It is declared as pandemic!

"The world is now at the start of the 2009 influenza pandemic," said the WHO director-general Dr. Margaret Chan on 11 June 2009.

So, when is a disease called as pandemic?

Phase 1-3 correlate with preparedness, including capacity development and response planning activities.
Phase 4-6 clearly signal the need for response and mitigation efforts.
Periods after the 1st pandemic wave are elaborated to facilitate post-pandemic recovery activities.

Criteria of each phase:

Phase 1: no viruses circulating among animals have been reported to cause infections in humans.

Phase 2: An animal influenza virus circulating among domesticated or wild animals is known to have caused infection in humans. It is considered as a potential pandemic threat.

Phase 3: There are sporadic cases or small clusters of disease in people, but has not resulted in human-to-human transmission sufficient to sustain community level outbreaks.

Phase 4: Community level outbreaks by human-to-human or human-animal transmission. It indicates a significant increase in the risk of a pandemic. Any country that suspects or has verified such an event should urgently consult with WHO.

Phase 5: Human-to-human spread of the virus into at least two countries in one WHO region. It is a strong signal that a pandemic is imminent. The time to finalize the organization, communication, and implementation of the planned mitigation measures is short.

Phase 6: Pandemic phase, characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in phase 5.

Post peak period: Pandemic disease levels in most countries with adequate surveillance will have dropped below peak observed level.

Post pandemic period: Influenza disease activity will have returned to normal level. The pandemic virus is expected to behave as a seasonal influenza A virus.

Our main concern: What is a GP's role in a pandemic preparedness?

First, we have to know what "pandemic preparedness" is. The pandemic preparedness is categorized as:

1) non-pharmaceutical (public health): It is aimed to reduce the social impacts, such as social distancing by prompt case isolation, household quarantine, and closure of school and workplaces. In addition, it includes data collection and surveillance and basic respiratory hygience practices as well.

2) pharmaceutical: It includes vaccination, anti-viral medications, stockpilling of vaccines and drugs and  co-ordinated effort in distribution. This would involve pre-pandemic vaccination and treatment of cases for secondary prevention.

Secondly, what role do we play? (scenario: H1N1 influenza pandemic)

1)  Teacher and psychologist: GPs should educate the patients about what the disease is, and the transmission mode. We must disseminate the information to the community on how to prevent the disease, from whom they can get health service and medication when they are ill, and the reinforcement of personal hygiene as well as the other precautious measures. Then, we have to get the feedback from the community and need to ensure that they can understand what we say and we solve all their puzzles regarding to the H1N1 influenza. Other than that, GP should also provide psycho-social support to the community. Therefore, GP should establish a good relationship with the community by having a great communication with them.

2) Detective, gate keeper, coordinator and reporter: The GPs are the gatekeepers. We play the frontier role in management of patients with influenza without complications to allow unexpectedly large numbers of ill patients to be managed in the community. So, we should be able to detect the epidemics and mini epidemics of viral illness in accordance to national guidelines to avoid missing cases. We can coordinate triage system for suspected cases. Then, we identify the vulnerable and at risk groups for necessary health protection. Specimens will be collected from the suspected cases for rapid diagnosis. Besides that, we have to coordinate the care for the close contacts or the family members of the suspected targets. If we have detected the patients with H1N1 influenza (cluster of people or large group of community with same sign and symptoms and tested H1N1 positive) we should report to the district health officer. The epidemiological data obtained in primary care represents the best proxy measurements of the day-by-day prevalence of ailments in the community. Since we play a role as detector and gatekeeper, self-protection is essential, so that we will not be infected with the virus.

3) Pharmaceutical measure: It includes the provision of vaccines, esp during the pre-pandemic period, anti-viral drugs, etc.

4) Monitoring and assessment: We have to monitor the suspected targets as well as their close contacts. We then assess their condition. For the follow up, it is preferred to implement home-visit-approach or setting a special review clinic to avoid cross infection. Moreover, we are responsible to monitor the resources in primary health care to ensure that we always have enough supply for our demands. We also need to assess the capacity to manage large number of ill patients.

5) Have a great communication with public health authorities: To get the epidemiological update and results of investigations, so that we can provide better, comprehensive and continuing care in this pandemic setting. Therefore, there will be no misdiagnosis and unnecessary referral to secondary care.

Wow, a lot of roles, right? Yea, being a doctor isn't an easy job, esp. when there is an outbreak of disease or a disaster happens.... This is absolutely a challenging job! ;)

Reference:
1) http://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/index.html
2) http://www.medicinenet.com/script/main/art.asp?articlekey=101133
3) http://www.who.int/csr/disease/swineflu/phase/en/index.html
4) http://www.biomedcentral.com/1471-2458/10/661

Surveillance? @.@ I know nothing about it!

Scenario:

"The number of HIV cases is increasing from 1990-2008 in Indonesia, while in other countries like Thailand, Myanmar and India, the HIV prevalence has declined. So what should we do now in order to reduce the number of HIV cases in Indonesia?? We do not know who are at higher risk and the major mode of transmission!"

