One afternoon in Lhok Seumawe, Nanggroe Aceh Darrussalam, the end of November 1997."Hello ...", phone ringing sound in the home office of Immigration head office of Class II Lhok Seumawe, Nanggroe Aceh Darrussalam. "Hallo ... This ...?", who answered Mrs. Urendeng-Banera, wife of the head office. "Mummy ..., this is of Micronesia, from Liti ...", replied the voice from beyond. "What ..., this is true Liti ...?", asked the lady. "Iyo mami, this is from Micronesia, the pa Liti ..." His accent is thick Manado in Miangas and color accent sounds typical, very familiar, make sure that the lady was really his son. The lady fainted. Haru happy mix. Later he knew that his son was still alive Urendeng Litisya midwife.Litisya Urendeng PTT is a midwife who was placed on the island Miangas, District Nanusa, who with his colleagues Albert Nusa Mantri and several others suffered ill-fated Miangas residents stranded on the island of Chuck, Republic of Micronesia, while referring to the mother gave birth to a health center of the island Miangas Karatung, the capital city Nanusa district.Starting from a mother who can not give birth because the pelvis is narrow, in early September 1997 and should be referenced. After the family agreed to be referred, they set off with wooden boats outboard motor and then lost in the Pacific Ocean, drifting amid fierce ocean waves for 72 days, before a Japanese ship to save them. In the event 10 people from 14 people who are in the boat were killed, including the infant.Footage of events over a re-recording phenomenon Nanusa islands as cluster outer islands in conjunction with the dilemma referred patients, which is repsentasi of many similar events and in the same matters as well. Referring patients!Imagine, just because business must compete refer patients to die berkubur lives even oceans. Do not know rimbanya. Strange indeed! While in some places to refer patients no longer a problem. Nanusa Mar in the islands, it is inversely proportional, occurs in the middle of the flow of information, communication and an increasingly sophisticated global transportation.Nanusa Islands is a cluster of islands in the area of governance Talaud Islands which are geographically located in the northernmost part of NKRI which directly borders with neighboring countries, the Philippines. Three of the five clusters in the outer islands of North Sulawesi province in this region, namely the island Miangas, Marampit and Kakorotan (Presidential Decree No.78/2005). Most of its population classified as "elite" (aka poor = difficult economic times), difficult to access due to various limitations and frequent disasters, especially lack of food (if you do not want to be regarded as famine) only because the weather is less friendly so that access to transportation to food distribution stalled.Now, a decade so passed, a rather long period of time to reform the slightest problem (or for?) Refer patients. Bijaklah we glanced backward at the position in 1997 Nanusa Islands in the affairs of referring patients, and compare it with current circumstances. To be honest, the island state of Nanusa now directly proportional to the situation a decade ago. Still the same! Just "nut in the split second"!Referring patients remains a serious problem, the root of the problem is multi-complex that need solving a complex multi as well. Nanusa Islands refer patients not just a health problem. Many facts are undeniable, proves this.Geographical circumstances Talaud Islands (CBS Talaud, 2005) which consists of the islands far-flung and hard to reach, especially Nanusa Islands, a factor which makes it difficult for patients to seek treatment or in effort to refer patients. Moreover, the distance with Mala Hospital in the capital of the district as a referral center is considered extremely remote.To refer patients Miangas island, a distance of 129 nautical miles from Melongguane, the district capital (CBS Talaud, 2005), Mala Hospital requires at least three days travel time by boat pioneer, having to drop anchor in every harbor pilot. Green, cited Sarmudianta, 2002, states that the distance and travel time is an enabling factor to hamper efforts to seek treatment (health seeking), adherence to treatment (compiliance) and referral (referral system). The accumulated distance and time will make the transportation costs would be higher.The absence of cost is a major problem families in an effort to refer patients. An empirical fact is that when the clinic made the decision to refer a patient, always collided with the problem of the cost of the family. Especially in a state of emergency patients must be referred at the time, then the "cost" for the family is like a time bomb ready to explode at the time.This can be understood considering the economic conditions mentioned above, make the family was not ready in terms of financial. Poor card that is expected to be the god of rescuers, unable to do much, because of poor cards are used to finance treatment and care, and not for transportation.Health financing in the budgets allocated pemkab Talaud Talaud 2006, 3.78% of the total 321 billion (Talaud Health Profiles, 2006), with funding per capita USD. 146 587 is already on target Millennium Development Goals, Rp. 120,000 per capita (MDGs, 2005), but can not be felt touching the public service to refer patients to a level as it is still more widely used to fix the health infrastructure, as a consequence of the new expansion area.The condition of absence cost a bit more severe when the time does not refer patients to coincide with the schedule so that the pilot boat Sea must use Pusling or motor boat population, because families have to be confronted with a larger jump in costs, the cost of fuel. Very high fuel prices severely limit the purchasing power of families, so that the fuel purchased is limited to "important to their destination" without any backup. A condition that is very risky!Tragically again, it is time to refer patients if fuel is not available in shops or at food stalls. Authors and other Karatung clinic staff with patient's family had the experience to push the cart from house to house residents, just to collect one or two bottles of kerosene for purposes of referring patients.Policies that prohibit passengers PT Pelni contain kerosene, especially gasoline, in the pioneer ships, adding more fuel access kusutnya red thread, because it almost made Nanusa Islands residents access to the fuel to be none at all, In this condition, look for fuel in the islands Nanusa is like "looking for a needle of a haystack." Even if there exorbitant price!The difficulty of transportation access to its own problems in terms of referring patients. In