Implementation of the Cervical Cancer Early Detection Program with the IVA Test Method in Cilegon City in 2022

Melisa Charoline Rembet, Mardiati Nadjib

Faculty of Public Health, Universitas Indonesia, Indonesia

Email: [email protected]

Keywords

ABSTRACT

Early Detection, IVA Test, Cervical Cancer, Public Health Center Management

Background: With the high number of cancer cases and deaths and the continued increase in cancer financing, which has caused a number of countries, including Indonesia, to continue to struggle to reduce the impact of cancer, the things that must be done are detection, screening, and treatment, as well as palliative care, which are key components of the response to cancer. Early detection is a major step toward increasing the chances of cancer survivors becoming survivors. The achievement of early detection of cervical cancer in Indonesia in 2019–2021 is still low, at 6.83%, or as many as 2,827,177 women aged 30–50 years have undergone early detection of cervical cancer with the Visual Acetate Inspection (IVA) method. Banten Province only reached 5.61%, which means that it is below the average achievement of Indonesia, and Cilegon City is also still low in the achievement of early detection of cervical cancer in 2021, which is 1.2%. The purpose of this study is to determine the picture of the implementation of the cervical cancer early detection program with the IVA method in Cilegon City and identify obstacles that arise in its implementation. Method: This research is qualitative research with a descriptive approach. Data collection techniques include in-depth interviews, group discussion forums, and document review. Results: The results showed that the availability of SOPs, facilities, and infrastructure that support the implementation is not yet balanced between human resources and the target of the cervical cancer early detection program. There are constraints in the process of implementation, recording, and reporting, as well as low differences in perception in calculating the target achievement of the cervical cancer early detection program. Conclusion: The implementation of the early detection program in all Public Health Center in Cilegon City in 2022 is in accordance with the policy, even though there are still obstacles in its implementation, both passively and actively, so that achievement is still very low.

INTRODUCTION

Cancer has the highest incidence rate in women, at 16.6 per 100,000 population, with an average mortality rate of 9.6 per 100,000 population for breast cancer, followed by cervical cancer at 9.2 per 100,000 population, with an average mortality rate of 9.0 per 100,000 population (Globocan, 2020). The incidence of cancer in Indonesia (136.2 per 100,000 population) ranks eighth in Southeast Asia and 23^rd overall in Asia (Ministry of Health of the Republic of Indonesia, 2022). Then cancer data based on the results of Basic Health Research, where the comparison of cancer prevalence in 2013 and 2018 has increased, cancer prevalence is 1.4 per 1000 population in 2013 (Riskesdas, 2013), to 1.79 per 1000 population in 2018 (Riskesdas, 2018)

In 2020, 19.9 million catastrophic cases were borne by the Social Security Organizing Agency Health at a cost of IDR 20.0 trillion, or 25% of all health care claim costs. Where in the proportion of catastrophic financing, cancer is in second place at 18%, after the highest position of heart disease at 49%, and followed by stroke at 13%, kidney failure at 11%, followed by thalassemia, cirrhosis hepatis, leukemia, and hemophilia (BPJS, 2021)

From the description above, where the increase in cancer prevalence rates, high mortality rates due to cancer, and the high burden of cancer health financing, the things that must be done are detection, screening and treatment, as well as palliative care, which are key components of the response to cancer (WHO, 2021)

Early detection is a major step to increasing the chances of cancer survivors becoming survivors. So that cancer patients have the best chance for successful treatment, low costs due to cancer treatment, cancer intensity, disability due to cancer, and or even death can be controlled. When cancer treatment is delayed or inaccessible, there is a lower chance of survival, greater problems related to treatment and higher treatment costs (Ministry of Health of the Republic of Indonesia, 2023).