"I think what we should do now is to conduct a surveillance".

After reading the scenario, you may ask: Surveillance? hmmm...sounds familiar but I don't know what it means...So, what on earth is it?Why do we need to do a surveillance?

Yea, I'm sure you have come across with the word "surveillance" in my previous blog. Surveillance is defined as the ongoing, systemic collection, analysis and interpretation of health-related data (e.g. regarding agent/hazard, risk factor, exposure, health event) essential to the planning, implementation and evaluation of public health action to reduce morbidity and mortality, and improve health status. It can also serve as an early warning system for impending public health emergencies. Besides that, documentation of the impact of an intervention can be done through surveillance. It can also be used to monitor and clarify the epidemiology of health problems, to allow priorities to be set and to inform public health policy and strategies. By doing the surveillance, it can prevent and control a disease, especially if it is a sudden outbreak.

How do we get the data when we are doing surveillance?

There are a lot of sources, such as:

• mortality reports
• morbidity reports
• reports of individual case investigation
• reports of laboratory utilization (including laboratory test results)
• special surveys (e.g. hospital admissions, disease registers, and serologic surveys)
• information on animal reservoirs and vectors
• demographic data
• environmental data

After collecting data, what should we do next?

(cont' of the scenario given above) "So, what is the result of the surveillance? How do we apply it?"

Let's look at the chart below:

The chart above is drawn after the collection and compilation data. This is the analysis. From the chart above, (interpretation of data) we can see that unsafe sex and injecting drug use are two major mode of transmission. In other words, those who are having unsafe sex and using injecting drugs have relatively higher risks to get infected with HIV, compared to normal people. We also know that HIV can be transmitted to other people through blood and mother-to-child transmission, although the risks are relatively lower than that of unsafe sex and injecting drug use. After that, we should disseminate the data to the public. Therefore, by using this surveillance data, we can raise the awareness of all parties and also take few actions (utilization of surveillance data), e,g. set health policy and strategies in reducing the numbers of injecting drug users, promoting use of condom, set our target population and give them education, promote the program of VCT(voluntary counselling and testing), PMTCT (prevention mother to child transmission), PTRM(program terapi rumatan methadone), etc. Through these, HIV cases can be reduced and the health status of the community, hence, will be improved.

So, from the scenario I created, do you have a clearer picture of what surveillance is, the steps of how to do it, how we utilize the information that we get from a surveillance and the purpose of doing it? Hope it helps =)

Reference:
1. Dr. Luthfan Lazuardi. Lecture: Surveillance, Response, and The Role of Public Health Informatics
2. http://www.who.int/topics/public_health_surveillance/en/
3. http://www.cdc.gov/ncphi/disss/nndss/phs/overview.htm
4. http://www.searo.who.int/LinkFiles/Publications_HIV_AIDS_Report2009.pdf

STOP spreading the HIV!

HIV/AIDS disaster?
It is defined as continous increment of the number of HIV+/AIDS cases in a certain population/region/country after implementation of nation-wide programme in a certain periods of time.

Let's have a look of the data regarding to HIV/AIDS:

HIV cases in Asia



NO. OF NEW HIV INFECTIONS, AIDS CASES AND AIDS DEATHS BY GENDER PER YEAR REPORTED IN MALAYSIA

(From 1986 until December 2008)

HIV cases in Indonesia from 1987 to 2008

When you look at the data of HIV population, will you be as shocked as me? shocked bcoz the prevalence and the incidence of HIV and AIDS-related death are increasing with years.

Supposedly, the rate will be dropped as time goes by bcoz there should be increasing number of humans with higher education level compared to 1990 or years before. don't you agree with this point? government from other countries has been giving the citizens free education frm primary to secondary school, so that more people are educated. with higher education level. People should realise the danger of going for prostitution, the danger of having unsafe sex, how to protect themselves by using condom when having sexual intercourse with sex workers or strangers...etc... but how on earth the prevalence and incidence are still increasing? oh, am i too naive? the reality isn't the same as what i think....

Why would this happen? What do you think?
lets see the possibilities of causing this phenomenon:

1) increasing number of adolescents having sexual intercourse at earlier age?
2) increasing number of rich and horny guys who go for the prostitution, but not using condom bcoz they wana get higher pleasure when having sex?
3) more people having relationships with multipartners and have sex with anyone, including a stranger?
4) more people using narcotic drugs? sharing needles?
5) more girls wana make easy money by providing service to the men? they are willing to lose their self-esteem and dignity and pride?
6) increasing numbers of homosexual or heterosexual? esp the gays who do not use condoms when doing anal sex (i.e MSM)?
7) failure to promote or socialize the HIV prevention programme?
8) failure to treat?
9) failure to support or run the HIV/AIDS and STI prevention programme?
10) a problem of decentralization in Indonesia? The responsibilty of collecting data is devolved to the district level due to decentralization process. So now, there is limited human resources and competing claims on resources sometimes undermine activities such as data-collection, which are seen as NON-ESSENTIAL. A failure to maintain standards and quality in public-health-information systems.

