The Poor in ASEAN Cities: Perspectives in Health Care Management 9789812307217

Citation preview

The Poor in ASEAN Cities

The Institute of Southeast Asian Studies was established as an autonomous organization in 1968. It is a regional research centre for scholars and other specialists concerned with modern Southeast Asia, particularly the multi-faceted problems of stability and security, economic development, and political and social change. The Institute is governed by a twenty-two-member Board of Trustees comprising nominees from the Singapore Government, the National University of Singapore, the various Chambers of Commerce, and professional and civic organizations. A ten-man Executive Committee oversees day-to-day operations; it is chaired by the Director, the Institute's chief academic and administrative officer. The Social Issues in Southeast Asia (SISEA) programme was established at the Institute in 1986. It addresses itself to the study of the nature and dynamics of ethnicity, religions, urbanism, and population change in Southeast Asia. These issues are examined with particular attention to the implications for, and relevance to, an understanding of problems of development and of societal conflict and co-operation. SISEA is guided by a Regional Advisory Board comprising senior scholars from the various Southeast Asian countries. At the Institute, SISEA comes under the overall charge of the Director while its day-to-day running is the responsibility of the Co-ordinator.

The Poor •

ID

ASEAN Cities Perspectives in Health Care Management Compiled by Trinidad S. Osteria

I5ER5

Social Issues in Southeast Asia INSTITUTE OF SOUTHEAST ASIAN STUDIES

Published by Institute of Southeast Asian Studies Heng Mui Keng Terrace Pasir Panjang Singapore 0511 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Institute of Southeast Asian Studies. © 1991 Institute of Southeast Asian Studies

Cataloguing in Publication Data

Osteria, Trinidad S. The poor in ASEAN cities: perspectives in health care management. 1. Urban poor - Medical care - ASEAN countries. 2. Urban health- ASEAN countries. 3. Poor- Medical care- ASEAN countries. 4. Medical care - ASEAN countries. I. Title. 1991 sls91-70079 HV4141 A5085 ISBN 981-3035-76-5 (soft cover) ISBN 981-3035-84-6 (hard cover) The responsibility for facts and opinions expressed in this publication rests exclusively with the compiler and her interpretations do not necessarily reflect the views or the policy of the Institute or its supporters.

Typeset by International Typesetters Printed in Singapore by Kin Keong Printing Co. Pte. Ltd.

Contents List of Tables List of Figures

Chapter I Chapter II Chapter III Chapter IV

Chapter V

Chapter VI

vi viii

Preface

ix

Acknowledgements

xi

Project Participants

xii

Urbanization in the ASEAN Region and Its Health Implications

1

Health Management of the Urban Poor in Four ASEAN Cities

18

An Appraisal of Health Policies and Programmes in the Four ASEAN Cities

27

Perceptions of Planners, Policy-Makers, and the Community in Urban Health Programmes

65

Community Participation in Urban Health Services Delivery: Lessons from Four Case Studies

84

Evolving a Viable Operational Framework in Urban Health Care Delivery

140

Notes

155

Appendices

159

Glossary

185

List of Tables 1. Changes in Total Population and Annual Growth Rate in Four Selected ASEAN Countries, 1950-2000

4

2. Estimates of Urban Population, Annual Growth Rate, and Level of Urbanization in Four Selected ASEAN Countries, 1980-2025

9

3. Comparative Analysis of Urban Health Policies and Programmes

59

4. Distribution of Respondents by Categories

67

5. Ranking of Components of Primary Health Care (Bangkok, Thailand)

76

6. Perception of Elements of Primary Health Care in Jakarta, Indonesia

78

7. Perception of Elements of Primary Health Care in Manila, Philippines

79

8. Perceptions of Policy-makers and Programme Planners on Primary Health Care Components in Kuala Lumpur, Malaysia

80

9. Perceptions of Policy-makers, Providers and the Community on Current Health Programmes

81

10. Types of Problems Encountered and Proposed Activities

92

11. Comparison of the Four Participatory Urban Health Care Projects in Four Cities of the ASEAN Region

131

List of Tables

vn

12 Project Characteristics of Programme Sites

13 4

13 Involvement in Planning and Organization

135

14 Criteria for Selection of Community Sites and Community Health Workers

136

1 50 Duration, Methodology and Content of Health Workers' Training

137

16 Involvement of Project Participants in Evaluation

138

0

0

0

0

1 7 Community Participation in Health Services Delivery 1 3 9 0

List of Figures 1. Conceptual Framework for the Analysis of the Health

22

Management of the Urban Poor in the Four ASEAN Cities (Kuala Lumpur, Jakarta, Bangkok, and Manila) 2. System Diagram of Urban Health Planning, Programming, and Implementation Process

29

3. Organizational Structure of the Atma Jaya Project

107

4. Position of the Health Cadre within the Health Service System

109

5. A Viable Operational Framework for Health Care Development in Poor Urban Communities

152

Preface This book is the result of a project funded by the International Development Research Centre and Ford Foundation to study the health care management of four cities in the ASEAN region. The focus of the research was the analysis of major problems and issues facing health decision-makers and practitioners in the planning and implementation of primary health programmes for the urban poor. In undertaking the structural review, the questions that were foremost included the extent to which there were recurrent themes transcending the divergence in the programmes of the four cities in the region Bangkok, Jakarta, Kuala Lumpur, and Manila; and how can policies, strategies, and programmes be developed to effectively meet the health needs of the urban poor? Additionally, to what degree are the city health policies and programmes reflective of the problems, and how can the policy and programme prescriptions be modified to accommodate the various concerns within the region? While it is possible to arrive at plausible generalizations on the nature of health problems among the urban poor in this area, it is to be recognized that the issue is the health vulnerability of specific categories of the population, and their poverty problems. It has been estimated that between 1975 and the year 2000, cities of the developing world could expect to contain 70 per cent ofthe population gains - most of them poor. Few of these areas are prepared for the unprecedented growth that is inevitable in the coming decade. While urban areas have benefited from a disproportionate share of the resources available for health care, there is an increasing awareness on the part of governments that resource allocation among the urban population is inequitable. By its magnitude, urbanization has been considered a severe problem, which is enhanced by the rapid pace in the growth of slum and squatter settlements. Slum and squatter dwellers account for more than half of the urban population. In the four ASEAN countries of the Philippines, Thailand, Malaysia, and Indonesia, the annual urban growth rates in the past decade have

X

Preface

exceeded by a considerable margin the estimated growth rate for the region, which indicates an accelerating pace of urbanization. This emerging phenomenon has shifted the focus of government planners from the inaccessible rural populations to the urban poor - the inhabitants of slums and squatter settlements. This study sets out to assess the plans and actions that have been taken by governments to eliminate the pervasive health problems of the urban poor and seek ways for improving their welfare; to review the current perceptions of the health planners, providers, and the community on the programmes, their management, and ways of improving the system, and to describe case studies of strategies taken in health care development and identify the factors that account for their successful implementation and maintenance. Increasingly, a cause of government concern is the role and scope of planning in health care development in each ASEAN city. The assessment of health programmes being undertaken for the urban poor, in terms of both explicit and implied health policies derived from peripheral social measures, would help to identify the constraints as well as facilitating factors in adequate health care programming. The analysis of health policies and programmes will also help to draw out basic themes and issues. Thus, recommendations can be made for a meaningful urban health strategy. This study is divided into six chapters. The first chapter provides the substantive framework of the analysis, giving an overview of urbanization and the poverty dimension of the region. The second chapter focuses on the methodological considerations such as the objectives of the study and the mechanisms by which the research design was implemented. The policies and programmes of the city health offices in the constituent ASEAN cities are analysed in the third chapter in so far as they address the needs of the urban poor. In the fourth chapter, the perceptions of the three major actors in the health programmes- the policy-makers, the programme planners, and the community - will be delineated in an effort to detect congruence or divergence in the prognostication of specific health delivery issues. The penultimate chapter presents case studies of participatory health service delivery in poor urban communities aimed at extricating key issues in their organization and delivery that may be replicated in other milieus. Finally, the three data sources (programmes and policies, interviews of key informants, and case studies) are consolidated to arrive at a viable operational framework for appropriate health service delivery in urban slum communities.

Acknowledgements I wish to thank Dr Dae Woo Han of the Internationational Development Research Centre and Dr David Winder of the Ford Foundation for providing the funds and making this book a possibility. The collaborators who collected the data and prepared the country reports were Dr Boonlert Leoprapai of Thailand; Dr Charles Surjadi, Dr Attashendartini Hasbjah and Mrs Maria da Cunha all of Indonesia; Prof Khairuddin Yusof, Dr Low Kwai Sim, Dr Can Chong Ying, Ms Wong Yut Lin of Malaysia; and Dr Sonia Sarcia of the Philippines. Their inputs to the project are invaluable. I would also like to thank Prof. K. S. Sandhu, the Director of the Institute of Southeast Asian Studies, for his support, and the staff of the Institute for providing administrative assistance.

Project Participants Dr Trinidad S. Osteria Institute of Southeast Asian Studies Singapore

Regional Co-ordinator

Dr Boonlert Leoprapai & Dr Orapin Singhadej Mahidol University Institute of Population and Social Research Bangkok, Thailand

Co-ordinators (Thailand)

Dr Sonia Sarcia Philippine Children's Memorial Hospital Quezon City, Philippines

Co-ordinator (Philippines)

Dr Charles Surjadi & Dr Attashendartini Habsjah Atma Jaya University Faculty of Medicine Jakarta, Indonesia

Co-ordinators (Indonesia)

Dr Khairuddin Yusof Faculty of Medicine and Deputy Vice-Chancellor University of Malaya Kuala Lumpur, Malaysia

Co-ordinator (Malaysia)

chapter one

Urbanization in the ASEAN Region and Its Health Implications

I

n 1975, the World Bank indicated that many of the developing countries were entering into a period of dramatic and far-reaching changes. It was predicted that in less than half a century most of these countries would move from the predominantly rural to an urban economy. 1 The increased urbanization is considered a result of the overflow of rural poverty wherein a new socio-cultural phenomenon is created and perpetuated in the cities, characterized by unprecedented social, health, and economic problems. The gross ineffectiveness and inequities in basic needs distribution characterizing urbanization in the developing nations are a cause of concern for governments. It has been projected that by the year 2000, 1.3 billion inhabitants will be added to the urban populations of developing countries, which is twice the present population of cities in the developed world. During the height of the so-called "population explosion" in the late 1960s and early 1970s, economists had prescribed a population redistribution policy based on the assumption that in a dynamic economy, different regions will grow at different rates, and labour mobility will be required to ensure the most effective development of the economy. Migration was viewed as an investment in human capital - one of the major ways of improving human capabilities.

2

chapter one

Many governments in developing countries responded positively towards this recommendation so that in the last decade, the urban population in many of these nations experienced rapid growth and expansion. However, in many of these cities, the employment absorptive capacities were not in line with the volume of in-migration. Planners and policy-makers have thus become increasingly concerned about the relationship between urbanward migration and socioeconomic development. Issues of employment, housing, education, health, and related services have arisen and they have been linked to the extent of migration and the characteristics of migrants." This relatively recent phenomenon and the intensity of migration have brought to the forefront the need to investigate systematically how governments cope with the situation. The centrality ofthe migrationurbanization issue in the comparative development context within the ASEAN (Association of Southeast Asian Nations) region and the importance of understanding problems in the formulation of policies and plans in less developed nations argue strongly for the undertaking of a study that examines the responses of the government and the private sector to the welfare problems posed by the urban migrants and their families. The increasing concentration of people in urban areas is often associated with a number of adverse situations: serious disequilibrium in the growth of urban centres, contamination of the environment, inadequate housing and social services, socio-psychological stress resulting from competition for limited jobs, and limited access to health, housing, and educational facilities. Migration to larger cities results in increasing spatial polarization. To the extent that such migration is not fully justified by economic developments in the city, it contributes to perpetuating massive urban poverty in the midst of economic, cultural, social, political, and modern centres of the nations. Considerable evidence based on a United Nations report suggests that problems of rural to urban migration are moving into the forefront of government concerns. Of the 116 less developed countries surveyed by the United Nations in 1978, 94 per cent expressed some degree of dissatisfaction over their population distribution patterns and about 60 per cent reported such patterns to be highly undesirable. 3 Greater concern is now being expressed by governments about their distribution and migration patterns rather than the excessive rates of population growth which had engaged the world's attention in the past. While statistical overviews of the rates, levels, and the future

Urbaniza tion and its Health Implicati ons

3

trends of urbaniza tion for countrie s and regions of the world have been undertak en, little is yet known on how governm ents respond to the problem s that relocatio n in an urban environm ent creates for the migrants . In short, the governm ent program mes addressi ng migrant problem s and needs, particula rly in health care, remain to be documen ted and analysed , as does the migrant response to such program mes. Urbaniz ation in Selected Countrie s ofthe ASEAN Region The four countrie s in the ASEAN region (Indones ia, Malaysia , Philippi nes, and Thailand ) that are under study here have different cultural and historica l backgro unds with common alities relevant to the problem s of external migratio n and urbaniza tion. These countrie s are predom inantly rural, with extreme ly uneven populat ion distribut ion. In the 1960s, these countrie s were characte rized by rapid populati on increase as a result of continue d declines in mortality and high fertility. While the governm ents of these countrie s adopted family planning measure s to reduce the high rate of natural increase , the results were not significa nt in certain areas. With this astoundi ng growth of the populati on in the post-war era, there was an observed influx of populati on into the urban areas for economi c reasons. While there has been increasin g evidence in recent years of a relativel y fast decline in the rate of populati on growth in the ASEAN region, dispariti es have been noted ranging from 1.9 per cent in Indones ia to 2.4 per cent in the Philippi nes. Except for Indonesi a, the present growth rates are conside rably higher than the contemp orary developi ng world. Althoug h Indones ia has registere d the lowest populati on growth rate, its large populati on base gives it the largest net addition among the four countrie s, with an anticipa ted net increase of 50.7 million between 1980 and 2000 (Table 1) The urban populati on in all four countrie s grew consider ably faster than the total populati on although the differenc es narrowe d from the 1950s to 1960s, and widened thereafte r. Except for the Philippi nes, the annual growth rates of the urban populati ons of the ASEAN countrie s in the 1970s were consider ably higher than selected developi ng countrie s in the United Nations reports. The annual urban growth rates of the four ASEAN countrie s exceede d by a consider able margin an estimate d annual growth rate of 2.99 per cent for the developi ng region projecte d by the United Nations for the period 1970-80. These results indicate an accelera ting pace of 4 urbaniza tion of the ASEAN region.

TABLE 1 Changes in Total Population and Annual Growth Rate in Four Selected ASEAN Countries, 1950-2000* (In million persons for total population , and per cent for annual growth rate) 1950 Indonesia Total population Growth rate(%) Malaysia Total population Growth rate(%) Philippine s Total population Growth rate (%) Thailand Total population Growth rate(%)

1960

80.02

1970

109.71 2.00

6.25

122.21 2.24

8.17 2.68

20.86

10.86

28.10

20.97

27.23 2.61

14.07

37.54

17.69

49.21

36.50 2.93

21.27 1.84

62.83 2.44

47.06 2.55

198.69 1.36

2.29

2.71

2000

173.53 1.59

2.59

2.90

1990

148.03 1.92

2.85

2.98

1980

77.04 2.04

57.89 2.07

68.61 1.70

* It should be noted that although these four ASEAN countries conduct their population censuses on a periodic basis, the timing differs from country to country. For this reason, the results of population projections prepared by the United Nations in 1980 were used for comparativ e purposes. (The same reason applies to Table 2. For instance, the intercensal annual population growth rate between the last two population censuses for each country is as follows: 2.42 per cent for Indonesia [1971-80], 2.32 per cent for Malaysia [1970-80], 2.71 per cent for the Philippine s [1975-80], and 2.56 per cent for Thailand [1970-80]). Smwc:E: United Nations, World Population Prospects as Assessed in 1980 (New York, 1981), based on N. Ogawa, "Urbanizat ion and Internal Migration in Selected ASEAN Countries. Trends and Prospects," in Urbanizati on and Migration in ASEAN Developme nt, edited by P. Hauser, D. Suits and N. Ogawa (1985), p.85.

