Problems of Health Services in the Border Areas and the Efforts to

Overcome

Ratna Dwi Wulandari

Facult

Public Health, Universitas

irlan

ore

o, Suraba

a, Indonesia

Keywords: Health problems in border area, People mobility, Improve health service.

Abstract: Frontier areas have specific characteristics due to the impact of different environmental conditions,

e.g. the distance away from the centre of government and geographical conditions that tend to be

difficult. The easy movement of people from one region to another has an impact on the rapid

transmission of disease. Therefore the health care system in border areas requires specific handling

because it involves two or more districts. This research study was conducted to identify health service

problems in the border areas in East Java, so then a recommendation can be made to improve the

appropriate health service system. This research is a descriptive research study with a cross-sectional

design. The location of the study was in four of the outermost regencies in the East Java Province. The

results of the research indicate that some of the problems identified are the high utilisation of cross-

border health services that has an impact on the incomplete health services provided to the community,

and that there is no inter-region case reporting mechanism. Some efforts that can be undertaken to

improve the health care systems in border areas include developing cooperation for better coordination

in the case of inter-regional population mobility, standardised service procedures and reporting

recording systems, and floating surveillance networks.

1 INTRODUCTION

Indonesia is one of the largest countries in Southeast

Asia, with an area of 5,180,053 km

. It consists of a

total land area of 1,922,570 km

, and an area of

3,257,483 km

of sea, which is divided into 34

provinces. Since 1999 with the enactment of Law

number 22/1999 on Regional Government, and also

Law number 25/1999 on Fiscal Balance between

Central and Regional Governments, the Indonesian

government embraces the decentralisation system by

granting state authority to the district/city

governments.

The government of Indonesia has stipulated that

the implementation of health services in border areas

and isolated, vulnerable and municipal islands is the

duty and responsibility of the district health

authorities. Each district must prepare adequate

health resources in order to be able to properly carry

out the health services in those areas.

People living in rural and remote areas,

including those living in border areas, face

challenges in accessing appropriate health services

(Bourke, et al., 2011). Border areas have their own

problems and peculiarities (Gogoi, et al., 2009). The

public health situation in the border area is actually

similar to other regions, but they have different

characteristics as a result of different environmental

conditions. The environmental conditions that make

the public health situation in the border area

different from elsewhere is related to accessibility.

The border area is a long distance from downtown.

The long distance has several consequences, such as

the number of human resources, the health worker

and health facilities being limited, access to health

care facilities especially secondary and tertiary

health care facilities becoming more difficult, and

the referral time becoming longer. Klobuchar (2014)

state that patients in rural areas with serious

conditions such as heart disease and cancer must

travel longer distances than patients in urban areas to

see specialists. Almost all border areas are in rural,

so this kind of difficulty is also faced by people in

the border areas.

In some areas, the distance or travel time to

another city centre is faster than to the centre of the

city of origin. This causes people to prefer to seek

treatment at health facilities in other districts /cities

that are nearby. Similarly, in the referral process, the

First Level Health Facility (FKTP) prefers to refer

patients to other district / city hospitals.

Community mobility between regions also

affects the public health situation in the border areas.

The easy movement of people from one region to

another has an impact on the rapid transmission of

disease.

Wulandari, R.

Problems of Health Services in the Border Areas and the Efforts to Overcome.

In Proceedings of the 4th Annual Meeting of the Indonesian Health Economics Association (INAHEA 2017), pages 277-281

ISBN: 978-989-758-335-3

277

Thus, the public health status in a region is not

only determined by the performance of health

services in the area, but also is strongly influenced

by the situation in other areas, especially the

immediately adjacent areas. Therefore, health

problems in adjacent areas or regions need joint,

integrated and coordinated management by

involving the relevant sectors so that the existing

problems can be resolved optimally.

Health services in border areas require specific

treatment because they involve two or more districts.

Several important issues related to health services in

the border areas are services to the poor, the

continuity of care between different treating

professionals and organisations (Commission Of

The European Communities, 2008), referral health

services, infectious diseases, the adequacy of health

personnel and the handling of outbreaks and

disasters. The spread of infectious diseases does not

recognise geographic region. Many diseases are

transmitted through both animals and humans.

Along with the easier access between, the spread of

diseases between regions is also increasing, for both

old and new diseases. The era of globalisation and

technological progress has also accelerated the

transmission of disease without recognising

geographical and administrative boundaries. Several

diseases which often become a problem because of

the speed their transmission includes TB, Malaria,

AIDS, and other related immunisation diseases

(Kamel, 1997

). Kamel (1997

) also state that

borders are crucial entry point for communicable

disease which, if it not properly managed, would

affect the community health status.

The previous research by Bourke, et al., (2011)

has develop six key concept as a framework of rural

and remote: (i) geographic isolation, (ii) the rural

locale, (iii) health responses in rural locales, (iv)

broader health systems, (v) broader social structures,

and (vi) power relations at all levels. These six

matters are interrelated in raising public health

issues in the border region. That is why public health

problems in the border area seem more complex

than health problems in other regions. On this basis,

it is important to identify what health problems are

happening in the border areas, as well as what

efforts can be made to strengthen the health care

systems in border areas.