What are the prevention efforts?

1) health promotion
2) strengthen health care system
3) multi departmental program

 

Note: HAART=highly active antiretroviral therapy; PEP=post-exposure prophylaxis; PrEP=pre-exposure prophylaxis; STI=sexually transmitted infection; Bolded items are those that use antiretroviral agents.

 Why is STI concerned in HIV prevention?
STI patients have a 2-9 times greater risk of being infected with HIV than people who do not have STI. Therefore, effort to test for and treat STI should be put in.

Why can circumcision decrease host susceptibility to HIV infection?
Because after circumcision the glans penis will develop a stronger layer of squamous epithelium.

How to promote condom usage?
It should be done by:
1) free distribution of condoms to sex establishments at the initial stage, and condom social marketing at later stages;
2) encourage the sex workers to consistently have clients use condoms during sexual intercourse.

BUT, how if the clients and sexual workers insist not to use condom?
1) According Prof. Dr. Siswanto, there is an approach of encouraging the sexual worker to help the clients to wear the condom by using a more interesting tactic, so that the clients will not reject to use condom.
2) Enforce the law: Penalties against any sex establishments that do not consistently use condoms.

Besides that, we should attract the attention of executor and senators,by presenting the cases(including showing them the prevalence of HIV infection) to them so that they will give response upon this issue. A sentinel surveillance should be conducted to monitor STD (sexually transmitted disease) and HIV and condom-use compliance.

Harm reduction among the IDU (injecting drug user): PTRM?
Perhaps you ever hear about VCT (voluntary counselling and testing), PMTCT (prevention mother to child transmission). How about PTRM? Here i would like to explain PTRM briefly.

PTRM (Program Terapi Rumatan Methadone) is a therapeutic programme for the IDU (injecting drug user) to substitute the narcotic drugs with methadone. By using this approach, they expect that there will be decrease of numbers of IDU, hence reducing HIV transmission caused by drug injection.

Who are responsible in preventing HIV transmission?
HIV/AIDS prevention is a national issue. It needs to be tackled through a national response. Hence, efforts should be implemented by the community, the government, and NGOs on a partnership basis. The community, together with NGOs (non-government organization), should be the leading agents while the government takes responsibility for steering, guiding and creating a conductive atmosphere to support HIV/AIDS prevention.

In conclusion,
HIV prevention is focused on:

A: Abstinence
B: Be loyal
C: Condom use
D: No drugs

We, as the doctors, besides taking part in health promotion, and prevention, we should identify those with risks of getting HIV infection, and help the HIV patients to get treatment. There should not be any discrimination to the HIV patients.

HIV/AIDS should not be treated as a stigma in the community. All of us shall participate in this programme and work hand in hand.

 Reference:
1) Dr. Sunardi Radiono. Lecture: HIV/AIDS Disaster and HIV/AIDS in Nature Disaster.
2) Dr. Yanri Wijayanti Subronto. Lecture block 3.6: Screening HIV.
3) Lecture block 3.6: Disease Related to Unsafe Sex and Injecting Drug Use.
4) http://www.ptfmalaysia.org/statistic.htm
5) http://data.unaids.org/publications/irc-pub06/jc978-indonesia_en.pdf
6)http://www.healthpolicyinitiative.com/Publications/Documents/1345_1_Indonesia_HIV_Audit_FINAL.pdf
7)http://www.satuportal.net/content/sebanyak-11-puskesmas-di-jakarta-dilengkapi-prtm-online
8) http://www.thejakartapost.com/news/2010/11/27/national-aids-commission-upbeat-reaching-targets.html

MONEY! How is the payment mechanism for the health care provider?

"When you become a doctor, you can be very rich!" This kind of statements have been made, regarding to our profession.

In fact, is every doctor rich? or it depends on the field you specialize in? or depends on what country you are working in? where there are different payment mechanism in different country. Look at the following table and diagram.

 

Internist, Surgeon and Ob-gy get highest payment in these 8 provinces.

 

Different country, different payment mechanism

Why is provider payment mechanism concerned?

Different payment mechanism will affect a doctor's performance and behavior. A doctor may:


a) provide as many treatments as possible

b) attract as many patients as possible (e.g. by prescribing many drugs, even placebos)

c) sending patients with financially unattractive or hazardous conditions to other providers, such as hospitals
d) asking patients to come back several times even when it is not necessary

e) unnecessarily using expensive equipment they have purchased (e.g. X-ray equipment) in orfer to amortize its cost.

Therefore, a good payment system must be established in order to prevent the kinds of waste and unnecessary services provision described above. besides that, it can prevent brain-drain. A good payment system can also motivate the physicians to perform well during medical practices if they get a reasonable income.

So, what kind of payment mechanism are there?

