43 MATERNAL AND CHILD HEALTH SERVICES IN THE BORDER AREA OF INDONESIA-EAST TIMOR-BASED ON COMMUNITY EMPOWERMENT APLONIA PALA, PhD. C. ENDANG LARASATI, PhD. C. SRI SUWITRI, PhD. C. NGALIMUN NGALIMUN, PhD. C. Diponegoro University, Faculty of Social And Political Sciences, prodidap@gmail.com Article history: Accepted 20 April 2019 Available online 28 May 2019 Keywords: Public Health, North Central Timor Regency, Empowerment, Community Health Health Resources A b s t r a c t Health care is a human right for communities who arranged mandatory organized by government mandate bases on Constitution 1945. Maternal health services include antenatal, childbirth services and parturition. While children's services are, include the ministries of the newborn, baby and toddlers. In North Central Timor Regency (TTU) in the last five years maternal mortality (AKI), infant mortality (AKB) and Mortality Toddler (AKABA) is very fluctuating. This illustrates that the district health degree requires revamping TTU Regency thoroughly of all aspects related to it. The acceleration of the decline in the mortality rate of mothers, babies and toddlers will improve public health degrees in North Central Timor. This done through community empowerment approach in the field of maternal and child health in which the community does not placed as health development destinations but placed as subjects of health development to enhance the knowledge, attitudes and behavior as well as self-reliance community for healthy living. Community empowerment in the health field can be encouraged through the Health Efforts Resource of Community (UKBM) such as the village health post, a postal village, the construction of an integrated, unified service and post maternity huts are scattered in the whole area villages of North Central Timor. Through community empowerment in the health community field, getting involved is active in the health service because the public join the plan, monitor, evaluate and keep maternal and child health services According to applicable minimum service standard. It can also increase public awareness in the mindset and behave clean living and healthy because of the maternal and child health issues in North Central Timor Regency not only just the responsibility of the Department of Health of North Central Timor, but also be the responsibility of all elements in society. Therefore, it takes cooperation of cross- program and cross-sector, i.e. Government Sectors, Private Sector, Community and Health Care in this area so as able to increase the degree of maternal and child health in North Central Timor Regency. Introduction Health care is a human right for every citizen who arranged into mandatory Government organized by the appropriate mandate of Constitution 1945 Article 28 H subsection (1). It stated "everyone has the right to live prosperous and inner, resides and get good environment condition and healthy as well as has the right to obtain health services" and article 34 paragraph (3) "the State is responsible for the provision of health facilities and decent public service facilities". Health care is every effort being held alone or together in an organization to maintain and promote health, 44 prevent and cure disease and restore the health of individuals, families, groups and or community (Azrul, 2010). The purpose of national development in the health field in fact is to increase awareness, willingness and ability of healthy living for everyone in order to materialize the optimal degree of public health (Departemen Kesehatan Republik Indonesia, 2015). Public health degrees could see, among others, of the mortality rate, the number of pain and nutritional status. Death rate used is the Maternal Mortality (AKI), Infant Mortality (AKB) and Toddler Mortality (AKABA). The higher of these mortality rates of mothers, infants and toddlers in this region indicates that the area of health degrees does not fullfil the expectations of countries. Therefore, the Government should continue to work better in order to suppress the decrease in maternal mortality, infant and toddler. North Central Timor Regency (TTU) is a county located in the Indonesia-Timor Leste border has a mortality rate of mothers, infants and toddlers are still fluctuating in the last five years (2013-2017) where the year 2017 in North Central Timor Regency going 2 cases of maternal death or equivalent 39.50/100,000 live births. Maternal mortality tends fluctuate that shows that maternal mortality has not well controlled. After soaring in 2012, maternal mortality gradually declines until 2014, but increased in 2015 and to decline again in 2016. Maternal mortality in North Central Timor Regency of 39.50/100,000 live births had already reached the target of its medium term development plan Area i.e. 192.95 deaths per 100,000 live births. Within the last three years, the case of exogenous infant mortality in North Central Timor Regency has decreased significantly in 2013 where there were 101 cases of death of 5,124 live births being 61 cases of live birth amount 5,101. Infant mortality in 2016 is 18 per 1,000 live births or 98 cases of death. Therefore, in total, the number of infant deaths in 2017 is as many as 29 cases or 5.73 deaths/1,000 live births. Toddler death rate in North Central Timor Regency is decline within the last three years of which in the year 2013 as much as 23 cases (4.5 per 1,000 live births) and the year 2014 as many as 17 cases (3.32 per 1,000 live births). In addition in 2015 up again into 54 cases (10.59 per 1,000 live births) in 2016 down again to 28 cases (5 per 1,000 live births). The case of the death of the toddler and the mortality rate of toddlers (AKABA) are per 1,000 live births. Fluctuation of maternal mortality, infant and toddler in North Central Timor