Logistic Management Support

“Logistics” comes originally from the military procedures for the procurement, maintenance, and transportation of material, facilities, and personnel. Generally, logistic refers to a system whose parts interact smoothly to help reach a goal promptly and effectively by optimized use of resources. In emergency, logistics are required to support the organizational and implementation of response operation in order to ensure their timeliness and efficiency.

Below are 10 classes of medical logistics classified by PAHO-WHO: Medicines, Health supplies/kits, Water and Environmental Health, Food, Shelter, Logistic Administration, Personal needs/Education, Human Resources, Agriculture/Livestock and unclassified. Unclassified items include expired supplies, poor labelling supplies etc.

Losses of life or injury are unavoidable when a disaster strikes. To preserve life or health of the disaster victims, it is essential for drugs and medical equipment to be available in sufficient amount. However, there are still problems that may arise due to poor logistic management. For example, there were thousands of help or medical aids received by local government and international organization during the Acheh Tsunami. But ends up, the government spent billions of rupiah to dispose the chemical waste.

Therefore, the authority must optimize the use of all the resources, by storing and distributing the medical supplies properly to assure their quality and rational use. One of the management strategies suggested by the National Volunteer and Donations is to begin the donations activities before the declaration of disaster. Coordinated donation planning and management can avoid difficult problems later such as chaos, waste of time and underutilized volunteers. Besides that, the use of team approach, flexible strategies and information management is essential in disaster operations to manage operational activities.

References:

1. Hazard, Disaster, and Your Community in National Disaster Management Division, Government of India Ministry of Home Affairsw

2. Logistic Management Support, dr. Sulanto Saleh-Danu

Psychological and Social Scars- The Worst Scars in Disaster

When an event of disaster happens, it does not only cause physical damage to properties and lives, but it can also cause complicated mental health and psychosocial problems. One out of three survivors experiences severe stress that can lead to posttraumatic stress disorders, anxiety disorders, or depression.

Disasters can provoke specific emotional reactions that take on a variety of different psychological responses, affecting primary victims (those directly involved in the disaster) and secondary victims (such as relatives, co-workers, and schoolmates). Other people who can experience mental health issues include onlookers, rescuer, body handlers, health personnel, evacuees, and refugees.

The three forms of mental health problems that may follow a disaster are acute stress reaction, posttraumatic stress disorders (PTSDs), and adjustment disorders or enduring personality change.

Acute reactions are characterized by absence of emotion; lack of response to external stimuli; total inhibition or outward activity and random movements; persons being stunned or shocked; and psychosomatic symptoms such as tremor, palpitation, hyperventilation, nausea, and vomiting.

PTSD is defined as: An anxiety disorder (and diagnostic construct used in the Diagnostic and Statistical Manual of Mental Disorder-IV) that can develop after exposure to a terrifying event, or ordeal in which grave harm occurred or was threatened. The criteria for PTSD require:

a. Exposure to a traumatic event

b. Reexperiencing of the event (nightmares)

c. Persistent avoidance of stimuli associated with the trauma (substance use)

d. Persistent increased arousal (panic attacks, rage)

e. Duration of B, C, D of more than one month

f. Clinically significant distress or impairment (severe anxiety and/or severe depression)

The National Center for PTSD states the factors that might be protective, including social support, higher income and education, successful mastery of past disasters and traumatic events, reduction of exposure to trauma, and provision of regular and factual information about the emergency.

So what can be done by the health workers to help? Well, experts recommended some early intervention actions. It is provision of psychological help to victims and survivors within the first month after a critical incident, traumatic event, emergency, or disaster aimed at reducing the severity or duration of event related distress. This may involve psychological first aid, needs assessment, consultation, fostering resilience and natural support, and triage, as well as psychological and medical treatment.

Therefore, we as health workers should promptly evaluate the mental status of the disaster victims. The key to a successful intervention of their mental health problem is the early identification and early treatment.

References:

1. Disaster Management in Mental Health, dr. Bambang Hastha Yoga

Problems of Indonesian Health Insurance System

I would like to share some problems about the health insurance in Indonesia. Firstly, it is about Jamkesmas. The Indonesian Health Ministry claims to have spent eight years drafting a universal healthcare bill, but has been facing a series of hurdles: lack of funding and other technical issues.