Because of the importance of early detection of cervical cancer, the Government of Indonesia made a Strategic Plan, especially in the health sector, where in the latest Strategic Plan in the Regulation of the Minister of Health of the Republic of Indonesia Number 13 of 2022, concerning Amendments to the Regulation of the Minister of Health Number 21 of 2020 concerning the Strategic Plan of the Ministry of Health for 2020-2024, the target of early detection of cancer is districts / cities that organize early detection of cancer  The cervix is at least 80% of the female population aged 30-50 years or women who have a history of active sex. Where actions are taken to reduce the high cases of cervical cancer through IVA tests (Ministry of Health of the Republic of Indonesia, 2022). Then the cervical cancer policy issued by the government is the Regulation of the Minister of Health Number 34 of 2015 concerning the Management of Breast Cancer and Cervical Cancer (Ministry of Health of the Republic of Indonesia, 2015), and Regulation of the Minister of Health of the Republic of Indonesia Number 29 of 2017 concerning Amendments to the Regulation of the Minister of Health Number 34 of 2015 concerning the Management of Breast Cancer and Cervical Cancer (Ministry of Health of the Republic of Indonesia,  2017)

A policy was also established for the district / city level, namely the Regulation of the Minister of Health of the Republic of Indonesia Number 4 of 2019 concerning Technical Standards for Fulfillment of Basic Service Quality in the Minimum Service Standards in the Health Sector. The Regency / City Government implements Minimum Service Standards in the health sector, so that it can be obtained by every Indonesian citizen at a minimum. IVA examination services (for women aged 30-50 years) as an effort to early detect cervical cancer are included in the sixth point of twelve SPM points, namely health services at productive age with a target of 100% (Ministry of Health of the Republic of Indonesia, 2019).

Various efforts have been made to achieve the target of early detection of cervical cancer, such as health promotion / education, target calculation, target mapping, mapping and strengthening human resources with training, fulfillment of infrastructure facilities, strengthening program integration with PIS PIS PK, KB and encouraging the involvement of private health facilities, the achievement of the cervical cancer early detection program Cilegon City still ranks 3rd lowest in Banten Province (Provincial Health Office Banten, 2021), in 2018 it only reached 0.99%, in 2019 it reached 0.89%, in 2020 it reached 1.78%, and in 2021 it reached 2.05% has not reached the national target of 80% and The Regency / City Government implements Minimum Service Standards target of 100%. In 2020 from a total of 642 people who carried out cervical cancer early detection examination from the target of 36,033, 7 people were found with positive IVA results, in 2021 from a total of 765 people who carried out cervical cancer early examination with the IVA method from the target of 36,582 people, 40 people were found with positive IVA results, there was a significant increase in the discovery of cases with positive IVA (Cilegon City Health Office,  2021).

Given the importance of achieving the cervical cancer early detection program in Cilegon City, it is necessary to assess the implementation of the cervical cancer early detection program in Cilegon City so that problems that arise can be identified so that the implementation of the program can be carried out properly so that it can achieve the specified target. This study aims to determine how the implementation of the cervical cancer early detection program in Cilegon City in 2022 and identify challenges that arise in its implementation.

METHODS

This research is a qualitative research with a descriptive approach. The purpose of qualitative research is to understand the condition of a context by directing a detailed and in-depth description of the portrait of conditions in a natural context (natural setting), about what actually happens according to what is in the field of study (Nugrahani, 2014). Data collection techniques use in-depth interviews, group discussion forums and document review. This research instrument uses a research questionnaire. The components studied are categorized into 7 variables, including input components consisting of Human Resources, SOPs, Financing, Facilities and infrastructure. The process component consists of the implementation of early detection checks, recording and reporting. The output component consists of the achievements of the cervical cancer early detection program in Cilegon City in 2022. The informants in this study were the Head of UKM-UKP at the Health Office, program holders at the Health Office, Head of Public Health Center and program holders at public health center. Triangulation of data sources is carried out by confirming to IVA operators of public health center (doctors / midwives), cadres, and the community as recipients of services.

RESULTS AND DISCUSSION

Cilegon City has 8 sub-districts with 9 public health center with the target number of cervical cancer early detection programs in Cilegon City in 2022 of 71,139 women aged 30-50 years who are married or have a history of risky sexual relations.

