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CONTENTS

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Post-Donation Donor Notifications and Behavioral Strategies Counseling Approach to Decrease Outspread of HIV Putu Ijiya Danta Awatara*, Januardi Indra Jaya** and Lim Zhan Heng*** *Second Year Medical Student, University of Brawijaya, ijiyadanta19@gmail.com) **Forth Year Medical Student, University of Brawijaya, (januardi.indra@gmail.com) **Second Year Medical Student, University of Brawijaya, (allele94@gmail.com)

Abstract The Human Immunodeficiency Virus (HIV) is a retrovirus that infects cells of the immune system and already become a concern to a lot of countries including Indonesia. The government's efforts to prevent the spread of HIV is still lacking. One of the way to stop the outspread of HIV is to perform early detection and it regularly been done to a healthy person is in the blood donor center. Therefore, we propose a system for optimizing the function of blood donors in an effort to suppress the outspread of HIV. The method used in this paper is literature review, and the materials are relevant scientific journals. The system is a postdonation service system which including post-donation notification, counselling and treatment referral. Blood donor will receive a notification letter after the blood screen test is positive. If the donor does not call in two weeks, a second similar letter is sent, followed by a telephone call. If it's not answered , clinicians with HIV or counselling background from community health care centre (Puskesmas) will be sent to donor house. Patient is recommended to hospital after received positive result from repeat testing. The application of the post-donation service can detect more than 7,900 HIV positive person each year. Some developed countries and developing countries have applied the system without noticeable problems. The health facilities needed for this system and the system for counseling in blood donor center is already established. The existence of notification system will benefit not only the HIV infected person but also the blood donor center and the blood recipient. This system is able to decrease HIV by notifying HIV positive blood donors to increase their awareness of

self-status and counseling through behavioral strategies approach, to sustain safer sexual behavior and so avoid further transmission.

Keyword : HIV, Blood Donor, Post-Donor Notification

Post-Donation Donor Notifications and Behavioral Strategies

Counseling

Approach

to

Decrease

Outspread of HIV Putu Ijiya Danta Awatara*, Januardi Indra Jaya** and Lim Zhan Heng*** *Second Year Medical Student, University of Brawijaya, ijiyadanta19@gmail.com) **Forth Year Medical Student, University of Brawijaya, (januardi.indra@gmail.com) **Second Year Medical Student, University of Brawijaya, (allele94@gmail.com)

lacking. The government has attempted to

Introduction

reduce the spread of HIV cases through The

Human

Immunodeficiency

Virus (HIV) is a retrovirus that infects cells of the immune system, destroying or impairing their function (WHO, n.d). It kills more than 1.5 million of people in Indonesia and already become a concern to a lot of countries including Indonesia. In Indonesia, HIV shows an increasing trend

Permenkes No. 21in year 2013 about countermeasure of HIV and AIDS.However, it has not produce optimal resultswhereas the key to fight against HIV is to stop the outspread of it, because it has the characteristics of easy to transmit and Insidious (National AIDS Commision Republic of Indonesia, 2009).

and threat to society.According to data from Dirjen PP & PL, Kemenkes RI, 2014,

One of the way to stop the

in 2013 there were 2.1 million cases of

outspread of HIV is to perform early

HIV. While new HIV cases have increased

detection. However, because of the bad

from 21,591 cases in 2010 into 29,037

paradigm of HIV, people who did early

cases in 2013 (Infodatin Pusat Data

detection is still low, even for high

Informasi Kemetrian Kesehatan RI, 2014).

educated people who live in big city (Boonstra, 2008).

Although the data conclude an

Apparently, the only detection of HIV that

increasing in the number of cases and

regularly been done to a healthy person is

mortality ofHIV, the government's efforts

in

to prevent the spread of HIV is still

nowadays, theresult of early detection in

the

blood

donor

center.However,

7

the Blood Donor Center in Indonesia only

through digital and non-digital information

serves for screening blood donors, which

from literature such as journals and

is to determine whether the blood is safe or

reports. The method of data analysis

not to be accepted by the recipient.

literature

But,theydid notinform the result and did

approaches, namely:

notprovidecounseling to the donors who tested positive for the HIV virus and there is no system that seeks it in Indonesia.

Whereas if the system enforced, it can

conducted

through

two

1. Method of exposition, that the presented data and facts that may ultimately sought correlations between these data.

potentially reduce the outspread of HIV by

2. Analytic methods, namely through the

early diagnosis and treatment which results

analysis of data or information by giving

from donor notification. Therefore we

the argument through logical thinking and

propose a system for optimizing the

were then taken to a conclusion.

function of blood donors in an effort to suppress the outspread of HIV.

Results: The proposed system is a post-donation service system which including post-

Methods This scientific paper was based on literature review through analytic study on the effort of optimizing the function of blood donor center in order to reduce the outspread of HIV in Indonesia. Some methods and program were carefully examine in order to find the right method for the blood donor center optimization.

Socioeconomic

and

characteristic

of

mentioned region were considered in order to meet the right methods for the system

donation notification, counselling and treatment referral. This system is mainly aim for blood donor who have positive in HIV test during blood screening. Blood donor will receive a notification letter after the blood screen test is positive. Two important goals of the notification process are to ensure that donors receive their test results and that donors whose test results make them ineligible for future donation understand their deferral status (Kotwal, Doda, Arora, & Bhardwaj, 2015).

proposed.