Regency Government requires continued effort to press and maternal mortality, infant and toddler. Efforts have been made by North Central Timor Regency Government is improving the quality of health services for mothers and babies who reaffirmed in a Regulatory region Number 4 in 2012 on health of mothers, newborn babies, infants and Toddlers ( Infant Mortality Rates). Although these efforts have done but up to now the mortality rate of mothers, babies and toddlers would still fluctuate. Therefore, it is necessary to other efforts so that this problem can be resolved. The limited infrastructure consist of such as public transportation, a highway connecting the villages, districts and counties, means of communication and information, the resources of health care personnel, budget, facilities and health equipment, geographical conditions and topographic and quality of human resources. North Central Timor Regency is a barrier factor for North Central Timor Regency Government in maternal and child health services are in the area of the border of the Indonesia- Timor Leste. Therefore the issue of maternal and child health services in East North Central is an issue that is very complex so that the necessary cooperation of cross-program and crosscutting. Because the maternal and child health services not only just the responsibility of the health services North Central Timor but also the responsibility of all the elements that are in the area, namely the Government, the private sector and the community. Bases on the number of restricting factors of maternal and child health care services in North Central Timor then these health services need to be adapted to the conditions of the area and residents of North Central Timor. This implemented by the empowerment approach the community. Community empowerment is the way to foster and develop norms that make the community able to behave to live clean and healthy or process helps targets/beneficiaries. In order transformed into known/aware, willing and able to carry out the activities and programs of health through increased knowledge and skills followed by a change in behavior so that it can cope with the problems encountered. This strategy aimed at primary targets those who exposed to health problems or those of knowledge and behavior about altered (Nugraha, 2009). Thus, it concluded that with the empowerment of the community in the field of health are able to change the mindset of the people to clean and healthy life behaved. 45 Conducting maternal and child health services are which include as follows: 1) health services antenatal care of pregnant or mothers. 2) maternal maternity medical services 3) health service maternal childbirth or post-delivery; 4) newborn health services; 5) toddler health services in North Central Timor Regency has done Minimum Service Standards (SPM) of Health care but have not managed to optimally because it still puts the community as objects. It is not as the subjects of health development so the knowledge, attitude and behavior as well as self-reliance community for healthy living is still not adequate. Therefore community empowerment in the areas of health need to put as the subject of community health development so as to enhance the knowledge, attitudes, behavior and independence community to behave a life clean and healthy. 1. Reserach Method This research method using in depth interviews and the technique of purposive sample (Buchari Lapau, 2012). The informant was the patient pregnant women, maternity and childbirth clinics from Napan and Wini Community Health Centre, and Public Hospitals Area of Kefamenanu. Interviews also conducted with a midwife, nurse, doctor, medical specialists and other health care personnel including cadres of Maternal and Child Health Services as provider of health in the border region as well as the head of Department of health North Central Timor Regency and the head of the field of public health as health policy makers. The number of informants as many as 40 people comprising elements of the leadership organization of the health districts, sub-districts and villages. Those Elements of leadership become the informant consists of as follows: Head of Department of North Central Timor, Head of Public Health Agency of North Central Timor Regency, Director of the Regional Public Hospital at Kefamenanu. Moreover, Head of Napan and Wini Community Health Centre, Head Space of Peninatologi General Hospital, Regional General Hospital of Kefamenanu, Head of Space an Obgyn at Kefamenanu’s Regional General Hospital. To find out about maternal and child health services in North Central Timor Regency informant also extracted from the patient is pregnant, birthing mother, mother childbirth and contraception acceptors. Whereas in observing about community empowerment in maternal and child health services starts from an Effort of Community Health Ventures (UKBM). Informants were taken from Maternal and Child Health Services known as (Posyandu). Supporting data done through observation in the field and study the documents on the website of research related to maternal and child health services across the Wini and Napan Community Health Centre, as health centers that is located directly adjacent to Timor Leste, Regional General Hospital of Kefamenanu and health service of North Central Timor Regency. 