The results of the study include an overview of input components (Human Resources, SOPs, Financing, Facilities and infrastructure), process components (implementation of early detection examinations, recording and reporting), output components (achievements of cervical cancer early detection programs), are as follows:

INPUT

Human Resources

In the Human Resources criteria, which carry out IVA examinations consisting of the number of IVA test operators (Doctors and Midwives), training has been followed and motivation from the implementers of the cervical cancer early detection program obtained the results of in-depth interviews that the number of Health Human Resources in the implementation of the cervical cancer early detection program in Cilegon City all Public Health Center already have IVA operators in the implementation of the cervical cancer early detection program and  have attended training in early detection of cervical cancer IVA method. Training that has been held has been held by the Cilegon City Health Office and the Provincial Health Office.

“Untuk SDM di puskesmas sudah dilatih, Cukup mbak, hampir semua tenaga dokter dan bidan sudah dilatih IVA” (KA-BID) 

“Pelatihan dan pelaksanaanya dari Dinas Kesehatan Provinsi dan Kota Cilegon. Kalo provinsi perwakilan, dibagi jadi beberapa batch. Kalo Cilegon

semua puskesmas ikut. Satu Puskesmas 2 orang. Terakhir bulan Oktober 2022. “ (OP-JOM)

IVA operator personel are not comparable to the target population aged 30-50 years, this causes the lack of IVA operators in Public Health Center, Cilegon City. There are still doctors and midwives who have not been trained because they are waiting for their turn in training carried out by the Health Office.

“Cukup sih... karena yang dilatih ada dokter dan bidan, tapi kan.. kalau dilihat dari sasaran IVA nggak akan cukup untuk operator kita, tetep masih butuh pelatihan lagi…..” (KA-GRO) 

“..., dokter dan bidan yang ikut pelatihan, pelatihan terakhir ada di oktober 2022 kemarin, tapi yang boleh ikut kan bidan sama dokter aja, perwakilan masing-masing puskesmas 1 aja, yang lain mungkin nanti gantian…” (PJ-DIN)

From the results of the document review, the number of doctors in the Public Health Center was 25 people, midwives were 147 people, nurses were 140 people, who had been trained by the number of doctors in the Public Health Center as many as 20 people, midwives as many as 29 people, nurses as many as 6 people

Some informants said that the person in charge of the cervical cancer early detection program has a large task and responsibility so that the workload is quite a lot, because the NCD (Non-Communicable Diseases) program includes other NCD disease programs such as Hypertension Screening, DM and POSBINDU (elderly) activities.

“soalnya kan PJ IVA itu PJ PTM mbak, PTM itu banyak loh yang masuk SPM, seperti Hipertensi, DM, trus kan ada posbindu juga..” (KA-GRO)

“mbak, sasaran IVA itu banyak banget…., dan tenaga operator kita masih belum mencukupi…” (OP-CIL)

From the results of the above research, it is in accordance with research conducted by (Anggraini, 2013), that the person in charge of the IVA program has been given other responsibilities, so that his duties and responsibilities are duplicate. Then a study by (Mwaka et al., 2013) whose results are the problem of prevention and management of cervical cancer screening, which requires more trained health workers. According to (Indiahono, 2009) failure in implementation often occurs because human resources are insufficient, inadequate, or incompetent in their fields.

In this context, it is important to identify specific human resource needs based on the workload of health resources, as well as conduct appropriate recruitment, training, and development to meet those needs.

SOP (Standard Operating Procedure)

In the input component of the SOP criteria for the interview results, it is known that all Public Health Center in Cilegon City already have SOPs (Standard Operator Procedures). SOPs are prepared by the person in charge of the Public Health Center program, the coordinating doctor of the Public Health Center, and the head of the Public Health Center. IVA operators in carrying out cervical cancer detection are in accordance with the established SOP.

“Pemegang program yang membuat SOP. Acuannya dari buku yang didapat dari pelatihan, nanti sama Kepala Puskesmas di pelajari dan di acc. Petugas/ operator melaksanakan sesuai SOP. SOP sudah sesuai karena yang melatih itu” (OP-CIB)

“Ada SOP, saya yang bikin sama dokter koordinator, acuannya dari permenkes. Pelaksanaannya sesuai dengan SOP” (PJ-PUL)

During the interview, a crosscheck was conducted to adjust the answer to the conformity of the SOP with the implementation of the IVA Test, it was found that not all informants answered correctly the SOP that had been made, there were several steps in the procedure that were missed. Obstacles in implementation according to SOPs are because there are still new IVA operators, who have not been exposed to existing SOPs at Public Health Center.

