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Providing Primary / Reproductive Health Services in Asian Urban Areas with Attention to Vulnerable Populations, Especially Women and Girls

Section Two - Nine AUICK Associate City (AAC) Reports

9. Surabaya, Indonesia


Introductory Notes

A Historical Background of the RH Program in the City of Surabaya

The MCH Program in Surabaya

Statements of the Policy Makers, Program Administrators and Community Workers

MCH and Performance Indicators

Concluding Notes


Prof. Haryono Suyono, MA, PhD 
Member of AUICK International Advisory Committee (IAC); 
Vice Chairman, DAMANDIRI Institute (Member, AUICK International Advisory Committee) 
Prof. Kuntoro, MD, MPH, DrPH 
Professor of Biostatics and Population Study, Airlangga University, Surabaya (Participant of AUICK Second 2008 Workshop) 
Sunarjo, MD, MS, MSc, PhD 
Head, Department of Public Health and Preventive Medicine, Airlangga University School of Medicine 
Pudjo Rahardjo, MPIA, PhD 
Deputy Executive Director, DAMANDIRI Foundation (in charge of Program Education and Training), DAMANDIRI Foundation Nunik Puspitasari, BSPH, MhealthSc Faculty of Public Health, Airlangga University 

Surabaya Map

Introductory Notes

This study was undertaken as part of the long-standing collaboration between AUICK and the City Government of Surabaya, and with the strong support of DAMANDIRI Foundation, implemented in collaboration with the Indonesian Institute for Human Development (IIHD). 

The study aims at assessing the implementation of the Millennium Development Goals (MDGs). To this end, of the eight goals of MDGs, Goals number 4 and 5 are devoted as the focus of our assessment, i.e. the reduction of maternal mortality and the improvement of child health, including family planning/reproductive health, especially as these are applied at the grass roots in the City of Surabaya. 

The City of Surabaya is the second largest municipality in Indonesia, Jakarta as the nation’s capital being the first. It is the capital of East Java Province, and is also second in the volume of business and manufacturing industries in the country. As a large municipal area, it embraces a vast complex social and economic environment, including the population segments of the more and less fortunate social status. This is manifested in the overcrowding of certain sites within the city, the apparent dichotomy of housing complexes and urban slums. It is in this regard, data collection and availability is rife with problems, as this study reveals. 

The study is done in two stages. Firstly a qualitative assessment was done with in-depth interviews with major informants, i.e. major policy decision-makers, and program implementers and administrators at the county level and down to the grass-roots community workers. Simultaneously, secondary data collection and processing was done utilizing service statistics at the municipal level, from various health and other related agencies. 

Important to note is the fact that not all of the required data are available, in which case the study team were compelled to resort to two options, i.e. (1) to impute the data based on available proxy information, and (2) to imply and interpret concluding notes from the qualitative information (from the in-depth interviews). 

The study team comprises of experts and staff of the Indonesian Institute for Human Development (IIHD) and Airlangga University, the DAMANDIRI Foundation, INSTAT Foundation, and the active participation of the respective local government branches in the city. 

A Historical Background of the RH Program in the City of Surabaya

Surabaya is the second largest city in Indonesia, and similar to Jakarta, the capital of the nation, it is inhabited by various ethnic groups, each with its own customs and value system. As a major metropolitan city, it is characterized by modern health services (according to the national health standards), it is also the education hub for the surrounding areas, and it is abundant with recreational facilities, and other urban development activities, such as real estate and housing developments. 

Surabaya is also an autonomous city, as are other government structures such as the provinces and counties (Kabupatens). In that regard the city government has to generate its own budgetary resources, although some activities are subsidized by the central government. It is headed by a Mayor as the Executive Officer for the City, assisted by the city parliament or City Council as these are known elsewhere. In fact the municipal or city government can be looked at as the miniature government of the whole country. 

The governance structure of the city divides Surabaya into 31 sub-districts (Kecamatan) and 153 villages (Kelurahan). Further down, each Kelurahan is divided into Community Organizations (Rukun Warga=RW) and into smaller units of Neighborhood Associations (Rukun Tetangga=RT). Surabaya has 1.350 RWs and 8,762 RTs. Being the smallest unit in the structure of governance, each RT consists of about 30 households. These RTs and RWs are headed by volunteer chairpersons, thus reflecting the principle of democracy throughout the country. 

