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Atik Triratnawati
Department Of Anthropology, Faculty Of Cultural Science Gadjah Mada University,Yogyakarta 55281, Indonesia Makara, Kesehatan, Vol. 10, No. 1, June 2006

Average number of consults per week is 6 in Barualte and 0-1 in Imelda Underutilization of health centers in Cluster 10 To identify factors that affect underutilization of health centers To develop plans that aim to maximize utilization of health care services in rural areas

Health systems of Kenya, Ghana, Zaire, Pakistan, Indonesia and Bangladesh

Nation wide networks but with weak supportive structures and underutilized health services Lack of implementation of plans Declining share in the national budget Most hospitals and medical schools in Indonesia are private

Indonesia Health Vision by 2010

Providing PHC by the government Hospital-doctor oriented care to community-based PHC Health paradigm, decentralization, professionalism and manage care 215 million in more than 13,600 islands Variety concerning race, ethnic, religion, social strata, education and language Total health cost Rp. 5.1 billion
30% government (2.5% of total annual government budget) 70% private sectors

Community health centers or Puskesmas

Health status of the Indonesians increased gradually After the economic crisis in 1997, many people could not afford to fulfill basic needs Most Indonesian health care centers are under-utilized

United Nations report (1979)

<10 visitors a day at some centers <10 % of the surveyed people have ever been examined by a physician <40 % have ever been to the health center 20 % of mothers attended a Maternal Child Health center

Patients seek care from more readily accessible and supporting traditional practitioners or from local equivalent of drugstores

Purworejo Regency, Central Java

utility of PHCs seemed to be decreasing Purworejo has 25 PHCs, 63 subPHCs, 81 physicians, 26 dentists, and 233 paramedics comprised of 16 sub-districts and 494 villages Infectious and nutritional deficiencies of women and children

PURWOREJO 25 PHCs 81 physicians

SAN JUAN 42 Barangays MHOs DFCM residents Pedia residents Medical Interns

1 physician/puskesmas
1 Midwife : 1 puskesmas 10 Health personnel/puskesmas 30, 000 people/puskesmas

2-3 medical interns

1 Midwife: 2-3 BHC 5-6 BHW/health center (Cluster 10) 1556 (Barualte) 905 (Imelda)

To investigate the utilization of PHC units through health sociology approach, focusing on the bureaucratic, administrative aspect of health care management, health seeking behavior, medical pluralism and labeling of community health centers

Puskesmas in Purworejo District, Central Java Qualitative method using in-depth interview, observation and Focus Group Discussion
In-depth interview of 3 health personnel and 3 persons FGD among 8 types of groups: paramedic, non paramedic , laboratory staff, bureaucrats, mothers who have children < 5, adolescents, adults, and elderly 8-10 participants from different villages or different Puskesmas

Data collection from FebruaryMarch 2000 Data classified into certain themes Data analysis was descriptive with health sociology perspectives

Some PHCs in remote (mountainous) areas had only few patients
Problems Identified: [1] Transportation [2] Physician not available [3] Limited facilities (including medical equipment) [4] Health personnel not available during working hours

Different characteristics of the population
The government not concerned with the basic needs of society; concerned only with reaching their planning target

Purworejo district is divided into 16 subdistricts, each with own health center Staff - full time physician - 10 or more health workers - nurse - midwife - sanitary inspector - laboratory personnel - communicable disease worker

Health personnel with difficulties in serving patients due to strong bureaucratic system and regulations Dilemma of health personnel
To treat emergency cases or wait for physician (who controls all decisions) However, in some districts, the physician is not available during working hours Thus, the strong bureaucratic system is not applicable to all districts (decentralization)

Hierarchical structure of authority - Top managers who make decisions without consulting others - Paternalistic culture among health personnel

Physicians not always available during working hours

Patients are dismayed after spending time and money for transportation Physicians available 1-2x/week due to other activities (duties as private physicians, meetings, ceremonies, training courses, seminars)

Midwife or health personnel replace the role of physicians Patients resort to consulting private clinics

Community health centers have the responsibility to deliver health care to the community Collaboration with other divisions is needed Lack of coordination + overlapping health programs overloading health personnel Influences efficiency and productivity in providing adequate health services

Community health centers: open 8 am 11 am (others closed later) Long waiting hours before being seen by the physician or paramedic For severe cases, medical equipment not available so patients are referred to hospitals

FGDs : Perception that PHCs are only suitable in curing diseases such as common colds, cough, fever or diseases of children < 5 Most patients are children and women
Antenatal care or tetanus toxoid immunization

Elderly patients consult for achy joints or fatigue Teenagers and adult males rarely consult

Belief: Health center can only address acute cases but not chronic ones Belief: Drugs available in the center are very limited Belief: Drugs from private physicians or hospital are better quality

TMS still dominant Ministry of Health with program for village midwives to help in deliveries and management of sick children Traditional birth attendants still popular
Most give birth at home

Health seeking behavior: self-medication

Self-care not limited to individual but to own household family operates as a therapeutic group and shares prescriptions Higher income families go to private physicians

Community Participation plays a role in health and development process Government still has a strong role
Local government needs income derived from health centers Physician has a target income, thus patients are not getting attention

Health service utilization

Not a single behavior Chain of behavioral events

Purworejo health care system is markedly pluralistic

competing medical systems (traditional and cosmopolitan medicine)

Medical systems and multiple alternative sources of care which the patients could choose influence under-utilization of health centers

Un-bureaucratic, less paternalistic - Health personnel would be more capable in
making their own decisions

Emphasis on continuing education programs to increase efficiency and effectiveness The availability of physician during working hours will motivate patients to go to health centers.

Integration and coordination between departments of government and nongovernment institutions should be improved in order to reduce the task of health care staff. Government should consider the improvement of community participation.

Average number of consults per week is 6 in Barualte and 0-1 in Imelda Underutilization of health centers in Cluster 10 To identify factors that affect underutilization of health centers To develop plans that aim to maximize utilization of health care services in rural areas

Interview with midwife and BHWs of Barualte and Imelda revealed the ff possible reasons for under-utilization
Smaller population Self-care employed for minor illnesses Consult private practitioners for chronic and/or severe illnesses Distance of health center from home (especially in Imelda) Some still prefer traditional healers (hilot)

No provision of interview and FGD questions in the study Replication will require construction of own guide questions Explore benefit of a community survey in clusters with under-utilized centers