Type of payment mechanism

 Here, I would like to focus on few payment mechanisms only:

1) Fee for service. It is the fee for specific services and prices per item for drugs or appliances. It is the most common method of payment and the most market-like. For example, a physician gets paid for a consultation or an examination; a pharmacist gets paid for a pack of drugs.

 Problem of this mechanism? These fees or prices may be uncontrolled, meaning that each health service provider can charge as much as the market will pay, so it is difficult to have proper budget. The provider may: a) increase the number of acts (services), resulting in under referral and tendencies for supplier induced demand; b) reducing the quality of the services; c) delegating more acts to lower-paid personnels (eg nurses).

Solution? To solve this, devise a fee or price schedule, setting the upper and lower limit on the prices that may be charged. For instance, In German, physicians are not allowed to charge fees higher or lower than the schedule fees. Another solution is to fix tariffs if there is no compulsory fee schedule. It is important to specify the fees that the health fund is prepared to pay because it is either the health insurance company need to pay for the charges or the patient themselves.  Do utilization review.

How to calculate the fees for specific acts? by using the following: a) the factors used (eg. labour, capital costs, materials); b) the number of units of each factor used; c) the price of one unit

 Benefit? if there is competition among the providers, the quality of service can be maintained at a standard level because patient will not come to the clinic if the quality is not good.



2) Capitation fee. It covers services for one health fund member over a certain period (normally one year). The fee is paid to a nominated provider who has the responsibility to provide health care, without discrimination, for the duration of the cover period. The capitation fee is based on the pooling of risk by the provider. So, if the insured person doesn't use the health service at all during the period covered, the provider will get the profit from there.This payment mechanism is suitable for primary care providers and hospitals. The capitation fees would cover any or all services required at primary and secondary levels. In this context, the GP act as a gatekeeper, acting as a rationing device for utilization of secondary care services. This mechanism is not suitable for the specialists working alone (should apply case payment or even fee-for-service).and pharmacies.

Calculation? It consists of 2 parts: 1) the fee itself; 2) a register of providers (physicians and hospitals) and patients who have registered with each. The patient must declare to health fund which physician or hospital he/she has chosen, so that the provider can be paid. The fee is calculated by dividing the estimated cost of physician's labour, material, capital expenditures and staff by the estimated number of patients per provider.

Benefit? cost containment. Besides that, it encourages the insured person to use one physician on an ongoing basis as they can only register with one physician and hospital. In this way, the medical history of the patient will be known and hence, minor illnesses and chronic diseases can be managed effectively and efficiently.

Problem? It can reduce incentives to provide good quality service. If a provider is guaranteed a payment for each person on his/her register, there may be no motivation to provide high quality care. Therefore, doctor's attention is low and consequently, patient satisfaction is low. Underutilization may happen (supplier reduce demand). There may be excessive referral. 

Solution? The patient is allowed to change providers after a certain period (usually one year) in order to maintain competition among providers. Moreover, we can establish and apply clear standards for the provider. If the providers do not meet the standards, health fund can withdraw them from the list of providers.

3) Salary. It is normally based on a labour contract between the provider and the health fund. The provider is paid monthly The amount of paid is the same, regardless of the number of the patients to be treated. Equipments, materials, and additional staff are paid by health fund.

Problem? Emploted staff may have fewer incentives to perform well and maintain high standards than independent staff. However, the employee's motivation depends to a greater extent on the quality of management (amount of salaries, promotion prospects, the organization and responsibilities of individual units, the scope for decision making, etc). Bureaucracy, formalism, inflexibility and lack of motivation are the problems. The admistraion costs are likely to be higher.It is hard to guarantee the same performance of the providers (quantity and quality of work).

Benefit? Planning and budgeting is easier.



Comparison of performance of different payment mechanism

What are prospective and retrospective payment systems?

a) Prospective: capitation, salary

b) Retrospective: fee-for-service



Can these mechanisms be applied together?

Yes. As an example: a capitation fee as the basic payment; fees for service for certain acts (immunization, night calls); a flat rate for approved investments (eg. physicians receive a fixed budget to buy equipments); a budget for drugs and ancillary services

Reference:

1. Charles Normand and Axel Weber. Social Health Insurance: A Guidebook for Planning. WHO and International Labour Office.1997.

2. Prof Dr. Laksono. Lecture: Provider Payment Mechanisms.

3. Prof.Dr. Laksono. Lecture: Introduction of Block 4.2 and Health System and Its Outcome. 

Is cultural aspect important in medicine?

What is culture?

*jing jing* This is what I understand by reading the lecture note. Sets of ideas, concepts, rules, meanings, beliefs, custom, knowledge, morals, capabilities, habits, skills, and art will be relfected by action or our actual practices or daily performance. This is called as CULTURE.

What role does the cultural aspect play in medicine? Should it be taken into account when we, the doctors, give a treatment to the patient or give an education to the community about the prevention of a disease or promoting health?

Scenario 1:

When i'm very sick, I will go to the clinic to see a doctor. The doctor will usually use less than 5 min to take an anamnesis. If go to GMC, they will finish taking anamnesis and physical anamnesis within 5 min.

