CHAPTER 16 AVAILABILITY OF FAMILY PLANNING AND HEALTH SERVICES

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1 CHAPTER 16 AVAILABILITY OF FAMILY PLANNING AND HEALTH SERVICES Using the Health and Family Planning Service Availability Questionnaire (SDKI 94-KKB), the 1994 Indonesia Demographic and Health Survey (IDHS) collected information about family planning and health services available to women and children in the sampled clusters. In this analysis, family planning and health services available to women and children refer to those provided at the nearest of selected types of facilities visited by the IDHS interviewers. As such, the service availability sample is representative of the nearest facility to the sampled women and children, and does not represent all facilities in the country. In the 1994 IDHS, the sample cluster came from the smallest geographic administrative unit--the desa in rural areas, and the kelurahan in urban areas. The service availability data were collected in two stages; in the first stage, an interview was held with knowledgeable residents, including the head of the sub-unit (dukuh, RT, or RW), at least one ever-married woman age 15 to 49, and other residents who were familiar with the area, to represent users of health and family planning facilities. It should be noted that although the term "area" in this survey should refer to the sampled cluster, it may be perceived by informants as covering a larger geographic entity, such as a village. Information was collected on the availability of selected family planning service providers: the family planning post (PAKBD), the family planning distribution post at the locality level (PPKBD), the family planning distribution post at the sub-locality level (sub-ppkbd), the family planning acceptors group (paguyuban KB or kelompok akseptor), and the health post (posyandu). In addition, informants were asked to identify various types of stationary facilities located in the area, or nearby, that provide health and family planning services. These facilities are the general hospital, the special hospital, the health center, the auxiliary health center, the village delivery post, the midwife assigned to the village, the private doctor, the private midwife, the pharmacy, and the traditional birth attendant. Specifically, information was recorded on the location of these facilities, distance from the cluster to the facility, most common mode of transportation, and one-way travel time. For each type of facility, a complete address was recorded. If more than one of the same type of facility was reported by informants, the interviewer was instructed to record the facility located closest to the cluster. During the interview, informants were also asked about the accessibility of subdistrict and regency/municipality offices, and visits by family planning fieldworkers in the six months preceding the survey. The second stage of data collection involved visits by IDHS interviewers to selected types of facilities, namely, general hospitals, health centers, private doctors, private midwives, and pharmacies. Combined, these types of facilities supply 70 percent of modem contraceptive users (see Chapter 5). Moreover, they are the main outlets for other maternal and child health services, e.g., providing antenatal care for 70 percent of births. Hereafter, these five facilities will be referred to as principal family planning~maternal and child health (FP/MCH) outlets. Interviewers visited the nearest of each type of principal FP/MCH outlet if it was located within 10 kilometers of the cluster in urban areas and within 30 kilometers in rural areas. During the facility visit, interviews were conducted with the director or administrator of the hospital, health center and pharmacy, or the private doctor or midwife. Information was obtained from these respondents on the distance and one-way travel time between the facility and the cluster. In addition, questions were asked 225

2 about the availability of specific family planning methods, including the pill, IUD insertion/removal, injection, condom, Norplant insertion/removal, and male and female sterilization. For hospitals, health centers, and private doctors, information was obtained on whether the following services were available in the facility: antenatal care, postnatal care, delivery assistance, immunization of children, and child growth monitoring. For private midwives, questions were asked about antenatal care and delivery assistance. In some cases, a facility was identified as the nearest outlet of its type by community informants in more than one cluster. When this occurred, the facility was visited only once, and information on the availability of family planning methods and health services obtained during that visit was recorded for all other clusters in which the facility was named as the nearest outlet. For these other clusters, distance and travel time data were obtained from information provided by community informants, not from facility respondents Availability of Selected Family Planning Providers in the Area As mentioned above, in each sample cluster, knowledgeable residents were asked if specific family planning providers were available in their area (without specifying the meaning of "available.") Table shows the percentage of currently married women who live in areas where these providers are available. Among currently married women, 86 percent live in clusters served by a health post (posyandu), while family planning distribution posts at the locality level (PPKBD) and sub-locality level (sub-ppkbd) are available to 57 percent and 60 percent of respondents, respectively. One in three respondents lives in a cluster that is served by a family planning post (PAKBD). This proportion is lower than for other services, because family planning posts are a newly established distribution network. Fortyfour percent of currently married women live in clusters where a family planning acceptor group (paguyuban KB or kelompok akseptor) is available. Table Availability of family planning providers in the area: background characteristics Percentage of currently married women with selected family planning providers in the area, by type of outlet and background characteristics, Indonesia 1994 Family Family Family planning planning planning distribution distribution acceptors Family post at post at group planning locality sub-locality (paguyuban Health Number Background post level level KB/keL post of characteristic (PAKBD) (PPKBD) (sub-ppkbd) akseptor) (posyandu) women Residence Urban ,591 Rural ,595 Region/Residence Java-Bali ,663 Urban ,523 Rural ,140 Outer Java-Bali I ,619 Urban ,423 Rural ,197 Outer Java-Bali ,903 Urban Rural ,259 Total ,