From the results of the above research, these findings are in accordance with the research of Herlambang et al. (2022) which shows that SOPs have a positive and significant effect on service quality. Therefore, efforts are needed to ensure that every IVA operator receives adequate training and understanding of the applicable SOPs, based on the reference used, namely the Regulation of the Minister of State Apparatus Empowerment and Bureaucratic Reform of the Republic of Indonesia Number 35 of 2012 concerning Guidelines for the Preparation of Standard Operating Procedures for Government Administration.

Financing

The input component of the financing criteria is known that the financing for the implementation of the cervical cancer early detection program at the Cilegon City Health Office from health is sourced from the APBD and at the Public Health Center from the APBD and APBN. Financing at the Health Office IVA test activities, entering into productive age activities, financing includes cancer socialization activities, IVA networking, IVA operator training financing. Funding at the Public Health Center level is allocated for the transportation of health workers who carry out IVA outside the Public Health Center building/ Public Health Center Network and food and beverages for IVA implementation.

Some informants said that the costs needed to support IVA examination activities were still lacking, most community informants said IVA activities might need to be given gifts / souvenirs for people who will do IVA tests, cervical cancer health promotion activities tend not to be allocated specifically to improve the achievement of cervical cancer detection programs. Transportation activities of officers are still insufficient to attract people who want to do IVA tests, so their activities are often included with other activities, such as family planning activities.            

“Kalau di dinas kegiatan untuk IVA masuk ke dalam kegiatan usia produktif mbak, ada kegiatan sosialisasi kanker di hari kanker dan penjaringan IVA, untuk pelatihan tenaga dari dana APBD mbak, tapi yang mengelola bidang SDM..” (PJ-DIN)

“Gak ada biayanya mbak kalo untuk menarik perhatian masyarakat, ini juga untuk transport petugas aja, test IVA itu sering bareng sama KB, misalnya ada safari KB, kan banyak yang pasang KB IUD jadi sekalian” (KA-CIL)

The results of the above research are in line with Riyadini's research (2015) where Public Health Center experienced limited budget in developing the implementation of the program. In this discussion, it is important to address the limited financing faced by Public Health Center in implementing cervical cancer early detection programs. Public Health Center needs to take strategic steps, such as submitting funds to related parties and optimizing the use of existing funding sources, to overcome these limitations.

In addition, it is also important to strengthen coordination between the Public Health Center, Cilegon City Health Office, and Provincial Health Office in overcoming financing problems faced. Thus, it is expected that sufficient financing can be available to expand and improve the quality of the implementation of cervical cancer early detection programs in Cilegon City.

Infrastructure

The input component in the criteria for facilities and infrastructure is known that nine Public Health in Cilegon City have met the standards of facilities and infrastructure in accordance with Regulation of the Ministry of Health of the Republic of Indonesia No.35 of 2015, when a survey was carried out it was found that a closed room with a size of nine square meters with sufficient lighting and ventilation, has a standard examination table (gynecology table), it is a support in the implementation of the cervical cancer early detection program at the Public Health Center.

The availability of equipment at the Public Health Center for IVA test examination is adequate and sufficient. Some informants of IVA operators said that consumables such as applicator cotton were sometimes still lacking, some health centers made the applicator cotton manually.

“Sarana prasarana IVA di Puskesmas sudah lengkap teh.. cuma saja kapas aplikator harus buat sendiri, agak repot siii….” (OP-PUL)

            The provision of facilities and infrastructure at the Public Health Center in Cilegon City comes from the Health Office and sometimes receives equipment assistance from the Ministry of Health which is distributed through the Provincial Health Office.

“waktu tahun 2019 apa 2020 itu dapat alat dari kemenkes, tahun sebelumnya sudah dapat juga alat dari dinkes sini” (PJ-CIT1)

The results of the above research are in accordance with research conducted by Susilawati (2019), which found that facilities and infrastructure are inadequate and greatly affect the achievement of health service targets. Guidelines for IVA examination facilities and infrastructure: The guideline that is referenced in this study is the Regulation of the Minister of Health Regulation No. 34 of 2015 concerning IVA examination facilities and infrastructure.