Hmm...lets think: A patient, named Pak A, with acute attack of asthma.What does a doctor usually ask and do? maybe as usual: apa keluhan utama? sejak kapan? ada bunyi ngik ngik? pernah ada sesak nafas kayak gi ni? if yes, sejak kapan? apa yang meringankan dan memberatkan sesak nafas? ada allergy terhadap apa-apa? and ask other questions in order to rule out other disease, like CHF, COPD. Then the doctor will auscultate. I think this is what a GP will ask n do, in the reality (sorry, if I am wrong). They will finish doing these within 10 minutes.

BUT my question is: Are those questions sufficient for you to treat a patient with chronic disease? If you do what I mention above only, do you think the patient can control the asthma well?

So, how about the cultural aspect? In order to help a patient to control asthma, do we need to explore the patient's perspective on asthma?

Different people have different perspective on an issue/problem/health-illness. A patient may see "asthma" as an acute and temporary disease in which they just need to take reliever (like salbutamol), but don't need to take corticosteroid; A patient may feel ashamed of using a medication due to the stigma; A patient may care about the side effect of corticosteroid, such as weight gain. Most of the  female patients will care about that; A patient may think in this way: I don't have asthma attack for a month. So I can go jogging/ marching/ dancing!! These perspectives contribute to asthma exacerbation. Besides that, how about the socioeconomic status of the patient? Is the patient having financial problem in buying medication?

By reading these, do you think that exploring emic perspectives is important in order to treat a patient, especially those with chronic disease?

Scenario 2:

The mentawai community may consult a sikerei whenever they are sick. A sikerei is a person consulted by people for any illness. His technique involves magical power to resist and prevent illness.

If you are a GP in that community, you encounter that people rather consult a sikerei than going to your clinic to consult you, what you will do?

In my opinion, in this situation, we should know the concept of how the sikerei treat the patients, the community's belief, perspective of illness, how long does this belief have been inherited in that community, how much does a sikerei charge the patient, the education level and socioeconomic status of the community, etc

Scenario 3:

If you want to organize a campaign of smoking cessation, what will you do?

emphasizing on how to stop smoking, explaining the impact of smoking on health? by the way, before you promote the way of smoking cessation, do you explore the reason why a smoker smoke? do they ever try to stop smoking? what kind of smoker are they? From what age do they start smoking?

A smoker can be an in-control smoker (they will smoke in certain situations only), confirmed smoker (always smoke, with no control in smoking), contrite smoker ( they regret and actively trying to extricate themselves from smoking), etc. According Johnson et. al., 2003, multiple dimensions constituted the youth's smoking identities: their smoking behavior and experiences; their awareness of the role smoking plays in their lives; their aspirations with regard to smoking; and the degree to which the social construction of "smoker/nonsmoker" had been accepted, rejected, or integrated into their lives. Few questions have been raised: do smokers not see themselves as smokers and therefore deny the need for cessation programmes? A good example is given in Johnson et.al, 2003. There were some in-control smokers describing themselves as non-smokers who happened to smoke in certain situation. Note "non-smokers"! They don't see them as smokers! That is one of the reasons why the tobacco control initiatives yield such a low participation and success rates.

Therefore, insight into varied non-smoking identities and the different ways they position themselves contribute to improve tobacco education programs based on social influence models. Besides that, we can see that a one-size-fits-all approach to smoking cessation may not work well. A more tailored approach that responds to and incorporates the range of identities may yield a more promising successful results in tobacco controlling programme.

In conclusion,

there are a lot of diversities of the perception of health-illness and health seeking behavior, depends on the ethnic group, socioeconomic status, knowlege, habituation, religion or beliefs of the community. Due to these factors, doctors and patients will usually have different perception on a disease or problem. So, to be an ideal doctor, we should have these: knowledge, skill, experience, ability to integrate patient's beliefs, values, experience and views to the mangement or daily medical practice (prevention, promotion, treatment, rehabilitation).

Wait a minute! How should we collect the data in order to know the cultural aspects of the patients?

There are two ways: 1) quantitative (questionaires, self-reported data); 2) qualitative ( observation, chatting with patients, in-dept interview, prolong anamnesis, narrative inquiry)

When two people of different cultural background communicate, this is called as cross cultural communication. In this kind of communication, we should:

1. avoid ethnocentrism (seeing his/her own culture to judge practices by other culture)
2. avoild chauvinism (seeing his/her own culture as the best culture for people to adapt to)
3. avoid stereotyping (seeing the negative practices as done by all the people in the ethnic group)

Reference:
1. Dr. Retna Siwi Padmawati. Lecture: Cultural aspects in medicine.
2. Dr. Retna Siwi Padmawati. Practical session: Narrative Writing.
3. Johnson J.L., Lovato C.Y., Maggi S., Ratner P.A., Shoveller J., Baillie L., et. al. Smoking and Adolescence: Narratives of Identity. Wiley Periodicals, Inc. Research In Nursing and Health 2003; 26: 387-397.

