Searching for Suitable Cure: Understanding Medical Pluralism in the Urban Poor Neighborhood in Jogjakarta, Indonesia Retna Siwi Padmawati, Laksono Trisnantoro, Soenarto Sastrowijoto, Amalia Muhaimin, and Nurazid Mahardinata Center for Bioethics and Medical Humanities, Faculty of Medicine. Gadjah Mada University, Jogjakarta, Indonesia
Background Since 1980 s the government has been establishing public health centers (puskesmas) all over the country (in 1990 --3000 centers and 260,000 integrated health post) Services included: primary care for general population reproductive health for women vaccination for children and adult women malaria treatment and control oral re-hydration for diarrhea in children management of nutrition family planning
Only few utilized health centers Factors attributing to low utilization of primary health centers Minimum care provided Ineffective treatment Limited time for consultation Limited skills of paramedical staff Private practice by all health staff after office hours
Where do the people go for their health problems? Self-treatment Homemade preparation Kiosk which sell modern and traditional medicines Drug store and pharmacy Private practitioners GP Specialist doctor Traditional healer, etc.
National Socioeconomic Survey (2004) self-treatment 66 64 62 60 58 56 54 52 50 2002 2003 2004
Jogjakarta Welfare Indicators (2004) Self-treatment 12.34 18.23 69.43 Modern Medicine Traditional Medicine Combined
It is assumed that people back and forth from self treatment to outside treatment, and from formal to informal sector of providers (modern and traditional or alternatives) in search of their treatment
Objectives Understand the patients perspectives in dealing with illnesses Mapping the utilization of health resources in the poor neighborhood
Method Qualitative ethnographic approach (18 months) 28 families and 29 all sorts of private health care providers Serial interviews (3-9) using open-ended and semi-structured questionnaire. Survey among 220 households members in the poor neighborhood (every 3 months for 12 months)
Research setting Jogjakarta has population of approx. 10,00,000 Urban poor neighborhoods in Jogjakarta along river bank and railways. Working in informal sectors (small grocery kiosks, labors, paddy-cab drivers, scavengers, singing beggars) Under-employment and unemployment Most of the residents had only elementary and junior high school education Foto-foto
Types of providers in private sector Formal Sector hospital, lung clinic, specialist doctor, paramedic, and polyclinics. Informal sector small kiosk selling medicines and herbal medicines. Traditional and faith healers, Massagers, and Herbalist, etc.
Health seeking behavior For common illnesses, people bought medicines from the kiosk in the neighborhood. If the condition did not improve in one day or two, they would seek other services. Mostly people would apply one system and at the same time would seek for another, they were back and forth from one system to another
Table1. Household Utilization of Health Resources Health Resources Round 1 Round 2 Round 3 Round 4 (n) (%) (n) (%) (n) (%) (n) (%) Health Center 46 26.90 47 27.17 68 23.94 77 Private Practice/Clinic 34 19.88 40 23.12 58 20.42 56 25.6 7 18.6 7 Public Hospital 1 0.58% 1 0.58% 4 1.41% 13 4.33 Private Hospital 7 4.09% 6 3.47% 9 3.17% 8 2.67 Alternative/ traditional healers 3 1.75% 7 4.05% 15 5.28% 24 8.00 Self-treatment 80 46.78 72 41.62 130 45.77 122 Total 171 100.00 173 100.00 284 100.00 300 40.6 7 100. 00
Household Utilization of Health Resources in one year 43% Health Center 5% 3% 2% Private Practice Public Hospital 21% Private Hospital Alternatives Self-treatment 26%
Sequence of treatment-seeking options Home preparation Over-the-counter medicines (kiosk or pharmacy) Outside healers (doctors, paramedics, massage, herbalist) Multi-system People valued the health resources on the basis of the most suitable medicines given by the providers.
