |
25.0
45.5
1.1 |
1
0
0 |
16.7
0.0
0.0 |
17
14
1 |
22.4
18.4
1.3 |
359
206
17 |
49.4
28.3
2.3 |
Click Here to see larger view.
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
| |
Frequency |
% |
Always
Often
Seldom
Once
|
113
144
447
23 |
15.5
19.8
61.5
3.2 |
| Total |
727 |
100.0 |
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
| Health Personnel |
frequency |
% |
Always Doctor
Sometimes Doctor
Always Midwife or Nurse s
Sometimes not Doctor, Midwife or Nurse
|
117
309
265
36 |
16.0
42.5
36.5
5 |
| Total |
727 |
100.0 |
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.
To Top
Table 4.22 The Duration of Medical Examination
in Puskesmas
| Time (minute) |
Frequency |
% |
< 15
15 - 30
> 30 |
419
246
62 |
57.6
33.8
8.6 |
| Total |
727 |
100.0 |
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
| |
Frequency |
% |
|
Social Insurance of Work Force
Insurance for Governmental Official
Insurance for Nongovernmental Official
Others
Not Member of any Insurance
|
96
60
25
12
354 |
13.2
8.3
3.4
1.7
52.6 |
| Total |
727 |
100.0 |
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 %).
To Top
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
| The Degree of Satisfaction |
Frequency |
% |
Very Unsatisfied
Unsatisfied
Moderately Satisfied
Satisfied
Very Satisfied |
0
19
240
450
18 |
0
2.6
33.0
61.9
2.5 |
| Total |
727 |
100.0 |
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
| Type of Services |
Frequency |
% |
Medical Care
Immunization
Family Planning
Dental care
Antenatal care
Minor Surgery
Emergency Unit |
677
553
532
528
519
169
127 |
93.1
76.1
73.2
72.6
71.4
23.1
17.5 |
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
| Time of Service |
Frequency |
% |
Too short time
Moderate time
Too long time |
159
567
1 |
21.9
78.0
0.1 |
| Total |
727 |
100.0 |
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.
To Top
Table 4.27 The Tariff of Services in Puskesmas
| |
Frequency |
% |
Very cheap
Cheap
Expensive |
64
653
10 |
8.8
89.8
1.4 |
| Total |
727 |
100.0 |
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
| Health Facility |
Reason |
| Cheap |
Complete
Facility |
Conven-
ience Room |
Near |
Satisfied
|
Always
Available |
Total |
| f |
% |
f |
% |
f |
% |
f |
% |
f |
% |
f |
% |
f |
% |
GP
Puskesmas
24 Hour Clinic
Private Hospital
General Hospital
Specialist
Midwife
Alternative Medication
Nurse
Others |
73
316
36
20
10
4
17
11
2
27 |
14.1
61.3
7.0
3.9
1.9
0.8
3.3
2.1
0.4
5.2 |
33
4
24
31
16
7
0
0
0
2 |
28.2
3.4
20.5
26.5
13.7
6.0
0.0
0.0
0.0
1.7
|
57
16
15
16
7
10
6
2
2
3 |
42.6
11.9
11.2
11.9
5.2
7.5
4.5
1.5
1.5
2.2 |
119
144
78
13
11
2
7
1
0
5 |
31.4
37.9
20.5
3.4
2.9
0.5
1.8
0.3
0.0
1.3
|
292
69
82
56
19
27
17
14
2
19 |
48.9
11.6
13.7
9.4
3.2
4.5
2.8
2.4
0.3
3.2 |
30
1
15
6
3
0
0
1
0
8 |
46.8
1.6
23.4
9.4
4.7
0.0
0.0
1.6
0.0
12.5
|
604
550
250
142
66
50
47
29
6
64 |
33.4
30.4
13.8
7.9
3.7
2.8
2.6
1.6
0.3
3.5 |
Click Here to
see larger view
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
Mean
Median
SD
Minimum
Maximum |
13,615.4
10,000.0
12,062.0
0.0
100,000.0 |
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
| Health Personal |
Frequency |
% |
GP
Specialist
Midwife
Nurse
Other |
972
79
67
17
24 |
84.7
6.9
5.8
1.5
2.1 |
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.
To Top
Table 4.32 Time of Services Expected By The
Respondents
| Time of Service |
Frequency |
% |
Morning
Evening
Morning and Evening
24 Hours |
132
121
423
471 |
11.5
10.5
36.9
41.0 |
| Total |
1147 |
100.0 |
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
| Time (minute) |
Frequency |
% |
< 15
15 – 30
> 30 |
416
451
280 |
36.3
39.3
24.4 |
| Total |
727 |
100.0 |
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.
To Top
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
To Top
4.3.1.2 Type of Personnel
| Type |
Qualification |
Status of Employee |
| Chairperson |
Doctor |
Permanent |
| Staff |
BSPH |
Permanent |
| Performer |
Midwife/Third Diploma of Midwife |
Permanent |
| Performer |
Nurse / Third Diploma of Nursing |
Permanent |
| Performer |
First or Third Diploma of Nutrition |
Permanent |
| Performer |
Third Diploma of Environmental Health |
Permanent |
| Performer |
Dentist |
Permanent |
| Assistant Performer |
Senior High School |
Honorary |
| Assistant Performer |
Third Diploma of Pharmacy |
Honorary |
| Assistant Performer |
Junior High School |
Contractual |
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.
To Top
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:
| Type |
Qualification |
Status |
| Chairperson |
BSPH |
Permanent |
| Performer |
Doctor
Midwife
Assistant Pharmacist
Nurse |
Permanent |