2. Result And Discussion Public health service in North Central Timor Regency has implemented bases on standardize of public health minimal service applied. In addition, health services are also Mothers, infants and toddlers have done according to applicable health service standardize. It seen from the Maternal Mortality (AKI), Infant Mortality (AKB) and Childhood Mortality (AKABA) in the last five years in a North Central Timor slightly reduced though still fluctuates due to maternal mortality, infant and toddler it is one of the indicators to see the degree of public health in North Central Timor Regency. Maternal mortality is the death of a woman in while pregnant or within 42 days after the end of pregnancy, without considering the long gestation, and the location of all the causes that relate to or caused by pregnancy and its condition but not because the cause of the accident or incident (Retnaningsih, Misnaniarti, & Ainy, 2012). While infant mortality is, the death that occurred between the times after the baby is born until the baby has not aged exactly 1 month (28 days). Broadly speaking, from the side of the cause, infant mortality is comprised of two kinds, i.e. endogenous (neonatal) and exogenous (from 1 month up to 12 months ahead). There are three kinds of delay must be prevented so as to reduce the cases of maternal mortality are. 1) the delay in the level of family in recognizing the signs of danger and made the decision to get help; 2) delay in achieving health care facilities; 3) delay in healthcare facilities to get the help needed (Kementerian Kesehatan RI, 2013) . Low level of education of the mother in North Central Timor Regency and flow of decision-making must involve the family because the local culture a factor causes high mortality of pregnant women, maternity and childbirth. The delay in taking such decisions have an impact on health facilities reached late because the mileage to clinics and hospitals pretty much with the limited means of transportation and the impact of this is belatedly got the help is needed. This is because the limited health facilities and medical personnel in handling patient pregnant women, maternity and childbirth. In 2016 the infant mortality was above 28 days in North Central Timor Regency high enough for example as much as 67 cases while babies aged 28 days as many as 132 case while cases of maternal deaths by as much as 7 cases. The high factors cause infant mortality in 2016 in North Central Timor Regency are: 1) the low level of public awareness for checked myself into a health worker during pregnancy; 2) pregnant women who have been 46 missing sometimes origin of the trail since resettled or returned to areas of origin at the time of giving birth; 3) pregnant women who should be referred to the health facilities still have to wait for the permission of the family despite her condition is critical so that pregnant women who will give birth late tackled. To address this preventative efforts as party North Central Timor Regency of health service in continue gives to community outreach through education to the villages. The efforts increased healthcare quality standards in North Central Timor Regency in continue and continuously carried out by the health service at North Central Timor Regency. One effort to improve health services to the community of North Central Timor Regency is to accredit health infrastructure. From 26 clinics in North Central Timor Regency, only eight clinics that already accredited such as five clinics graduated with basic level clinics, 3 graduated with associate level. Currently the processes of accreditation of clinics in North Central Timor Regency keep it running so that it becomes the target of health service North Central Timor that later in 2019 all clinics in North Central Timor already accredited. As for the basis of accreditation of clinics doing this for the fulfillment of the service standard of quality health care to the community as this will, affect the fulfillment of standard services namely services clinics, individual health businesses, health the community or the community and the administrative management service. With the accreditation of some clinics in North Central Timor Regency of community health needs fulfilled in public health because when it accredited the clinic already means any clinics have two doctors so that medical services will better. In the Long Term Development Plan abbreviated as (RPJP) of Health during the period 2015-2025 explained that challenges the future health development is community empowerment in the field of health in General is still putting the society as an object, not a as subjects of health development. In addition, a knowledge attitude and behavior as well as self-reliance community is still not adequate. Community empowerment is in fact involve the community to be active in public service (to serve), active in the implementation of health advocacy (to advocate) and active in critiquing the implementation efforts of health (to watch). A model of community empowerment in health are categorized in 3 models of empowerment according to (Rothman, Erlich, & Tropman, 2001) in (Anggraeni Diah Kurnia; Sulaeman, Endang Sutisna, 2013), namely: 1) model of planning social (social planning models): 2) models of social action (social action model) ; 3) model development environment (the locality development model). Social planning model has the objective to plan, compose, create, serve and work on the problems of the society in finding solutions in a variety of wellness activities program. Social action model has the purpose of carrying out the transformation (the fundamental changes) that is thorough in many areas of public life, organize the structure of power, sources of decisions making and customs the community. The locality development model is a process-oriented activities with the aim to provide active learning experience to society, pointed on the importance of consensus (Agreement) and cooperation between citizens, build identity and pride as citizens of the community. It is as well as caring as a part of the community or in brief that the process of community empowerment in health can take optimal if public participation in set goals and