2 METHOD

This research is descriptive because it was done to

obtain the best description of health problems in the

border area, with a cross-sectional design. The data

collection was conducted in 2015 in 4 of the

outermost regencies in the East Java Province;

Ngawi, Bojonegoro, Sumenep and Banyuwangi

districts. The respondents consisted of two groups;

community and health personnel. Communities as

respondents are the people who live in the outer

regions bordering other areas. For each district, 100

community respondents were drawn, so there was a

total of 400 respondents in the 4 cities. Data from

the community was collected by using a structured

questionnaire to describe the utilisation of cross-

border health care facilities. The officers consisted

of a midwife from Polindes in the border area, a

Puskesmas officer in the border area, and staff from

the District Health Office. For the health officer

respondents, data collection was done through a

Focus Group Discussion (FGD). FGDs were

conducted once in each area, so there were 4 repeats

of the FGD. FGDs were conducted to discuss the

findings from the results of the community surveys,

so that further health problems and solutions could

be identified.

3 RESULT AND DISCUSSION

A border area is a meeting area of two or more

regions with different administrative authorities, i.e.

between district and inter-provincial boundaries.

Each region has the authority to regulate its own

territory in accordance with their respective policies

on the basis of the real needs of the community. The

identification of various health problems in the

border areas is important in order to improve the

health care system for people living in there so that

their health status will be better. In addition, good

handling of the health care systems in border areas

can also prevent the expansion of health problems.

The special characteristic often encountered in

the border area is the great distance from the city

centre. The city centre is usually identical to the

central government. Therefore one of the limitations

faced by people living in border areas is that it is

more difficult to access government services located

in the city centre, such as local public hospitals. For

people living in border areas, sometimes access to

health facilities in their area is more difficult due to

the longer distances involved than to other area

health facilities. The impact of this condition is the

occurrence of cross-border health utilisation. This

means that residents of district A go to district B, or

vice versa. Table 1 represent the results of the

INAHEA 2017 - 4th Annual Meeting of the Indonesian Health Economics Association

278

survey of 400 residents living in the border area on

the utilisation of cross-border health facilities.

Table 1. Utilisation of cross border health facilities by communities in border areas in the Banyuwangi, Bojonegoro, Ngawi

and Sumenep districts, 2015

Utilisation of cross border health facilities Frequency

District

Ban

uwan

iBo

one

oro

Ngawi

Sumene

Prefer to seek treatment at health

facilities in other districts

n 89 81 6 33

% 89,0 81,0 6,0 33,0

Yes

n 11 19 94 67

% 11,0 19,0 94,0 67,0

People from other areas who

seek treatment at health facilities

in this area

n 72 82 55 99

% 72,0 82,0 55,0 99,0

Yes

n 28 18 45 1

% 28,0 18,0 45,0 1,0

Based on Table 1, it can be seen that there are

residents who prefer to seek treatment at health

facilities in other districts, mostly in Ngawi. The

next order is in the Sumenep, Bojonegoro and

Banyuwangi districts. This is because the distance is

closer. For the case of residents from other areas

who seek treatment in other health facilities, this is

the most widely available in the district of Ngawi.

Next is in Banyuwangi, Trenggalek, Bojonegoro and

Sumenep districts. In Ngawi district, people living in

Kendal district are closer to Magetan district with

only about 20 minutes' travel time. Meanwhile,

people living in the Mantingan sub-district are closer

to the Sragen district. For reasons of close proximity

and easier access, this is also the reason why many

Ngawi people are treated in other districts.

The same condition also occurred in Sumenep.

For people living in Pragaan sub-district, they prefer

to go to Pamekasan because it is closer and there is

easier access. In addition, there is a growing image

in Sumenep society that the health service in

Pamekasan is better, mainly because of its more

complete health personnel. This results in the

community going to Puskesmas Pragaan. If referred

to the hospital, they prefer to go to Pamekasan rather

than to Sumenep. As for the Sumenep people who

are in the archipelago, they tend to seek out the

nearest health services. For example, the

examination of Hajj health is closer to the Bali

island than to Sumenep. In Bojonegoro District,

Puskesmas, which borders with the Cepu district,

sometimes prefers to refer patients to hospitals in

Cepu rather than to hospitals in Bojonegoro because

of the proximity to the house. Before Padangan

Hospital was established, 40% of Padangan residents

preferred to go to Cepu. But now the condition is

turning, as the Cepu people prefer treatment at

Padangan Hospital.