So it can be emphasized that although all Public Health Center in Cilegon City already have facilities and infrastructure in accordance with the guidelines, there are still obstacles in the availability of consumables. In addition, it is also important to pay attention to the role of the Cilegon City Health Office in ensuring the availability of consumables needed in the implementation of cervical cancer early detection programs. Regular coordination and monitoring need to be done to ensure that all Public Health Center have adequate supply. Therefore, the fulfillment of optimal facilities and infrastructure is an important factor in ensuring the successful implementation of cervical cancer early detection programs.

PROCESS

Early Detection Implementation

The process component of the Early Detection implementation criteria is obtained information that all public health center in Cilegon City have implemented policies that have been prepared and ratified by the central government, actively or passively.

Passively, in the implementation of cervical detection carried out by the public health center, it was found that all public health center had carried out routinely at the public health center by trained officers once a week, combined with family planning activities, then one public health center also carried out routinely in the public health center network, namely POD (Pos Obat Desa), Pustu (Puskesmas Pembantu).

“Kalo dalam gedung kita masuknya lintas program masih jalan sampai sekarang. Sama promkes, otomatis. Sebenarnya UKP juga berperan, BP umum, lansia sama IMS. Jadwalnya setiap hari senin minggu ke-1 ke-2.“ (PJ-PUR)

“Kita kerjasama sama KB mbak, di rabu berKB, kalo ada yang mau pasang IUD skalian periksa IVA, di BP juga gitu, kalo ada yang keluhan kita sarankan periksa IVA dihari rabu” (KA-CIT2)

Actively, the implementation of early detection has been carried out by coordinating and collaborating with the village and sub-district to disseminate information on the implementation of early detection of IVA examinations and there is collaboration with the Office of Women's Empowerment, Child Protection and Population Control and Family Planning, has been running well, IVA activities are often carried out together with Family Planning Safari activities.

“kalo saat pelaksanaan, informasinya kita share lewat WA grup, kita kan ada WA grup lintas sektor tuh, sama kelurahan dan kecamatan, grup kader sudah disosialisasikan. Nanti dari kader di share lagi ke masyarakat. Seminggu sebelum pelayanan. Dari bidan share status, kader share ke masyarakat. Aksesnya dengan media sosial ini jadi lebih mudah” (PJ-JOM)

 Based on information in six other Public Health Center that cross-sectoral cooperation, some informants consider cross-sector roles only as a formality and only as coordination.

“... iya mbak,, kadang lurahnya, ya gitu deh,, kegiatan kita itu mereka cuma anggap biasa aja, harusnya kan di dampingi atau gimana gitu ya mbak…” (PJ-PUL)

From the results of interviews with people in the field, some people refused to be examined because the community had anxiety if the test results were positive, then other reasons were because of shame, still considered taboos and fear of illness during the examination, not allowed by their husbands and many other reasons that made them not examined.

“Malu bu,,,,, soalnya kan yang diperiksa itunya….” (M-GRO)

“Saya pengen diperiksa, tapi takut bu,,, saya takut kalo seandainya beneran positif, saya makin takut bu ngebayangin nya…” (M-CIT)

“Kadang sudah di data sama saya bu, mau tuh, giliran hari H, ada aja alasannya gak mau datang periksa” (KR-GRO)

Research shows that all public health center in Cilegon City have implemented government policies related to early detection of cervical cancer, in accordance with existing regulations, both passively and actively. However, despite socialization efforts, there are still many people, especially women, who are reluctant to carry out early detection checks. Some of the reasons found were unrest over positive results, embarrassment, taboo perception, fear of pain during the examination, and prohibition from the husband. These social barriers are consistent with previous research showing low priorities related to women's health in patriarchal societies, as well as myths and misconceptions related to early detection.

This is in line with research by (Shamseddine et al., 2010) where social barriers to early detection are due to low priorities related to women's health problems in patriarchal societies, fear related to myths and misinformation.

According to (Azwar, 2005), attitude is an evaluation of feelings and potential tendencies that influence individual behavior. Factors such as personal experience, culture, the influence of others, mass media, educational and religious institutions, as well as individual emotional factors can influence the formation of attitudes towards early detection of cervical cancer.