Urbanization and its Health Implications

5

Malaysia Urban growth in Malaysia was quite rapid in the 1970s and the subject of urbanization became an important policy issue related to migration and socio-economic development. In the Second Malaysia Plan (1971-75), it was stated that: the introduction of modern industries in rural areas, the developmant of new growth centres in new areas and the migration of rural inhabitants to urban areas are essential to economic balance between the urban and rural areas and the elimination of the identification of race with vocation as well as location. 5

Therefore, the migration of rural people to the towns was seen as an essential aspect of Malaysia's new economic policy of narrowing the economic gap between ethnic communities. While the tempo of urbanization was rapid from 1947 to 1967, the movement was due to the internal redistribution of the population in the 1 950s in compliance with the policies adopted during the Emergency, 194860. The decline in the rate of urbanization in Kedah and Pahang could be due to the end of the Emergency in 1960 and the consequent return of people to the rural areas. The launching of rural land development schemes also attracted migrants back, not only from within the state of Pahang but also from other states. A significant aspect of urbanization in Malaysia is the increasing number of indigenous people living in towns and cities. With urbanization, opportunities for employment have also increased as a result of the development and expansion of industries. The greatest increase in employment has been in the building and construction industries, stimulated by the setting up of factories. The overall level of urbanization in Peninsular Malaysia increased from 20.4 per cent in 1950 to 29.4 per cent in 1980. Between 1947 and 195 7, all ten states with urban areas experienced an increase in the level of urbanization- with the largest increase being registered in Pahang, followed by Selangor. During the period 1957-80, the tempo of urbanization in all the states slowed down compared to the preceding intercensal period. However, the Federal Territory, Selangor and Pahang remained the three main receiving states, while Malacca, Perak, Kelantan and Kedah were the four primary out-migration states. 6

6

chapter one

The Philippines Cities developed in the Philippines as a phenomenon of the Hispanic colonial order and not from the generative processes of the indigenous societies. 7 Sustained growth of Manila and of provincial urbanism began with the rise of commercial agriculture and the stimulation of internal trade in the late eighteenth and mid-nineteenth centuries. The last fifty years of Spanish rule saw increased economic transition to export-oriented commercial agriculture, accelerated immigration of the Chinese, and important urban post growth in secondary and even tertiary tank settlements. At the turn of the century, there were periods of relatively moderate (1903-39), rapid (1939-60), and slow (1960-80) tempos of urbanization, as indicated by both urban and rural population growth. While a slackening in the pace of urbanization was observed, despite the recent pattern of urban ward transfers, urban concentration increased considerably. This is demonstrated by the much larger population in Metro Manila compared to the next three largest cities: Cebu, Iloilo and Bacolod. Reclassification of areas accounted for a significant portion of urban growth in the earlier periods but natural increase (that is, increase in births over deaths) later became the biggest component. As expected, migration was a significant contributor to the growth of Metro Manila and other big cities. 8 A projection of the level of urbanization placed it at about 49 per cent by the year 2000. Of the city residents, 62 per cent, or about 16 million, are concentrated in Metro Manila. This migration type features a rise in illegal squatter settlements in the heart of the city. Indonesia As in the Philippines, urbanization in Indonesia increased with the coming of the Dutch as urban life in early Java was mainly confined to trading posts along the northern coastal areas and the capitals. Owing to its historical division into smaller administrative units, urbanization was on a smaller scale compared to the other Southeast Asian countries. In each of the intercensal periods from 1920 onwards, the rate of urban growth outstripped that of the rural population and the overall growth of the total population. Jakarta is now the largest city in Southeast Asia and its increasing dominance of the urban hierarchy is matched by an elevation in its relative position among the major metropolises of the world. An estimate of the source of urban growth revealed that natural increase contributed less than half, with the remainder accounted for by net migration gains."

Urbanization and its Health Implications

7

Thailand Even taking underestimation of the urban population into consideration, the overall level of urbanization in Thailand remains quite low, at less that 25 per cent, although the rate of urban population growth is high. Using the municipal areas as the equivalent of urban areas, the average annual rate of urban population growth between 1960 and 1970 was 3.4 per cent, whereas the rural population grew by 2.6 per cent each year. Between 1970 and 1980, the urban population increased at an average annual rate of 5.3 per cent, compared with the 2.1 per cent growth rate ofthe rural population. It should be noted that, for both periods, although the urban growth rates exceeded those of the rural areas, the differential increased. The rate of urbanization increased from 0.6 per cent for the former period, to 3.2 per cent for the latter period. 10 National registration data provide slightly different figures, which suggest that urban growth was faster than that indicated by the census data during the 1 960s, and slightly slower than that based on the census for the 1 970s. The registration data, however, still show that the growth rate for the 1970s was higher than that for the 1960s. The average annual population growth rates in the municipal areas, derived from the registration data, were 4.3 per cent for 1960-70 and 4.8 per cent for 1970-79. The registration data allow a basic breakdown of the municipal areas, permitting an examination of the growth of those places with populations of 25,000 or more. The growth rates for these places were higher than those for the municipal population as a whole in both the periods 1960-70 and 1970-79. Again, the rates for the 1970-79 period were noticeably higher than that for the earlier period- 6.1 per cent per annum in 1970-79, and 5.6 per cent per annum in 1960-70. 11 These figures indicate two main trends: first, the urban population grew at a faster rate during the 1970s than the 1960s; and secondly, the larger urban areas grew faster than the smaller ones. These differentials can be partly explained by the fact that, in 1972, the two largest municipalities, Bangkok and Than Buri, were officially combined into one metropolitan area and the municipal boundaries were extended to cover the two provinces (changwat), Phra Nakhon and Thon Buri. This redesignation alone, not to mention the redesignation of other municipal areas which occurred between 1970 and 1980, accounted for approximately one quarter of the total population growth in the 1970s. The growth and extension of the boundaries of some small municipal areas also brought them into the

8

chapter one

larger urban category. This, and the fact that there was no reclassification of small settlements to urban, help to explain the slower growth of the smaller urban areasY Future Pace of Urbanization Table 2 presents the 1980 United Nations projections on urban population growth and the level of urbanization for each of the four ASEAN countries in the period 1980-2025. The urban populations of these four countries are expected to increase steadily. Thailand, which had the smallest urban population of the four in 1980, is projected to undergo the largest relative gain. Having the largest urban population among these countries in 1980, Indonesia is expected to see an increase of this population by 4.3 times. Although these four countries will expand their urban populations continuously, the tempo of growth is expected to differ considerably. The projected peak of the urban population growth in Indonesia is 3.90 per cent per annum in the period 1990-95. For Malaysia, it is 3.88 per cent from 1985 to 1995; for the Philippines, 3.88 per cent from 1980 to 1985; and for Thailand 4.59 per cent from 1995 to 2000. The urbanization level is projected to continue to rise in all four countries until the end of the century. The Philippines is now the most urbanized, and by the year 2025 two out of three persons are expected to reside in urban areas. Malaysia, the second most urbanized, is projected to double its level of urbanization over the next forty-five years. Indonesia, ranked third in urbanization, is estimated to have slightly more than half its population resident in urban areas by 2025. Thailand, the least urbanized in this group, is expected to almost triple its urbanization level over the projected time period. 13 As distinct from the pattern of urban growth in industrialized countries, urban areas in ASEAN contain relatively small modern sectors and rapidly growing urban informal sectors with a rapidly increasing population of urban squatters. A direct consequence of this rapid population growth is the proliferation of slums and squatter settlements, considered as the urban unserved and underserved. The countries in the ASEAN region have felt the magnitude and urgency of the problem and claim to be facing an "urban crisis". It has been extrapolated that by the turn of the century the urban poor will constitute a quarter of the region's population. The Poverty Dimension in Urbanization The informal economic sector, which is highly prevalent in many

TABLE 2 Estimates of Urban Population, Annual Growth Rate, and Level of Urbanization in Four Selected ASEAN Countries, 1980-2025 Time Period Country Indonesia Urban population (millions) Growth rate(%) Urbanization(%) Malaysia Urban population (millions) Growth rate(%) Urbanization(%) Ph iii ppines Urban population (millions) Growth rate(%) Urbanization(%) Thailand Urban population (millions) Growth rate ( 01) Urbanization (%)

1980

1985

29.91

36.04 3.73

20.21

29.36

:l1.46

17.82

34.19

21.63 3.88

36.21

26.16 3.80

38.66

6.76

15.63

17.45

19.93

26.70

30.44

66.11

33.10

38.14 2.83

3.16 34.33

71.20 1.93

63.1

28.26 3.47

3.84

60.25

64.65 2.23

59.88

23.76

19.62 4.19

23.18

56.44

17.34 2.08

56.84

57.84 2.51

51.96

15.63 2.35

5:1.24

51.03 2.85

52.82

15.91 4.59

49.47

44.24 3.16

49.04

12.64 4.48

45.57

37.78 3.59

45.12

10.10 4.17

41.59

31.57 3.76

41.64

8.20 3.86

37.58

128.26 2.23

48.14

13.90 2.69

2025

114.75 2.46

44.20

12.15 2.99

2020

101.48 2.75

40.20

10.4{) 3.36

2015

184.45 3.03

36.20

8.85 3.72

2010

76.0 3.41

32.26

7.34 3.88

2005

64.09 3.77

28.44

{).05 3.88

2000

53.09 3.90

25.17

4.98 3.75

1995

43.68 3.84

22.44

4.31

14.37

1990

38.31

42.32

SouRCES: United Nations, Estimates and Projections of Urban, Rural and City Populations, 1950-2025: The 1980 Assessment (New York, 1982); and Ogawa, op. cit., p.99.

10

chapter one

cities of the developing world, by nature of its labour absorptive capacities, is able to contain a large number of the urban poor, but at very low levels of living, with many squatter settlements lacking even minimal public services such as water, electricity, transportation, or health services. These settlements have been seen as another survival strategy for people whose participation in the informal economy is geared towards maximizing earnings and minimizing the cost and level of consumption. 14 The World Bank has compiled statistics on the urban poor based on two categories: those living in "relative poverty", defined as persons having less than one-third the average per capita income of the country; and those in "absolute poverty" who cannot afford a minimal nutritionally adequate diet plus essential non-food items. According to this report, of a total of 150 million urban dwellers in absolute poverty in the less developed countries with market economies, 24 per cent are in Southeast Asia. In most of these countries, more than 50 per cent of the urban population are in absolute poverty. The poor have many demographic, reproductive, educational, locational, nutritional and health, and political characteristics that combine to create the consumption and capital formation disadvantage described as urban poverty. Distribution of the urban population in terms of age show that lowincome groups have the lowest median age and the highest dependency burden within the total population. High birth rates prevail as a result of early marriage. Analysis ofthe school attendance pattern shows that the poor have the highest proportion of household heads with only primary education since low household incomes force children of high-school age to seek employment rather than secondary education. This results in the lowest school enrolment among the poor households. 15

Bangkok, Thailand The percentage of the population in Bangkok Metropolis classified as "urban poor" depends on the definition adopted. The National Housing Authority, in 1985, defined the "urban poor" as those who dwell in slum areas. 1 " The study estimated that in 1985 there were 1,020 slums with about 1.01 million population, representing about 19.6 per cent of the total population of Bangkok. The above estimate is much higher than the registration data of the City Planning Division, Office of the Permanent Secretary, Bangkok Metropolitan Administration (BMA). 17 In the latter data, there were 656 slum communities with about 141,089 households and 773,540 residents

Urbanization and its Health Implications

11

in 1987. The difference in estimates stems primarily from the definition of the slum community as adopted by the two sources. Utilizing the registration data on the population of Bangkok Metropolis in 1987 as a base, slum residents represented about 13.8 per cent of the total population of Bangkok Metropolis, a still relatively high proportion. Although it is recognized that not all the people residing in the slums should be classified as "poor", selected demographic, social and economic characteristics of the urban poor and non-poor in Bangkok Metropolis have indicated that these two groups are different in many respects. The average size of urban poor households is larger than that of the non-poor. Thus, income earners in the urban poor households have to bear a heavier burden of the population. The urban poor is also less mobile, and as the heads ofthe households are less educated they are engaged in occupations with lower status. A higher proportion of household income is spent on food. Their house and land tenures are less secure. The percentage of households owning certain consumer items such as refrigerators and television sets is lower. More than half of the poor households do not have access to public water supply and about 15 per cent are still without electricity. All these more or less depict the characteristics of households in the slum areas in Bangkok. Therefore, the definition that those who dwell in the slum areas are urban poor could well be accepted.

Metro Manila, Philippines In the Philippines, the level of urban poverty is best recognized by examining the various indicators as posited by social scientists and relevant officials. Debate still rages on the threshold level for what is considered a "poor" person or household. In the past, about eleven poverty lines or standards were established by many government and private groups. In 1971, the range was from a low of P1,771 (US$86) in annual income for the urban areas to a high of P9,151 (US$458). Measured by the food consumption index based on the Food and Nutrition Research Institute's (FNRI) nutritionally adequate minimum-cost diet, poverty increased in the Metropolitan Manila areas but decreased slightly in other urban centres over three reference years- 1961, 1965, and 1971. These findings indicate that in 1971, nearly three million Filipinos living in the cities did not have adequate food and that half of the urban population was considered poorY The 1983 figures from the National Census and Statistics Office's

12

chapter one

quarterly national income survey indicated that the poverty line was P2,500 (US$125) per month. This amount was the lowest level required to provide decent daily meals, shelter, clothing and other essential necessities for a reference family of four. Urban poverty levels especially in Metro Manila are expected to rise above national figures because of the generally higher cost of living in the cities. 19 The government reports suggest even further economic decline, with the poverty level estimated to lie between a low of P2,800 (US$140) per month and a high of P5,000 (US$250) per month. Based on these standards, 70 to 80 per cent of the 54 million population, or approximately 11 million urbanites, are now estimated to be poor. 20

Kuala Lumpur, Malaysia The "urban poor" in Malaysia is usually defined as those earning less than M$500 per month in the Federal Territory, although the absolute poverty line is usually taken as M$300 per month. Based on this definition, more than 36 per cent of the total households, or 35 per cent of the city's population, involving more than 300,000 persons would be considered as poor. Most of the urban poor are squatters while the rest who are not classified as such are tenement dwellers living in the city slums and low-cost high-rise flats. Squatters are defined as unauthorised occupants of private and state lands, and altogether there are 177 squatter settlements with more than 40,934 dwellings nested on 1,771 hectares, or 8 per cent of the land area in the city. Some of these squatters are given temporary occupancy licences but the majority of the dwellings are built illegally along railway lines and river-banks. Others live in very fragile environments, such as near the tin-mines, or flood-prone low-lying areas, while still others build shelters on the hillslopes which are often subject to the ravages of natural hazards, such as landslides. Over time, these squatter settlements assert a natural claim on the sites, marking the start of an evolution of community kinship and sense of belonging with its own complex social and political structures. 21 Jakarta, Indonesa There are many definitions of poverty in Indonesia, but the general one is to use a poverty line based on acceptable living standards and material needs below which the people would be considered poor. Base on this definition, there are 15-40 per cent of the poor in the

Urbanization and its Health Implications

13

urban areas. However, experts still disagree on the standard appropriate to measure the percentage of the poor population. A compilation made by Surjadi 22 in 1987 revealed that poverty is seen as a composite of low living standards and lack of material resources in relation to the average living standards. The urban poor is thus defined as those living in the slum areas and squatter settlements, and who are lowly educated and mostly unskilled labourers. Based on this definition, it is estimated that they constitute 70 per cent of the population in Jakarta, 85 per cent in Surabaya, and 79 per cent in Ujung Pandang. These estimates seem rather high, however. An analysis based on the per capita expenditure for food and non-food items in 1979 indicated that the poor constituted 38.8 per cent in the cities while in the rural areas, the percentage was 40.4. In 1981, the figure declined to 38.1 per cent in the cities and 26.5 per cent in the rural areas. Rise of Slums and Squatter Settlements in the ASEAN Cities The rapid population growth, rural-urban migration, and the duality of the economy gave rise to the rapid proliferation of slums and squatter settlements in the cities ofthe Third World. These structures have increasingly represented a larger concentration of the Asian countries' urban growth.

