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

Requirement for the Implementation of Hospital??

There was once my friend asked me, “When will you establish your own hospital? What will you need to do that?” I couldn’t answer his question because back then I did not know the requirements to set up a hospital. However, interestingly, in Block 4.2, there was lecture about Hospital Law which discussed about this subject.

Hospital, by its definition is a public service institution that administers any plenary individual health service providing inpatient, outpatient treatment and intensive care. One of the main functions of hospital is to undertake medical cure and recovery of patient in accordance with the hospital service standard. So what requirements are needed for the implementation of hospital?

Basically, requirements for the implementation of hospital include location, building, infrastructure, human resources, pharmaceutical and equipment. If the stated requirements are not met, the operating permit or license will not be issued.

First and foremost, a new hospital needs a location which satisfies the provisions on health, environment safety, building, and environment layout criteria.

As for the building, it requires general administrative and technical requirements for its construction. Special technical requirements are also needed for hospital building in compliance with its function, comfort and convenience in giving services, protection and safety to all people especially disable persons, children and old age people.

The infrastructures of the hospital must achieve the standard specified for hospital undertakings with respect to its service, security, safety and health. Those infrastructures must be in good condition, well maintained and function properly. They shall be conducted by competent employee and evaluated continuously.

Human resources are one of the important elements for normal functioning of the hospital. The hospital shall employ permanent workers in accordance with the hospital type and classification, namely medical staff, paramedics, nurses, pharmaceutical workers, hospital management staff and non-medical staff. However, hospital may also employ non-permanent workers and consultant. All human resources are obliged to hold practical permit or working permit.

Other than that, hospital can hire foreign medical staff according to the service needs. These foreign workforces can be considered for technological and scientific transfers and also to overcome the insufficiency of local medical staffs. Of course, in order to practice in this country, all foreign medical staffs must already possess registration certificate and practice license.

In pharmaceutical aspect, the hospital must be able to secure the availability of stocks and qualified, benefiting and accessible medical equipments. It must follow the pharmaceutical service standard. The price of the medicine must be reasonable and according to the reference price set by Government.

Last but not least is the equipments requirement. The medical and non medical equipments must fulfill the service standard, quality requirements, security and safety. It must be tested and calibrated periodically, and operated by competent technicians. The usage of the equipments must be conducted in accordance with patient medical indications.

In conclusion, all these requirements have to be met in order to operate a well functional hospital.

References:

1. Hospital Law, Guest Lecture

Health Insurance in Indonesia

The health system in Indonesia is generally underfunded. For example, the total health expenditure of Indonesia is less than 2% gross domestic product per capital. Although the health financing in Indonesia is a mix system between health insurance, tax funded, and out of pocket, majority of the people are still paying health services out of pocket.

There are two health insurance company run by the government, which are PT Askes and PT Jamsostek.

Askes is a compulsory health insurance scheme for civil servants and the members only need to contribute 2% of their monthly salary to Askes. All members are entitled to comprehensive medical benefits regardless of their income. Meanwhile, Askes pay the health care providers, usually consists of public health centers and public hospital prospectively.

Jamsostek is the social security scheme for private sector employers and employees. The government enacted Law No.3 on social security programs in 1992, and appointed Jamsostek to cover companies employing 10 workers or more, or those paying the monthly salary of Rp1 million or more. It covers employment injury, death, health insurance and a provident fund type Old Age Benefit.

In 2005, Askeskin or “health insurance for the poor” was introduced to increase access of health services for the poor. The card holder just need to pay as low as Rp 5,000 per month to receive health care varies from simple common cold to heart surgery and haemodialysis.

In conclusion, there is still a lot of Indonesian that are not covered by insurance. Besides that, the underfunded health system in Indonesia can cause several problems, for example low health services quality and unequal distribution of health care providers. Thus, steps need to be taken overcome this issue and cooperation between government and insurance company are needed.

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.

Paying Out-of-Pocket for Health Care in Asia? Part 2

p/s: Please refer to my previous post if you haven't read the Part 1 of "Paying Out-of-Pocket for Health Care in Asia?"

3. Household budget shares of out-of-pocket payments

The World Bank examined the shares of household budgets absorbed by OOP payments for health care. For low- and middle-income territories, the household budget is defined as the value of consumption, including that from home production. For the high-income territories (Hong Kong, Taiwan and South Korea), the household budget is given by expenditure on market goods and services.

There is substantial variation across territories in the OOP budget share. On average across all households, OOP payments for health care absorb 4-5.5% of total household consumption in China, India, Bangladesh and Vietnam. All four of these countries rely on OOP payments for at least 60% of health financing. With the exception of (urban) China, they are amongst the poorest countries examined here. Associated with poverty, population health deficiencies drive up expenditures on health care and medicine

The mean OOP budget share is much lower – 1.4-2.7% - in Malaysia, Thailand, Indonesia, the Philippines, Sri Lanka, Hong Kong, Kyrgyz and Nepal. With the exceptions of Indonesia, Kyrgyz and Nepal, these countries are less poor than the first group and rely less heavily on OOP financing. The low OOP budget shares in Indonesia and Nepal are somewhat surprising given heavy reliance on OOP financing.