The implementation of early detection of cervical cancer in Cilegon City is in accordance with government policy. However, there are social barriers that affect the participation of communities, especially women, in early detection. To overcome these barriers, more efforts are needed to socialize, educate, and remove stigma related to early detection of cervical cancer.

Recording and Reporting

The process component of the recording and reporting criteria is known that the recording of the results of cervical cancer early detection services at Public Health Center is inputted into the application, namely e-puskesmas and the Aplikasi Sehat IndonesiaKu (ASIK) which is carried out after the IVA test service. Input is carried out by the public health center admin based on the results provided by the IVA operator and / or the person in charge of the cervical cancer early detection program at the Public Health Center.

The use of the e-puskesmas and ASIK applications has several obstacles in the form of dense data entering the application, so that access to the application becomes slow because along with the input of the results of Public Health Center services both inside the building and outside the building on the same day in the e-puskesmas application, then another obstacle in the ASIK application is that there are many steps that must be filled in,  so that filling one patient in the application is a bit long, then the NIK if it is not appropriate it will not be detected, and if one of the letters is a different person whose name is in the ASIK application, internet network constraints are also sometimes an obstacle to filling in the ASIK application.

“Di ASIK banyak yang harus di isi juga mbak, jadi memang pengisian satu pasien agak lama trus  NIKnya  klo gak sesuai gak terditek..” (PJ-JOM)

“kadang loading lama juga mbak…” (PJ-PUL)

 From seeing the ASIK data application directly, data on the implementation of early detection of cervical cancer is not available, only those who are sick with cervical cancer are available.

The implementation of the cervical cancer early detection program IVA test method of the Public Health Center records and reports to the head of the public health center, after being verified by the program coordinator, then submitted to the person in charge of the cervical cancer early detection program of the Health Office, routine reporting is carried out by the Public Health Center and no later than the report is received by the person in charge of the cervical cancer early detection program of the Health Office every 5th of every month.

“Laporan tiap bulan kita buat mbak, serahkan ke kapus, trus di bawa kedinas” (PJ-JOM)

“..laporan diserahkan ke dinas itu minimal tanggal 5 mbak tiap bulannya” (PJ-CIL)

From the results of the above research, in accordance with research conducted by (Riyadini, 2015) which states that recording and reporting are carried out through electronic media sent from the public health center to the Health Office, while monthly reports to the head of the public health center are still carried out manually. The application of management principles in recording and reporting health programs is very important. The principles include proper recording and reporting of data, secure storage, efficient data processing, and effective dissemination of information. By applying these principles, it can ensure the availability of relevant data accurately and in a timely manner to those involved in decision-making and program implementation. (Wardhana, 2022).

To overcome obstacles in the use of e-puskesmas and ASIK applications, efforts need to be made to increase the capacity of officers in managing these applications, improve network infrastructure to speed up application access, and carry out regular monitoring and maintenance of the application system. In addition, it is also important to provide training to officers on the use of applications with simple steps and ensure the suitability of data such as NIK to avoid input errors so that the program runs effectively and efficiently.

OUTPUT

Achievements of the Cervical Cancer Early Detection Program

Based on the results of interviews and document studies obtained from the Cilegon City Health Office, it is known that the achievements of the cervical cancer early detection program in 2022 are as follows;

Table 1 Achievement of the Cervical Cancer Early Detection Program in Cilegon City

per sub-district in 2022

NO	DISTRICT	PHC	Public Health Center Carries Out Iva Method Early Detection Activities	WOMENAGE 30-50 YEARS	EXAMINATION OF THE CERVIX		POSITIVE IVA
					FRI- JUST	%	FRI- JUST	%
1	CILEGON	CILEGON	CILEGON	7,815	438	5.6	7	1.6
2	JOMBANG	JOMBANG	JOMBANG	10,990	190	1.7	0	0.0
3	CIBEBER	CIBEBER	CIBEBER	9,503	63	0.7	0	0.0
4	PURWAKARTA	PURWAKARTA	PURWAKARTA	6,823	101	1.5	2	2.0
5	GROGOL	GROGOL	GROGOL	7,001	80	1.1	0	0.0
6	CIWANDAN	CIWANDAN	CIWANDAN	8,116	105	1.3	0	0.0
7	CITANGKIL	CITANGKIL 1	CITANGKIL 1	6,189	139	2.2	6	4.3
8		CITANGKIL 2	CITANGKIL 2	6,772	9	0.1	0	0.0
9	PULOMERAK	PULOMERAK	PULOMERAK	7,930	101	1.3	4	4.0
NUMBER (DISTRICT/CITY)				71,139	1,226	1.7	19	1.5