Bangkok, Thailand Present estimates indicate a population of one million living in slum communities in Bangkok. These people are mainly in wage labour jobs or self-employed, with an average monthly income of between 1,100 and 3,000 baht. In the 24 districts of Bangkok, 656 slum areas have been identified. The Health Department of the Bangkok Metropolitan Authority is responsible for serving the health needs of the population. It has planned health programmes for the low-income slum residents and the peri-urban communities through health education and other activities at three levels: the community, the local government, and the national government. In 1981, plans were undertaken by the Bangkok Metropolitan Authority to identify the basic minimum needs of the poor communities and by 1985, basic indicators were formulated that are being used as standards for achievement by the year 2001. In 1980, the Prime Minister's Office attempted to compile relevant statistics on the slum areas in Bangkok. The study revealed a population growth rate of more than 3 per cent per annum and a high infant and childhood mortality rate. Communicable diseases also remained prevalent. 23

14

chapter one

Kuala Lumpur, Malaysia Squatter settlements have increased dramatically in the past decade in Kuala Lumpur. In 1967, there was an estimated 26,500 squatter households with a population of 150,000. This increased to 29,000 households by 1973, with a population of 165,000, and towards the end of 1980, there were 48,709 households distributed over 140 squatter settlements consisting of a population of at least 250,000. The environmental sanitation of these settlements is poor. Pit latrines are the usual method of sanitation, which are often dug by the squatters themselves and bordered by wooden walls and covered by a nipa roof. Water supply for those who have no access to standpipes is usually from wells. Where stand-pipes are available, there is always a long queue. Garbage disposal is done by burning. Piles of garbage which attract rodents and other disease-carrying vectors are common. No proper containers are used to store garbage. Thus, there is a high risk of contracting communicable diseases, particularly tuberculosis. Immunization protection is low - below 30 per cent for polio, diphtheria, and whooping cough. Despite the availability of health facilities, the antenatal coverage is only 18 per cent. In 1980, family planning was practised by 29 per cent of the urban poor, which was lower than the national prevalence level of 36 per cent. The slum families have a mean per capita income of US$96 per month and a mean per capita expenditure of US$94 per month. This implies that these households literally live from hand to mouth. Furthermore, 69.9 per cent of the expenditure is spent on food and beverages, leaving behind very little for other household needs. The mean number of children (4.0) is also higher than the national level. The utilization rate for modern health facilities is relatively low. Besides, health centres are inaccessible to them. Early marriage and high parity appear to be the twin features affecting the lives of women in these communities. As a result, 77 per cent of the mothers experience anaemia. Post-partum haemorrhage is common and 42 per cent of the mothers give birth to babies with low birth weight. More than half of the mothers do not breastfeed at all.Z 4 Jakarta, Indonesia Jakarta is similar to the leading cities of other populous nations. It has eight million inhabitants and is increasing at nearly 6 per cent a year, with migration contributing half the increase. The average income for families in the slum neighbourhoods is Rp250 ($0.60) per

Urbanization and its Health Implications

15

day and about Rp50 ($0.15) is spent on food. The slum dwellers are daily labourers, wastepaper collectors, petty traders, and pedicab drivers. A survey of housing conditions indicated that 65 per cent of all households had no private toilet facilities, 80 per cent had no electricity, and 90 per cent had no piped water. Approximatel y 30 per cent still depended solely on water vendors for their supply. Much of the population had no alternative but to use the drainage canals for bathing, laundering, and defecation. Other badly neglected services included garbage collection and water drainage. Most of the city's uncollected garbage ended up in canals and rivers and along the roadside where it clogged drainage channels and caused extensive flooding during the rainy season. Flood-waters would sweep the raw sewage and garbage out of ditches and canals back into the communities. As might be expected, many of these low-income groups with inadequate sanitation experience chronic health problems. The leading causes of death are pneumonia, malnutrition, bronchitis, tuberculosis and cholera. Infant mortality in the kampongs is high (160 per 1000 live-births) and approximately 50 per cent of all kampong children show symptoms of malnutrition. About 80 per cent of the population are chronically infected with waterborne parasites. Besides the metropolitan government and mayoral district, Jakarta consists of 30 kecamatans (cluster of villages) each headed by a cam at responsible for security, public health, and building control. The lowest administrative unit is the kelurahan (village) headed by a lurah who administers refuse collection and community groups and supervises two internal levels of government: the RW (cluster of households) with 150 families; and the RT (lowest organizational unit within the village compound) with about 30 families, headed by a volunteer member who organizes community efforts in refuse 25 disposal, dissemination of government information, and so forth. Statistics are grossly inadequate on the number of slum and squatter settlements in Indonesia. The population is expected to increase to 12 million by the year 2005. Government interest has focused on this group and expressed the importance of urban primary health care. However, no specific national policy has been developed on urban health yet. A Coordinating Committee on Urban Health Care was set up recently composed of government agencies and academic institutions to evolve appropriate programmes addressed to the poor. A number of intervention schemes set up by non-governme ntal organizations have been developed, such as the Penjaringan Project

16

chapter one

of Atma Jaya and the Tambon World Bank project. Critical areas for action include improvement of the concept of community participation and intersectoral collaboration in the field.

Metro Manila, Philippines In Metro Manila alone, it has been estimated that a considerable number of inhabitants are squatters, consisting of about one-third of the city's population of six million. This group is growing at the rate of 12 per cent a year in the 415 slum colonies scattered all over the area. A study in one slum community showed that 66 per cent of the households had incomes of less than P400. Furthermore, residents tended to spend more than what they earned per month (for example, P392 vs P371). The largest share oftheir budget (79 per cent) went to food, followed by much lower allocations for shelter (10 per cent), education (5 per cent), and health (4 per cent). Due to the slum dwellers' activities revolving around economic survival, other essential services are given less emphasis. Inadequate water supply is a perennial problem. Less than one-third (28.5 per cent) of the slum households in the Manila communities had piped water inside the house. Another problem is garbage disposal- open dumping into vacant lots, reclamation areas, highways, bodies of stagnant waters, estuaries, and canals are the predominant means of disposal. Toilets are considered luxuries in the slums. Most of the residents use the "wrap and throw" method in disposing their wastes. The open pit is also popularly utilized. A higher fertility rate has been observed in these communities. However, the infant and childhood mortality rate is also high. The leading causes were found to be infectious and communicable in nature, such as pneumonia, diarrhoeal diseases, bronchopneumonia, tuberculosis and measles. Severe and moderate malnutrition is prevalent in children aged between one and two years. In 1984, less than 20 per cent of the children had been immunized. Social distance may ensue between the medical personnel and patients, which is most pronounced in the lowest income groups. 26 Prior to the accession of the new government, the Metropolitan Manila Commission was responsible for the health management of the urban poor. With the assumption into office of President Aquino, the tasks were transferred to the health ministry and the city health departments. Therefore, the health delivery system is being carried out by the health centres, maternity clinics, and hospitals. In 198182, there was a reorientation of the primary health care system

Urbanization and its Health Implications

17

towards the poor urban communities. Two areas emerged in the study of the structure: the need to involve people in family and village level monitoring and to decentralize the responsibilities for primary health care to the district office and health care centre. The need to improve the linkages with other agencies responsible for dealing with environmental and other problems such as housing, water supply, sewage and garbage disposable was also expressed. In the aforementioned cities, it was noted that the governments have recently taken an active interest in the plight of the urban poor by setting up specific structures or systems addressed to their needs. However, adequate formulation and implementation of urban health programmes are constrained by the lack of information on the nature and magnitude of the problems, the need for understanding the components of the urban primary health care system, and the policy determination and planning capability in the health sector at the city level. Furthermore, city governments suffer from the lack ofresources to develop, sustain, and improve current health programmes. This, however, may be mitigated by improvements in community participation, intersectoral co-ordination and private sector involvement. Urban poverty and its numerous ramifications have raised serious questions concerning the health welfare of these urban dwellers, particularly the linkage with the government and the political system.

chapter two

Health Management of the Urban Poor in Four ASEAN Cities

I

n July 1987, the Institute of Southeast Asian Studies, with funds provided by the International Development Research Centre (IDRC), and Ford Foundation, embarked on a research project involving four cities in the ASEAN region, Jakarta, Manila, Kuala Lumpur, and Thailand. The general objective of the research was to develop viable operational plans to meet the health needs of the urban poor in these cities. Specifically, the objectives were as follows: 1. To describe and analyse existing health policies and mechanisms

by which government and non-governmental organizations meet the health needs of the urban poor- that is, a) review the role and responsibilites of government and nongovernmental organizations in providing health services to the urban poor. b) evaluate the extent of complementarity between the public social services and health services and the degree to which they are exploited in programme design and implementation (intersectoral co-ordination for the development of basic health infrastructure). c) determine the extent of vertical co-ordination between the hospitals and health centres in the communities (outreach services, referral).

Health Management of the Urban Poor

19

2. To examine local resources utilization schemes, such as ways

by which the community extends different forms of support for health care (community participation). 3. To analyse, integrate, and draw inferences from case studies of selected community-based projects in health care for the urban depressed communities by dwelling intensively on the description of the processes involved in the initiation, planning, organization, implementation and assessment of each particular project. 4. Through the comparison of different city strategies, to determine variations in implementation mechanisms of the various programmes in their many facets, including priorities for action programmes, resource mobilization, supervision, support, and evaluation in order to identify both the major obstacles and facilitating factors to the expansion of primary health care in depressed urban communities. 5. Finally, based on the abovementioned approaches, to evolve a model for general usage and formulate a set of country-specific policy and programme guidelines for the planning and implementation of health programmes for the urban poor. Rationale for the Study More and more governments are beginning to realize that the plight of urban families with low-incomes requires quick and effective action. This realization is shown by the growing number of countries in the ASEAN region that have expressed the need for policies to improve the situation of the urban poor. For many of them, recent policies have seen a shift from a negative, forcible stance to enlightened measures such as the setting up of community-based maternal and child health programmes. To identify what is being done for the ASEAN region's urban poor, explicit as well as indirect urban health policies formulated by both government and nongovernmental agencies should be examined. Likewise, community efforts to meet their health needs should be sufficiently documented. Although the health departments in the ASEAN cities recognize the need to respond to the problems of the urban poor and have expressed the desire to try out new approaches, four clusters of constraints seem to preclude adequate health programming: 1) the shortages in personnel, managerial capability, and

organizational infrastructure;

20

chapter two

2) lack of specific programmes to guide the health providers; 3) limited participation by community residents in health

programmes; and

4) absence of intersectoral co-ordination in programme imple-

mentation.

The failure to grasp the intricacies of urban health problems and the corresponding health delivery systems, as well as the lack of necessary resources required to formulate the appropriate solutions account for the inability of governments to implement adequate programmes. The co-ordination of the functions of several agencies for multi-pronged approaches creates an arena of competition in which every agency strives to co-ordinate the others and resists being co-ordinated itself. Moreover, the lack of dialogue between government officials and the community hampers efforts to improve the capacity of the government to meet their health needs. In planning to deal with the health needs of the urban poor, better and more adequate information is required to determine the magnitude of the problem and to persuade the governments concerned that there is a system to adequately respond to it. Many pilot programmes do not succeed because of the neglect of the social, cultural, and administrative base of existing health services. By examining the variability of governmental responses to similar problems, lessons can be drawn that will guide planners and policymakers in other settings in formulating their own health plans. It is not the intention of this research to furnish a lengthy discussion of the health problems of urbanization but rather to undertake an analysis of the major problems and issues facing health decisionmakers, practitioners, and the community and to extrapolate an appropriate model for providing health services to low-income communities in the urban areas of the region.

Methodology The project constituted three major components to address the objectives stated. First, documents on health programmes and policies in the four cities were examined. Likewise, literature on the topic was explored to find out the extent of the empirical research done in the field. From this compilation, the basic issues and themes underlying the current response of the health system (both government and private) to the health needs of the urban poor were extricated. Secondly, the community and key informants, including government

Health Management of the Urban Poor

21

policy-makers, health planners both from the government and the private sectors, health service providers at all levels, community leaders (formal and informal), and service recipients were interviewed to elicit their perceptions of the current programmes, their strengths and limitations and to procure suggestions for programme improvement. Thirdly, case studies were drawn to present as succinctly as possible the processes adopted by the government, community, and non-governmental organizations to health care delivery in order to analyse the factors that may have conditioned the achievement of goals. Consideration was given to the selection of the study sites, the planning processes, the mode of service delivery, and the nature of community participation. In the case studies, emphasis was placed on the identification of goals, the formulation of implementation plans, the mobilization of the community, and operational problems. The implementation or operations procedures of the project (task allocation, resource utilization, staff training, modifications, supervision, monitoring, and participation schemes) were likewise described. Finally, an assessment was made on whether the project activities were congruent to the goals set and the extent to which they addressed the perceived problems of the community. The evaluation focused on the limitations as well as the merits of the programme. The major findings of this research were summarized on a national basis and compared cross-nationally by looking across the three sets of data (documents and literature review, key informants interview, and case studies). Inferences were then drawn on how primary health care programmes can be adequately formulated for poor urban settings by highlighting issues of comprehensive coverage, emphasizing multisectoral, vertical, and community links, thus providing for a better understanding of the complexities of the health programmes for the urban poor, locally and regionally. Guidelines and operational strategies were then evolved for a more efficient and effective management of the health problems of the urban poor. Theoretical Construct A theoretical framework was developed to guide the implementation of the project. In drawing up this framework, the objective was to enable the research teams, drawn from a variety of natiopal contexts within the region, to examine the structure and processes of planning and health care delivery as they address the needs of the urban poor and to ascertain how these factors affect their health situation. To

FIGURE 1 Conceptual Framework for the Analysis of the Health Management ofthe Urban Poor in the Four ASEAN Cities (Kuala Lumpur, Jakarta, Bangkok, and Manila)

Programme Planners

Policy-makers

Health Agency

'

City Health Co-ordinator

Community Worker (Health Centre/Field Worker)

Health Centre Staff

I Community Structure and Organization

Support and Supervision System including Referrals

Community (Service Users)

Intersectoral Link with Other Agencies

Community Component

--

Health Programme Component

Health Management of the Urban Poor

23

guide future policy and programme planning on urban health care, the findings from this research will be presented in a form that will give both an overall strategic perspective and specific suggestions for programme operations. Thus, the framework is sufficiently comprehensiv e and detailed to allow both types of results to be generated. The structure of health care delivery in poor urban settings can be conceptualize d in terms of two concrete parts: the programme component, that is, the agency or agencies formulating and providing the health services; and the community component, that is, the people who utilize and participate in the delivery of the health services. The linkages between them is a crucial aspect in the study of health service delivery. Three sets of processes are examined, that is, health planning and implementatio n strategies as they relate to the health policy-makers and programme providers, the implementatio n of programmes, and the community response. Within the community subsystem, two elements are distinguished which play functionally different roles: the programme planners and policy-makers, who formulate strategies and legitimize as well as authorize the mobilization and allocation of resources, and the health centre through which the services are delivered to the recipients. Four distinct sub-elements of the health implementing agency are recognized: the programme co-ordinator in charge of the administration of the providers at the city level, the staff of the programme at the local level (health centre personnel, private organization's staff), the field workers (volunteers or paid) who interact directly with service users, and the community who are recipients as well as participants in programme activities. The elements in the community or service user subsystem interacting directly with the health service agency will be included, such as the community health workers or any community organizations involved in health care. Issues that will be clarified and analysed with respect to how they influence the urban health care system will focus on participatory management for co-ordination and integration.

Study Population and Sampling Four cities in the ASEAN region were included in the study: Bangkok, Jakarta, Kuala Lumpur and Manila. A typical slum community was selected purposively in each city. Each community had about 500 families and an existing primary health care programme. Health resources within the community were identified and the key

chapter two

24

informants were listed. The following informants were considered: A. Policy-makers through purposive selection; B. Health service providers through purposive selection; and C. Community leaders and families through random sampling.

Data Collection

Instruments Development A.