3 Table also shows that, according to community informants, these providers are slightly less available in rural areas than in urban areas. Women in Outer Java-Bali II are less likely than women in other areas to live close to any of the listed family planning providers. On the other hand, women in Outer Java-Bali I are more likely to be served by a PPKBD, a sub-ppkbd, and a posyandu. Looking at provincial differentials (see Table ), between 9 percent (East Timor) and 58 percent (Bengkulu) of currently married women live in a cluster served by a PAKBD. In Bali, although sub-ppkbd are not widely available, posyandu are available to all women. In fact, posyandu are available to 90 percent or more of currently married women in 14 of the 27 provinces in Indonesia. Family planning acceptor groups are generally less common in the Outer Java-Bali II region. Table Availability of family planning providers in the area: region and province Percentage of currently married women with selected family planning providers in the area, by type of outlet and region and province, Indonesia 1994 Family Family Family planning planning planning distribution distribution acceptors Family post at post at group planning locality sub-locality (paguyuban Health Number Region and post level level KB/kel. post of province (PAKBD) (PPKBD) (sub-ppkbd) akseptor) (posyandu) women Java-Bali ,663 DK1 Jakarta I,I 40 West Java ,170 Central Java ,302 DI Yogyakarta East Java ,209 Bali Outer Java-Bali I ,619 Dista Aceh North Sumatra ,374 West Sumatra South Sumatra Lampung West Nusa Tenggara West Kalimantan South Kalimantan North Sulawesi South Sulawesi Outer Java-Bali 1I ,903 Riau Jambi Bengkulu East Nusa Tenggara East Timor I 15 Central Kalimantan East Kalimantan Central Sulawesi Southeast Sulawesi Maluku I lrian Jaya Total ,

4 16.2 Distance and Time to Selected FP/MCH Outlets Providing Family Planning Methods Additional insights into the availability of family planning services in Indonesia are provided through an examination of the data on distance (in kilometers) and one-way travel time (in minutes) from the IDHS clusters to the nearest of each of the five visited principal FP/MCH outlets, i.e., general hospitals, health centers, private doctors, private midwives and pharmacies. In examining these data, it is important to remember that facilities were visited only if they were within 10 kilometers of a cluster in urban areas and within 30 kilometers of a cluster in rural areas. The information collected on family planning was limited to whether or not the facility offered any modem contraceptive method. Table presents the percent distribution of currently married women by distance to the nearest visited principal FP/MCH outlet offering modem contraceptive methods. Thirty-eight percent of currently married women live in areas where family planning methods are offered at one of the outlets visited by the interviewers, a similar percentage can obtain this service at a distance of 1 to 4 kilometers, and 16 percent must travel 5 to 9 kilometers to a principal FP/MCH outlet. Urban women are generally closer to an outlet offering family planning than rural women. While virtually all urban women live within 5 kilometers of a principal FP/MCH outlet, fewer than seven in ten rural women do. Women in Java-Bali are slightly less likely than women in the other regions to have an outlet in their cluster, but are more likely to have one within 5 kilometers of their cluster. There are strong urban-rural differentials in all regions. Table Distance to nearest principal FP/MCH outlet offering modern contraceptive methods: background characteristics Percent distribution of currently married women by distance to nearest visited principal FP/MCH outlet offering modern contraceptive methods, according to background characteristics, Indonesia 1994 Distance (kilometers) to nearest principal FP/MCH outlet offering modern methods No Number Background services of characteristic < known Total women Residence Urban ,591 Rural ,595 Region/Residence Java-Bali ,663 Urban , ,523 Rural ,140 Outer Java-Bali ,619 Urban ,423 Rural ,197 Outer Java-Bali II ,903 Urban Rural ,259 Total ,186 i Includes outlet located in the area 228