Jamsostek? Askes? Jamkesmas? CONFUSED!!

"Arghhh!! Help! What are the difference btwn Jamsostek, Askes and Jamkesmas??"

Does this question ever come to your mind? One of my friends asked me this question. Here I would like to explain briefly.

Health care programs in Indonesia have elements of a three-tiered health insurance system.

1. 1st tier: PT Askes and PT Jamsostek. Askes is a compulsory health insurance scheme for active and retired civil servants, retired military and police officers, veterans, and national patriots and their families. Jamsostek is the social security scheme for private sector workers and includes a health component. It provides health insurance for some formal sector workers.
2. 2nd tier: Private health insurances provided through private insurance companies, self-insured schemes and other initiaves.
3. 3rd tier: Jamkesmas and Jamkesda (local government initiatives) or direct financing to health care providers. These are run by the Ministry of Health and local authorities for the uninsured poor citizens.

Reference:
1. Prof. Dr. Ali Ghufron Mukti. Regional Conference on "Revitalizing Primary Health Care",Jakarta, Panel C: Health Financing and Poverty Alleviation; WHO Regional Office for South-East Asia, 2008.

Being a doctor is a risky job? We will be sued by patient!

"Doctor A is sued by the patient due to miscommunication"

"Doctor B is sued because the doctor reveal the patient's condition to other people"

Hmmm...Being a doctor is not that easy. We are at the risk of being sued by the patient. So why do we need bear the risk? Better not! Come, let's change the course now. DROP OUT!

Agree with the last statement? Better don't be a doctor because we are at own risk??

No, DON'T WORRY. We are protected by the LAW!

In Indonesia, there is this law--UU. 29 Tahun 2004, paragraf 6, pasal 50. It is stated that doctors will be protected by the law as long as we perform our job and provide medical service to the patient according to the standard operational procedure and professional standard.

Therefore, we just need to make sure that we always conduct all the procedures according to the standard. Remember the 4R: Do the right thing to the right person at the right place with the right skill.

What are the things that we need to do to minimize the errors?

According to UU.29, paragraf 1, pasal 44:

We MUST follow the standard medical service which is regulated by regulation of minister. In this context,  the "standard medical service" is differentiated by type and strata of health care facilities.

According to UU. 29, paragraf 6, pasal 51, we must:

sarana pelayanan kesehatan. health care facilities.

1) provide medical services in accordance with professional standards and standard operational procedures

operasional serta kebutuhan medis pasien; operational and medical needs of patients

  as well as the patient's medical needs.

2) refer patient to another doctor with better competency and capability when we are not able to perform an examination or not able to give a treatment.

3) patient's medical record is confidential. Therefore, we need to keep it as a secret, even after the patient has died.

4) Give medical help in an emergency case based on humanity, EXCEPT when we are sure that there are other people who are on duty and manage to help.

5) Gain medical knowledge and develop it.

hmmm...when you read "(5) gain medical knowledge", what do you think? Don't be sad. That is our fate. We have to continue studying even after we have graduated or even if we just wish to be a GP only. haha. hey teman-teman, learning is life-long. Never put a fullstop. Enjoy studying,dudes! ;)

Oh yea, keep the 4R in mind: Do the right thing to the right person at the right place with the right skill.AND don't forget to explain every procedures u will do to the patient and the risk of the procedures. MUST get informed consent. DON'T simply answer the patient's question if you are uncertain, eg how long the patient can live. If you wanna tell the patient about the prognosis, u must specify that is only a prognosis and he/she may live longer or shorter than that.

 Reference:
1. http://taradigadingdangdong.files.wordpress.com/2008/08/uu-29-2004-pradok.pdf
2. Prof. Dr. Adi Utarini. Lecture: Quality framework, clinical governance and patient safety.

Rp 26 000 is not a big amount money for you, but it is for me

During osce remedial of year 3, I had to repeat eye/ENT station.

"I will refer you to eye specialist," I said to a simulated patient with glaucoma.

"But how much is the fee?" asked the patient. I was stunned when she asked that question.

"You have Jamkesmas, don't you?" I asked.

"No, I don't have" said the patient.

"oh...If you go to Hospital Dr. Sardjito, you can just have to pay about Rp 26 000 for the registration and specialist consultant fees. Don't worry, it is not too expensive," I said with a confident smile.

"Rp 26 000 is not a big amount money for you, but it is for me. I can't afford the payment," said the patient.

Read till here, what is your comment?

Although this is a conversation between a simulated patient and me, this actually reflects the current situation in Indonesia. A poor patient without Jamkesmas. What do you think? Is she categorized as moderate income group,but not yet near-to-poor group? or because the information about the existence of Jamkesmas and ways to register it, is not disseminated well, so she does not know how to register for Jamkesmas? If she is in the middle-income group, does it imply that citizens in this group will not apply Askes, not until they suffer from a chronic disease or sustain a heavy injury, in which they need to pay a huge amount of money for the treatment?

Why would this happen?