With regards to the national health system, each Kecamatan should have at least one PHC (Public Health Center = PUSKESMAS), as well as the whole string of the educational system from Elementary to First Secondary and Senior Secondary Schools. Further on the community health development, each local community in the villages establishes their own POSYANDU (Integrated Family Planning and Health Posts), and also their own POSDAYA (Family Empowerment Posts). The Posyandu actually serves to ensure that the coverage of primary health and MCH services are extended all the way down to individual families. 

The above brief is a cursory description of the governance of Surabaya and the basis of operations with regards to the Millennium Development Goals (MDGs) and any other community development efforts. 

As a major metropolitan city, Surabaya has attracted in-migrants from neighboring Kabupatens and also from adjacent provinces, especially from the eastern part of Indonesia. The attraction is not only its seemingly unending employment opportunities which, by the way are becoming scarcer with the years, but mainly it is the educational facilities the city offers. As the city’s population nears its saturation point, i.e. where the carrying capacity of its opportunities has become so much reduced, the catchment or buffer zone has shifted to the outskirts and just beyond the city’s administrative boundaries. Hence, housing developments prosper in the neighboring Kabupatens, yet on workdays people flock to the City in great numbers, whereas at the end of the workday the influx go in the opposite direction. The consequences of this phenomenon are numerous, e.g. in the tax revenues of the city as well as the deteriorating social and recreational facilities. 

With regards to the living conditions and the quality of life in the city, whereas one could see marked and significant progresses made, challenges are abound as the following paragraphs portray. 


The MCH Program in Surabaya

Summary Figures 

The following is a summary table of RH and FP services in Surabaya. Note that most data are not specifically available, and the years may not be sufficiently circumscript. Two sources are resorted to, i.e. the Surabaya Municipal Health Office, and the Surabaya Statistical Office. 

Surabaya Basic Data on Health, Family Planning and RHSurabaya Basic Data on Health, Family Planning and RH (Continued)

The above data are obtained primarily from the Statistical Office of the Municipal Government of Surabaya, and from the City Health Administration Office (Dinas Kesehatan Kota). Other sources were the Faculty of Public Health of Airlangga University and the Office for People’s Empowerment (Bapermas) of the City of Surabaya. One could readily observe that in general the data is not yet specifically geared toward obtaining information on the effectiveness of services or the impacts of those services. Rather it is a rather haphazard collection of ad hoc service statistics of the various branches and divisions in the Municipality Office and of the various Municipal Health Offices. One could see differences of those data in the description presented in specific paragraphs of this report. 

Preceding the analysis of the available data, the following presents an analysis of the views of the city administrators and community workers. 

Statements of the Policy Makers, Program Administrators and Community Workers

The following paragraphs present the summary of findings obtained from the in-depth discussions with major informants of the present study. Important to note is that the informants were the Mayor, Vice Mayor, the City Health Administrator and his Senior Staff, a sample of sub-district Heads (Camat) and Village Heads (Lurah), and a number of community leaders and NGOs working in the communities. In addition, senior lecturers who are intimate with community efforts in Surabaya were included as informants. 

The Mayor of Surabaya has shown his strong support to the overall health and RH programs since early in his term of office. He actually promotes family planning and reproductive health in virtually all his political and public statements. The study also interviewed and discussed the multiplex issues of RH with the opinion and political leaders and members of the Surabaya Municipal Council, the City Health Authorities and prominent NGOs such as the city’s Family Planning Association. In a more specific term, notes on the various issues were recorded by the study team as the following. 

On the issue of the importance of RH:

In various discussions with the study team the Mayor indicated his concern on the increasing trend of the prevalence of HIV/AIDS in the City. To his opinion the figures indicate the lack of knowledge of the people in general on the dangers of this disease and knowledge on its spread. In this, he advocates for increased socialization and Information, Education and Communication (IEC), particularly as directed towards the younger ages of the population, including the youth and young couples. He also advocates that IEC should commence at the youngest possible age segment of the youth. In this regard he emphasized the importance of RH education, with special emphasis on issues related to STD. This position is shared by virtually all upper echelon policy decision-makers in his administration. 