fact Nanusa transport access to the Islands are only accessible by sea which is served by vessels Pelni pioneer and a ship and takes place only once in 2 weeks (CBS Talaud, 2005).In the context of transportation access, refer patients from the island Miangas like "waiting for fate" of having to wait for the pioneer ship schedule with no other choice. Even more tragic if the ship could not be able to pioneer docked at the pier Miangas because of the unfriendly weather, then refer the patient as "pungguk miss the moon." Not at all! Far from the truth!Weather conditions more or less friendly. is a complication that almost no intervention because they have to deal with the forces of nature, is another obstacle in the effort to refer patients. A provincial official who visited the Islands Nanusa, whether true or not, once said that 10 months from 12 months a year, in the Islands Nanusa is tight season.Interestingly, in these circumstances, when referring patients is an absolute choice and must use a pusling sea, the decision to refer patients is highly dependent on the "engineer" who seemed to body and soul are united with the sea and weather. Although the patient was ready to be referred, if the engineer says "Torang Blum may brangkat now is the hour bagini this wind mo batiop kancang" then the health care workers and family do not helpless and instantly trust. A state that is less acceptable to common sense, but more truth than hurt.Inadequate health resources on the islands Nanusa, is a true priority in development efforts in the health sector in Talaud Islands, because in addition to quantity and quality is lacking, also because of the ease of intervention. Assuming that the health sector is the domain of regional autonomy (Law No.22, 1999), then the above problems can easily be intervention by the regional health department through a proposal to the local civil service agency.In terms of quantity, the ratio of health resources versus the total population (Minister of Health Decree No.1202, 2003), in the islands can be said Nanusa already adequate, especially the ratio of general practitioners and nurses. Nanusa Islands with a population of 4206 people (BPS Talaud, 2005) ideally 1-2 people served by general practitioners and 5 nurses, and is in conformity with the current state of the field. The ratio of midwives are ideally served by 4 people new midwife realized 2 people who all concentrated in the main clinic.But on the other hand, the geographical conditions of the islands, the ratio was felt still less and was not evenly spread, since most health resources are concentrated in health centers as the holders of the parent program. This situation is seen from the sub-health centers that have not been in occupied health resources. Even the Village Maternity Clinic Poly (Polindes) which should be occupied by a village midwife, everything is still empty. From the program side, the ratio of health resources are also still seem less, is proven by the clinic staff who still holds the dual program.Looking ahead, the state ratio of health resources will be even more stagnant because many health resources that do not want assigned to this area, because it considers this area as a place of exile and the only decent occupied by employees with problems, as punishment, so that the various kinds of ways trying to avoid the placement of tasks in this region (similar to Nusa Kambangan?).Lack of training on emergency management and how to maintain a patient's life (survival), making quality health resources on the islands still impressed Nanusa inadequate. When the constraints as mentioned above, offset by the ability of health resources, especially nurses and midwives, in the management of emergency and how to maintain a patient's life, then at least a referral of patients to be delayed until the ship arrived or awaiting readiness pioneer families of patients.Whatever the reasons and background, whether consciously or not, the empirical fact already happening. Referring patients from the islands Nanusa is like "eating the fruit simalakama". A real dilemma! Not referred, the patient died! Referred, families and health workers battered! For that we need a fundamental review, in order to obtain design policies that fit the typical of this region, so that the constraints in referring patients can be eliminated or at least reduced.Given the geography and natural conditions typical Nanusa areas that are less friendly, which can not intervene because they have to deal with the forces of nature, coupled with other constraints, hence improving the quality of health resources is the first choice. Training on the management of kegawat daruratan and how to maintain a patient's life is a "conditio sine quo none". A must!Cut the reference distance, is another alternative for accelerating patient referrals to the referral center. Distance of 129 nautical miles and takes about 3 days from the island of Mala Miangas to hospital, was too much for patient referrals. So Talaud district government plans to build a hospital in Gemeh (North Karakelang region), an alternative telling to cut the distance from the islands Nanusa reference.Another alternative is the provision of fuel depots in the islands Nanusa. It is not merely to refer patients needs, but also in touch with the needs of everyday life (daily living needs) such as the fuel needs for the fishermen and affairs in the kitchen cooking. With a fuel depot, then access to that barely any fuel can be overcome.Improving transportation access, is another choice that feels more difficult to be realized because not only involve Talaud district government, but that does not mean not at all. Experience that has ever existed a local shipping entrepreneur who open access cruises to the region Nanusa (KM Alkasa and KM Raflesia), can be considered Talaud district government to lobby other employers, open access cruises to the islands Nanusa, so that people have other alternatives besides pioneering vessel, including alternatives in referring patients.The authors very much hope, or at least suppose if there is improved quality of health resources, decrease the distance reference, the realization of fuel depots and the expansion of access to transport, hopefully to eliminate or at least reduce the constraints in the affairs of referring patients in this region, so that the future will no longer Litisya midwives and other Mantri Albert, who must compete in the wilderness of ocean life, simply to refer matters patient. And the most important thing is to refer patients from the islands Nanusa no longer an issue.Hopefully! He ... he ... he ...!
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