QUESTIONNAIRES

Three sets of questionnaires (see Appendices I-III) were developed addressed to the programme planners and policy-makers; the health service providers; and the community in the key informants' interview. For the planners, policy-makers and providers, the following variables were identified: 1) existence of a primary health care policy or programme addressed to the urban poor; 2) urban health services provided; 3) coverage; 4) vertical co-ordination; 5) priorities; 6) resource mobilization; 7) monitoring and evaluation indicators; 8) intersectoral co-ordination; and 9) community participation. For the community, apart from basic service utilization questions, issues on community participation were raised. In most cases, the questions were open-ended. Likewise, guidelines were provided for the appraisal of policies and programmes and of the case studies. B. CASE STUDIES Case studies were undertaken on selected communities that had a participatory dimension in their primary health care programmes to document the activities of the community who were engaged in the project planning and implementation, the problems and issues evolving from the programme operations, the nature of community involvement, the identification and resolution of problems, outcomes of efforts by the community to seek health care, and the community's response. Lessons were drawn from the case studies in which mechanisms were delineated in order to extrapolate specifically these experiences to subsequent health programmes. Some of the areas considered were community perceptions about the project, the expected outcomes and implementation mechanisms, project inputs, management and supervision, the degree of participation and the roles of health planners and implementers. While the case studies selected were notable in terms of their attempt to involve the population in health care delivery, the

Health Management of the Urban Poor

25

mechanics of project implementatio n have not been adequately analysed nor evaluation systematically undertaken. It is therefore the objective ofthis report to comprehensiv ely document and analyse the projects in terms of the sequence of their implementatio n, to extricate the crucial issues in community involvement in health care delivery and to derive a meaningful plan for health care among the urban poor. Basic questions that were addressed included: which aspects of primary health care can be effectively undertaken and managed by the community? How can community efforts be systematically linked with government efforts to assure an effective support and referral system? Given the broad range of health promoting components in urban development programmes, how can these be prioritized? What steps can be undertaken to initiate changes in resource allocation? Data Analysis In developing the study design and the methods of data collection, the project undertook a qualitative approach, focusing on how specific urban health care programmes are organized and implemented with a view to assessing the way in which their structures and procedures inhibit their utilization by the urban poor. Likewise, various modalities of community participation were explored. Consequently, this is a "process" rather than an impact analysis. The quantification of data was minimal. Open-ended questions permitted the exploration of specific issues in each city, thus allowing comparability while retaining the uniqueness of each programme. Phase I: Documents and Literature Review In this phase, a comprehensiv e review of documents embodying policies and programmes related to the health management of the urban poor as well as empirical literature was undertaken. In the analysis, the extent of recognition of the problems and the mechanisms for addressing them were determined. Gaps in the policies and programmes were also identified in relation to the responses obtained in interviews with the key informants and the community, and the case studies. Phase II: Interviews with Key Informants and the Community Information obtained from these interviews was aggregated to determine commonalities and variations in the issues addressed. Such aggregation extricated the orientation of health policy-makers

26

chapter two

and service providers on the one hand, and the community on the other, on how current health programmes are operationalized, and their perceptions on basic issues, such as the reorientation of urban health service delivery, equity in urban health care, priority setting, resource mobilization, assessment indicators, intersectoral coordination, vertical linkage, and community involvement. The extent to which such perceptions affect the operation of current programmes was analysed and related to current mechanisms for health service delivery. Since most of the questions were open-ended, analysis was more textual and comparative in scope. Attempts were made to link the answers of the respondents at three levels - policy, health service delivery, and community- so as to determine how differences or similarities affect health service utilization. The community participation component of the programme was underscored. Phase III: Case Studies These studies gave insights into the mechanism of organizing and implementing significant participatory health programmes for urban deprived communities. In analysing these programmes in its multifarious dimensions and stages, attention was given to the assessment of the extent to which the different programmes developed implementational mechanisms which most suited their socio-cultural milieu and perceived health needs. The studies covered the location, the planning phases, project implementation, problems, and issues. In documenting these projects, attempts were made to identify the possible causative factors that could account for successful programme operations.

chapter three

An Appra isal of Healt h Policies and Progr amme s in the Four ASEAN Cities

he process of urban health policy and programm e formulati on as well as its implemen tation can be understoo d more clearly by undertaki ng a comprehe nsive analysis of urban health programm es and policies in the four cities of the ASEAN region. Such an assessmen t will cover a large range of issues, such as the role and responsib ilities of governme nt and non-gove rnmental agencies in meeting the health needs of the urban poor; the extent to which specific goals are enunciat ed in the programm es, such as compleme ntarity between the public social services and the health services; and the degree to which they are exploited in programm e design and implemen tation; the extent of vertical co-ordina tion between the hospitals and health centres; local resource utilization schemes; supervisio n; and support. It will also emphasiz e significan t policy segments perceived to have a considera ble impact on the health status of the communi ty as well as address in a comprehe nsive manner questions of urban health administr ation, managem ent, and planning. In so doing, current policies and programm es will be studied, including major statement s and recommen dations as well as objectives and strategies, the implemen tation plans of specific programm es, and the organizat ional and managem ent structure. Taylor and Williams drew a paradigm for policy analysis. This was modified to

T

28

chapter three

suit the health programmesY In this model (Figure 2), a balance is sought between the formulation of long-range health strategies and the development of short-term health action programmes or projects. The process is viewed as both continuous and cyclical in that the health planning agency moves through the entire sequence of tasks, from the description of exisiting health conditions and trends, the formulation of long-range strategies, the development of specific five-year and annual action programmes, to the monitoring and evaluation of the implementation scheme. This cyclical process enables the health planner to enter at any point. The model describes the entire health planning, programming, budgeting, implementation, evaluation and feedback sequence. Emphasis is placed on formulating health programmes, priorities, and an integrated annual health development plan co-ordinating sectoral activities. In the model, existing conditions and trends are described and analysed based on an information system that integrates data on basic health resources and population, after which alternative health strategies are set and evaluated. A specific health plan is evolved taking into account other key resource constraints. Issues arising from the model include the creation of an appropriate balance between long-range strategies and short-term action programmes, and the comprehensiveness that a given health plan should take, including potential problems with strategic planning (such as setting priorities, and mechanisms for arriving at a particular strategy).

Bangkok, Thailand 28

National Health Policies and Development Strategies A review of the national health policies and development strategies outlined in Thailand's five-year national health development plan, which is an integral part of the five-year national economic and social development plan, indicates that primary health care has been and continues to be the basic policy approach. In the current Sixth Five-Year National Health Development Plan (1987-91), one of the policy statements is [to] support the effort of the communities both in the rural and urban areas in initiating or extending primary health care activities in order to solve the existing health problems based on local conditions and potential of the individuals, families and people within each particular community.

FIGURE 2

Process System Diagram of Urban Health Planning , Programming, and Impleme ntation

Planning Agency

Alternative Health Strategies CJl CJl

~

u

Evaluation of Alternative Health Developme nt Strategies

Optimum Health Strategy

Specific Plan of Action

Determinan ts of Health

IntegratAd Health

0

~ ~

"zz I

Joint

~....l

~

Existing Health Conditions and Trends

Health Programme Formulatio n

Project Detailing

Health Programme Implement ation

Sector Agencies

Countries (Pergamon Press, 1976), p.7. SOURCE: Modified from john Taylor and David Williams, eds., Urban Planning in Developing

30

chapter three

Of the twelve policy statements in the Sixth Plan, the word "urban" appears only in the statement quoted above. Perhaps the policy statement which might apply more directly to the urban poor is the policy which aims: [to] develop new alternative systems of health financing which respond to the concept of people participation and reduction in health expenditure in order to make use of the mobilized resources for health expenditure or provision of essential services for the poor and the aged.

The poor and the aged here include those who live in both urban and rural areas. The policy statements in the Fifth Plan (1982-86) are even more rural biased, although the word "urban" appears more frequently than in the Sixth Plan. "To accelerate integrated health services to meet the need of urban and rural population by focusing on activities which deal with preventable diseases and health promotion ... " and "to modify and develop health service delivery system for urban and rural areas through systematic health planning ... decentralization ... " are two policy statements in the Sixth Plan. The only policy statement which may be considered as relevant to the urban poor is the one which states: "to provide free medical care services to the underprivileged groups, notably the low income and those who are more than 60 years old". In fact, the policy of the provision of free basic medical and health care services for the aged, children and low-income population has been adopted by successive governments since 1977. From 1982 onwards, a separate health development plan was formulated and integrated with the national health development plan. In the 1981-86 Bangkok Metropolis Health Development Plan, two of seven policy statements made specific reference to the urban poor: 1) to upgrade the quantity and quality of service units of Bangkok Metropolis in an integrated manner and to improve the coordination of government and private health service units in order to be able to provide adequate service to people in slum areas; and 2) to assist the low income people in obtaining free medical care with assistance from the central government. As for policy statements in the 1987-91 Bangkok Metropolis Health Development Plan, a direct reference to Bangkok's urban poor is in the preamble, which states that "the plan aims to serve low income people". Other statements in this Plan resemble very closely those of the national development plan. The only difference is that the former

Health Policies and Programmes in the Four ASEAN Cities

31

makes direct reference to the rural population whereas the latter refers to the urban population. A review of the development strategies as specified in the 1987-91 Bangkok Metropolis Health Development Plan also gives the impression that they are an abridged version of the development strategies of the national health development plan for the same period. The development strategies which may be considered as having a direct bearing on the urban poor in Bangkok are the three statements: 1. upgrade the existing health facilities in inner and outlying

areas in order to increase coverage and quality of care; 2. convert six existing health centres in outlying areas into 30-

bed community hospitals in order to provide medical services to people residing in outlying areas; and 3. provide free medical care to low income people.

Policies and Development Strategies of Non-governmental Organizations Development activities implemented by nearly thirty nongovernmental organizations (NGOs) in the low-income communities of Bangkok Metropolis are mostly ad hoc in nature. Moreover, the areal coverage of these organizations is confined to one or two communities. The two community development projects which cover quite a large number of slum communities and are implemented on a continuous basis have been initiated and implemented by two political parties. The first project is the Bangkok Community Development Project initiated by the Prachakorn Thai Party (Thai Citizen Party) in 1980. The second project, entitled Urban Community Development Project, was initiated by the Prachathipat Party (Democrat Party). The source of funds for these two development projects is the government budget which has specifically allocated a certain sum for each Member of Parliament annually for use in development activities in his/her own constituency. These two projects, however, are considered non-governmental because they are implemented and controlled by the political party. The stated goal of these two projects is to improve the quality of life of the population, with emphasis on the people's participation in development efforts. The initial task of these two projects is to encourage the community to establish a committee which will be under the guidance of full-time volunteers of the projects. The activities of the committee include collecting data and information, analysing the community's problems

32

chapter three

and identifying its needs. Based on the priorities determined by the committee, the project will then provide partial support either in the form of cash or materials or both. Members of the community contribute labour or money or both as appropriate. Many services are provided for the community at no cost. Medical care services are provided by means of a mobile medical team consisting of one physician and one or two nurses. The team visits the community on dates fixed and agreed upon by the committee. The committee is responsible for the location of the service as well as the care to be provided. Other health-related activities include health education, anti-rabies vaccination, nutrition, family planning, sanitation, and vector control.

Role and Responsibilities of the Government and NGOs in Meeting the Health Needs of the Urban Poor From the description of the health policies and strategies of the national and local governments and that of the private organizations made above, it may be seen that the responsibility of meeting the health needs of the poor lie mostly with the government. Programmes and activities implemented by the non-governmental organizations, even those by the two political parties, reach only a very small proportion of the urban poor. Moreover, there is no co-ordination not only between the NGOs themselves but also between the NGOs and the city health authority. Reports of the two community development projects showed that there is no Bangkok Metropolitan Authority (BMA) representative in either the steering and coordination committee or the executive committee. Perhaps one of the weaknesses is the absence of co-ordination between these two sectors. In fact, the promotion of co-ordination, including the exchange of knowledge and experience, has always been in the health policy statement and development strategy of the two BMA health development plans. The objectives, however, have never been achieved despite several attempts made by the parties concerned. In the BMA Health Development Plan (1982-86), the Primary Health Care Development Project to improve the health status and access to health services of the urban poor was planned and implemented. The specific objectives of the project were to help the poor or disadvantaged communities with their health problems and to achieve an acceptable level of health, as well as to develop an environment and life-style which would be physically, mentally and socially healthy. This project has been modified and expanded to

Health Policies and Program mes in the Four ASEAN Cities

33

take into accoun t the social and econom ic aspects of health care delivery . In the Third BMA Develo pment Plan (1987-91), health is one of the four sectors in the Quality of Life and Social Develo pment Plan. The other three sectors are educati on, social welfare and social develop ment. The commo n policy stateme nt which appears in these four sectora l plans is "the improv ement of quality of life based on people' s particip ation in develop ment efforts" . Anothe r strategy aimed at the poor is the provisi on of free medica l services through two channe ls: the low-inc ome card system, and services from a networ k ofBMA general hospita ls and health centres, supplem ented by mobile medica l and health teams. The poor, or low-inc ome people, are defined as "those who earn insuffic ient income to purchas e food and other necessi ties". A person with a per capita income of approx imately US$198 or less is qualifie d to apply for the low-inc ome card and be entitled to free medica l services at governm ent-des ignated health institute s. The procedu re for obtainin g the low-inc ome card, howeve r, is very compli cated and a person has to satisfy a number of conditi ons, one of which is proof of residen cy in the city, which many low-inc ome people, especia lly migrant s from upcoun try, do not have. Conseq uently, only a small proport ion of the estimat ed poor populat ion in Bangko k Metrop olis can avail themse lves of the card and become eligible for free medica l services through this channe l. The second is the provisi on oflow-f ee medica l service s at the four general hospita ls, 58 health centres and 85 health subcent res scattere d around the Bangko k Metrop olis. Free medica l service s in these institut ions can be obtaine d by those who carry low-inc ome cards and those who are certifie d by the social welfare worker attache d to each institut e that the service recipien ts cannot afford to pay the cost. Service s provide d by these static health service units are supplem ented by the mobile medica l and health team organiz ed specific ally for the low-inc ome commu nities. Based upon the assump tions that primary health care activitie s can adequa tely meet the needs of the urban poor and that the medica l treatme nt require d by them is the same as those of other Bangko k residen ts in general , it is estimat ed that during the three-y ear period, from 1983 to 1985, the primary health care project covered only 12.5 per cent of the urban poor. About 13.2 per cent of the poor are in the peri-urb an villages , of which 10.9 per cent are in the congest ed commu nities. In terms of curativ e services , the city health service networ k covered only 28 per cent of the estimat ed episode s of illness

34

chapter three

of the urban poor. It should be observed, however, that the above estimate has not taken into account the fact that Bangkok is a city endowed by both public and private health resources.

Intersectoral and Vertical Co-ordination One of the most important elements in achieving the targets of primary health care is co-ordination, both intersectorally and vertically. This is marked in the quality of life development approach which uses the basic minimum needs as targets because it involves co-ordination between health and non-health sectors within the BMA and with other public and private organizations. The absence of intersectoral co-ordination between the offices within the BMA and between the BMA and other governmental and non-governme ntal organizations must have been well recognized by the authorities concerned. One of the problems identified in the current quality of life and social development plan was that "there is no established pattern for coordination in the slum development between community committee, private sector, BMA and other government agencies, resulting in each agency following its own policy and program leading to the absence of such coordination to mobilize resources effectively". In health care service delivery, there exists a vertical co-ordination among the different levels of health service units within the BMA. A person requiring health and medical treatment will be referred by a community health volunteer to a health subcentre or health centre. This same person may again be referred by the health centre to a BMA hospital or vice versa. A co-ordination mechanism between the BMA and other public and private health providers has not yet emerged. Even the vertical co-ordination between different health service units within the BMA seem to suffer since the hospitals confined their activities to curative health and occasional participation in outreach services. Health centres on the other hand are entrusted with all the functions of preventive, promotive and curative health services through outreach services, training and referral. Issues and Problems In general, it can be observed that the city authorities have a specific policy and programme to meet the health needs of the urban poor. However, the health programmes that have been implemented to date are perceived by those concerned as still being inadequate. This may be due to many factors, such as the magnitude of the needs

Health Policies and Programmes in tl1e Four A SEAN Cities

35

which cannot be satisfied with the existing resources and infrastructure. However, with non-city governmental and nongovernmental health resources concentrated in the city, the health needs of the urban poor could be better, if not adequately, served if there is an efficient co-ordinating mechanism. With a view to increasing the health service coverage and the quality of care, the city has planned to upgrade the existing health infrastructure. There have been attempts to redress the inequity in health care through the provision of health services to the low-income communities by medical mobile units. The number of low-income communities, recorded as 656 in 1987, makes it difficult for the city to adequately meet their health needs, even though such activity has been supplemented occasionally by several private social and welfare agencies. Certain problems faced by the city health authority can be partially dealt with if there is an effective health management information system. The information can be used not only for specific realistic targets but also for setting priorities, resource allocation, evaluation of activities, and monitoring of the progress made. In fact, one of the development strategies of the current health development plan is "[to] develop a decentralized system of data collection, analysis and processing at different levels and utilize the information for planning, monitoring and evaluation". Yet, the mechanism to implement this strategy has not emerged. The people's participation has been and will continue to be the major emphasis of the government's policy and plans, but ways and means to mobilize participation effectively have still to be found. Kuala Lumpur, Malaysia 29 In Malaysia, the Ministry of Health has adopted a strategy of "health for all" by using the primary health care approach to reduce the disparities in health status among different population groups and regions within the country.

Policy Presently, there is no national health policy specifically targetted to the urban poor in Kuala Lumpur. They are encouraged to make use of the existing health facilities provided by the government and nongovernmental agencies. Kuala Lumpur has a health system administered by the Ministry of Health and City Hall, which directly and

36

chapter three

indirectly cater to the urban poor. Prior to 1957, some large urban areas in Malaysia, such as Kuala Lumpur, were managed by the local government s, which had their own local council overseeing the developmen t of the town, including the provision of infrastructu re and amenities such as water, sanitation, waste disposal, and health services. The health services provided were mainly preventive. The Ministry of Health, while catering to the whole country, now has jurisdiction over health at the local governmen t level. Programme

The functions of the Ministry of Health are both preventive and curative, but mainly curative. Instead of the maternal and child health clinics (MCH), there are thirteen polyclinics located in highdensity low-income areas, while the two government general hospitals serve as referral centres. In this way, the policy-mak ers have consciously attempted to cater to the health needs of the urban poor. Four governmen t agencies are involved in health service delivery: the City Hall Health Department (maternal and child health services, environmen tal health, school health services, health education), the National Population and Family Developme nt Board (family planning services and family developmen t services), the Ministry of Health (curative services are provided by the general hospital, polyclinics, the National Tuberculos is Centre, and dental services), and the University Hospital. The private sector provides curative services through the medical practitioner s in private hospitals, nursing homes, maternity hospitals, and private clinics, as well as through traditional health practitioner s.