In the two high-income territories operating a social insurance model with co-payments – South Korea and Taiwan – the mean OOP budget share is in the middle of the range, around 3.8%. The lower average budget share in Hong Kong (2.3%) is understandable given its higher levels of income and population health and, in comparison with South Korea, by its lower reliance on OOP financing.

Bangladesh, India and Indonesia are among the poorest countries included in the study. The most plausible explanation of the steep income gradients in these countries is that the better-off can respond to health problems with the purchase of medicines etc, while the poorest of the poor cannot afford to divert resources from very constrained budgets.

However, one should not overlook the fact that the poorest households in Bangladesh - a very poor country – spend a larger fraction of their available resources on health care than the richest households in high-income Hong Kong. This is explained by the tremendous differences in population health and insurance coverage. China and Vietnam are similar to Bangladesh and India in having a high mean OOP budget share but differ in that the distribution does not display a steep income gradient.

In China, the rich actually spend relatively less out-of-pocket on health care. A consequence, one might suppose, of the lack of any fee exemptions for the poor, the collapse of collective payment schemes in rural areas and the greater health insurance cover enjoyed by the better-off, urban population. Fee waivers exist in Vietnam but are restricted to the indigent identified by village committees.

4. Catastrophic payments

In the absence of insurance cover, households with severe and immediate medical needs can be forced to expend a large fraction of the household budget on health care. So, the concept of catastrophic payments has been out into operation by defining them as occurring once OOP payments cross some threshold share of household expenditure. Note that the catastrophic effect of OOP payments may be incurred in the short and/or long-term.

World Bank presented the catastrophic payment headcount (CH)- the percentage of households incurring catastrophic payments. Catastrophic payments are most prevalent in Bangladesh, Vietnam, China and India. Vietnam has a higher proportion of households than Bangladesh spending in excess of 5% of the budget on health care but the ordering is reversed at all higher threshold values.

At the lower threshold value of 5%, South Korea is close to Taiwan, with around 20% of households spending in excess of this threshold. But at higher thresholds, Korea is closer to the high incidence group and actually has a higher proportion of households than India spending in excess of 15% and even 25% of the budget. In fact, direct payments for health care absorb in excess of 25% of total expenditure in a remarkable 2.5% of Korean households. This reflects the very extensive use of co-payments, the non-coverage of many treatments and, in particular, the partial coverage of expensive inpatient care provided by the Korean social insurance system.

By contrast, in Taiwan protection against very high OOP expenditures is similar to that in tax-financed Hong Kong. The incidence of catastrophic payments is lowest in Malaysia, Sri Lanka, Thailand, Indonesia and the Philippines, with less than 5% of households spending more than 10% of total expenditures on health care.

As is to be expected, and has been demonstrated elsewhere, countries relying most on OOP financing generally have the greatest prevalence of catastrophic payments. Of course, reliance on OOP financing is negatively correlated with national income and so there is a negative relationship between catastrophic prevalence and national income.

For example, while China relies on OOP financing only slightly more than Indonesia, the prevalence of catastrophic payments is much higher in China than Indonesia. Clearly, the propensity to spend on medicine is higher in China than Indonesia and there is less protection against very high medical bills that exhaust a substantial share of household resources. There is evidence that government intervention in Indonesia is effective in reducing exposure to catastrophic health payment risks.

5. Poverty impact

Medical expenditures can be impoverishing. Paying for health care can be at the expense of meeting basic needs for food, clothing and shelter. They referred the difference between poverty estimates net and gross of health payments as the poverty impact of those payments.

They also presented the poverty headcount ratios (PH) based on household consumption/expenditure both gross and net of OOP health payments relative to each of the two poverty lines. Results are not presented for the three high/middle income territories (Hong Kong, South Korea and Taiwan) since absolute poverty is near non-existent and it remains so after taking account of OOP health payments. Poverty is highest in Nepal, where we estimate 39.3% of individuals live on less than the equivalent of $1.08 per day (1993 PPP), followed by India (31.1%), Bangladesh (22.5%), the Philippines (15.8%) and China (13.7%).

6. Conclusion

First, there is still heavy reliance on out-of-pocket financing of health care in Asia. The OOP share of health funding is at least a third in all territories included in this study, exceeds three fifths in Bangladesh and China and over three quarters in Vietnam, India and Nepal.

Second, such heavy reliance on OOP financing has important consequences for household living standards. OOP payments for health care absorb more than one quarter of household resources net of food costs in at least one-tenth of all households in Bangladesh, China, India, Nepal and Vietnam. Such levels of spending can only be accommodated through the diversion of considerable resources from other items of consumption and/or through the disruption of consumption paths across time. The consequent negative welfare costs may be termed “catastrophic”.

Third, there are important differences across countries, not only in the scale of OOP payments for health care, but also in their distribution. In high-income territories, catastrophic payments tend to be evenly distributed, or even slightly concentrated on the less well-off. In most low-income countries, however, it is households with higher total expenditure that are more likely to spend a large fraction of those resources on health care. This reflects the inability of the poorest of the poor to divert resources from basic needs.

Fourth, despite the concentration of catastrophic payments on the households with higher total expenditures in the majority of low-income countries, OOP payments still push lots of Asian families (further) into poverty.

Reference:

Paying out-of-pocket for health care in Asia: Catastrophic and poverty impact