5 Distance to the nearest visited principal FP/MCH outlet offering modern contraceptive methods varies by region and province (see Table ). In Java-Bali, the nearest principal FP/MCH outlet is within a radius of 5 kilometers for all women in DKI Jakarta, while the proportion is 83 percent or less in Central Java and East Java. Variations in distance are larger in the Outer Java-Bali regions. While 82 percent of currently married women in East Kalimantan have an outlet within 5 kilometers of their cluster, about four in ten women in Lampung, East Timor and Irian Jaya, and six in ten women in East Nusa Tenggara have to travel 5 kilometers or more to reach the nearest principal FP/MCH outlet providing family planning methods. In Central Sulawesi, Maluku, and Irian Jaya, family planning services are not known or not available in the specified distances for 8 percent or more of women. Table Distance to nearest principal FP/MCH outlet offering modern contraceptive methods: region and province Percent distribution of currently married women by distance to nearest visited principal FP/MCH outlet offering modern contraceptive methods, according to region and province, Indonesia 1994 Distance (kilometers) to nearest principal FP/MCH outlet offering modern methods No Number Region and services of province <l t known Total women Java-Ball ,663 DKI Jakarta ,0 1,140 West Java ,170 Central Java , ,302 DI Yogyakarta East Java ,209 Bali Outer Java-Bali I ,619 Dista Aceh North Sumatra ,374 West Sumatra South Sumatra Lampung , West Nusa Tenggara West Kalimantan South Kalimantan North Sulawesi South Sulawesi Outer Java-Bali I I ,903 Riau Jambi Bengkulu East Nusa Tenggara East Timor Central Kalimantan East Kalimantan Central Sulawesi Southeast Sulawesi , Maluku , lrian Jaya Total ,186 t Includes outlet located m the area 229

6 Table 16.3 shows the percent distribution of currently married women by distance (in kilometers) to the nearest visited principal FP/MCH outlet offering modem contraceptive methods, according to type of outlet. Overall, the median distance to the nearest outlet providing family planning services (and visited by the IDHS interviewers) is 3.6 kilometers. The median distance to a private midwife or to a health center is 4.2 kilometers, while the distance to a private doctor is 4.8 kilometers. A pharmacy or hospital is 9 kilometers or more from the clusters in which women live. Table 16.3 Distance to nearest principal FP/MCH outlet offering contraceptive methods by type of outlet Percent distribution of currently married women by distance (kilometers) to nearest visited principal FP/MCH outlet offering modem contraceptive methods and by urban-rural residence, according to type of outlet, Indonesia 1994 Type of principal FP/MCH outlet Distance to Health Private Private Any nearest outlet Hospital center doctor midwife Pharmacy outlet Urban < 11 km km km km Distance unknown No nearby outlet Total Number 7,591 7,591 7,591 7,591 7,591 7,591 Median distance Rural <11 km km km km Distance unknown No nearby outlet I 1.2 Total Number 18,595 18,595 18,595 18,595 18,595 18,595 Median distance Total <11 km km km km Distance unknown No nearby outlet Total Number 26,186 26,186 26,186 26,186 26,186 26,186 Median distance I Includes outlet located in the area 230

7 Table 16.4 Time to nearest principal FP/MCH outlet offering contraceptive methods by type of outlet Percent distribution of currently married women by one-way travel time (minutes) to nearest visited principal FP/MCH outlet offering modern contraceptive methods and by urban-rural residence, according to type of outlet, Indonesia 1994 Type of principal FP/MCH outlet Time to nearest Health Private Private Any outlet Hospital center doctor midwife Pharmacy outlet Urban In the area <15 min , rain min min min Time unknown No nearby facility Total Number 7,591 7,591 7,591 7,591 7,591 7,591 Median time Rural In the area <15 min min min min min Time unknown No nearby facility Total 100,0 100, Number 18,595 18,595 18,595 18,595 18,595 18,595 Median time Total In the area , <15 min min min min min Time unknown No nearby facility Total Number 26,186 26,186 26,186 26,186 26,186 26,186 Median time