implement the actions can be grown. The locality development model is a suitable model applied in the maternal and child health care services in North Central Timor Regency because the model can bring change for people in life behave clean and healthy through participation active local communities with development potential and local assets (socio- cultural values). Program community empowerment in the health field has been done by the Department of Health in North Central Timor Regency cooperate with Probe Indonesia Vision (WVI) that implement the Global Partnership Projects for Social Accountability (GPSA) Since 2014. This Program supported by the World Bank through his voice and Citizen-focused government accountability to improve basic services maternal and child health. North Central Timor Regency is one of the areas of implementation of the project and there are 20 villages became the location of this program. Through community empowerment approach in the field of the health related services changes the basic maternal and child health in North Central Timor Regency occur starting from the community involvement in monitoring and assessing the facilities services birthing. These are such as Health Village Centre known as (Polindes), Village Health Post known as (Poskesdes), post construction (Posbindu), associate (Pustu) clinics and community health centers (Puskesmas). The community empowerment approach able to strengthen health centers as the central role of the community and society as well as North Central Timor became know about standard medical services in each health facility. With understanding and insight which is owned by the public about the health service standard is certainly the community get involved in directing and escorting the existing health services so that health services are appropriate minimum service standard. It can be seen from the degree of health, decline, where maternal mortality cases in 2016 of maternal mortality reaches seven cases whereas in 2017 decreased to 2 cases of maternal deaths. 47 Table 1. The Health Level in North Central Timor Regency during the period 2013-2017 No Health Level Indicators 2013 2014 2015 2016 2017 1 The Number of Infants Death 101 122 61 98 80 2 The Number of Toddler Death 23 17 54 28 8 3 The number of Maternal Death 14 7 11 7 2 4 Infant Mortality 19,7/1.000 23,81/1.000 11,96/1.000 18,69/1.000 15,80/1.000 5 Mortality Toddler 4,5/1000 3,32/1.000 10,15/1.000 5,34/1.000 1,58/1.0000 6 Maternal Mortality 273,22/100.000 136,64/100.000 215,64/100.000 133,49/100.000 39,50/100.000 Source: Health Profile of TTU in 2017 Data table one above shows that Maternal Mortality (AKI), Infant Mortality (AKB) and Mortality Toddler (AKABA) in North Central Timor Regency still fluctuate in the last 5 years (2013- 2017). Therefore need increased community empowerment approach through the efforts of Health Community Resources (UKBM). Where the community involved and actively participate in the activities of health in the Village Idle, Poskesdes, Posbindu, Polindes, and Community Health Centre abbreviated as Posyandu of this Maternity Health Unit Society abbreviated as UKBM because of the community, by the people and for the people. Through these community UKBM can plan, implement, monitor any existing health services in the community health service so that the agreed standards. As the county border with Timor-Leste, the Health Service of North Central Timor Regency and society continues to strive to increase the degree of maternal and child health through community empowerment-based Health Resources Community. There are currently 88 villages in standby, 16-post Health Village, 144 Maternity Village Centre, 58 posts; the construction of integrated and integrated service of 498 posts. Not all villages in East North Central Regency of Health Resource have a Business Community like a village, this health post standby and integrate coaching post since the formation of the agreement and in accordance with the needs of the community. Maternity village center consist of evenly on each village across the North Central Timor Regency because average people in these villages more use maternity village center as the nearest health services facilities. Community Health Centre abbreviated as Posyandu is a type of business Health Community with the most resource and there is not only the village but until neighboring area in accordance with the settlement. Based on the quantity of Health Community Resources Effort which is in North Central Timor Regency adequate in terms of quality while still not adequate due to the efforts of the Community not yet Sourced Health provide positive benefits for the public in accessing information about health care services. A lot of effort of Health Community Resources formed due to the interest element of Government without considering the elements of community empowerment approach so that community who don't have a sense of belonging as a result the community apathy in the presence of Community Health Resources Efforts. The apathy communities because of the community have not yet understand about the existence of Health Community Resources and the benefits gained from the Effort of Health Community Resources. Therefore, being the duties and responsibilities of Government, the private elements, the element in the Health Care Community and the North Central Timor Regency in providing knowledge and understanding to the public is the importance thing of Health Community Resources around health service activity for this community. Integrated Service Post in North Central Timor Regency amounted to 498 areas of Community Health Centre known as Posyandu, active as many as 463 Posyandu or 92.97% and there are evenly distributed on the settlement are still not functioning to