Data of the targets(Low income group) is not complete yet. Besides, Ministry of Health is not able to reach all the target due to the limited budget on dissemination of information regarding to Jamkesmas.

According to Prof. Dr. Ali Ghufron Mukti, the community need to pay for Askes by themselves regularly. Dr. drg. Yulita Hendartini and PT askes cabang DIY told us that the community have to pay around Rp. 28 000 per month. Lets apply the scenario above to this reality. Do you have a clear picture why not all poor families with Askes? Just imagine the bread winner of a family earns Rp 1 500 000 per month. Lets give an example. Say, there are only 3 persons in a family: father, mother and a kid. They spent Rp 5000 per meal (eg tempe/sayur+telur+nasi). Everyday, they take 2 meals. So, they will spend Rp 900 000 per month on meals only. What about the transport fees? assume Rp 2 000 per trip. The breadwinner go to work per day. round trip per day costs Rp 4000. In a month, total is Rp120 000.  How about the electricity n water bills?more than Rp 400 000? How about school fees for the kid? Hmmm...yeah, Rp. 28 000 is not a small amount of money for them. Note, it s per person. So, if one wants to pay for the whole family, then it will be more than Rp. 50 000. Can such a family afford the payment?

Other than that, in Indonesia, decentralization has affected health finance system. The government has limitations in pooling the fund from the community and private sector. One of the solution for this issue is pooling the fund from community through health insurance mechanism. BUT, this is not as easy as we think. In the reality, the community has lost faith to the government because all this while, the health standard is not satisfied and consequently their demands are not fulfilled yet. So, the community has lost the credibility to this health insurance mechanism.

Due to these factors, 70% of health care expenditure is still currently paid "out-of-pocket". This deters the poor to seek medical care when they are sick.....

So, what is the solution for the scenario I mentioned above?

Tell the patient that she can apply Jamkesmas through RT (rumah tetangga). =)  p/s: the examiner suggested this option to me. To my friends who read this post, don worry, the examiner in the Eye/ENT station told me that I did very well and I pass! yeay!! :D

Hopefully more communities are covered by health insurance, so that more people can access the health service, and hence increase of health status.

Reference:
1. Prof. Dr. Ali Ghufron Mukti. Lecture: Health Finance
2. http://www.searo.who.int/LinkFiles/Conference_Panel-C2.pdf
3. Dr. drg. Yulita Hendrartini and PT Askes Cabang DIY. Panel discussion: Physician economics behavior, health insurance, managed care and quality.
4. Laksono Trisnantoro. Desentralisasi Kesehatan Di Indonesia Dan Perubahan Fungsi Pemerintah: 2001-2003. UGM Press. Juni 2005.
5. Menteri Kesehatan Republik Indonesia. Jamkesmas tahun 2008.Disampaikan dalam Rapat Dengar Pendapat Dengan DPRRI. 27 Maret 2008.

Shortage of health workforce? What is the solution? Globalization helps?

Who are the HUMAN RESOURCES in a hospital?

Shortage of health workforce? hmmm....i can't imagine. Can you give me a clear picture?

This is Bappenas study in 2005 conducted in 32 districts.  What can you see from the table? do u get the picture? okay let's see the figure below....

There are currently 57 countries with critical shortages equivalent to a global deficit of 2.4 million doctiors, nurses and midwives. The proportional shortfalls are greatest in sub-Saharan Africa.

Still remember the 1st tutorial scenario is about?

The shortage of medical doctors happens especially in remote areas and other unattractive areas, where community’s health status is also lower than those in non-remote areas.  Quality of service suffers because of this shortage. In regions without medical specialist, a general practicioner can be forced to do specialists’ tasks. This situation may violate Medical Practice Laws and needs specific additional clinical training for the general practicioner. It needs a careful preparation for taskshifting.

This scenario happens in all the countries, I bet. It is not limited in Indonesia, but also Malaysia. It reminded me of the district hospital, Batu Gajah Hospital, where i did my clinical attachment in M'sia during July holidays. In that hospital, there are no specialist, but medical officers only. The medical officers are very busy, and they have lots of workloads 24/7. When I was working in the general ward, the doctor in the emergency department was sick. So, the doctor who was in charge of the general ward, had to go to emergency department to cover for the ER doctor, so she did not visit her ward in that morning, not until she settled the problem in ER. Normally, she finished checking every patient in her ward by 12pm, but on that day, she finished by 2pm....there was another case. The medical officers refer a lot of patients to the provincial hospital, Hospital Ipoh, whenever they can't manage the case. For instance, when the medical officer in the labour ward could not detect the placenta of the pregnant woman by using USG, she referred the patient to hospital ipoh. Another example, a pregnant woman had entered stage 2, but having difficulty in delivering the baby. I could see the head of the baby when the nurse was trying to assist in the delivery. Along that period, there were only nurses. They called the sister, the head of the nurse, in the labour ward. She then discovered the patient having fever and the amniotic fluid are stained with meconium. Then they called the medical officer to come. But after 20min, the M.O. did not reach there yet. After the doctor reached there, she decided to send the patient to hospital Ipoh. Note, journey from Batu Gajah Hospital to Hospital Ipoh took 30 mins. In the journey of sending the patient to the destination, what would happen? Would the baby and the mother affected? If there is prolonged stage 2, it may cause baby's condition unstable..just like what we had learnt in the skill lab "neonatal resuscitation" in Block 4.1.  These are the problems encountered in the hospitals where there is shortage of physicians.