With regards to family planning, viewpoints are shared by the Mayor and most of his administrators, all the way down to village heads and village volunteers. In the many public statements the Mayor emphasizes the importance of population growth and development, and more specifically the significant link between family planning and family welfare. This stance is reflected in statements by other policy decision makers at the municipality level of Surabaya and their subordinates at lower levels. 

On issues related to infertility, the Mayor and his senior staff are ambiguous, as this issue is not at the top of their priority list. Yet, on the issue of safe motherhood, they appear to be on the same page with regards to the urgency of the matter and the need to significantly lower the rate and ratio. They do understand that it is an important indicator of people’s welfare and of Human Development Index (HDI). 

On the level of RH conditions: 

The various informants of this study appear to agree that RH conditions in Surabaya need more improvement. The arguments, however, differ among the informants. The Mayor is of the opinion that competition among inter-agency priorities is the cause of the lack of quality of RH services, and thus the need for improved RH conditions in general. 

Health Authorities are of the opinion that they have done their utmost, yet what is lacking is the total commitment, resulting in the lack of the desired conditions of RH. However, by-and-large the RH conditions are improving, although not as rapidly as they would wish. 

The political sphere, as reflected in the City Council opinion, is that in general they are satisfied with the progress made thus far with regards to RH conditions, although they would argue and strive for more efforts in improving the conditions. This is not totally shared by the NGO circles, as they blame the municipal government for not seriously putting their efforts into improving conditions. However, they are of the opinion that things are improving and are looking up. 

On the priority the city gives to RH Services:

Overall, the general opinion is that the city government has given moderate priority, although the informants generally agree that the problem is indeed pressing. In the face of competing priorities, RH is relegated to being less important compared to the emphasis on physical infrastructure. An example is hygiene and sanitation, which the city government is putting so much energy to, and the results are indeed forthcoming, whereas in RH, where the challenges are less obvious, the slower improvements would not justify their high attention. 

On the other end, the government does encourage the private sector and the NGOs to do more. The NGOs, on the other hand, complain that they could not do more as they have very little command over resources and fund mobilization. 

On the issue of the resource availability for RH services:

After considerable probing, the general sentiment is that funding and resource allocation to RH services is somewhat deficient. This is especially in relation to the availability of personnel and service time especially devoted to the broad agenda of RH. This is understandable considering the fact that Health and Medical Services do carry a complex area of concerns, ranging from Communicable Disease Control (CDC) to health promotion and the regular medical services. 

With special regards to the overall City budget, and the allocation to health, MCH and reproductive health services, a cursory glance at the figures in Table 1 portray a rather unfavorable scenario. For the year 2009 the total city budget amounted to IDR 2,741,835,447,249, or the equivalent of around US$ 250 million. Out of this total, Public Health Center (Puskesmas) renovations and maintenance got 0.45%, health promotion activities got 1.33%, health services for the poor got 1.33%, MCH gets 0.02%, whereas the provision of drugs and equipment was allocated 0.34%. These figures and percentages appear to be minute to the total budget, but they are significant considering the number of competing programs and activities within the city, in all sectors, which can amount to hundreds. 

Within these figures, general RH services are included, as well as services to the poor and the “floating” populations. 

On the issue of specific needs to improve RH services:

On this particular issue the consensus among the policy decision makers as well as field implementers, including NGOs, appear to be focused on funds, personnel and equipment. In particular, policy decision makers urge the private sector to contribute more within the purview of funds, personnel and equipment. 

Important to add is that the private sector and NGOs are already contributing significantly, for example private schools are doing much more public education and advocacy in health promotion, including RH, compared to five years ago. Yet, policy decision makers would urge more NGOs and private enterprises to be involved in this endeavor. 

