Paying Out-of-Pocket for Health Care in Asia? Part 1

1. Introduction

I would like to share an interesting article entitled ‘Paying Out-of-Pocket for Health Care in Asia: Catastrophic and Poverty Impact” by World Bank in EQUITAP Project Report. It stated that Out-of-pocket (OOP) payments are the principal means of financing health care throughout much of Asia. OOP payments include fees, insurance co-payments, user charges for public care and purchases of medicines, appliances, diagnostic tests, etc.

This has consequences for the utilisation of health care and household living standards. Welfare is reduced by the uncertainty of medical expenditures. Some households may be able to borrow to cover unexpected medical bills but at the risk of being trapped in long-term debt while some may be able to finance medical expenses from savings, by selling assets or by cutting back on expendable items of consumption.

More severely economically constrained households may be forced to cut back on necessities and consequently pushed into, or further into, into poverty. Thus, illness then presents a difficult choice between diverting a large fraction of household resources to cover the costs of treatment and forgoing treatment at the expense of health.

In the report, they described the magnitude and distribution of OOP payments for health care in fourteen countries and territories accounting for 81% of the Asian population. They focused on expenditures that may be considered catastrophic, in the sense that they absorb a large fraction of household resources, and on the impoverishing effect of payments.

Catastrophic payments have been defined as those in excess of a substantial fraction of the household budget. Spending a large fraction of household resources on health care is disruptive to living standards.

On the other hand, impoverishment is examined by estimating the number of individuals that are pushed below the poverty line once OOP expenditures on health care are subtracted from household resources. In shorthand, we refer to this as the poverty impact of OOP payments.

Besides that, they analysed the data from national representative household expenditure surveys that record both OOP payments for health care and total household expenditure in detail and so offer accurate estimates of the magnitude of OOP payments relative to the household budget.

2. Out-of-pocket financing of health care in Asia

In the second section of the report, it stated that poorer countries rely more heavily on direct payments. The OOP contribution reaches three-quarters or more of TEH in Nepal, India and Vietnam. OOP financing has been reduced in Hong Kong, Malaysia and Thailand by greater reliance on taxation and in Taiwan and South Korea through the development of universal social insurance. In Bangladesh and Sri Lanka, only a tiny fraction of OOP payments are for care delivered in the public sector.

In Bangladesh, principally, medicines are for poor and civil servants but in practice most medicines must be purchased from drug outlets. On the other hand, Hong Kong and Malaysia charge inpatient and outpatient care in public sector at a very moderate level and with exemptions for the poor, civil servants and health service staff.

By contrast, payments for care received in the public sector account for around a quarter of total OOP payments in India and Indonesia and more than a third in Thailand and Vietnam and more than two-fifths in Kyrgyzstan.

Interestingly,there are no charges for vaccinations, immunisations and family planning services in Bangladesh, China, India, Malaysia, Nepal, Taiwan and Thailand. However, consultations with hospital specialists are free only in India and Kyrgyz.

I will share more about the report in Part 2. J Hope this link can help you understand more about the post:

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

Introduction of Disaster Management

Indonesia, a country with approximately 220 million inhabitants living in 1.3 million hectares of land, consists of 17 583 islands, which is also home to 120 active volcanoes and 5860 rivers.

Due to these circumstances, Indonesia is vulnerable to various potential hazards. For example, Indonesia is geologically prone to earthquakes, tsunami and volcano eruption while hydrometeorologically, it is blatantly exposed to flood, flash-flood, typhoon and drought. Not to forget, there are other types of hazards such as biological threats (epidemics, disease and pest), environment degradation (deforestation, forest fire, haze, water and air pollution), technological failure (transportation and industrial accidents) and social conflict (civil unrest and terrorism).

All these risks, whether it is natural or man-made, are a threat to Indonesia and its people, causing significant physical damage or destruction, loss of life, or drastic change to the natural environment. As for Jogjakarta, the city I currently residing in to pursue my degree, eruption of Mt. Merapi has claimed 174 souls through burn injury while 85 lives were lost due to non-burn injury. (Updated from Bakornas PBP, The National Coordination Board for Disaster Management, on 15/11/2010)

Therefore, it is very important for a medical student to understand the management of disaster. First, we need to know that there are disaster management organizations in Indonesia, notably Bankornas PBP (Badan Koordinasi Nasional Penanggulangan Bencana dan Pengungsi), Satkorlat PBP (Satuan Koordinasi Penanggulangan Bencana dan Pengungsian), Satlak PBP (Satuan Pelaksana Penanggulangan Bencana dan Pengungsi).