From the table above, it is known that the target of early detection of cervical cancer in 2022 seen from women aged 30-50 years is most found in the Jombang Health Center as many as 10,990 women, and at least in Citangkil 1 Health Center, while women aged 30-50 years who carry out cervical cancer early detection examinations in 2022 in Cilegon City are the most from the Cilegon Health Center as many as 438 women aged 30-50 years or 5.6% of the target,  while the least number of women aged 30-50 years who carry out early detection of cervical cancer is at the Citangkil 2 Health Center amounting to 0.1 of the target women aged 30-50 years in their area.

Information from several program PJ informants obtained is not similar to the number of target estimates of the IVA test examination program. In interviews, researchers found inequality in achievement targets in a year.

 “Target IVA 25% dikali jumlah WUS 30-50 tahun, misalkan ini jumlah WUS 30-50 tahun jumlah WUS 1000 misalnya, otomatis kan 1000 bagi 4 berapa? 250 kan, nah 250 itu di bagi 3, jadi ini target untuk 3 tahun, ini aja masih termasuk tinggi untuk target WUS, pelatihan di propinsi tahun kemaren, inget banget saya, ohh 25% itu 3 tahun,,,,, berarti kita harus mulai dari tahun berapa ke berapa itu, harusnya dari awal kita dikasih tau, misalkan 2020 nih sampai 2023 target IVA nih, berarti kan 25% itu dalam setahun kalo di bagi 3 jadi 8 koma lah ya…..” (PJ-JOM)

 “Dari capaian, di bagi sasaran, sasarannya kan dari jumlah penduduk ya, misalnya sasaran usia 30-50 tahun, kalo IVA 70%, target per sasaran dari usia 30 - 50 tahun di kali 100, itu saya dapat dari orang provinsi ya..“ (PJ-DIN)

From the results of the study above, the challenges identified include too high estimation targets and dissimilarities in perception between the Cilegon City Health Office and public health center. In line with research (Riyadini, 2015), where the coverage target has not been achieved. The coverage target is calculated based on demographic data on the number of women aged 30-50 (thirty to fifty) years in their work area. Because the program stipulates a minimum of conducting examinations every 5 (five) years, the target amount can be divided into 5 (five) years to set targets per year. Then the target per year is divided by 12 (twelve) for the target each month (Ministry of Health of the Republic of Indonesia, 2017)

In the face of these obstacles, it is necessary to make more targeted and comprehensive efforts. The Cilegon City Health Office needs to evaluate realistic estimated targets to match field conditions. In addition, coordination and communication between the Cilegon City Health Office, Public Health Center, and the Provincial Health Office and Local Government need to be improved to equalize perceptions and strategies so that the community wants to carry out cervical cancer detection tests so that they can achieve the targets that have been set.

CONCLUSION

The implementation of the early detection program in all Public Health Center in Cilegon City in 2022 based on input components (Human Resources, SOPs, Financing, Facilities and infrastructure) is basically in accordance with the policies used as the basis for implementing early detection of cervical cancer, but there are still obstacles to human resources. The components of the process of implementing early detection, recording and reporting examinations) refer to the Regulation of the Minister of Health Number 34 of 2015 and Regulation of the Minister of Health Number 29 of 2017 and are in accordance with the Regulation of the Minister of Health of the Republic of Indonesia Number 4 of 2019 concerning Technical Standards for the Fulfillment of Basic Service Quality in the Minimum Service Standards in the Health Sector, although there are still obstacles in its implementation both passively and actively. The output component (achievement of cervical cancer early detection programs) is still very low, and there are differences in perception of target calculations.

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