its full potential. Most people have understood the role of Posyandu in KIA'S service but there are also some people still do not understand the benefits of Posyandu as Community Health Resources. Integrated Service post in North Central Timor Regency community is seen as the only place of the activities of 48 the mothers become pregnant, nursing mothers, and infants and toddlers are done routinely every month to weigh the baby and vaccine or immunization only. Many mothers who do not follow the activities in integrated service post after her son finished getting full immunization of the motherhouse once it started dropping off her child mingier to the integrated service post. Integrated service posts servicing target is infants less than one year, toddlers ages 1-5 years old, pregnant women, nursing mothers, mother childbirth and women of fertile age/age pairs lush (Wahid Iqbal Mubarak: 2012). Community Health Centre activities include: 1) maternal and child health; 2) family planning; 3) immunization; 4) improved nutrition; 5) combat diarrhea; 6) basic sanitation; 7 essential drug supply). Community empowerment approach in the health field implemented through activities at Community Health Centre known as Posyandu so that people can change the mindset and behavior in increasing clean and healthy life patterns. North Central Timor Regency has 59,886 households, the number of which is monitored by the health services and clinics in North Central Timor Regency as much or as much 51,107 85.3% households, the number of households with Clean and Healthy Lifestyles known as (PBHS) is still very low i.e. 17,520 households or as much as 34.3%. This data shows that the public are still not aware of TTU patterns and behavior of living clean and healthy because of household air-clean living and Healthy Behavior just revolved around 34.3%. Therefore Community Empowerment needs to be enhanced continuously through the efforts of Community Resources such as Health alert village of health post, a postal village, the construction of an integrated, unified services and post maternity village community have an understanding of the importance of living behavior patterns as well as clean and healthy. Need the cooperation of cross-sector and cross-program in North Central Timor Regency in health services in East North Central public health issue because it is not only just the responsibility of the TTU health service but also the responsibility of all the elements related such as the Government sector, the private sector and the community. Conclusion and Suggestion 1) Maternal mortality, infant and toddler in North Central Timor Regency are still fluctuating in the last five years (2013-2017). Due to the low level of public awareness for checked myself into a health worker during pregnancy, pregnant women are already origin. Sometimes the lost footsteps since resettled or returned to areas of origin at the time of childbirth, pregnant women who should be referred to the health facilities still have to wait for the permission of the family despite her condition is critical so that pregnant women who will be giving birth late tackled. 2) The limited infrastructure resources of the health workforce (Doctor and specialist doctors, midwives, nurses and other health care personnel), budget, facilities and health equipment, geographic and topographic conditions and the quality of human resources becoming a barrier to maternal and child health care services in North Central Timor Regency. 3) The society still placed as an object, rather than as subjects of health development. 4) Knowledge, attitude and behavior as well as self- reliance community for healthy living is still not adequate. 5) The village health post, a postal village, the construction of an integrated, unified services and post maternity huts of the village as a business of Health Community resources yet underutilized by the public in accessing health services. 6) Integrated Service post only used once a month and is limited to the weighing weight baby and immunization for pregnant women, babies and toddlers. This research also consists of various suggestions as follows: 1. Health service of North Central Timor Regency do need guidance about the maternal and child health continuity, integrated and sustainable in villages throughout North Central Timor Regency. 2. North Central Timor Regency Government needs to increase the quality and quantity of infrastructure, medical and non-medical, health facilities and tools, increased health budget from the budget of income and Expenditure and an increase in human resources quality of North Central Timor community. 3. Communities should placed as an object health development with a community empowerment approach. 4. It still needed to improve the Community quality of Health Resources such as the village health post, a postal village, the construction of an integrated, unified services and post maternity village through community empowerment approach so that Community Health Resources can provide positive benefits in the services especially in villages. 5. Integrated Service Post should be utilized in appropriate health care functions, namely: 1) maternal and child health; 2) family planning; 3) immunization; 4) improved nutrition; 5) combat diarrhea; 6) basic sanitation; 7) essential drug supply. 6. It needs increased cooperation of cross-sector and cross-program in North Central Timor Regency in maternal and child health services. 49 References 1. Anggraeni Diah Kurnia; Sulaeman, Endang Sutisna, L. P. M. (2013). Hubungan antara Kecemasan dengan Frekuensi Bangkitan pada Penderita Epilepsi Parsial di RSUD Dr. Moewardi. Nexus Kedokteran Klinik. 2. Azrul, A. (2010). Pengantar Administrasi Kesehatan. 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