Voluntary Organizatio ns The voluntary agencies provide a range of services which include promotive, curative and rehabilitativ e. Some examples of these organization s are the Malaysian Red Crescent Society; the Selangor and Federal Territory Family Planning Association ; associations catering to the blind, deaf and mentally retarded; Malaysia Muslim Welfare Organizatio n (PERKIM); Malaysian Care; and The Little Sisters of the Poor. The voluntary organizatio ns cater mainly to the poor, needy, and handicappe d. As far as health service delivery is concerned, the governmen t sector is well organized and has an established infrastructu re. Primarily, City Hall is responsible for the preventive services and the

Health Policies and Programmes in the Four ASEAN Cities

37

Ministry of Health, for the curative services. The City Hall's nineteen static clinics for maternal and child health services are located in low-income areas while the two mobile clinics serve the poor areas which are far from the static clinics. The patients pay a nominal fee which represents only a tiny fraction of the cost of total care that the patient receives. Moreover, the fee is waived for those who cannot afford to pay, indicating that the City Hall is considerate of the needs of the urban poor. The limitation is that only pregnant women and children below seven years are served in these clinics. The Environmental Health Division in the Health Department caters to all socio-economic groups. The Ministry of Health's thirteen outpatient polyclinics are located in areas where accessibility of the services to the majority and the poor has been taken into consideration. Both inpatients in hospitals and outpatients pay nominal fees, which are exempted if they cannot afford to pay. The University Hospital also charges a nominal fee, but none at all for those who are assessed to be very poor.

Horizontal and Vertical Linkages There are intersectoral linkages between the various government departments at the planning stage. For example, in the planning for the development of an area, representatives from City Hall, the Water Works Department, the Ministry of Health, and the Prime Minister's Department sit in a committee. However, at the implementation stage it may be found that the decisions made during the planning may not necessarily follow intersectoral links, as each department has its own priorities and budgets during the operational stage. Within City Hall itself, there are horizontal linkages between the health department and other health related departments, both in planning and implementation. However, this has not been adequately described. As far as health and medical care referrals are concerned, the General Hospital of Kuala Lumpur and the University Hospital act as the centres for receiving referrals from the polyclinics, the City Hall health clinics, the private clinics, and the voluntary sector. Generally, the urban poor gravitates towards these two hospitals when more sophisticated diagnosis and treatment are required. The private hospitals and clinics run independently, providing curative care to those who can afford to pay. Those among the urban poor who work in the larger factories and companies have the privilege of receiving medical care from company doctors in the private sector.

38

chapter three

The voluntary organizations also work independently, being funded by charitable organizations. Their functions with regard to health care are mainly supportive and rehabilitative. Within the government sector, the role of the various departments are complementary in nature. Each department has a defined role and develops its services according to the public need. The private sector develops its services according to market demand, and the voluntary organizations provide the services perceived as needed and affordable. There is little linkage between the government sector, the private sector and the voluntary organizations in terms of planning for health service delivery. In terms of coverage, 99.5 per cent of the population in Kuala Lumpur live within three kilometres of either a static government or private health service facility and there is no geographical barrier to health care. There is, however, a tendency for the poor to seek health care from the government sector and the voluntary organizations. The poor community is totally dependent on these two sectors for health services. With this situation, any increase in the number of poor in the city requires a commensurate expansion of health services.

Health Policy and Priority Setting In view of the national health strategy which broadly aspires to achieve health care for all, there is no explicit health policy for the poor, whether in the rural or urban areas. Although the health services delivery system does not exclude the poor and, in fact, subsidizes the health needs of the poor, in practice it may be necessary to set the poor as one of the target beneficiaries of available health services in the future. Health Management and Equity The dualistic health services delivery system as practised in the city of Kuala Lumpur, in which curative services are predominantly delivered by the Ministry of Health and preventive health services by City Hall, has implications on the health services for the urban poor. Since the Third Malaysia Plan of 1976-80, the Ministry of Health has recognized the inequitable distribution of health facilities and personnel between the urban and rural regions in the country and has, thus, concentrated health expenditure in the rural areas. The health needs of the urban poor population are presumed to be met adequately by the relatively well-developed health facilities found in the city. However, health resources are not equitably

Health Policies and Programmes in the Four ASEAN Cities

39

distributed within the city, especially among the various income groups. Better health resources are managed by the private sector. Forty-five per cent of the registered doctors in Kuala Lumpur in 1985 were in private practice, and there are many private hospitals and maternity homes. These private services may not be accessible to the urban poor. Thus, it cannot be assumed that the health needs of the urban poor are adequately met or that the health services they receive are better than those in the rural areas, despite the better health infrastructure in the city. With regard to preventive health services, although there is no doubt that maternal and child health services as provided by City Hall are adequate, the same cannot be said for the distribution of basic amenities in the city.

Resource Mobilization, Community Participation and Self-Reliance Two related issues of health financing and community participation arise in the practice of subsidizing health care for the poor in government health centres, and in the traditional relationship between the government as health services provider and the community as the recipient of such services. As has been mentioned before, the city's health services are subsidized for those who cannot afford to pay. However, the national health budget allocation has been reduced. In the face of escalating costs in health care and a progressive growth in the population of Kuala Lumpur, the continual subsidy to health services and the maintenance of a good health status become questionable. Appropriate and equitable health financing strategies, thus, need to be formulated for the longer term. An assessment of City Hall's community participatory project has reconfirmed the traditional roles of the government and community as provider and recipient of health services, respectively. The latter approach is not in keeping with the national strategy of "health for all" which emphasizes community responsibility and participation in health care. It is timely, therefore, to review the role and contribution of the community in this respect. Evaluation and Monitoring At present, health indices are collected for the whole of Kuala Lumpur without specific monitoring schemes for the urban poor. Hence, there is a dearth of information for this group. It is timely, therefore, to have systematic evaluation and monitoring of the health

40

chapter three

problems and activities specific to the urban poor so that appropriate health management strategies can be formulated. Jakarta, Indonesia 30 The Jakarta government health office is involved in health programmes for the urban poor. There are four major areas of coverage: community health promotion, basic health services, communicable disease control and prevention, and environmental health. A health services model has been formulated according to the community's capacity and available health facilities. Health care efforts are carried out in an integrated fashion, encompassing health improvement, prevention of disease, treatment, and rehabilitation organized within a referral system. At the household level, the family, especially the mother, is expected to meet the health problems of the family members by providing nutritious food, producing salt and sugar solutions for diarrhoea, improving the environment, and administering first aid when required. At the RW level, the community should have an integrated health post to implement the programmes. At the public health centre or puskesmas level, health services can be provided in the form of professional outpatient treatment. At this level, two sub-levels are delineated: the subdistrict puskesmas which provides health care comprising thirteen basic health components, and the district puskesmas which co-ordinates and manages all activities conducted by the subdistrict puskesmas. Limited specialist services are also provided, such as paediatrics, radiology, and surgery. At the municipal level, regional hospitals are designated for inpatient treatment and medical referral services from the public health centre. At this level when a government hospital is not available, private hospitals become the regional hospitals and referral centres. Health Programmes The health programmes are enunciated in terms of goals, components, venue and targets. 1. Goals. Health activities are aimed at reducing infant and childhood

mortality, increasing life expectancy at birth, reducing crude death rate, and inducing the acceptance of a small family norm. 2. Components. Public health activities include promotive and preventive services which are integrated with curative and

Health Policies and Programmes in the Four ASEAN Cities

41

rehabi litative tasks using approp riate technology and involving the community. 3. Venue. The programmes are implem ented mainly throug h the public health centre s which offer basic services, as well as the hospit al for referrals. 4. Targets. Health services are available to all citizens of the city, with specia l attenti on being given to low-income groups, infants, childre n under five, pregna nt and breastfeeding women, and the produc tive age group. The strategies undert aken are as follows: 1. Integrated health posts have been establi shed to facilita te the transfer of technology and management skills in health and family planni ng activities. 2. These posts provid e health services, preventive care, and first aid. These services are provid ed by volunt ary health workers who are trained and superv ised by the public health centre person nel. 3. Public health centres have been establi shed to carry out both preven tive and curative tasks. 4. Hospitals act as referral centres for health problems which cannot be manag ed by the public health centres. 5. Non-governmental organizations are partne rs of the govern ment in improv ing the health status of the low-in come people. Implem entatio n Mecha nism The health services programme aims: 1. to improv e the existing referral system by upgrad ing hospit al facilities in Jakarta; setting up a centre for emergency care; and allocating 5 per cent ofthe health budget for the hospit alizati on of the urban poor. All hospit als in Jakarta have to reserve 25 per cent of their beds for the poor (the cost for hospit alizati on is Rpl,OOO a day); 2. to improv e the health services of public health centres, includ ing limited specia list services. 3. to increas e the coverage of health services throug h the provis ion of health facilities and the training of additio nal health personnel. The objective is to provid e one public health centre for 25,000 person s in order that 40 per cent of the sick who seek health care can be served by the public health centres.

chapter three

42

4. to improve the number and quality of posyandu (health centre)

services by having three posyandu for every RW (600 families); increasing the quality of services of the posyandu through training courses in leadership, strengthening community organization, community funding and instituting a community participation mechanism so that the posyandu can provide the following services: monthly weighing activities; food supplementation programmes for malnourished children; immunization for infants and pregnant mothers; giving oralite for diarrhoea; first-aid treatment of diseases; first-aid for accidents; antenatal and postnatal care, including giving vitamin and ferrous tablets to pregnant mothers; health, nutrition and family planning education; and giving contraceptives to eligible couples.

Non-governmental Organizations In Indonesia, NGOs are recognized as community organizations by the Department of Health. Two other types of community organizations are the village community resilience committee and the Family Welfare Movement. There are four types of NGOs: 1. those that provide basic social services for the poor; 2. those that improve the community's self-reliance;

3. those that enable the community to express their needs to the government; and 4. facilitators of community development programmes. The NGOs involved in health services include the following: Religious groups such as the Muslims (Muhamaddiyah, NU), Catholics (Perdhaki), and Christians (Pelkesi). They are spread nation-wide. 2. Non-religious groups such as the Indonesia Sejahtera Foundation, Bina Swadaya Foundation, Lembaga Study Pembangunan, Indonesian Foundation of Children Welfare, which have activities not only in Jakarta but also in other parts of the country, including the rural communities. 3. International NGOs such as Save the Children, World Vision, Catholic Relief Services, Church World Services, Rotary Clubs, and Lion Clubs. Save the Children carries out a child survival project through a primary health care programme in one 1.

Health Pohcies and Programmes in the Four ASEAN Cities

43

kelurahan (district) in Jakarta. Others organize charity programmes through private or government clinics such as food supplementation, training of voluntary health workers, and provision of lavatory facilities. Members of the Indonesia Sejahtera Foundation and Pelkesi (Yakkum) have pioneering projects in Solo and Ban jar Negara, which have become prototypes of the primary health care approach. The NGOs operate: through their clinics or hospitals, in co-ordination with public health centres, by utilizing the primary health care approach and training voluntary health cadres in service delivery and community organization. Their tasks are mainly training and income generating activities; and 2. by assisting the government to develop training manuals for voluntary workers, and the training of public health centre personnel. 1.

Other activities include the training of clinic personnel and initiating sectoral meetings at the kelurahan level. There are no activities for the improvement of referral systems and the strengthening of the health infrastructure in their project area. Constraints that have been faced by these NGOs include the lack of manpower and financial support, as well as co-ordination and the attitude of the community.

Vertical Linkages Health problems within the family which are beyond the competence of the household head or the mother are brought to the attention of the volunteer health worker in the posyandu or integrated health service post, or to the puskesmas, private physician, or maternity clinic. Members of the community participate as volunteer health workers. Each posyandu co-ordinates six programmes, namely: maternal and child health, family planning, nutrition, immunization, diarrhoeal disease, and health education. Each neighbourhood (also called RW) has one posyandu. A posyandu refers patients it cannot handle to the nearest puskesmas which has better facilities and is manned by a midwife or a nurse. After handling the case, the puskesmas refers the patient back to the posyandu for follow-up treatment. The puskesmas also conducts training and counselling

44

chapter three

courses for the volunteer health workers. A puskesmas may also refer a case to another puskesmas if deemed necessary. Referrals between the puskesmas, private physicians, the maternity clinic, the dispensary, and the laboratory are made when: (a) cases are too difficult to handle; (b) patients are referred back after the specific nature of the illness has been diagnosed; and (c) laboratory examination is required for diagnosis and evaluation. A puskesmas refers cases it cannot handle to the Type C or D hospital. The hospital then refers the cases back to the puskesmas for further follow-up of the patients. A puskesmas may also refer and receive additional health workers. It can also send specimens to higher health facilities of the district or province for diagnosis. Type C and D hospitals refer cases they cannot handle to the regional hospital. Conversely, regional hospitals may refer the treated patients back to the Type C and D hospitals for follow-up treatment. The regional hospital staff are often involved in consultation or training of the health personnel at the lower level units. If necessary, private hospitals may be included in the federal system because of their more sophisticated facilities. Patients may also be sent back to private hospitals from which they were referred for follow-up treatment.

Intersectoral Co-ordination Co-ordinating bodies are set up for school health services and mental health treatment. Village committee boards and family welfare movements are also involved in health and family planning activities in the community. Other basic services in Jakarta which have intersectorallinkages are: 1. Kampung improvement programmes aimed at building drainage

and roads, collection of garbage, provision of clean water, and health centre construction, to improve the physical quality as well as the social environment of kampungs; 2. Income generating activities; 3. Education projects; 4. Skills development in women.

Monitoring and Evaluation Three tools have been used by health centres for planning, monitoring and evaluation of their activities: micro-planning, stratification of health centres, and mini-workshops. 1. Micro-planning at the health centre level aims to improve and

Health Policies and Programmes in the Four A SEAN Cities

45

expand the integrated health package based on the local health situation and the existing capabilities of the staff. The overall planning is for five years but every year, detailed planning for the coming year is carried out in the context of the previous year's plan. 2. Stratification of health centres is used for the assessment of the functions and performance of health centres with the goal of improving the health care coverage of the community. The stratification of the health centres is according to functional status. -Advanced -Standard 3. Stratum III - Sub-standard

1. Stratum I 2. Stratum II

The emphasis is on "Self-Assessment" by the health centre staff in decision-making, monitoring and evaluation. The general objective is to provide a continuous picture of the health centre's functional development over time. The specific objectives are: to evolve inputs for the future planning of health centre programmes and to obtain an overall picture of the status of health in the community. This includes health centres, sub-centres and mobile health centres and the following aspects are taken into consideration: 1. Achievement of programme goals- for example, coverage. 2. Improvement of management - namely, planning, imple-

mentation and evaluation.

3. Development of health facilities- including manpower. 4. Improvement of the environment.

3. Mini Workshops are carried out at the beginning of each month at a health centre. These are attended by the staff members of health centres and sub-centres to discuss the problems associated with the tasks. At times, the participants may include trained traditional birth attendants (TBAs) and cadres. Once every three to six months, the meeting involves representatives from other sectors and community leaders to discuss intersectoral and community-based issues. The workshops are oriented toward monitoring ongoing activities and evaluation, and are closely linked to micro-planning and stratification of health centres. At the workshops, a review of activities for the following month is carried out and critical problems

chapter three

46

encountered by the participants concerned are discussed and solutions found. This promotes team work and co-ordination and the decisionmaking process. If necessary, yearly plans of action are modified at the workshop sessions.

Analysis of Issues Due to funding constraints, not all programme sectors have been implemented. Hence, every five years, specific priority areas are selected for implementation. Reports on kampung improvement programmes in Jakarta have shown that the private sector as well as non-governmental organizations have not been much involved. No mention has been made in the plans to involve the NGOs in the comprehensive programmes. From the review of the NGOs' programmes, although they cover health, sanitation and income generation, not much attention has been given to comprehensive health activities. Their focus has been mainly on the delivery of health services and the training of voluntary health workers. In implementing comprehensive programmes that cover health, education, family planning, nutrition and income-generating activities, two alternatives can be drawn. The first one involves a single agency which is responsible for funding and has the authority for implementation, while other related agencies are clearly subordinate. The second is that multiple agencies work together to develop effective results. The need for intersectoral co-ordination is recognized but the mechanism has not been developed in Jakarta. Other problems include the fact that co-ordinating bodies are not well organized. No meetings and activities are held. There are no permanent representatives of the sectors at the meetings. There is also no budget for organizing and co-ordinating activities. Community participation is also limited because: -

the village resilience units, or LKMDs, do not function well and, therefore, no workshops are organized; the leadership of the lurah (village) is not well organized, and at times the lurah dominates the workshop. On the other hand, the village leaders do not have a clear idea of what the community problems are. Often, a long list oftasks is proposed without prioritization; the meetings are short and the proposed programme is not discussed adequately;

Health Policies and Programmes in the Four ASEAN Cities

-

47

the health centre personnel do not co-ordinate with the community .