On the size of slums which are below poverty levels (US $2 per day) 

The City Government of Surabaya does not categorize its populations into slum dwellers nor the more affluent segments. Nonetheless, all are registered and ID cards are issued to all adults, regardless of their socio-economic status. Determining the socio-economic status of each individual family is done through the annual Family Registration system. One could, however, determine daily income levels from CBS data. According to CBS for the City of Surabaya, the percentage of the population having to live with less than US$2 per person per day is 24.64%. However, this segment of the population is not concentrated in a particular area of the city, rather they are spread all over the city. Hence, specific RH programs for them are not that discernable. Access for them to those services is made available through Public Health Clinics found in all sub-districts all over the city. They can also access RH services from FP fieldworkers operating in all villages in the city. Thus, they are not discriminated against, nor are they favored. 

With regards to increasing access to them, as they are neither favored or under-privileged to those RH services, the only avenue open for them to get wider access is to be motivated and encouraged to come to those service points. Even for those abject poor, access to free services can be obtained by requesting a letter from the village head stating their poverty status. 

Burden to the City caused by in-migrants 

The Health Administrators Office and the Faculty of Public Health of Airlangga University share the information on the magnitude of in- and out-migrants to and from the city that is recorded at the Population Services Office of the City Government, and appropriate statistics are maintained by the Statistics Office of the city. The statistics indicate the following pattern: 

Surabaya Migration

One would observe that the trend of in-migrants into Surabaya is relatively constant, with the exception of 2008, which is suspected to have been caused by the catastrophe in Sidoarjo District, where the continuous volcanic mud eruption caused people to move out and thus the larger influx into the City of Surabaya. The contrast is the steady and constant movement out of Surabaya, which is caused by various reasons, particularly the more affluent moving to the suburban areas outside the city boundaries, yet still maintaining their work in the city. Note that Surabaya is known as the second largest industrial center in the country, having numerous factories, especially in electronics and hi-tech plants located at the outer boundary of the city.

Concerning this portion of the out-migrants, the City still has to bear the burden of providing public services. For example, while living outside the City, they are still enrolling their children in the city schools system. Also, they still seek health and medical services in the city, where the quality is much better compared to where they are residing. Hence, the city still has to serve these “floating” populations. 

The above in-migrants and the circular migrants seeking employment and education can be termed as the “floating” population, which in all respects can be a threat to the overall health and welfare of the city. Hence, the need to provide “special” services for them. Whereas the magnitude of the number of this segment of the population is important, it is noted that the 2010 Population Census did obtain this specific data, yet according to the City Statistical Office the data is not yet processed, hence it is unavailable to the public. The needs for providing services for this segment are included in the elaboration on the non-discriminatory services for as long as they are registered at the respective RTs and RWs. 

MCH and Performance Indicators

Whereas Table 1 summarizes the general population and RH services in the city, the following data and elaborations are the more detailed presentation. 

The following table is a summary of the MCH program in the City of Surabaya. As one can observe, certain pertinent data are not available. Although there are interpolations using significant assumptions, the final conclusions are rife with different interpretations. While this is acknowledged, the following are submitted to portray the situation and conditions to date. 

Surabaya Performance Indicators of MCH and RH

1. Child Mortality (0-4 years old) per 1,000 Live Births 

At the moment it is difficult to obtain the data concerning mortality among children of 0-4 years old every year based on registration. Such data are obtained from surveys conducted by BPS (Central Bureau of Statistics). The causes of death of children under five years are mainly due to external factors such as lack of safe water, bad environment of housing, lack of nutrition, no accessibility to health facilities, bad nursing patterns for children including accidents and child abuse, and immunization not done during the first year after birth. 

In 2000, child mortality was 40 per 1,000 live births; by 2005 it had declined to 23 per 1,000 live births. These achievements are above the national target of Healthy Indonesia 2010. The target is 58 per 1,000 live births (Kep. Men. Kes. No. 1202 tahun 2003). These achievements are also above the target of the MDGs for 2015, which is 23 per 1,000 live births. Hence, in 2005 the City of Surabaya has achieved the target of the MDGs (MDGs BPS Jawa Timur). Community participation, Local government including institutions concerning MCH and family planning programs, and the private sector seem to have contributed to this achievement. However, all components should at least maintain this condition or enhance their performance. The child mortality rates in other cities and districts within East Java Province are still higher than that in the City of Surabaya. Hence, the city government should be aware of the possibility of increasing child mortality due to urbanization of people with low economic income, who have children with a high risk of contracting infectious diseases and live in bad environments with no access to health facilities. Other factors of which the local government should be aware are the knowledge, attitude and practice of mothers concerning utilization of the Integrated Service Posts (Posyandu) for promotive and preventive programs. Another factor is that mothers work outside their homes, while their children are raised by maids or other members of their families who do not care about the health of the children. One idea is for Posyandu to open at weekends to accommodate mothers who work outside of their homes. 