Figure shown below reflects the relationship and level of each component and its chairman. Bakornas PBP is a national coordinating board for disaster management, chaired by the Vice President of Indonesia. On the other hand, Satkorlak PBP is a provincial coordinating unit for disaster management, chaired by Governor in the respective area while Satlak PBP is a district or municipal implementation unit for disaster management, chaired by Bupati or Mayor of the city.

The National Coordinating Board, Bakornas PBP has the following members: vice president, minister of people welfare, minister of home affairs, minister of energy and mineral, minister of social affairs, minister of health, minister of public works, minister of finance, minister of transportation, minister of communication and information, armed force commander, chief of national police, chairman of red cross and chief executing officer.

All of them have to work together to formulate and stipulate policies in disaster management. Besides that, they also coordinate the implementation and monitor activities in disaster management. In addition, they will have to render guidance and direction to manage disaster.

There are four phases based on Disaster Management Cycle, which are Mitigation, Planning/Preparedness, Response and Recovery. Whenever a disaster happens, the first step that has to be done is mitigation and prevention. This can be done by scientific hazard analysis, simulation and modeling, vulnerability analysis, risk assessment and mapping, structural measure (building stock assessment) and non structural measures (awareness campaign, training and capacity building).

Then, they will switch to preparedness mode by having resource inventory, stockpiling, logistic planning, evacuation planning, communication planning and needs assessment. Normally, there’ll be sign of the forthcoming disaster. When disaster inevitably happens, the organization will response by conducting situation analysis, crisis mapping, information delivery, evacuation and providing shelters, dispatching resources and early damage assessment. Lastly, in the recovery phase, they will focus on reconstruction and rehabilitation of spatial planning, infrastructure, housing, livelihood, social security, transport, water, communication, housing and agriculture.

In conclusion, it is an uphill struggle to cope with disaster. All parties should be responsible and play their roles well. There is still space for improvement in the management of disaster in Indonesia.I hope I can share more about disaster in the next 2 weeks classes. Till next time.

Below are some interesting links that you may not want to miss if you wish to know more about disaster management:

1.Disaster Wikipedia

2.Badan Nasional Penanggunglangan Bencana

3.Disaster Management in Indonesia

4.Disaster Management in Indonesia

5. Indonesia Disaster Management Information System

6. Indonesia National Programmes in Disaster Management

Keep holding on, Indonesia!!!

Sorry for the late update. On the night I posted the second post of this blog, Mt. Merapi erupted. I could hear the thunderous sound of the volcano, although it was 30km away. The volcanic ash and gravel rain prevented me from going back from the internet café until about three o’clock in the morning.

The next day, which was Friday, I was supposed to have lecture and clinical audit practical session but instead I received message stating that all classes were cancelled. Not long after that, I received another message to ask us to be prepared to be evacuated to Solo. Without wasting much time, I took the emergency bag that I had packed earlier to our rendezvous which is the Faculty of Medicine, UGM.

After settling the documentation, we left the city of Jogjakarta. Honestly, I was a bit scared by eruption. I would like to stay to help if I’m given the opportunity. I believed it was the time for me to be in the real setting of disaster management. However, as Prof. Laksono said before, they have enough workforces to help, plus it is not ethical to let medical students who haven’t entered clinical rotation to perform medical intervention. So, I could do nothing but left.

Only when we reached Solo that we knew we were going to be sent back to Malaysia by military plane on Sunday. We had our own emergency committees to arrange the immigration procedures. I was thinking of going back to Jogjakarta to donate some of my clothes but there wasn’t any transportation provided for me to go back. As a result, I missed another chance to help.

Dear Indonesia, my prayers is always with you. You are such a beautiful country but unfortunately with so many potential hazards geographically, hydrometeorologically, biologically and socially. Let us pray and lend our hands to those who need helps. There’s always hope. In my next post, I will briefly give my prior knowledge about disaster management in Indonesia.

Lastly, I would like to dedicate this song (although it's meant for Haiti) to Indonesia. Be Strong! Keep holding on!