The utilisation of cross-border health services, if

not managed properly, will be able to trigger the

emergence of several other problems. One of the

problems that can arise from the movement of these

patients is related to the problem of recording and

reporting health data. Biases on recording data occur

as a result of patents crossing border for hospital or

health care. Biased statistics misrepresent what is

needed and can affect the adequacy of health care

planning and delivery (Kamel, 1997

). Important

things for strengthening health services in border

areas are to create and manage mechanisms for

identifying and managing cross-border issues (NHS

Commissioning Board, 2013).

One of the important problems is related to

immunisation. Based on the results of Focus Group

Discussion (FGD) with health personnel in the

Ngawi District, it was found that there were

differences in the determination of immunisation

status between the Ngawi and Sragen regency. For

example, in the Ngawi disctrict, Tetanus Toxoids’

(TT) immunisation status is calculated based on

birth history, whereas in the Sragen regency, every

pregnant mother is given TT immunisation because

all pregnant women need TT.

Another problem identified from the FGD with

health personnel in Ngawi District is the occurrence

of loss control towards high risk pregnant women.

The antenatal care procedure (ANC) of Ngawi

Regency compared to Sragen is different. According

to resource individuals from Ngawi District, the

community considers the ANC service in Ngawi to

be more stringent, in the sense that more checks

have to be done, thus causing certain communities to

prefer ANC in more relaxed areas. In East Java,

Problems of Health Services in the Border Areas and the Efforts to Overcome

279

there is a policy of determining high-risk status by

using the Pudji Rochyati Score Card (In Indonesia:

Kartu Skor Puji Rochyati or KSPR), whereas in

Central Java Province, this does not exist. This is felt

by the people who live directly adjacent to the

Sragen regency who feels that in Sragen, the criteria

are looser. This has resulted in some pregnant

women who initially conducted a medical

examination in Ngawi District to have finally moved

to the Sragen regency. If the mother continues to get

health services in other districts, this makes the

recording continuity of antenatal care services in

Ngawi District disturbed. If this condition occurs in

high-risk pregnant women, it is feared that it could

endanger the health condition of the mother and

foetus, because the new health facility does not have

the history of pregnancy.

The phenomenon above illustrates that one of the

reasons for the change of health service from one

district to another is the patients desire to get a

simpler service procedure. Another reason is related

to the quality of service. The public tends to choose

a place of service which, according to him, is more

qualified, even if the location of the health care

facility is in another district. The results of this study

are in line with previous research that found those

cross-border health users are usually linked to

service quality issues (Rich and Merrick, 2006;

Dejun Su, et al, 2011).

Several other studies have found that the use of

cross-border health services is linked to the cost and

health insurance issues, such as Dejun Su, et al

(2011) and Miller and Thayer (2010). Dejun Su, et al

(2011) in his research at United Stated found that the

most significant predictors of health care utilization

across border were lack of health insurance coverage

and dissatisfaction with the quality of health care.

The results of Miller's study in Mexico also found

the same thing, the utilization of cross-border health

services was triggered by the lack of quality of

service, access difficulties, and low coverage of

health insurance in the region of origin (Miller and

Thayer, 2010).

The third problem is related to the recording and

reporting of health data. The health data recording

and reporting system is hierarchical. Recording and

reporting is done in stages, from the smallest service

unit to the centre. The Puskesmas (Public Health

Center) network consists of Polindes, Ponkesdes,

Puskesmas Pembantu, and other health care facilities

in the Puskesmas working area, reporting the results

of their activities to the Puskesmas. Furthermore, the

Puskesmas reports its data to the District Health

Office/City. District Health Offices conduct

recapitulation and forward the information to the

Provincial Health Office, and then from the

Provincial Health Office to the Ministry of Health.

So its nature is vertical. There is no routine reporting

mechanism that is horizontal (except for certain

cases), such as for Pulmonary TB and Dengue

Fever. As stated by the resource persons from

Sumenep District, TB already has a reporting format

across multiple regions.

To overcome this issue, the government should

ensure that arrangements are in place so that public

health bodies engage populations across the border

in discussions on quality and the changes to the

services provided. This is to ensure that there are

well-defined and clear protocols for managing

changes in where a patient is treated (NHS

Commissioning Board, 2013). Miller and Thayer

(2010) suggest that those problems can be solve

through innovations in cooperation projects on

health, the facilitation of health care access for at-

risk populations, and increased economic

opportunities in health care on both sides of the

border.

4 CONCLUSIONS

Environmental characteristics in the border areas

make these areas face several health problems. Some

of the public health problems occurs in the border

areas are the high population mobility, resulting in

statistical biased related to the recording of patient

health data. The consequences of this situation is

incomplete of monitoring health status that cause in

the emergence of other health problems, such as

misidentification of immunization status and

inaccuracy detection of risk factors for pregnancy,

One important step should be taken to reduce or

prevent the emergence of these problems is to build

cooperation between districts, so there is agreement

between two interdependent areas on the mechanism

of handling cross-border society problems.

ACKNOWLEDGEMENT

This research was supported by Research and

Development Agency of East Java Provincial

Government.

INAHEA 2017 - 4th Annual Meeting of the Indonesian Health Economics Association

280

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