8 Women in urban areas are generally closer to any outlet offering family planning methods than rural women; the median distance to the nearest outlet is 1.9 kilometers in urban areas, and 4.7 kilometers in rural areas. In urban areas, all outlets are within 3.5 kilometers of the cluster, while in mral areas the distance varies from 4.9 kilometers for private midwives to 12.5 kilometers or more for pharmacies and hospitals. Additional insights into the relative accessibility of family planning methods can be obtained by examining the distribution of women by distance to the nearest visited principal FP/MCH outlet. While nine in ten urban women live in a cluster with a health center that provides family planning methods within a radius of 5 kilometers, only about half of rural women do. About 80 percent of urban women live within 5 kilometers of a private doctor, a private midwife, or a pharmacy offering modern contraceptive methods. The corresponding proportion for rural women is 35 percent for a private doctor, 50 percent for a private midwife, and only 7 percent for a pharmacy. The greatest urban-rural difference is found in the accessibility of hospitals; 61 percent of urban women live within 5 kilometers of the nearest hospital providing family planning methods, while only 6 percent of rural women do. In fact, the nearesl hospital or pharmacy offering family planning methods is not available within the specified distances for nearly four in ten currently married women in rural areas. Table 16.4 presents the distribution of currently married women by one-way travel time (in minutes) to the nearest visited principal FP/MCH outlet offering contraceptive methods, according to type of outlet. The data show that, overall, women are about 15 minutes from the nearest outlet. Travel time to general hospitals (30 minutes) and pharmacies (21 minutes) is slightly longer than to health centers, private doctors, and private midwives (16 minutes each). In general, travel time to an outlet offering contraceptive methods in rural areas is at least twice that in urban areas. The median one-way travel time to the nearest outlet is 15.7 minutes in rural areas, compared with 6.6 minutes in urban areas. This pattern is true for most types of outlets investigated in the survey, i.e., general hospitals, health centers, private doctors, private midwives, and pharmacies. Pharmacies are much more available in urban areas than in rural areas. The median one-way travel time to the nearest pharmacy is 10.6 minutes in urban areas, compared with 30.5 minutes in rural areas Availability of FP/MCH Outlets Offering Maternal and Child Health Services Table 16.5 shows the percentage of currently married women for whom specific maternal and child health services are available at the nearest of three types of FP/MCH outlets. Again, it is important to note that the nearest FP/MCH outlet of each type was visited only if it was located within 10 kilometers of a cluster in urban areas or within 30 kilometers in rural areas. Almost no women live in an area where none of the MCH components included in the survey--antenatal care, tetanus toxoid (TT) immunization for pregnant women, delivery assistance, postnatal care, child growth monitoring, child immunization, and dental and mouth careiare available. In fact, more than half of currently married women in Indonesia live in an area where the nearest hospital provides all of the services mentioned above. Except for delivery assistance, all MCH services are more likely to be available through health centers than through hospitals or private doctors; although, antenatal care and postnatal care from private doctors are available to more than 60 percent of currently married women. Less than 30 percent of women live in an area where a private doctor provides 'IT injections and child immunization. In this survey, dentists were not included among the private doctors visited; therefore, private doctors were not asked about provision of dental and mouth care. 232

9 Table 16.5 Availability of specific MCH services at nearest principal FP/MCH outlets offering MCH services Percentage of currently married women for whom specific maternal and child health services are available at the nearest visited principal FP/MCH outlets offering MCH services, by type of services, type of outlet, and urban-rural residence, Indonesia 1994 Type of maternal and child health services available Type of Tetanus Child Dental principal toxoid growth Child and Number FP/MCH Antenatal immuni- Delivery Postnatal moni- immuni- mouth All No of outlet care zation assistance care toring zation care services services women Urban Hospital ,591 Health center 99. I ,591 Private doctor NA ,591 Rural Hospital ,595 Health center ,595 Private doctor NA ,595 Total Hospital ,186 Health center ,186 Private doctor NA ,186 NA = Not applicable Comparing urban and rural areas, Table 16.5 indicates that, in general, urban women are closer to a visited principal FP/MCH outlet that offers MCH services than rural women. Overall, urban women are about 20 percent more likely to live in areas where MCH services are offered at the nearest principal FP/MCH outlet. This is tree for all types of services except delivery assistance; rural women are more likely to live close to a health center that provides delivery assistance than urban women. On the other hand, urban women are more likely to live close to a hospital that offers delivery assistance Distance and Time to Nearest FP/MCH Outlet Offering Maternal and Child Health Services As in the case of family planning services, the availability of maternal and child health services can be determined by examining the data collected on distance and one-way travel time from the IDHS cluster to each of the nearest of four principal types of FP/MCH outlets: general hospitals, health centers, private doctors, and private midwives. It is important to remember when examining these data that facilities were visited only if they were within 10 kilometers of a cluster in urban areas or within 30 kilometers of a cluster in rural areas. An FP/MCH outlet facility was considered to provide maternal and child health services if any of the following were offered: antenatal care, postnatal care, delivery assistance, immunization of children, and child growth monitoring. Private midwives were only asked about antenatal care and delivery assistance. In particular, they were asked the number of cases they had in the six months preceding the survey. Virtually all of the midwives visited in the survey reported giving antenatal care to at least one client and assisting at the delivery of at least one baby. 233