Health System and Systemic Thinking

When I was a high school student, things I know about health care consist only doctors, nurses, pharmacists and radiologists. However, as I entered the first year of medical school, I realized that the public health plays an important role in health care. Now, being a fourth year medical student, I am learning even more sophisticated health system that I would like to share with everyone.

Anyway, before I proceed to the definition of health system, I would like to share some interesting lessons learnt in the practical session about systemic thinking. In order to apply the concept of systemic thinking in health, we are first exposed to systemic factors in life. Fortunately, my group gets to observe the sewage system in the university canteen.

To achieve its goals which include maintaining maximal effectiveness in sewage removal and providing cleanliness to our environment, the essential components of the sewage system are water, filter, temporary waste reservoir, waste pipe, and gravel-filled sewage tank. All the essential components are important to keep the system running efficiently and efficaciously. However, to distinguish the essential and accessorial components of the sewage system isn’t easy. I am very proud of my group because everyone shares their opinion to make the discussion effectively.

Now, let’s get back to the definition of health system. The World Health Organization (WHO) defines health systems as “all the organization, institutions, and resources that are devoted to producing health actions”. It encompasses all levels: central, regional, district, community and household. The World Health Report 2000 (WHO 2000) identifies the four key functions of the health system: stewardship/ governance/ oversight, financing, human and physical resources, and organization and management of service delivery.

By applying the concept of systemic thinking in health system, a highly functioning health system need to continually exchange feedback among these four components to ensure that they remain closely aligned and focused on achieving the goal of the system, which is “improving health and health equity in ways that are responsive, financially fair, and make the best, or most efficient, use of available sources”. For example, if the financing in the health system is weakened or misaligned, it will affect the entire system. Thus, the system has to make necessary adjustment to achieve its goal effectively.

In conclusion, a good health system requires integration and cooperation among the stewardship, financing, human and physical resources, and organization and management of services delivery. Without a good inter-relationship, health system can be said to be a pile of sand instead of a system. Nonetheless, there are still a lot to be improved in health care performance. Perhaps by understanding this relationship, we can find some solution to the problems.

References :

1) Lecture Note Block 4.2 - Introduction to Block 4.2 and Health System and Its Outcome (Prof. Laksono)

2) World Health Organization - http://www.who.int/en/

1. 3)WHO: Key Components of a Well Functioning Health System

1. 4)The World Health Report 2000

1. 5)WHO: Health Systems

Decentralization and Its Negative Impact

The Indonesian government has imposed Law no. 22/2002 to decentralize government functions and authorities to regional administrations, including healthcare.

It was a brilliant idea with good intention to increase the quality of public health services delivery. However, surveys and studies on basic health indicators and accessibility to health care services proved otherwise.

So, here I would like to share the negative impacts and challenges of the implementation of decentralization in health sector. What have gone wrong? What problems were faced by the provincial authorities in implementing the health decentralization system?

First of all, decentralization has considerably weakened the unified national health system including the once established disease surveillance system as well as public health programs. The communicable diseases that were supposed to be eliminated are reemerging, for example polio and leprosy.

Besides that, animal-borne disease including avian influenza and rabies were also spreading. For instance, before 1997, only 5 provinces were affected by rabies but after decentralization, the outbreak of rabies has affected 24 of the country’s 34 provinces, and claimed 143 lives a year on average.

It was difficult to address the epidemic and implement measures to track Rabies since it first emerged in Bali in November 2007. It was due to lack of coordination between provincial and regional health officers. The weak health policies and unclear prevention and eradication concepts have worsened the problems.

Secondly, decentralization has widened the gap of availability of healthcare services and facilities in urban and rural areas. The essential public health services such as maternal and child health, immunization, health promotion, disease surveillance, disease prevention and control including response to epidemic have become less accessible.

Thirdly, it has also further widened the existing huge gaps in the distribution of human and financial resources across provinces and across cities and districts within each province. The deployment of medical professionals lies in the hands of provincial and regional authorities. This affected the number of medical professionals working in the regencies. For example, in the remote area of Ende of East Nusa Tenggara, the 28 community center Puskesmas shared just 4 doctors.