The targets of the programme s are mainly mothers and children. As a result, most women are involved in the health care activities and almost all community -based activities are directed towards maternal and child health. Other local problems, such as tuberculosis and the prevention of dengue haemorrhag ic fever, attract attention only when the number of cases rises. In some areas the three managemen t tools are utilized by health centres to evaluate the supply of services (programme s, facilities, etc.) and the demand as well as the needs ofthe people. Appropriate intervention can then be designed and modificatio ns of vertical programme s carried out. Some problems encountere d in the application of these tools are the lack of capability of health personnel to use them and the limited number of manuals available so that not all staff members of health centres are familiar with their use. Ideally, the puskesmas should adapt its health programme s to the needs of the people in the work area. The target for each programme , however, is usually set at the provincial level or even at the national level, and thus, does not take into account the situation at the local level. Metro Manila, Philippines31 There is no specific national policy on urban health in the Philippines . However, in the past, the National Health Plan, the Human Settlements Policy, the Philippines Food and Nutrition Programme and the Population Programme Policy indirectly reflected the needs of the urban poor in their draft plans. For Metropolita n Manila, an urban area composed of four cities and thirteen municipalit ies, Executive Order 4-77 created the Health Operations Center (HOC) for providing technical supervision , co-ordinatio n and monitoring of the services in the area. Likewise, Section 4, no. 11 of PD 824 created the Metro Manila Commissio n (MMC) to act as a central body in co-ordinatin g and monitoring governmen tal and private activities pertaining to essential services such as transportati on, flood control, drainage, water supply and sewerage, social, health and environmen tal services, housing, park developmen t, and so forth. The urban health programme as reflected in the National Health Plan continues to implement existing health and health-relat ed

48

chapter three

legislation encompassed in the policies of the National Development Plan ofthe country. The following major health policies were adopted and implemented: 1. institutionalization of the primary health care (PHC) concept; 2. development and utilization of resources indigenous in the

community;

3. improvement of intra/intersectoral collaboration in health care

delivery;

4. development of a hospital-based referral system that would

serve the needs of the population at a minimum cost but with maximum effectiveness; 5. provision of accessible, appropriate and adequate health services; 6. integration of the private health sector into the total health delivery system; and 7. improvement of existing programmes and formulation of new programmes in support of primary health care. The non-governmental organizations that participate in the development of primary health care for low-income groups include the Philippines Paediatric Society, the Philippines Medical Women's Association, the Maternal and Child Health Association of the Philippines, the Philippines Academy for Family Physicians, the Council for Primary Health Care, and mutual self-help groups. Others involved include civic groups, such as the Rotarians, Jaycees, and Lions; religious groups, such as the Sisters of Charity, and parish groups; and student groups such as the clinical affiliates, post-graduate interns in private schools of medicine and allied professions.

Co-ordination Within and Between Sectors The primary health care committees, the population committees, the development councils at the regional, provincial, municipal and barangay levels have existing mechanisms that can provide closer co-operation within the health sector and to secure the participation of other sectors in health programmes and projects. The Quezon City Health Programme The past decade has shown that the Quezon City Health Department has been sustaining its efforts to improve the overall health and nutrition status of the population through the delivery of com-

Health Policies and Programm es in the Four A SEAN Cities

49

prehensiv e health services to the people. Strategies aimed at encouragi ng communi ty involvem ent and participat ion in all health programm es have been adopted. The objectives enunciate d were as follows: 1. effective provision of essential health services;

2. improvem ent in the impleme ntation of preventiv e and promotive health programm es; 3. improvem ent of the skills of all health and health-rel ated workers at all levels, including those in the communi ty; and 4. more aggressive health informati on and education campaign s and activities for the public.

These are aimed at reducing the infant mortality rate, the crude death rate, the crude birth rate, second- and third-degr ee malnutrit ion as well as the incidence of common infectious diseases, such as pneumoni a, diarrhoea and measles.

Health Manpowe r From the 336 staff members in 1975, the manpowe r strength at the Quezon City Health Departme nt grew to 547 (a 62.8 per cent increase) in 1984. Two-third s of the working force were directly responsib le for the delivery of health services. To cope with the increasing demands, the Health Departme nt expanded from 29 health centres and 2 Lying-in DOS Clinics in 1975 to 43 health centres and 4 Lying-in DOS Clinics in 1984, and to make the delivery of basic health services more effective, the city was divided into five health districts in 1982, compared to four in 1973.

The implemen tation of the nutrition programm e was transferre d from the Social Services Departme nt of the Mayor's Office to the Health Departme nt in 1975, and a nutrition service was added to the programm e in 1976. In 1977, it was expanded with the training of communit y-based nutrition workers, known as the Barangay Nutrition Scholars (BNS). In 1981, the Interventi on Referral Center for Drug Abuse Preventio n and Control was incorpora ted in the five Mental Hygiene Clinics. In 1979, the POPCOM Outreach Project was expanded to meet the increasing demands for the control of sexually transmitte d diseases as a result of rapid urbanizat ion. Another clinic for the control of sexually transmitte d diseases was added in 1984 in the Project 7 Health Centre. Providing adequate support to the basic health service delivery system were the pharmacy , laboratory ,

50

chapter three

veterinary medicine, food and drug, local civil registry, administrative and planning services. Budgetary allocation for the city health programmes increased from P2,086,311 in 1975-76 (covering 1,054,000 people) to P15,500,857 in 1984 (covering 1,442,036 people). These were earmarked for personnel services, maintenance and operating expenditures, and capital outlay. The personnel services accounted for two-thirds of the total health budget, while maintenance and operating expenditures accounted for 16.95 per cent and 7.33 per cent of the capital outlay respectively. In 1984, as a result of several presidential directives calling for budgetary restraints, the capital outlay was severely cut to a mere 2.3 per cent, while the allocation for maintenance and operating expenditures was increased to 25.4 per cent. The budget for personnel services was slightly reduced to 72.7 per cent.

Policy Development Measures taken were directed towards the maximum utilization of identified available resources for health service delivery. The involvement and participation of the community from planning to the delivery of services were encouraged, and intrasectoral and intersectoral linkages were strengthened. Efforts were also made towards the development of self-reliance among the people through continuing health education. Programme Development The components of the health programme were as follows: 1. Maternal and child health (MCH) 2. Communicable disease control (CDC) a) Expanded programme for immunization (EPI) b) Tuberculosis (TB) control c) Control of diarrhoeal diseases (CDD) d) Control of sexually transmitted diseases (STD) e) Disease surveillance and epidemiological investigation 3. Nutrition 4. Family planning 5. Environmental sanitation 6. Mental hygiene and drug abuse 7. Continuing education and staff development 8. Medical/nursing care (morbidity clinic)

Health Policies and Programmes in the Four ASEAN Cities

51

9. Dental service 10. Health education, information , and communica tion. To face the challenges, two community -based programme s were adopted in 1984 to bring the health services to the grass-roots level. They were the Urban Primary Health Care Programme and the Herbal Medicine Programme .·

Urban Primary Health Care (UPHC) Programme Primary health care is basically a community developmen t strategy using health as the point of entry. It consists of four processes: 1. Initiate dialogues to make people aware of and identify common problems that will lead to their solution; 2. Change people's attitudes and behaviour by improving their relationship with others and their social and natural environmen t; 3. Build community groups for action within the area and link them with all community -based health agencies; and 4. Set in motion processes to create skills and assets. The Urban Primary Health Care Programme (UPHC), as adopted by the Quezon City Health Department , aimed to: 1. develop individual, family, and community self-relianc e in health

care;

2. develop better intersectora l and intrasectora l collaboratio n and

co-ordinatio n at community level; and 3. ensure that all health services are made available, accessible and relevant to the needs of the people. There were 161 community health volunteers trained to man the different health stations established in the ten pilot areas. A community health volunteer (CHV) is an indigenous member of the community given the task of performing simple health and health-relat ed services, serving as a link between the community and the different governmen t and private organizatio ns, and monitoring the health of the families assigned. The CHV performs a purely voluntary task without any remuneratio n. Before undertaking the task assigned, the CHV undergoes an intensive training programme for two weeks, aimed at developing skills in communica tion, health education, and simple nursing care. The CHV is also trained to give first aid, simple remedies for cases like fever, colds, and headache,

52

chapter three

and provide oral hydration for simple, uncomplicated diarrhoeal cases. The CHV is under the close supervision of the health centre staff and maintains close links with other extension workers in the community, such as the barangay nutrition scholar, the barangay service point officer, and the day-care nursery worker. Part of the thrust of the UPHC is to encourage self-reliance among the members of the community. Several income-generating projects have been activated in the ten pilot areas. These projects include hatmaking, vinegar production, garbage recycling, and cloth butterfly making. One community conducted a rummage sale, the proceeds of which went into the furnishing of the health station. In all the pilot barangay, "Operations Linis" (Clean-Up) was also conducted. To keep the partnership approach alive, the health centre staff and the CHVs maintain a continuous dialogue with the barangay leaders through monthly community assemblies. During these meetings, the leaders are given information on the health situation in the barangay and the health problems, as well as the services provided. Thus, a two-way communication is established. Linkages with representatives of agencies such as the Quezon City General Hospital, NAWASA (National Water and Sewerage Authority), and the Engineering Department, are also established through these community assemblies.

Herbal Medicine Programme Guava leaves for diarrhoea; ipil-ipil seeds for worms; langundi tablets for cough, cold and fever; and sampaguita flowers for an eye washthese are some of the traditional plants and herbs used in treating specific ailments. These plants (herbs) were relegated to the background with the advent of modern-day pills and tablets. However, the present economic crisis has not spared the people the cost of modern-day pills and tablets which has spiralled beyond the reach of the ordinary people. The Quezon City Health Department thus adopted the Herbal Medicine Programme aimed at establishing herbal medicine gardens in all the health centres and health stations in the city. A training programme for all pharmacists, drug inspectors and health district staff was also initiated in October 1984. The objective of the programme was to provide the personnel of the department with the technical expertise on the recognition and use, and the preparation of these traditional medicinal herbs and plants, as well as to transfer this expertise to the communities.

Health Policies and Programmes in the Four ASEAN Cities

53

Integrated Development Programme on Health More recently, the Department initiated an integrated programme in health care with the following general objectives: 1. To maintain a population level in Quezon City suited to the

level of development opportunities that the city can provide; 2. To maximize the utilization of medical services and facilities of tha existing health agencies in the city through co-ordination and integration of their health services and programmes; 3. To increase the nutritional level of every city resident; and 4. To achieve and maintain a sanitary and attractive city environment. With these objectives, the tasks envisioned by the Department are: 1. To co-ordinate the activities of all departments pertaining to

the development of physically, mentally, and morally healthy city residents; 2. To regulate the balance of population distribution through comprehensive development of the city; 3. To co-ordinate with the regional and national agencies on plans and efforts concerning health, environmental sanitation, and nutrition programmes in Quezon City; and 4. To assume responsibility for health services to its populace. In line with these policies, the programmes would have the following components: 1. Population; 2. Health services and medical assistance;

3. Anti-air and water pollution;

4. City-wide environmental sanitation; 5. Nutrition;

6. Research and evaluation on population and health.

The specific objectives are: 1. To discourage population concentration in some areas of Quezon

City and to encourage the achievement of balance in spatial distribution of the city population; 2. To promote an integrated population control programme by involving not only the couple but the entire family, the "purok", the barangay, and the entire city in achieving a realistic city growth rate;

54

chapter three

3. To devise and adopt various systems and approaches in transmitting the city's population goals and policies to its residents; 4. To promote proper health care by increasing health consciousness among the city populace; 5. To concentrate on health services that are preventive in character; 6. To encourage physical fitness activities; 7. To improve existing health facilities of public and private health agencies; 8. To undertake continuous research and evaluation on the changing social conditions in the city to assure maximum and relevant health services, consciousness and environmental protection; 9. To encourage public participation in the realization of programmes pertaining to proper garbage collection and disposal; 10. To improve and maintain the city cemetery sites; 11. To identify possible cemetery sites to meet future burial needs in the city; and 12. To provide recommendations for the improvement of other funeral services in the city. Specific programmes designed to achieve the objectives included the following: 1. Information dissemination campaign on population control;

2. Family life education; 3. Research on urban change; 4. Population characteristics and trends; 5. Campaign against air, water and sound pollution; 6. Cleanliness and beautification; 7. Public places and homes; 8. Family operation "timbang" (programme to weigh children on a regular basis to monitor their nutritional status); 9. Green Revolution; 10. Nutrition education; 11. Prevention of communicable diseases; 12. Training on health and environmental protection at the barangay level; 13. Integrated services in city hospitals and health centres; 14. Barangay sports development;

Health Policies and Programmes in the Four ASEAN Cities

55

15. City-wide information dissemination on proper disposal of

solid wastes;

16. Citizen's participation in the efficient collection and disposal

of garbage; and

17. Identification and acquisition offuture cemetery sites

In 1986, a new project was developed entitled "People Development Towards Community Development" . The project had several phases. Phase I was the pre-planning phase. All agencies with programmes for the urban poor women and children met several times to discuss and analyse the situation of the target group as well as possible areas of co-ordination. As a result of these meetings, the group was able to assess the situation of the urban poor women and children; decide on the criteria for selection of target pilot areas; select the target areas; and establish areas of co-ordination. Phase II was the planning phase. The agency representatives formed and developed a programme called "Integrated Development Programme for Urban Poor Women and Children". Phase III, the pre-implemen tation phase, included launching of the project in four priority areas; establishing the base-line data; conducting community-in itiated activities; training and retraining of community health volunteers in order to establish the primary health structure; conducting a refresher course for the technical working group on community organization and development ; and organizing the work. Phase IV was the implementatio n phase, during which all activities would be done in the community. This would cover the period 1988-92.

Phase V would be the implementatio n phase. The goal of the project was the upliftment of the quality of life of the urban poor women and children in the selected blighted areas of Quezon City. By the end of 1992, it was expected that the level of awareness of various sectors, both government and non-governme nt, and the community on the situation of women and children in Quezon City would have been raised and their commitments secured. In addition, a comprehensiv e, effective and efficient delivery system for the provision of welfare/health services to the women and children of Quezon City would have been institutionaliz ed. Basic socioeconomic welfare services would also have been provided to the targetted communities. These basic services would include health and nutrition; education; income generation; legal/security and

chapter three

56

housing; spiritual; sports and recreation; and utilities such as water and electricity. The programmes also aimed at establishing the spirit of self-reliance among the targetted communities. The specific objectives of the project included: 1. the reduction of the infant mortality rate; 2. the improvement of the nutritional status of pregnant and lactating women; 3. the improvement ofthe nutritional status of pre-school children; 4. the reduction of morbidity and mortality from infectious diseases, particularly the immunizable diseases of tuberculosis, diphtheria, pertusis, tetanus, poliomyelitis and measles; 5. the reduction of the incidence of low birth weight infants, from 25.6 per cent in 1986 to 15 per cent; 6. the development of an information system, both at the micro and macro levels; and 7. the establishment of primary health care structures, such as day-care centres and crisis centres for abandoned street children.

The strategies included co-ordination/linkage/netwo rking, campaigns to motivate people to action, community organization, development, transfers of appropriate technology , and action research. The programmes consisted of various sectors: 1. Health and nutrition; 2. Community organization/ capability building;

3. Community upgrading; 4. Income generation/food production project; 5. Research, monitoring and evaluation; and

6. Protection of the rights of women and children.

The major activities can be categorized into two groups: agencybased and community-based. The agency-based activities included: 1. reviewing existing socio-economic programmes and services,

their delivery and utilization;

2. identifying existing constraints/problems that hinder the

attainment of the objectives of the different programmes;

3. developing a common programme plan of action for the

identified communities;

4. developing a sectoral information and feedback system at both

micro and macro levels;

Health Policies and Programmes in the Four ASEAN Cities

57

5. conducting refresher courses in community organization for

agency trainers; 6. evaluating slum and squatter areas for upgrading; 7. evaluating immunization programme coverage by cluster assessment; and 8. monitoring and supervising meetings. The community-ba sed activities included: 1. launching of projects in pilot areas; 2. establishing baseline data by actual survey in pilot areas; 3. community planning and organization; 4. community-in itiated activities; 5. training of community health volunteers and other forms of training as initiated/reque sted by the community; 6. provision of services by the community workers/volun teers to the community; 7. process evaluation by the community.

Management and Organization The project would be implemented under an agreed organizational set-up developed by the participating agencies. Six committees would be formed, each composed ofthe representative participating agencies and the community representative s. These committees, based on the programme components, would be responsible for: 1. community organization and capability building; 2. health and nutrition;

3. community upgrading;

4. income generating/foo d production project; 5. protection of the rights of women and children; and

6. research, monitoring and evaluation.