10 Since in the FP/MCH outlets visited in the survey the provision of family planning services is additional to the provision of basic maternal and child health services, the distribution of women by distance and one-way travel time to the nearest outlet offering MCH services is similar to that by distance to the nearest outlet offering family planning services. This is shown in Tables through Table Distance to nearest principal FP/MCH outlet offering MCH services: background characteristics Percent distribution of currently married women by distance to the nearest visited principal FP/MCH outlet offering maternal and child health services, according to background characteristics, Indonesia 1994 Distance (kilometers) to nearest principal FP/MCH outlet offering MCH services No Number Background Distance services of characteristic < unknown known Total women Residence Urban ,591 Rural ,595 Region/Residence Java-Bali I ,663 Urban ,523 Rural ,140 Outer Java-Bali I ,619 Urban ,423 Rural ,197 Outer Java-Bali I ,903 Urban Rural ,259 Total ,186 I Includes outlet located in the area 234

11 Table Distance to nearest principal FP/MCH outlet offering MCH services: region and province Percent distribution of currently married women by distance to the nearest visited principal FP/MCH outlet offering maternal and child health services, according to region and province, Indonesia 1994 Distance (kilometers) to nearest principal FP/MCH outlet offering MCH services No Number Region and Distance services of province <11 IM unknown known Total women Java-Bali ,663 DKI Jakarta ,140 West Java ,170 Central Java ,302 DI Yogyakarta East Java , ,209 Bali Outer Java-Bali I ,619 Dista Aceh North Sumatra ,374 West Sumatra ( South Sumatra Lampung , West Nusa Tenggara ( West Kalimantan South Kalimantan , North Sulawesi ,0 318 South Sulawesi Outer Java-Bali II ,903 Riau Jambi Bengkulu 47, East Nusa Tenggara East Timor Central Kalimantan , East Kalimantan , , Central Sulawesi Southeast Sulawesi Maluku , lrian Jaya Total , ,186 I Includes outlet located in the area 235

12 Table 16.7 Distance to nearest principal FP/MCH outlet offering MCH services by type of outlet Percent distribution of currently married women by distance (kilometers) to nearest visited principal FP/MCH outlet offering maternal and child health services and by urban-rural residence, according to type of outlet, Indonesia 1994 Type of principal FP/MCH outlet Distance to Health Private Any nearest outlet Hospital center doctor outlet Urban <11 km km km km Distance unknown No nearby lacility Total ) Number 7,591 7,591 7,591 7,591 Median distance I Rural <11 km km km km Distance unknown No nearby facility 38, Total Number 18,595 18,595 18,595 18,595 Median distance Total <l t km I-4 km km km Distance unknown No nearby facility Total Number 26,186 26,186 26,186 26,186 Median distance l Includes outlet located in the area 236

13 Table 16.8 Time to nearest principal FP/MCH outlet oft~ring MCH services by type of outlet Percent distribution of currently married women by one-way travel time (minutes) to nearest visited principal FP/MCH outlet offering maternal and child health services and by urban-rural residence, according to type of outlet, Indonesia 1994 Type of principal FP/MCH outlet Time to nearest Health Private Any outlet Hospital center doctor outlet Urban In the area <15 min rain min rain min Time unknown 0.8 I/ No nearby facility Total tl.0 Number 7,591 7,591 7,591 7,591 Median time I Rural In the area I <15 min / min I min I min rain Time unknown No nearby facility Total , /)1/.0 Number 18,595 18,595 18,595 18,595 Median time I Total In the area <15 min I min min I min I min Time unknown No nearby facility Total Number 26,186 26,186 26,186 26,186 Median time I 237

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