The 2008 health insurance scheme for the poor, Jamkesmas, is notorious for its complex procedures and documentation requirements. The notoriety in defining “poor” in Indonesia is because it is based on a local authority’s letter stating one’s poverty (surat pernyataan miskin).

Compared with the USA, where one must show one’s annual tax report statement that quantifies the exact taxable earnings. Such a subjective statement of being “poor” in Indonesia must be revised, which brings with it implications for tax-reporting procedures.

Secondly, for PT Jamsostek, it remained unable to effectively provide social protection to workers, mainly because of the absence of political commitment from the government to improve the social welfare of 107 million workers and their families, as evident in the discriminatory social protection policy.

The government enacted Law No. 3 on social security programs in 1992, and appointed Jamsostek to cover only companies employing 10 workers or more, or those paying the monthly salary of Rp 1 million or more, ignoring the jobless and around 77 million people employed in the informal sector.

Since the inception of the 1992 social security law, Jamsostek has registered only 24 million of 35 million workers in the formal sector, and so far only 9.2 million of the paid workers employed in the more than 11,000 companies that have remained active in the social security programs.

The absence of the state’s annual payment and the low percentage of contribution from employers and workers have deprived workers of maximum benefits from the programs. Employers pay only 6 to 9 percent of the workers’ monthly salaries to healthcare, death, occupational accident and old age risk plans wile workers contribute only 2 percent to the old-age risk scheme. As compared to Singapore, employers and workers contribute 20 percent to the Central Providence Funds, while Malaysia, their employers contribute 13 percent and workers pay 10 percent in the Employee Providence Fund (EPF).

Despite the solidarity and portability principles, participants have yet to receive maximum benefits when they get sick or enter retirement age. Workers suffering from major diseases could not get optimum healthcare in hospital referrals.

In a nutshell, there are still problems need to be solved in the aspect of health insurance in Indonesia. For example, perhaps Jamsostek need to be reorganized and turned into a non-profit institution which focuses on occupational accident, death and old-age risk schemes, while the healthcare and pension schemes should be handled by other professional institutions to give better service to participants. This will improve the quality of care and increase the accessibility of people to health.

References:

1. Health Financing in Indonesia: A Reform Road Map. Jakarta: World Bank

2. Social Health Insurance for the Poor: Targeting and Impact of Indonesia'a Askeskin Program, SMERU Research Institute.

3. Health Fincance, Prof. dr. Ali Ghufron Mukti.

From Malaysia: Too Many New Doctors and Too Few Hospitals to Train them

I was reading The Star, one of Malaysia leading English newspapers. One of the articles attracted my attention because it was related to one of the most talked current medical issues which is the excess medical workforce (medical housemen) in Malaysia. It was interesting because as I will graduate in about 2 years time, so I hope by the time I go back, the problem will be solved. So, today I would like to share about this issue.

According to the Ministry of Health, the number of medical housemen undergoing clinical training in most government hospitals has increased. There were 38 hospitals providing training to more than 3,058 housemen last year but the number has since increased to 6,253. Based on the statistic 5 years ago, one houseman looked after 10 patients in hospital wards but now it’s reduced to one to every 4 patients.

Besides that, in the past, there were 5 housemen in each department but now it could be 20 to 30 for each department. These lead to the situation where there were more housemen than patients in the training hospitals, including in Sabah and Sarawak. Each specialist was supervising four times as many housemen compared to a decade ago.

There are few reasons why overcrowding of interns in hospital can happen. With new medical schools opening up locally and lower fees being offered at new institutions aboard, a steady number of 4,000 Malaysian medical students are expected to graduate annually. Besides that, the action taken by the Health Ministry to increase the duration of housemanship from one year to two to overcome the lack of experience among housemen worsens the situation.

Actually, what is the impact of excessive medical housemen to the health care? Why the government and Health Ministry are concern about this issue? One of the reasons is they afraid that medical housemen may not get sufficient experience. The interns are seeing fewer patients and hence, have fewer opportunities to carry out adequate procedures.

Apart from that, excessive interns indirectly affect their attitude. They became less competitive and less responsible towards their patients. The Health Ministry stated that there were also interns who failed to give accurate diagnosis and relied too much in investigation tools. Thus, the quality of future doctors is affected.