Another scenario in Puskesmas that i had did my attachment in year 3. There was lack of physicians in the puskesmas when the two doctors had left the puskesmas after they finish their magang. So on the day when the two doctors had left the puskesmas, there were no doctors because coincidentally, another doctor went to other place to attend a talk. So, when we practised, we made diagnosis and prescribed the medicine without the guidance of a doctor. phewwww~~~@.@ hmm..reading until here, what is your comment? unethical to the patient? yes, it was unethical. =(

What threatens the health system, affecting the way the health workers respond?

Demographic and epidemiological transition drive changes in population-based health threats to which the workforce must respond. Financing policies, technological advances and consumer expectations can dramatically shift demands on the workforce in health systems. Workers seek opportunities and job security in dynamic health labour markets that are part of the global political economy. In many countries, health sector reform under structural adjustment capped public sector employment and limited investment in health worker education, thus drying up the supply of young graduates. Expanding labour markets intensified professional concentration in urban areas and accelerated international migration from the poorest to the wealthiest countries. Countries with critical shortage of workforce is characterized by severe shortages, inappropriate skill mixes, and gaps in service coverage.

Table: Passing rates of Indonesian nurses

Insufficiency of health workers often coexist in a country with large numbers of unemployed health professionals? You may ask: why would this happen paradoxically?  this could be due to poverty, imperfect private labour markets, lack of public funds, bureaucratic red tape and political interference.

In Indonesia, decentralization had exerted negative impacts on human resource. Few agenda, thus, are raised and wished to be settled:

a) communication with the central government, on the issue of preparing, supplying, educating and training the specialists, technicians, etc for those districts having difficulty of getting health workforces.

b) inter-district communication on how to administer regional health system, with direct implication of human resource management.

c) currently, not all the districts have the capability in managing human resources. They still need the assistance from the central government and the networking between districts in order to fulfil their demand for the health workforces.

So, what are the solutions?

Focus on 3 junctures:

a) Entry: preparing the workforce through strategic investments in education and effective and ethical recruitment practices.This can be done by building strong instituitions for education and at the same time, assure the educational quality through instituitional accreditation and professional regulation (licensing, certification or registration).

b) Workforce: enhancing worker performance through better management of workers in both the public and private sectors

c) Exit: managing migration and attrition to reduce wasteful loss of human resources. In poor countries and rural areas, international (from poor to rich country) and internal (rural to urban area) migration are the factors contributing to the shortage of workforce. Therefore, retention strategies should be made! This can done by tailoring education and recruitment to rural realities, improving working conditions more generally and facilitating the return of migrants, reduce occupational hazards, provision of effective prevention services,etc.

How about globalization? Does it help?

There are four ways: 

a) Cross-border trade (eg. get the service by telecommunicating)

b) Consumption abroad (patients travel to the other country to get health service)

c) Commercial presence (an international hospital owned by foreigners)

d) Natural presence (foreigners work in the local)

Each method has its pros n cons. To reduce the cons, policy should be made. for example, for consumption abroad, the foreign patients generate more revenues for providers. BUT, who gets the benefit? The public sector or the private? The truth is...the economic gains accrue to private investors. Hence, policy should be made, such as tax on medical tourist revenues.

In tutorial scenario 1:

some foreign countries offer medical doctors to work in remote areas in Indonesia. However, is it proper to allow foreign doctors to work in those difficult areas?   

In my opinion, importing foreign doctors may help, but short term only. When importing the health workers from other countries, assessment should be made; whether they are competent? are they willing to work in a rural area where the working environment is not too ideal? Do they have language barrier and how are they going to solve it? Bilateral agreements and contracts should be made. In long run, the best way to solve the problem of the shortage is producing more competent local medical practitioners through education and training. Besides that, the strategy of how to distribute the workforce within the country. I think contract should be made between the government and the health workers (fresh graduates), such as they have to serve the public sector for at least 3 years. That would be the mandatory service, but not up to the individual.

Reference:

1. The WHO Report 2006: Working together for health

2. Dr. Yodi Mahendradhata; Lecture: Globalization of trade in health services and workforce

3. Prof. Dr. Laksono: Lecture: Introduction of Block 4.2 and Health Systems and Its Outcome

4. Laksono Trisnantoro. Desentralisasi Kesehatan Di Indonesia Dan Perubahan Fungsi Pemerintah: 2001-2003. UGM Press. Juni 2005.

5. Dr. Andreasta Meliala; Lecture: Human Resource Management in Health Care Setting.