Last but not least, many elected heads of provinces and regencies as well as legislators were lack of knowledge and understanding about health issues. For example, the community center was run by a former lurah, or subdistrict village head, instead of health professionals in the village. Under these circumstances, it is difficult to expect basic public health function such as disease control and combating malnutrition.

In a nutshell, the Health Ministry should develop clear guidelines on the roles of central, provincial and district health authorities. They should open a wide network with international agencies and donors to support health services in provinces and districts. At the same time, provincial and district authorities must improve their human resources, technical and financial capacity in handling health issues in their respective areas.

References:

1. Impact of Decentralization on Universal Coverage: a case study in Bali, Indonesia

2. International Health and Decentralization, dr. Yodi Mahendradhata.

Public Health and its Contribution

Public health is defined as “the science and the art of preventing disease, prolong life, and promoting physical health and efficiency through organized community effort and the development of the social machinery to ensure to every individual in the community a standard living adequate for the maintenance of health.”

So based on the definition, public health is important to maintain community health and plays part in health system. I would like to share an interesting fact about public health. J Do you know that as early as 310 BC, public health philosophy was already established by the Romans?

At that time, they believe that cleanliness would lead to good health and made links between causes of disease and methods of prevention. For example, the Romans Empire made association between the increased death rate of persons living near swamps and sewage. As a result, they began working on two major public health projects in sanitation control: the building of aqueducts to supply clean water to the city and a sewage system to eliminate waste from streets.

Today, the benefits of public health infrastructure continue to strengthen the well-being of the society. In the past century (1900-1999), the 10 greatest public health achievements have been documented as the following:

1. 1. 1.Vaccination programs: eradication of smallpox; elimination of poliomyelitis in USA; control of measles, rubella, tetanus, diphtheria etc.

2. 2 2.. Motor-vehicle safety.

3. 3. 3. Safer workplaces

4. 4. 4.Control of infectious diseases.

5. 5. 5.Decline in the deaths from coronary heart disease and stroke.

6. 6. 6. Safer and healthier foods.

7. 7. 7. Healthy mothers and babies.

8. 8 8.. Family planning.

9. 9. 9. Fluoridation of drinking water.

10. 10. Recognition of tobacco use as a health hazard.

In conclusion, promoting and managing the health of a society have shown to increase the welfare of the community historically. The discipline, called public health, is a broad one, encompassing multiple sectors of the community and professional fields; government and non government agencies; and local, regional, federal, and sometimes international institutions. Collectively, these groups have to work in a team to fulfill society’s desire to create condition so that people can be healthy.

References:

1. Ten Great Public Health Achievement-United States, 1900-1999

2. Public Health Law, ethics, and human rights: Mapping the issues

Introduction

Being a 4th year medical students, I spent my past 3 years learning about the pathophysiology, treatment and management of the diseases. So, I wonder why we need to learn about health system and disaster management. Why does the faculty combine the health system and disaster management in a block? Will it help us in treating the patient? Will it benefits us as future health care providers? How can it improve the current health care management? Is it significant for us to have this block?

Well, my questions are answered during the overview of the block. A health system can be defined as a set collection of components organized to accomplish a specific function in health. We, as future medical practitioners, who are included in the health system play important roles to care about the health problems of individuals, families and communities.

So, it is important to understand the health system globally, nationally and locally. We can analyze the health system in a normal situation, but it can be disturbed or even destroyed in a disaster situation. For example, the tsunami in West Sumatra and eruption of Mount Merapi have continued to present a challenge to the disaster management of the health system. Therefore, we need to understand the impact of disaster towards health care, and the principle of disaster management.

In this block, we will learn about the public health policy in various aspects and its management, quality of care, social and political aspect of health, leadership, communication, and disaster management. Of course, we must revise the topics that we learn previously, such as epidemiology, basic management principle, emergency medicine and public health science. I am very excited to learn more about Block4.2. By writing this blog, I believe it is a great opportunity for me to summarize and share my knowledge, and improve my writing skills. In conclusion, let’s have fun and enjoy the new block!!

P/s: I totally agree with Prof. dr. Laksono who made an ‘Be Punctual, No Talking and No handphone’ agreement with us during the Overview of Block 4.2. By doing this, it provides a tranquil study environment and promotes better quality and professionalism in medical student. Perhaps, that will be the first of many simple steps to improve the quality of health, by improving the quality of future doctors. J