So, I think few steps can be taken to overcome this problem. First, there is a need to increase the number of training hospitals. (You can read my previous post about requirement to implement a hospital ) J

Second, we can increase the number of specialist to train the interns. For example, the Health Ministry is recruiting 58 contract specialists from Egypt, India and Pakistan to help supervise housemen and reduce the burden of the specialists.

In conclusion, I believe housemanship is the time where the medical students practice what they learned theoretically. Therefore, I hope the current situation will improve so that we can learn more and be more prepared to care for our patients.

References:

1. Too many new doctors and too few hospitals to train them, The Star

Practical Session: Medical Logistic for Disaster

In the practical session, I learned about how the medical logistic for disaster has been done. Firstly, we select a list of basic and critical medical supplies to be provided to the disaster victims. The selection criteria such as health care needs, the characteristic of the patients who require treatment, the availability of supplies and the capacity of health system are taken into account.

Then, the drugs and other medical supplies are procured to ensure that the quantities are enough to meet the victim’s demand. A few methods or formula can be used to estimate the needs of supplies. Below is one example of the formula:

Besides that, the storage conditions affect the quality and effectiveness of health supplies. Thus it is essential to create the necessary physical, hygienic and infrastructural conditions. We have to keep track of the stock level and monitor the expired dates of stored drugs to maintain an optimal use of the available resources.

Last but not least, we have to distribute the drugs and medical supplies properly based on the demand and existing stock. So, the various organizations that receive supplies and donation must coordinate well, especially with the government agencies to ensure the efficacy and efficiency of medical supplies delivery.

Refernces:

1. Logistic Management Support, dr. Sulanto Saleh Danu

2. Practical Session: Medical Logistic for Disaster, Rapid Response Team

Surveillance, For What Purpose?

In my previous blog, I have explained about components of surveillance system. Besides its function in detecting and monitoring an outbreak, there are other important functions of Surveillance such as:

1. Estimates the magnitude of the program: For example, the graph shows the total case of dengue fever based on symptoms from January 2002 until April 2004.

2. Determine geographic distribution of illness: For example, there is higher incidence of certain diseases near the river. So, instead of only focusing on curative medicine, we shift our attention to prevention and promotion of health.

3. Portray natural history of the disease: Incidence of Varicella is highest in the beginning of the year. It is most likely due to the weather.

4. Detect epidemics/ define a problem: Sudden increased of the Salmonellosis rate in year 1985 was due to contaminated pasteurized milk.

5. Generate hypothesis and stimulate research: The highest reported number of cases of pertussis (whooping cough) is in age group less than 1 year old. Research can do done to find the cause.

6. Evaluate control measures: The reported cases of poliomyelitis have declined after the introduction of oral vaccine in 1961.

7. Monitor changes in infectious agents: The percentage of nosocomial enterococci infection reported as resistant to vancomycin is higher in ICU than non ICU.

8. Detect changes in health practice: There’s a steady increase in caesarean delivery among all deliveries in US hospital. This may be due to the physicians who do not follow the standard, or perform caesarean section procedure upon patient’s request.

9. Facilitate planning: There number of tuberculosis cases is fluctuating between 1976 and 1996. Based on the date, we can do proper planning in the management of tuberculosis to decrease the number of new cases.

Oh No! Disease Outbreak? What Should We Do?

In scenario 3 entitled “A Poultry Worker”, it’s stated that a doctor suspected a poultry worker was infected by a serious viral disease, and might spread out to the community. As a result, he reported the case to the municipal health agency. The agency then performed outbreak and pandemic preparedness measures with a view to handle the worst case scenario. Hence, I will share more about what we, as health workers should do during an outbreak.

First and foremost, we have to collect information on a specific disease or other health-related event systematically. There are 3 types of data collection: universal case, sentinel and laboratory-based reporting. Sources of data include mortality or morbidity reports, individual case investigations, laboratory utilization reports, special surveys, information on animal reservoirs and vectors, demographic data and environmental data. These data can be obtained from the public and health care providers.

Next, the data will be analyzed and interpreted by the health agencies. The information is then disseminated to the public to reduce morbidity and mortality resulting in the improvement of health. The ongoing systematic collection, analysis, interpretation, and dissemination of data regarding a health related event for use in public health action is what we term as Surveillance.