2. Infant Mortality (0-11 months) per 1,000 Live Births 

The Infant Mortality Rate (IMR) tended to decrease during the period of 2006-2009. During 2006-2007 the decrease was quite steep. Concerning the high Infant Mortality Rate in 2006, the City Department of Health indicates the possibility of people living in this City who were not registered as residents. 

During 2007-2009, IMRs were above the national target of the MDGs of 17 per 1,000 live births. These achievements seem to be due to the contribution of internal factors such as good ante natal care (ANC), birth attendance by health professionals, exclusive breastfeeding, complete basic immunization for children under one year, and child growth and development monitoring in Posyandu.

Surabaya Infant Mortality per 1,000 Live Births

3. Measles Immunization Coverage for Children of <12 months 

Measles immunization among infants is one of the indicators of the MDGs, whereby one of the goals of immunization is to reduce IMR. During the period of 2005-2009 the coverage fluctuated from a slight decline then an increase in 2008. The highest achievement was obtained in 2005, when it was more than 100%. The lowest achievement occurred in 2009. The achievement tends to decline over the years, and is below the target of East Java Province. A possible explanation is the low awareness of mothers to visit Posyandu with their children, meaning that they who have not yet been immunized cannot be monitored. 

Surabaya Measles Immunization Coverage of Infants <12 Months

4. Measles Immunization Coverage for Children of 1-4 Years Old 

Surabaya measles Immunization Coverage for Children of 1-4 YearsMeasles immunization for children of 1-4 years old significantly influences on decreasing mortality among children of that age group. Not all children of 1-4 years old have the opportunity to receive measles immunization when they are less than one year old. Possible explanations are that their parents have no time to visit health facilities because they work daily, the children are sick, or some parents consider that immunization is not necessary for babies who look healthy, in their understanding. Measles immunization achievement in children of 1-4 years old in the City of Surabaya from 2005 to 2008 tended to decrease. However, compared to East Java Province, the achievement in the City of Surabaya is higher. 

5. Maternal Mortality per 100,000 Live Births 

Maternal mortality in Indonesia is an accumulation of various problems experienced by a female since she has not yet married or even since she has been a baby. In several groups of people in the community, a daughter has lower socio-economic value than a son. This belief may result in females being frequently considered as second class of members of households, even in the community. During childhood, a daughter usually receives smaller portions of meals compared to a son. In education, usually a daughter has less opportunity than a son. 

Frequently, a daughter, when she marries, is not adequately prepared to be a mother. Only age is an indicator of readiness of a female to be a mother. Very rarely a female in the premarital period is examined as to her nutritional status as well as her psychological and emotional status. A presumption in the community is that every female who will marry is exactly ready to have children and to be a mother. Also a presumption that a pregnancy is a natural event for a female who has been married may contribute to the high maternal mortality. Consequently, there is no more special treatment and attention for a female who is pregnant, since it is presumed as a natural event. 

When a pregnancy is looked on as a natural event, there is no special financial preparation from the family. This condition is quite different when a female marries with a great party that costs a lot of money. The parent is prepared to “sail through a new life” upon marrying, and a child will be born prepared to “sail through a new life thereafter”. All resources and attention are totally used up for the marriage, so that when she is pregnant there are no resources left. Antenatal care until birth is undergone as usual, and not even a birth attendant is arranged early. These are factors that may contribute to the high maternal mortality. 

From 2006 to 2009, the Maternal Mortality Rate (MMR) in the City of Surabaya tended to decrease. A significant decrease, almost 50%, occurred in 2006-2007. This decrease may be due to many factors, such as the increase of awareness among couples particularly to arrange antenatal care earlier and frequently, and births attended by health professionals. These conditions are indicated by the increased achievement of K1 (the first examination in the first trimester of pregnancy) and K4 (at least four times examination in the third trimester of pregnancy), and the increased achievement of births attended by health professionals. In the City of Surabaya, from 2007 until 2009, maternal mortality was below the target of the MDGs. This target for the year 2015 will be 102 per 100,000 live births. 