The committees would formulate and implement their respective programme plans of action (PPOA) which would include the tasks, activities and financial plans related to the programme. Each committee would be responsible for disbursing funds for the activities, subject to standard audit procedures. The committees were also expected to submit monthly reports to the Executive Committee. The six committees would meet as a body every quarter to evaluate the ongoing projects. A Care Group would be formed, composed of the chairpersons and co-chairperson s of the six committees as well as community

58

chapter three

representatives of the four districts of Quezon City. It would review, integrate and recommend to the Executive Committee the PPOA of the different committees and submit quarterly reports to the Executive Committee, NEDA and UNICEF. The Care Group would meet monthly to monitor the progress of the projects. The Executive Committee, comprising the different heads of the participating agencies, would review and endorse the PPOA of the different committees for fund approval. The office of the city mayor would give the final endorsement. It would be the signatory to all communications to the UNICEF and also endorse the release of funds. To facilitate programme implementation, the submission of reports and conduct of meetings, a project manager would be appointed from the members of the core group. He would be assisted by a technical assistant on a part-time basis. Appraisal of the Health Policies and Programmes It would appear that the health policies and programmes of the four cities studied have adhered to the tenets of the primary health care philosophy: comprehensivenes s, community participation, interagency co-ordination, vertical co-ordination, indigenous resource mobilization, and private sector involvement. However, the mode of interpretation in their implementation has varied so that the degree to which the urban poor has benefited from the health programmes has diverged widely. In Bangkok, the urban policy has been explicit in serving the people in the slum areas and providing assistance and free medical services to the low-income people. In Kuala Lumpur, no policy statement has been made that deals directly with the urban poor but the range of services has been deemed accessible to the entire population, including the underprivileged. In the city health plan of Jakarta, it was stated in the targets that "health services are available to all citizens of the city with special attention to the low income groups ... ". Specific mechanisms for reaching them include the allocation of 5 per cent of the budget for the hospitalization of the urban poor. While no national urban policy exists in the Philippines, the city health offices have drafted their own plans and the Quezon City Health Office has formulated a new project that focuses mainly on the "urban poor women and children". Backtracking to the Taylor and Willams paradigm, no mention was made in all these policies and programmes of how the needs assessment was undertaken or how the pre-existing trends and

TABLE 3 Comparative Analysis of Urban Health Policies and Programmes Bangkok

Kuala Lumpur

Jakarta

Metro Manila

Policy Statement (National)

not explicit on the urban poor

no national health policy for the urban poor

no national health policy

no specific national policy on urban health

Agency Specific

Bangkok Metropolis upgrade the quality and quantity of services; assist low-incom e people to obtain free medical services

provision of preventive and curative services by four govt. agencies, city health depts, Population and Family Devt Board, Ministry of Health, National Tuberculos is Centre and the University Hospital

Jakarta govt. health office has four major areas of coverage: health promotion , services, communic able disease control, and environme ntal health, multitiered

city health programme s for effective provision of essential services, improvem ent in programme implement ation

Role of NGOs

reaches a certain proportion of the population

number of agencies catering to the poor, needy, and handicapp ed

existent but face manpower and financial lack, and co-ordinati on problems

existent with specific programme areas

Intersector al minimal Co-ordinat ion

co-ordinati ng bodies for representat ives sit in the school health services, stage, planning at s committee mental health, kampung minimal at implement ation improveme nt stage

referrals by volunteers to Vertical Co-ordinat ion health centres and to hospitals

hospitals act as centres for receiving referrals

volunteer health workers refer to health centres, professiona ls, and hospitals

PHC committee s, population committee s and developme nt councils have plans for co-operatio n referrals to health centres and hospitals

60

chapter three

conditions were utilized in the definition of problems and the setting of goals. Although statistics have been generated by the city health offices, their utilization has not been specified. Agencies have been made responsible for the health programmes and services in the city - the Bangkok Metropolitan Authority (BMA) in Bangkok, the Ministry of Health and City Hall in Kuala Lumpur with their specific functions, and the city health offices in Jakarta and Quezon City. However, no systematic approach to health planning was adopted which aimed for a balance between the long-range strategies and short-term projects. Part of the problem may be the political nature of the appointment ofthe health department heads and the planners, which may be coterminous with the head of state. Mechanisms for Programme Implementation The strategies that have a direct bearing on the urban poor as laid down by the Bangkok Metropolitan Authority are "the upgrading of existing health facilities in the inner and outlying areas to increase coverage and quality of care; upgrading of six existing health centres to provide medical services to people in the outlying areas; and providing medical care to low income people". In Kuala Lumpur, health services- preventive, promotive, and curative- are delivered by "13 polyclinics located in high density low income areas with two general hospitals serving as referrals". These are conscious attempts of policy-makers to meet the needs of the urban poor. In Jakarta, a multi-tiered approach is used in which services start from the household level, with the regional hospitals at the apex, serving as in-patient and medical referral sources. To meet the needs of lowincome groups, integrated health posts have been established to provide basic services, with a vertical link to public health centres and hospitals. In Quezon City. the 1986 "People Development Towards Community Development" programmes aimed at the conduct of community-initiat ed activities and the training of community health vulunteers primarily for the urban poor women and children. In the Quezon City health programme, a specific urban primary health care model has evolved which is primarily people-oriented through dialogues, attitudinal and behavioural modification, community building, and skills creation. However, the health system needs resources to undertake these tasks and it was not explicit as to how these community mobilization processes can be effected. Likewise, evaluation should have been built into the new programmes

Health Policies and Programm es in the Four A SEAN Cities

61

to determine their feasibility and acceptabil ity, as well as to make necessary adjustmen ts. These integrated programm es on health have been phrased in such broad terms that it is difficult to translate them into specific implemen tation schemes, for example, such aims as "to maintain a populatio n level suited to the developm ent opportuni ties the city could provide"; "maximiz e the utilization of medical services and facilities of existing health agencies through coordinat ion and integratio n ... ". Clearly, the mechanis ms need to be clearly stated. While the integrated developm ent programm e on health specifical ly states the goal as the "upliftme nt of the quality of life of urban poor women and children" , the strategy for the achievem ent of this goal has not been worked out. It can be assumed that the inter-agen cy network will address these issues. Non-Gove rnmental Organiza tions These agencies abound in all four cities and have multifario us tasks. In Jakarta, they are given recognitio n by the Departme nt of Health and considere d as partn13rs of the governme nt in improving the health status of the low-incom e people. In this city, the tasks of NGOs involve the provision of basic health services and the improvem ent of the communi ty's self-relian ce. They are categorize d into religious, non-religi ous, and internatio nal organizati ons. Their activities vary from training, and communi ty organizati on, to services delivery. In Bangkok, nearly thirty non-gove rnmental organizati ons exist and function mostly on an ad hoc basis. Notable in terms of accomplis hments are the two political parties which are actively involved in the communi ty health projects that are based on the people participat ing in the planning and evaluation of their activities. However, the reach of these agencies is limited. In Kuala Lumpur, voluntary agencies provide a wide range of services independe ntly. In Quezon City, likewise, a number of civic and profession al groups assist the poor and the needy. Co-ordina tion While the virtue of co-ordina tion among sectors (private and governme ntal) has been extolled in the policies and programm es, the mechanis m by which this would be operation alized has not been extensivel y worked out. In a similar vein, the referral scheme (vertical co-ordina tion) has not been developed intensivel y. Attempts have been made to involve the communi ty and providers in the planning process.

62

chapter three

The Jakarta city health office has emphasized the need for the provision of training skills at the grass-roots level with a system of referrals. The three tools of microplann ing, stratificatio n, and miniworkshops are useful monitoring mechanism s, but there is a need to define exactly the mode of their implementa tion to ensure uniformity in the formulation of action plans. The Quezon City health plan involving people developmen t is moving towards a multi-agenc y, community -based programme that includes networking , advocacy and community organizatio n, although the mode of implementa tion is still under experiment ation so that lessons can be drawn for replication in other parts of the city. In linking the analysis of the health policies and programme s with the paradigm mentioned earlier, notable were the inadequate means of integrating operational with physical developmen t programme s, the lack of focus or intersectora llinkages and design, and the failure to review budgets to examine the financial feasibility of using selected strategies to include other programme elements within the health sector. There is a need to develop these goals, strategies, and policies in greater detail and precision so that each action programme involved in a particular sector can harmonize its activities within the overall framework of the city health plan. The different aspects of city health planning should be expressed in the policy papers, performanc e mechanism s, as well as standards. It has been noted that certain activities have been laid down (networking , advocacy, integration co-ordinatio n) in plans. A working handbook can be devised to describe all these activities, consistent with the specific proposal for which such activities will be undertaken. The Taylor and William strategy aimed at a balance between the formulation of long-range strategies and short-term action programmes . The process is reviewed as continuous and cyclical, moving through an entire sequence of tasks from the review of existing health conditions to the monitoring and evaluation of implementa tion. This model covers the entire planning, programmin g, budgeting, implementa tion, evaluation, and feedback sequence. In many of the health plans, a comprehens ive and cyclical approach to urban health planning was not adopted. Three areas of concern emerged in this analysis and review: the need for congruence between health policies and programme s in which goals and priorities are transformed into rules and guidelines within which the sectoral programme s will operate; the need for co-ordinati on of the sectoral programme s vertically and across the boundaries; and the need for

Health Policies and Programm es in the Four A SEAN Cities

63

flexibilit y to modify program mes and to update informat ion for feedback . The lack ofreleva nt statistics which constrai ns agencies in addressi ng health issues makes it difficult for city governm ents to reassess their requirem ents and to develop an adequate health program me. By and large, the commun ities have remaine d basically the recipien ts of health services, with the exceptio n of voluntee r village health workers who have been trained for referrals and basic health service provisio n. Thus, most pressing is the lack of a mechani sm for commun ity participa tion, such as how commun ity needs can be expresse d, and how regular dialogue sessions can be organize d to elicit the interest of the commun ity in participa ting in the planning , formulat ion, impleme ntation, and evaluati on of the health plans. While city governm ents have expresse d the desire to expand the health facilities , to operate public health centres and hospital s, and to improve the quality of services at all levels, the share of health in the governm ent budget is low and the prospect s for an increase are bleak. Increasin gly, the governm ent is turning to other sources such as the NGOs and the commun ity for alternati ves. Despite initiative s taken to formaliz e linkages with the private sector and the commun ity organiza tions, these have not evolved a well conceive d framewo rk for popular particip ation in urban planning and impleme ntation. This framewo rk would be essentia l in creating a consens us on health developm ent goals and program mes in the various health sectors. It would enhance the understa nding of health issues and provide a forum for the exchang e of views that would feedback to the health planning agencies the expectat ions and response of the people. The policies enunciat ed by the city health offices have the followin g characte ristics: goal-sett ing in terms of coverage , emphasi s on goods rather than the means by which they can be achieved , strong emphasi s on physical infrastru ctures (water supply, building sanitatio n, and drainage ), and the lack of interacti on with users, especial ly the lowincome groups. The emphasi s on short-ter m program mes leading directly to action is notable. In most of the cities, mention was made of the urban poor in the health plans but they have not been singled out in the program mes except in Quezon City, and to a certain extent, Jakarta and Bangkok . Limitati ons to the plans include the failure to consider longer-ra nge program me perspect ives in the need to impleme nt new projects, the inadequa te means of integrati ng socio-ec onomic with physical develop ment program mes, and the lack of focus on instituti onal linkages (horizon tal and vertical) and

64

chapter three

design. Longer term planning should be formulate d, with action plans and programm es being continual ly modified and updated. This can be done by setting goals, strategies, and policies on a chronolog ical basis, in more detail and precision, so that each action programm e and sectoral agency can harmoniz e its activities within the overall framewor k. Such planning can be reflected in policy document s and programm es.

chapter four

Perceptions of Planners, Policymakers, and the Community in Urban Health Programmes

T

his chapter will identify the critical issues of urban health management as reflected in the perceptions of current health programmes by the policy-makers, health service providers, and the community. In this analysis, possible new responses to the tasks facing urban health management in the region will be explored, placing emphasis on management and operational problems. According to Sivaramakrishnan and Green, prior to massive urbanization in the region, city management consisted of a few dayto-day functions, mainly in the delivery of essential public services (health care, water supply, sanitation, primary education, and so forth). The machinery of public administration for the discharge of these routine tasks was organized on traditional departmental and hierarchical lines, and sanctioned and defined by a slowly growing but substantial maze of rules and regulations. However, the recent migrations from the rural to the urban areas brought unprecedented problems far beyond the historical experience and capability of established institutions. The linguistic and cultural diversity of the cities increased, while the age and sex structure of the populations showed a progressive bias towards males and young persons. Family life and the stability it promotes deteriorated, and irreversible changes occurred in the organization of urban life in general. This rising flood of people overwhelmed existing health, sanitary, environmental

66

chapter four

and educational facilities and services. Moreover, as the cities grew, congestion and lack of access to industrial and commercial locations became serious problems. 32 Therefore, new initiatives had to be taken to accommoda te this phenomeno n. In com paring the strategies taken by the four cities, the perceptions on urban health programme s will be elicited from the three major actors: the planners, the providers, and the community . The philosophy is that urban health managemen t should not only be concerned with the basic routine procedures and the maintenanc e of essential infrastructu re and health services but also with innovative planning and experiment ation with alternative schemes. However, the constraints to which urban health managemen t is subjected by the relative scarcity of available finance and manpower is recognized. The Questionna ires Three sets of questions were formulated to address three groups of respondents - the policy-mak ers/program me planners, the health service providers, and the community . The detailed questionnai res are given in the appendices . For the policy-mak ers and programme planners, the questions included those on specific programme s addressed to the urban poor, the coverage and comprehens iveness of the programmes , the priorities, the social services sectors involved in urban health, the merits and limitations of the programme s, the ranking of primary health care components , the issues and problems related to the extension of health care coverage to the underserved , the involvemen t of hospitals and health centres, the obstacles to the expansion of primary health care, monitoring indicators, effective collaboratio n between the government and various non-govern mental organization s, community participatio n, evaluation in terms of coverage, sufficiency of services, resources within the community , and evaluation indicators. For the health service providers, questions were asked on programme coverage, linkage with other health and social service sectors, the degree of concern for the urban poor, specific activities, the frequency of interaction between the city health office and the community , the selection of recipients, the staffing pattern, the problems faced in service delivery, suggestions for an effective delivery system, assessment of programmes , ranking of primary health care components , obstacles to the expansion of primary health care in urban areas, community participatio n, and evaluation.