A surveillance system is an information loop or cycle that involves: healthcare providers, public health agencies and the public.

However, there are still some problems with the surveillance system in Indonesia. For example, the data collection is not systematically done, thus the processing of data into useful information can’t be achieved.

In conclusion, surveillance is the collection of data relevant to public health, which can then be analysed to guide action or responses for prevention and treatment programmes. Therefore, data should be collected systematically, so that it can be analysed and converted into information.

References:

1. Surveillance, Response and the Role of Health Informatics, dr. Luthfan Lazuardi

Act Now, Talk Less!!

I believe everyone still remember the catastrophic eruption of Merapi. Although the activity of Merapi has finally cooled down, it has caused irreversible damage to thousands of residents staying near the site of eruption.

Currently, there are approximately 45,000 homeless victims staying in the evacuation camp, and 6,000 of them are stationed in the Main Evacuation Camp, Posko Maguwoharjo. They lost their homes, properties, and most of them are still grieving for their loved ones. It’s time for us to stop talking about helping them and walk the talk instead!!

The items in the list below are basically what they need now. If you are willing to lend a hand, you can donate the stated items OR some money by clicking the link below or the link at the left side of my web page. Even a small contribution will make a big difference. You can make a difference.

UNICEF donate

List of items needed:

To provide warmth and comfort: Tikar (Mat), carpet, blanket

Toiletry: Soap, body shampoo, hair shampoo, tooth brush, tooth paste, towel

Cleaning: Cloths washing powder, brush, and dish washer liquid

Food: biscuit, mineral water

Special food: milk for baby more than 6 months all, elderly, pregnant mothers

Footwear: Sandals of all sizes

Cloths: Undergarments for male /female, bra of all sizes, clothes for children & baby

Education: School stationery for children

Special need: Elderly diapers

Religion: Praying head-scarf (kain sembayang) for muslim women

Besides providing what they need, we can also support them emotionally and mentally. Simple actions such as talking and comforting the elderly, playing and having fun with the kids mean a lot for them. If you have the time, why don’t you volunteer at the camp? As young doctor, let’s be active and creative, let’s share and care for the less fortunate ones. J

“Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around.”

~ Leo Buscaglia~

Procedure of Disaster Victim Identification in Indonesia

Few days after the lab, we had a lecture by Prof. Etty about the procedure of disaster victim identification in Indonesia. There are 5 phase of victim identification which will be conducted by a victim identification team that includes the police, medical doctors, SAR, army and trained volunteer.

The phase 1 is at the scene of disaster. The Interpol (international police) will be searching for bodies, body parts, properties that belong to the victim. Apart from that, they will have to map the area of disaster and label the body. After the documentation is done, they will put the bodies into the body bags and transport them to the hospital.

The setting of phase 2 is the mortuary, usually the hospital’s morgue where the post mortem examination will be done. First, the documentation regarding the bodies, body parts and properties will be done. Then, the external-internal examination and autopsy will be performed by forensic anthropologist.

At the same time, they will have to identify the victim’s race, age, sex and stature. The dental examination can be performed by either the forensic anthropologist or forensic dentist. The samples for DNA examination can be taken from blood or tissues. The upper and lower jaws x ray will also be taken. Lastly, they have to record all postmortem examination data in the pink form.

Then, in phase 3, ante mortem data will be collected from family, friends, doctor and dentists. The medical record will be needed for matching as the primary identification traits while data likes vital sign, specific characters, jewelleries, watch and clothes will be used for matching as the secondary identification traits. All these ante mortem data will be recorded in yellow form.

Reconciliation, which is comparing the ante mortem data and post mortem data, is performed in phase 4. Debate often occurs in this phase as mismatching might happen. Teeth, fingerprint and DNA will be used as primary identification method, while victim property, photography and document will be used as secondary identification method. When all evidence and proofs are matched, the victim is identified.

Last but not least, in phase 5, the body of the victim will be released to the family member, along with the letter of released. Basically, the Disaster Victim Identification team finishes their job and is able to leave after the documents are compiled.

In a nutshell, victim identification in mass disaster is not a simple job. Problems such as enormous number of victims, difficult transportation, post mortem changes and insufficiency inter department coordination complicate the job. Nonetheless, we should always bear in mind that the success indicator of victim identification is not the speed, but the accuracy.