Surabaya Maternal Mortlaity Per 100,000 Live Births

6. Births Attended by Health Professionals 

Births attended by health professionals directly contribute to the decrease of the Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR). The achievement of births attended by health professionals in the City of Surabaya from 2005 to 2009 tended to increase. Even in the first trimester of the year of 2010, the achievement reached 26.61%. This is really a great achievement. However, the achievement should be accompanied by the awareness of people in the community, particularly pregnant women, to undergo antenatal care by health professionals earlier, at least four times during pregnancy. The awareness of people in the community is needed for them to understand that any number of pregnancies is special, so that all requirements for birth attendance, particularly for birth attendants and the cost of birth attendance, are prepared earlier. In the future, it is expected that births attended by health professionals will reach 100%.

Surabaya Births Attended by Health Professionals

7. K1 Coverage (First Examination in First Trimester of Pregnancy) 

Earlier Antenatal Care (ANC) in the first trimester has a very important role for detecting the possible problems of pregnancy. However, some people in the community think that ANC in the first trimester is not important. Some give the reason that their pregnancy is “taboo” because the fetus does not yet have a life or soul, some that their pregnancy feels all right and that they are comfortable with it, and some that the pregnancy is not their first. These arguments are given by women who have been pregnant previously.

In the City of Surabaya from 2007 to 2009, the coverage of K1 tended to increase; even in the first trimester in 2010, coverage reached 27.87%. This indicates that people of Surabaya have understood the importance of earlier ANC. It is expected that in the coming year the coverage will increase. 

Surabaya Coverage of First Examination of First Trimester of Pregnancy

8. K4 Coverage (At Least Four Times Examination during the Third Trimester of Pregnancy) 

Like Antenatal Care (ANC) in the First Trimester, in the Third Trimester of Pregnancy, ANC should be undergone at least four times. It has a very important role in decreasing the MMR and IMR. Usually, if there is any complication during pregnancy, it will be detected in the third Trimester. If possible complication of pregnancy has been detected early, the choice of birth attendance process can be made beforehand. For example, when in the last examination it is detected that the position of the fetus is cross-sectional, then a health professional suggests a Caesarean rather than a normal delivery. 

In the City of Surabaya from 2005 to 2009, the coverage of K4 tended to increase. In the first Trimester of 2010, the coverage reached 26.57%. 

Surabaya K4 Coverage

9. Married Females of 15-49 Years Old Using Contraception 

Contraceptive use by females in the reproductive age of 15-49 years old who are married is addressed as a means to delay pregnancy, space pregnancies or limit the number of pregnancies. The percentage of these females from 2005 to 2008 tended to fluctuate based on data collected during the Susenas (national socioeconomic survey). 

The percentage of married females of 15-49 years old who have ever used contraceptives for five years also tends to fluctuate, and it has never reached 80%. This is probably due to reproductive-age couples who do not use contraceptives, as well as traditional methods in spacing pregnancies. 

Contraceptive use will directly affect the decrease of the birth rate, and the infant and maternal morality rates. Reproductive-age females who are married and less than 20 years old are suggested to delay their pregnancies since they have high risk pregnancies compared to those who are 20-35 years old. Such at-risk pregnancies may affect mothers and their fetuses. 

Surabaya Married Females of 15-49 Years using CopntraceptivesSurabaya Married Females of 15-49 Years Who Have Used ContraceptivesReproductive-age females of 20-35 years old are expected to space their pregnancies by a minimum of four years. Spacing pregnancy has strong reason. A female is considered to be a “manufacturer” that produces children. Birth spacing may provide opportunity for the mother to alleviate her physical condition after pregnancy and infant and child care before she plans the next pregnancy. At the same time her newborn baby may grow and develop optimally and have full attention from his/her parent until he/she leaves his/her under-five period to enter the school age period thereafter. 

Contraceptive use among reproductive-age females of below 35 years old is expected to reduce the risk of pregnancy that prevails in older age as well as younger ages. 