Percep tions of Planners, Policy-makers, and the Commu nity

67

n For the comm unity membe rs, issues raised includ ed the commo and known health proble ms of the commu nity, health faciliti es utilize d, obstac les to the effectiv e use of service s, rankin g of health of care compo nents, areas for commu nity partici pation , percep tion and mmes, the commu nity's capabi lity to partici pate in health progra evalua tion indicat ors. Policy and progra mme design s can lead to expect ed results when the proble ms and the mecha nism of health progra mme imples mentat ion are given consid eration . The limited capabi lity of policie ng induci in ints to influen ce progra mmes at the local level, constra commu nity partici pation , and the inabili ty of the poor commu nities that to mobili ze resour ces for the progra mmes are a few factors is It s. service inhibit the efficie nt deliver y and utiliza tion of health the within mmes percei ved that the manag ement of health progra le bureau cratic milieu is subjec t to politic al contro l so that multip To n. entatio implem and conflic ting goals are often encoun tered in mme bring these into the fore becom es a major concer n of health progra planni ng. The Respon dents The respon dents to the survey were selecte d from among the policymakers (indivi duals who were respon sible for the city health policy ers, formul ation and progra mme implem entatio n), the service provid r numbe the in noted were ons and random ly in the commu nity. Variati have could pines Philip the in r of respon dents. The small numbe mme been due to the timing of the intervi ew when the health progra the to ission Comm Manila Metro was being transfe rred from the staff. vel high-le the d affecte largely Depart ment of Health , which TABLE 4

Distrib ution of Respon dents by Catego ries Policy- Makers / Planner s

Cities - - - - - -

-------

- - - - -

Jakarta, Indone sia Kuala Lumpu r, Malays ia Bangko k, Thailan d Quezon City, Philipp ines

Service Provide rs

Commu nity - - - - - -

5

15

100

12

11

100

27

50

100

3

6

102

68

chapter four

Perceptions of the Current Health Programme Bangkok, Thailand Results of the survey among policy-make rs and programme planners, health service providers and community residents and leaders revealed that current health programme s, whether they are implemented by the Bangkok Metropolita n Authority, other government agencies or non-govern mental organization s, have not adequately covered the low-income communitie s. Nearly 60 per cent of the health policy-make rs and programme planners, for example, perceived that the BMA primary health care project had not covered the majority of the underserved . A similar perception also prevailed among the health service providers. Among those who responded that their programme s had specified targets on the percentage of the urban poor to be reached, only 18 per cent stated that their programme s had actually reached the specified goals. The extent of coverage of the present health programme s, perceived by the community 's residents and leader, was somewhat higher than the two previous groups of respondents . About 40 per cent of this last group of respondents stated that the present health programme s reached less than 60 per cent of the urban poor, and 41 per cent ofthe respondents stated that more than 60 but less than 80 per cent of the urban poor were reached. About 81 per cent ofthe policy-mak ers and programme planners gave the view that the programme s in promotive, preventive and curative health were comprehens ive enough to address the community 's health concerns. The percentage of health service providers who gave such a view was much lower, about 49 per cent. In terms of the adequacy of health services provided by the city and private organization s, policy-mak ers and programme planners said that health services provided by two-thirds of the non-govern mental organization s were inadequate. About two-thirds of the health service providers also gave the same view. The percentage of community leaders and residents who held similar views to those of the health service providers was, however, lower, that is, about 36 per cent The percentage of respondents who said that their programme s had linkages with other social service sectors was only 68. The BMA health service units' involvemen t in the provision of health care for the poor, as given by the health service providers, policy-mak ers, and programme planners, covered four areas, namely, outreach services, training, referral, and supervision . The hospitals' involvemen t was mostly confined to the provision of medical treatment through referral and occasional participatio n in outreach services. According to the health

Perceptions of Planners, Policy-makers, and the Community

69

service providers, problems encountered in the delivery of health services stemmed primarily from the people. They did not keep appointments, accept suggestions, or co-operate, and believed in traditional healers. The inadequate number of health personnel to provide services was mentioned by only one respondent. Suggestions for the improvement of services included the provision of health education, follow-up and home visits, including the organization of mobile clinics. Policy-makers and programme planners tend to perceive community participation in terms of having the community partially involved in and performing certain tasks such as in the provision of health education, implementation of certain activities, and coordination. Health service providers also perceived community participation in terms of tasks which the community had to perform. According to this group, the community had to be responsible for disseminating the information, motivating people to participate in the activities, attend meetings, and carry out some preventive and promotive health services, including referral. Community leaders and residents, however, perceived community participation in terms of the people contributing money or labour in the health service delivery. If the perception on the potential for a participatory programme is measured in terms of the community leaders' and the residents' willingness to participate in the primary health care programme, then the potential can be rated as "high" because 84 per cent of this group of respondents stated their willingness to participate. About 96 per cent of the health service providers and 63 per cent of the policymakers and programme planners expressed their willingness to have community leaders and residents take part in local health care deliberation. The attainment of health for all in the underserved areas is one of the stated goals ofthe BMA's health policies and programmes. However, the indicators which the policy-makers, programme planners and health service providers mentioned as being used for measuring the achievement of stated goals seem to represent the indicators which should be used rather than those which were actually used for the purpose. A number of indicators such as better health status of the people, equity in receiving health services, and the impact of the health project are either subjective or non-measurable. Furthermore, for some objective and measurable indicators, such as an increase in life expectancy, or a decrease in the number of malnourished children, there is a lack of required data and information, especially for the underserved areas. Data and information for the whole city are also lacking.

70

chapter four

Kuala Lumpur, Malaysia Policy-makers in this survey were high-level officials in the government and non-government agencies who planned the health programmes for the city. They included those who were not in the health departments but whose policy decisions for their departments would have an indirect impact on health, such as the officials of the Public Works Department, Drainage and Irrigation Department, and the Department of Environment. In the analysis of policy-makers' perceptions of the health programmes, the results varied. Health education ranked as very important to non-medical policy-makers but not to the medical personnel in terms of the impact on the health status. There was a consensus that the provision of safe water supply, sanitation, and food and nutrition was important to the community. There was likewise a common view that mental health and essential drugs were relatively unimportant. The non-medical group of policy-makers who essentially took charge of the basic amenities, such as water, housing and sanitation, felt that policies taken in their respective departments to cater to the urban poor were adequate although the implementation process was long as a result of financial and social problems. For example, the resettlement of squatters in new low-cost housing where all the basic amenities were available took time. The medical policy-makers, however, felt that if health facilities were upgraded, a better coverage could be achieved. Among the service providers in the government sector, there was a feeling that the government health programmes were adequate and comprehensive enough for the urban poor. However, there was room for improvement in certain areas. For example, there should be more polyclinics to cater to the large number of patients. Facilities in polyclinics should be upgraded to undertake investigative procedures. The other bodies perceived otherwise and felt that the health and medical services were inadequate and not comprehensive enough to meet the health needs of the poor. In terms of linkages, the government service providers generally felt that inter-departmental linkages in the government sector was satisfactory. Except for the Selangor and Federal Territory Family Planning Board, the other organizations felt that there was little communication between them. The government service providers had specific problems relevant to their own departments and posited suggestions for their improvement. The polyclinics found that there was patient overload

Perceptions of Planners, Policy-makers, and the Community

71

and not enough investigative procedures at the clinics. The Environmental Unit of the City Hall felt that the community did not play a useful role in environmental improvement. The maternal and child health services providers remarked that there was a problem in immunization coverage and compliance. The government service providers did not feel a need for community participation in service delivery as greater problems might arise when the community participated. They felt that in terms of the achievement of goals, their performance was satisfactory although there was room for improvement. Other agencies indicated that the demand for rehabilitative and supportive services was great. The implication was that the governmental agencies might have to expand their services to cater to this problem. The community perception of available health facilities and services was reflected in their utilization of specific services, the reasons for their choices, their assessment of the problems, and limitations of such services. The majority of the Sang Kancil communities utilized government health centres, followed by private clinics and the Sang Kancil maternal and child health (MCH) clinics. The two major reasons for the use of government health centres were the cheap fees and accessibility, and the two major factors for the use of Sang Kancil MCH clinics were reliability and the affordable rates. For the private clinics, the reasons were the qukk service and staff competence. It appears that the community perceived accessibility and low cost as important considerations, while the distance, the long waiting time and high fees were reasons for non-utilization. The majority of the Sang Kancil communities (65 per cent) perceived the available health services to be adequate. However, this was not representative of the slum communities. The limitations included inadequate services at the clinics, the lack of doctors, congestion, the lack of supplies (medicines) and the negative attitude of the clinic staff. The Sang Kanchil communities regarded immunization, maternal and child health care, and the prevention of endemic diseases to be the three most important components of primary health care. In terms of community interest, safe water and sanitation, maternal and child health, nutrition promotion, and immunization were ranked as important. The communities indicated that they could be involved and could implement the following components of primary health care: nutrition promotion; prevention of endemic diseases; provision of essential drugs; treatment of common diseases and injuries; and safe water

72

chapter four

and sanitation. Safe water, sanitation, and nutrition promotion would attract the highest degree of community interest and could be implemented by the communities. They also felt that there was high community interest in MCH and immunization but the communities would not be able to implement such projects.

Quezon City, Philippines President Aquino, upon assumption into office, transferred the tasks of health programme planning and policy formulation in the urban areas from the Metro Manila Commission to the Department of Health. The policy-makers, in this case, were mostly the city health staff. They felt that there was already a specific programme addressed to the urban poor, citing the plan of action for the urban poor women and children of Quezon City, which is a multi-agency programme involving the delivery of basic socio-economic and welfare services using volunteers. The activities included immunization, health education, fluoridation, nutrition, safe water supply, food sanitation, maternal and child health, growth monitoring, family planning, breast feeding campaign, and parasite and diarrhoeal disease control. The planners recognized a number of social services involved in health care. The problems, however, were lack of sustained co-ordination and collaboration, logistics support, lack of political will, and variations in agency priorities. The major issues related to the extension of services to the underserved were lack of manpower, lack of political will to support the programme, fast turnover of community volunteers, population mobility and community attitude. Community efforts could be systematically linked with government efforts if there was a continuous and sustained dialogue as well as a defined linkage mechanism. The policy-makers felt that the community should take part in local health deliberation and should be self-sustaining in financing basic necessities such as water supply, housing, and income generating activities. Achievements had fallen short of targets as a result of the lack of resources and manpower. Most ofthe health providers felt that the current health policy was not geared to the health needs of the urban poor because of lack of supplies (medicines) and centralized policies. Problems besetting them were the lack of medicines, inadequate personnel, lack of facilities, and the poor attitude of the community, which could be improved through motivation, information, and education programmes. Some suggestions for the improvement of health service delivery included giving incentives to volunteer health workers,

Perceptions of Planners, Policy-makers, and the Community

73

developing intersectoral linkages and community participation in health care, and involving the health providers in programme planning. A campaign for immunization was being undertaken on a participatory basis in the community. The major obstacles to efficient delivery of health care services in the community were the lack of supplies or medicines, the poor attitude of the staff, and manpower inadequacy. Very few were aware of a participatory programme in the community and most wanted to participate through the provision of services once or twice a week or through financial contributions (P1-P5/US$0.25) for the purchase of medicines. Most of the respondents felt that the community was not yet ready to participate in the planning, implementation and evaluation of programmes. They indicated that targets had not been reached and services were inadequate to meet the service requirements.

Jakarta, Indonesia All the respondents mentioned that they had services for the urban poor. A problem, however, was that the slum areas were scattered throughout the city, precluding adequate sectoral co-ordination. The inadequacy of some programmes emanates from the limited reach of hospitals, the sporadic delivery of certain services, the lack of facilities and manpower, the geographic location of the programme areas, the limited operation of the mobile puskesmas (health centre), the lack of co-ordination and cross-sectional co-operation, the social gap between the clients and the providers, and poor utilization of services by the urban poor. Increased co-operation between the government and non-government organizations could be achieved through workshops, information sharing, debureaucratization, deregulation, and co-operation between the city health council and the sub-council. The respondents recognized the need for community participation to develop human resources, and to complement government efforts. All respondents mentioned the presence of a community participation programme in their health jurisdiction either run by the public health centre, the village self-reliance council, or the private sector. Activities included raising funds, developing an integrated health service programme, cadre training, promoting good sanitation, and immunization. However, the level of community participation ranged from average to low. All the respondents agreed that the community leaders should take part in health care activities

~

~~ff~~

because of their authority and influence in the community and the potential for augmentation ofthe government's programme in support of the bottom-up planning approach. The methods suggested for community financing included donations, revolving funds, insurance system, mutual aid, contribution of members, and assistance of nongovernmental organizations. Achievements have fallen short of targets because of the lack of manpower, the negative attitude of the health providers, limited facilities, the community attitude, and budgetary constraints. While monitoring has been done through activity reports, suggestions for evaluation included an information system, pre- and postimplementation surveys, assessment of secondary data, third-person evaluation, and comparison of targets with results. All providers mentioned that services were geared towards the needs of the urban poor, and they were appropriate and adequate. Some problems encountered in the delivery of services were lack of cadre trainers, poor environmental sanitation, lack of community knowledge of the importance of health and nutrition, and ignorance on the part of the client (such as not wanting to wait in line for a service). Most of the providers were not aware of community participation programmes in their community and felt the need for an institution to mobilize the community. Financing schemes included mutual aid, insurance, and regular donations. The major obstacles in the use of health facilities, as posited by the community, were the fees, the attitude of the health personnel, long waiting times, poor services, and absence of doctors. While 40 per cent of the respondents felt that they were in a position to channel their views on appropriate programmes, the majority felt incapable of participating in health planning activities and programmes. Manpower was the major resource that could be mobilized, and most of them were willing to participate in health activities through labour provision (85 per cent), and monetary support (51 per cent). Ranking of Health Priorities The three groups of respondents were asked to rank the components of primary health care. In so doing, priorities were elicited. Likewise, the congruence of responses was delineated. Three main areas explored were the impact on health status, the capability of attracting community interest, and possible areas of community participation.

Perceptions of Planners, Policy-makers, and the Community

75

The respondents were asked to rank each component of primary health care according to the number of items. The average scores for each component were obtained and these were ranked, with the lowest score being the first in rank and the highest, the last.

Bangkok, Thailand Divergence in views was observed in Thailand where health education was considered by both the health providers and planners as having the greatest impact on health status, while the community felt that immunization was important, with health education ranking second. Again, differences were noted in terms ofthe areas attracting the greatest degree of community interest. The community indicated pollution control, while immunization and safe water and sanitation were posited by the providers and planners, respectively. Although eight components of primary health care are recommended by the World Health Organization, in Thailand in general and in Bangkok Metropolis in particular, five more components have been adopted: oral hygiene; mental health; the welfare of disabled persons; prevention and control of drug addiction; and health care for the elderly. However, these five additional components received relatively low ranking - that is, seventh or eighth- by the three groups ofrespondents with respect to different aspects, such as having the most impact on the health status, and being able to attract the greatest degree of community interest. It was found that the degree of agreement between the health service providers and the policy-makers and programme planners tended to be higher in many aspects compared to the degree of agreement between these two groups of respondents and the community leaders and residents. Jakarta, Indonesia Safe water and sanitation were considered important by the community in the two areas related to community attraction and participation. With regard to the impact on health status, immunization was considered important. The health providers shared this view in the area of community participation. However, the health planners viewed health education as having the greatest impact on health status, curative care as attracting the greatest degree of community interest, and nutrition as the most significant area for community participation.

TABLE 5 Ranking of Components of Primary Health Care (Bangkok, Thailand) Specifimtion Impact on Health Status

Cornn1r1nity

1. Disease prevention 2. Hcalth cducation 3. Nutrition promotion

4. Imnuinization

5. 6. 7. 8. D.

10. 11. 12. 13. Attracting the Greatest Degree of Communi tv Interest

Safe water and sanitation Disease control Esscntial drugs Pollution control Mental health MCII Oral hygiene Aged health care Disabled welfam

1. hn1nunizatiun

2. Pollution control

3. Disease prevention

Promising Areas for Community Participation

4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Essential dmgs Disease control Water supply Health education MCH Nutrition promotion Mental health Oral hygiene Aged health care Disabled welfare

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Pollution control Water supply and sanitation Disease prevontion Health education Disease control Essential drugs Immunization Nutrition promotion Mental health MCH Oral h ygigional Heelth Offic of North Jakarta Puskcsmns (District & Subdistrict)

PCF. POPCOM, Quzon City Health Office

Dt>partnwnts within the DM1\ (Health. Social Welfaw. Polin' & Planning. District Offic)

City Hall. Kuala Lumpur, Cynaecologist from Llnivursitv of Malaya UNICEF

2. Funding &

l'ERDHi\KI, Bishop Association. Ford Foundation, I'PIA. IIJRC. Ministrv of Health. Alma Java Hospital

lJNFI'A, PCF. Quezon Citv Health Offic. J'OPCOM, NElli\. MOl{, MLC, NCP

BMA Social St>n'ic Sector. other NGOs, UN!CEI' Community Contmittl~P. & Primary Hr~allh Care voluntm~rs under the supervision of BMA health officials

City Hall, Kuala Lumpur, Ministrv of Fedrmil Tmritorv. UNICEF. KEMAS, SKOSS. UN!Jl'. University llospital. /OlCFI', General Hospital. INTAN. lc.

lmpl(~IIJHntatiun

D. Whtm Est184

t'lH4

1'l7H

2. In project site .studied

19il4

191l4

1~JBI)

1'l7D

Project SitH

R\'\1 08 Pcnjaringan Subdistrict, the KlA post in RV\1 011 and llKl programnH; in RV\1 0". 07.

Dcpressr:!d conimunity in Quezon Citv

CongcstPd slum district in Bangkok Mdropolis

Selected squatter

KK Dcept. RW & RT !leads. l'KK LKMD nwmbers. City Hcolth Offic. Puskesmns. BKKDN. Alma Jaya Hospital

Project staff

Blvli\ Dt>pl. of Health Officials [ lJirer:t m-Cerwral & Deputy Ili rr'ctor-( ;.,nera I)

4 nurse practitioners from City Hell to run clinics. fidd workflrs

Health cadn;s. PKK. RW/Kl' Heads

Community nwmbers. Harnngoy Health Managers, & Volunteer Health Workers

Community leaders clr,ctnd bv residents & officials in the r.omn1unitv

PnJ-schooi

srJttl~:ments

OH, 01:!, 015 & 017

U. PPrsomwl 1. ProjPct Propmumls

&

2.

Communi!~·

teacht~rs

TABLE 11 (cont'd) Comparison of the Four Participatory Urban Health Care Projects in Four Cities of the ASEAN Region Penjoringon {l!u!onesin)

(,'hnrricft:risth ·.-..

Role of

Privalf~ St~dor

Alma Jaya Hospital~ JHO\'ision

of hnaJth

S!)fYiCt!S

Capri (J'!Jiliflj!illr'S)

-lead role ill projHd dm>ign & impknwnlation -[raining of trainers. \·oltlllle!~l' ht!