References:

1. Practical Session: Death Victim Identification in Mass Disaster, Dr. Yudha Nurhantari

2. Disaster Victim Identification, Dr. Yudha Nurhantari

3. Victim Identifications, Prof. drg. Etty Indriati

4. Conceptual Framework of Disaster and Disaster Management

Practical Session: Victim Identification in Mass Disaster

As we all know, recently in November 2010, mount Merapi erupted, claiming more than 200 innocent souls in Indonesia. Rubbing salt to the wound, the earthquake in Mentawai also caused the loss of more than 400 human lives.

During disaster, the survivors will be taken care by many departments, notably the health department, social department, state and International Red Cross.

However, who is responsible for the unlucky ones who perished in these catastrophic events? Will it be the police? Army? Doctor? Or perhaps the forensic pathologist? How about the victims with unrecognizable faces and bone exposure? How can we identify the poor victims?

All my questions were answered in the Forensic and Medicolegal practical session. During the session, we learned about the death victim identification in mass disaster. To make the class interesting, our doctor said that she wanted to play a game with us.

So, all of us were divided into two groups. The members of the first group were given a pink report each which is the post mortem report while the second group got the yellow reports which contain the ante-mortem information of the victims.

First, we analyzed the report. For example, I got the ante mortem report. So, I need to write down the name, age, gender and other details of the missing person.

Then, we brought the summary of the report to the doctor where she gave us the next clue. For example, I got the result of the blood test and the DNA analysis of the missing person that I had analyzed earlier.

Lastly, I had to compare my result with the other group that held the post mortem reports. In the end, I identified the victim by founding the matching DNA, blood type and medical record. It was an intriguing learning process and I really enjoyed it.

References:

1. Practical Session: Death Victim Identification in Mass Disaster, Dr. Yudha Nurhantari

2. Disaster Victim Identification, Dr. Yudha Nurhantari

Work in a TEAM to Improve Primary Care Practice? How?

In health care settings, individuals from different disciplines come together to care for patients: the surgeon, nurse, anaesthesiologist in the operating room; the oncologist, radiation therapist, and surgeon for patients with cancer, and the physician, medical assistant, and receptionist in the primary care office. But is a group of people who happen to be thrown together in a surgical suite or primary care office truly a team?

Discussion of team generally includes a consideration of 2 major issues: “Who is on the team?” and “How does the team function?” Now, I would like to share with you the 5 key characteristic of a cohesive health care team: clear goal with measurable outcomes, clinical and administrative systems, division of labor, training of all team members, and effective communication.

Key Element of Team Building

1. Defined Goals Overall Organizational mission statement Specific, measurable operational objectives	Examples: · Improvement of patient’s health · Reduction in barriers to access to care · Improvement in practice’s financial performance · Physician and staff satisfaction · At least 80 of diabetic patients in practise will have haemoglobin A1c lower than 8 · 90% of people calling for a nonurgent appointment will receive the appointment within 1 week · Practice will achieve a targeted level of practice revenue · Each team member will achieve an explicitly identified goal for personal professional development
2. Systems Clinical Systems Administrative Systems	· Procedures for providing prescription refills · Procedures for informing patients of laboratory results · Procedures for making patient appointments · Policies on how decisions are made in the medical practice
3. Division of Labor Definition of tasks Assignment of roles (Determining which people on the team perform which tasks within the clinical and administrative systems of the medical practice)
4. Training Training for the functions that each team member routinely performs Cross-training to substitute for other roles in cases of absences, vacations, or periodic heavy demands on one part of the team
5. Communication Communication Structures Communication processes	· Routine communication through paper and electronic information flow · Minute-to-minute communication through brief verbal interactions among team members · Team meeting · Giving feedback · Conflict resolution

In conclusion, teams with greater cohesiveness are associated with better clinical outcome measures and higher patient satisfaction. Moreover, medical settings in which physicians and nonphysician professionals work together as a team can demonstrate improved patient outcomes. However, a number of barriers to team formation exist, chiefly related to the challenges of human relationships and personalities. So, taking small steps toward team development may improve the work environment in primary care practices.

References:

1. Can Health Care Teams Improve Primary Care Practice?

2. Leadership and Team Work, Prof Dr. Budi Mulyono

3. Communication in Working Place, Guest Lecture