Concluding Notes

In general the study indicates that the MCH program in the City of Surabaya appears to be progressing adequately, although not yet satisfactorily. It is facing seemingly insurmountable problems and challenges, yet the local municipal government of this city is well aware of those challenges. 

One of the problems which the study portrays is the quality and availability of data. The desired management tools for attaining the successes of the MDGs are known to the local and municipal decision makers, and the road to achieving those is promising. It is in this regard that awareness of those challenges should dictate the continuation and broadening of the study, to cover not only further expansion of the study, but more importantly, the seeking of ways to streamline and the finding of ways to improve data generation and utilization. 

In specific terms, the study shows us the following concluding points: 

1. In general, FP, MCH and RH are considered important by the city officials and opinion leaders, and the profile of the city is improving over time, although some problems need to be addressed more seriously. Among other things is the coverage of RH and MCH services. 

2. Resources in funds, physical infrastructure, human resources and equipment need to be augmented, yet availability of these are scarce compared to the growing needs of the population, hence the dire need for increased commitment of the policy decision makers both in the public and private sectors. 

3. With regards to the circular migrants, temporary residents and slum dwellers which are generally termed as the “floating population”, no specific programs in RH and FP are provided, as long as those populations are registered at the Neighborhood Associations (Rukun Tetangga=RTs) and Community Organizations (Rukun Warga=RWs). Yet, the number is growing, as the suburban housing development increases, and disaster stricken areas surrounding the city increase in intensity. Worth noting is that the quality of services and educational facilities the city offers are far better than those available in the areas surrounding the city, hence the large influx of migrants into the city. 

4. The causes of death among under-fives are more related to external than internal factors, such as the availability of safe water, unfavorable living environment and lack of adequate nutrition, resulting in underweight children. Accessibility of services appears to be a problem too, as is immunization coverage. Remedial measures in those regards appear to be ignored thus far, and need to be constantly improved. 

5. The Posyandus (Integrated Family Planning and Health Posts) in the city are usually open on working days, and as parents are usually working, the under-fives are usually taken care of by maids or other members of the family. It is therefore recommended that Posyandus open on weekends rather than weekdays so that parents are more involved in the care of their under-five children. 

6. Still within the purview of immunization, health promotion and health education still need to be done to make parents aware that immunization of their children is essential. 

7. It also appears that pre-marital counseling is still an indispensible part of the pre-nuptial routine. This is one major effort in preventing and reducing maternal mortality. 

The Study Team is grateful for the assistance given toward the conducting of the study, which in fact enlightened many on the concerns for improving the RH and MCH services in the city, especially among the city officials. 

References 

- Badan Pusat Statistik {rovinsi Jawa Timur 2009, Hasil Survau Sosial Ekonomi Nasional Tahun 2005-2008 Provinsi Jawa Timur. 

- Dinas Kesehatan Kota Surabaya 2010, Pencapaian Indikator KIA kota Surabaya tahun 2005-2010.

- Pemerintah Provinsi Jawa Timur dan Badan Pusat Statistik Provinsi Jawa Timur 2008, Analisa Penyusunan Kinerja Makro Ekonomi dan Sosial Jawa Timur Tahun 2008 (Pencapaian Millennium Development Goals Tahun 2001-2008)

CONTENTS

Top

Foreword

Section One

The New Urban Challenge for Primary and Reproductive Health Care

Executive Summary

1. Background: Urban Growth and Urban Primary / Reproductive Health (RH) Services

2. An AUICK Research Project Report

3. Regional Findings

4. Individual City Findings

5. Summary and Implications

Section Two

Providing Primary / Reproductive Health Services in Asian Urban Areas with Attention to Vulnerable Populations, Especially Women and Girls:

Nine AUICK Associate City (AAC) Reports

6. Kuantan, Malaysia

7. Khon Kaen, Thailand

8. Weihai, China

9. Surabaya, Indonesia

10. Olongapo, Philippines

11. Chennai, India

12. Faisalabad, Pakistan

13. Danang, Vietnam

14. Chittagong, Bangladesh

Annex I.
Research Instrument: AUICK Research Project Outline

Annex II.
AUICK Research Project Participants


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