Perceptions on the available health resources Private practitioners were seen as more effective as compared to Public Health Center Quality of care and medicines Limited services, same medicines for different health problems Examination mostly done by nurses long queue, limited service hours could not be trusted to give good medicines Many health resources used interchangeably
The Case of Tyas 10 year old girl in her 5 th grade elementary school, suffered from diabetes and dependent on insulin twice a day since last year First, her father noticed that she had something wrong when she felt fatigue and kept urinating during the night for 2 days. She was weaker and weaker. A GP who has practice close to the house diagnosed her as having stomach problem and give her some medicines that made her having painful stomach before being hospitalized in a private hospital in the next day In the hospital, the first diagnosis was dengue that was very late. But after some medications, her condition was worsening. She sometimes unconscious, and when conscious, she then screamed even though she was very weak The second day, a doctor order for a scanning, then he diagnosed her as having virus. Medication was then given, but the condition was weaker and weaker
The case of Tyas (contd) A priest was invited to give prayers because she turned to a coma on the 3rd day of hospitalization. She was in the ICU room since then, up to 6 days, when another doctor examined her and asked for blood sugar level test. It was found from the test that her blood sugar level was 870. She got conscious after insulin injection was given every three hours. She had hospitalized for 12 days. Going home from the hospital, she should be injected using insulin for 20mg in the morning and 10mg in the evening While the father and mother only earned Rp 15,000 and Rp 10,000 one day, Tyas needed insulin that cost Rp 200,000 per week. The family has also still indebted to the hospital for her previous hospitalization
In trying to stop the insulin Upon a suggestion of a friend, the family brought her to a healer in Magelang where she got traditional herbs. The healer told the family to stop the insulin when taking his herbs. He was going to operate her after the blood level reached 200. But she had never reached 200, though she had been visiting the healer 10 times Then her parents brought her to a healer who was able to transfer the illness/disease to an animal. Her father bought a rabbit (who cost him Rp 25,000) and the healer did a transfer by putting his hands to Tyas head and then to the rabbit s body. They then slaughtered the rabbit and examined the lever. To the father s surprised, the rabbit had a black lever, indicating that the disease has already been transferred to the animal. Because her blood sugar level had never been decreased, the father stopped bringing Tyas to this healer after 3 times visits
In trying to stop the insulin One of the neighbors told the family to give her a certain preparation from herbs (akar duwet, daun petai, and akar benalu kelor). The mother gave her one cup of the preparation and got weaker and weaker, and finally fainted. The parents brought her to the same private hospital, she had only 19 for her blood sugar level. The doctor got very angry with her parents and warned them not to give any herbs to her Once, the family also brought her to a famous healer who has specialty in treating diabetes patient. He used leeches to cure the patient, by putting the leeches to the patients legs. When the leeches sucked enough blood, they will release by themselves. Terrifying with the leeches, she refused to come back to this healer Now, she is taking her insulin twice a day while also taking a homemade preparation of herbs to maintain
Diabetes: patient perspectives Disease of the old Disease of the rich Could be heredity The insulin dependency should be stopped making efforts to stop the insulin In search of suitable medicines or treatment, people will try every suggestion
Perceptions on the providers competence Good health practitioners give a good and suitable medicines--that cure the symptoms immediately Be ready to serve the people (24 hours) Could give medicines or treatment as demanded by people Affordable Always smile to the patients
Concept of cocok or suitable treatment When the medicine was curing the symptoms immediately or relieving the pain, then patients and families would say that the medicine and the healer were suitable or cocok for their illnesses. Thus, the patients would revisit the particular providers for the same and other health problems.
Concept of ichtiar Moral obligation to put big efforts into regaining health People should try every suggestion Failing to follow the suggestion-- and the patient gets worse, would cause the family and relatives of the sick person to be blamed by neighbors
Concept of ichtiar...i will do anything to cure the disease. There are many ways to cure the disease, so it is a must or compulsory to try [many medicines]. Man should always try and God will determine [whether it will be cured or not] In my mind, people should find the suitable [modern or traditional] one The important thing is [the disease] to be cured immediately.
Discussion medical plurality was heavily constructed by failure of the government health center in giving good services and access for urban poor, the free system of selling medicines and jamu, and by the expensive cost of modern formal medicines. It is suitable with the concept of people on searching the suitable medicine, the concept of ichtiar, and the concept of fate; allowing the urban poor to get the harm of medical plurality.
Discussion The urban poor had to pay the medicines that they supposed to get it for free because, among other things, the concepts and practices of medical pluralism as well as the many available health resources a greater degree of social and cultural sensitivity should be applied for facing the dilemma in promoting a good practice and especially in the formulation and implementation of public health reform.
Discussion This might be started from the effort of increasing the level of effectiveness of modern medicines in alleviating the disease. In an ineffective medical system, people who are supposed to be responsible for their own health would try all the available medicines. This is a process of not only people taking part of sustaining their own health, but the process of gaining the best condition to sell labor power that provides the primary source of living