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

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