In notification process, initially a

Data collection methods in this study

letter

communicating

a

nonspecific

conducted by the method of literature

abnormal finding in screening tests is sent

(literature review) based on issues, both

to all HIV positive donors so that the letter

8

provides sufficient confidentiality. The

of the finding and is recommended repeat

letter requests a telephone call for a

testing in Blood Donation Centre to

personal appointment for attend to Blood

confirm the result. Counselling not only

Donation Centre. If the donor does not

including comforting and give spiritual

call in two weeks, a second similar letter is

support to donor but also including risk

sent, followed by a telephone call. Finally,

review and extensive discussion which are

in case of no answer, doctor or well-

essential to help the individual understand

trained nurse clinicians with HIV or

the issues involved. Notification of a blood

counselling

from

donor about the abnormal test results is

community health care centre (Puskesmas)

thus a very sensitive and crucial aspect of

will be sent to donor house.

post-donation counselling as it has its

Fig.1.

background

Post-donation

service

system

psychological and social impacts so donors

scheme

may

benefit

extended

Post- Donation (Positive Result)

from

psychiatry

support (Delage, Myhal,

Letter*

GrĂŠgoire,

&

Simmons�Coley, 2014). It Notification

Letter and phonecall*

is also critical to remind these donors throughout the counselling process

Blood Donation Centre

Health worker visit

that they should never donate blood or tissues, because

of

risk

of

transmission of HIV to recipients.

Referral to Hospital

They

also

should aware and prevent involving any activities

*If there is no respond in a given period of time, second method of notification will be applied

which have high risk of transmitting HIV to others.

Patient is recommended to hospital

Breaking bad news and counselling will be conducted by doctors in Blood

after received positive result from repeat testing.

Donation Centre. On breaking bad news and counselling, the donor is made aware

9

Donor notification can decrease

Discussions Post-donation service system and HIV transmission The

time

outspread of HIV through increasing the number of HIV-positive person who are aware of their status and decreasing who

between

the

HIV

are unaware. Dr Valerie Delpech, head of

infection and the onset of symptoms of

Public

AIDS (the incubation period) ranges from

national HIV surveillance

a few months to ten years or more

knowing one’s HIV status is the key to

(Arkansas Departement of Health, n.d).

both effective treatment, and to preventing

According to WHO, only 54% people with

onward

HIV are aware of their infection (WHO,

England, 2014). A research result about

n.d), which mean 46% people with HIV

estimating sexual transmission of HIV

unaware of their infection and might keep

from persons aware and unaware that they

spreading HIV without awareness. Blood

are infected with the virus in the

donor who have infected with HIV will not

USA show that the HIV/AIDS epidemic

aware due to have not develop any

can be lessened substantially by increasing

symptoms, so blood donor who had been

the number of HIV-positive persons who

tested positive in HIV screening may

are aware of their status (Marks, et al,

transmitted the viruses through various

2016). 91% of HIV passes from those

ways unconsciously.

unaware they are infected or not in care

Health

England

transmission

state

(Public

(PHE)‘s that

Health

(Skarbinski, et al, 2015) and this show that

Figure 1. Percentage of TTI infection in blood bag in Indonesia from 2005-2014 10

increasing aware of their states is benefit

strategies approach to prevent spreading of

to decrease the HIV outspread. Moreover,

HIV. Based on CDC (2006) multiple

statistic published by ministry of health

approaches to prevention counselling are

shows that in 2014 0.26% of blood donors

available, including formal guidance from

are

3,054,747

the Centers for Disease Control and

production of blood bags each year, this

Prevention (CDC) for incorporating HIV

means the application of the post-donation

prevention into medical care settings. Such

service can detect more than 7,900 HIV

interventions have been demonstrated to

positive person each year and can give

be effective in changing sexual risk

consultation that can prevent the outspread

behaviour (Metsch , 2004) and can

of HIV to thousands of people (infodatin

reinforce self-directed behaviour change

PMI,2015).

early after diagnosis (Gorbach, 2006). The

HIV

positive.

With

Once blood donor aware his states and the next goal is through behavioural strategies approach to help HIV positive blood donor to sustain safer sexual behaviour,

and

so

avoid

onward

transmission. Multiple studies show that prevention

counselling

reduction of HIV transmission since the controlled viral load HIV patient have a very small chance, can even reach 0% to transmit it disease through sexual activity (Attia, et al, 2009)

frequently

With a positive trend of blood

neglected in clinical practice (Mayer,

donor, from less than 1.5 million in 2005

Morin,

post-donation

into more than 3 million in 2014, and the

counselling is important with behavioural

promotion of blood donating that is more

2004).

Thus,

is

early treatment given will also help the

Figure 2 Number of blood bag production in Indonesia from 2005-2015

11

intense to a lot of schools, office, music

counselling should also be addressed in the

concert and other events, blood donation

national blood policy and legislative

service can reach more people from

framework makes this system that we

different background and can indirectly

proposed have an indirect support from

optimize the effort of reducing the

WHO and others International community

outspread of HIV (infodatin PMI,2015).

and will be easier to be applied because of

Feasibility of post-donation notification service

a clear guidance written (Timberlake, 2000). The regulation from ministry of health in 2013 where every component of

Donor Notification system is a highly

society has an obligation to report the case

applicable

developed

of HIV and have an effort to reduce the

countries such as US, Australia, UK, and

outspread of HIV also give a legal support

even developing countries like South

toward the implementation of this system

Africa, Gambia, Ghana, and Egypt have

(Isnarti, 2015)

system.

Some

applied the system without noticeable problems (The Australian Red Cross Blood, n.d). The fact that in 2014 the International Federation of Red Cross and Red Crescent Societies (IFRC), the WHO and the United States Centers for Disease Control

and

Prevention

(CDC)

are

collaborating to published the “Blood donor

counselling

implementation

guideline� means that this effort are largely accepted and crucial for a current condition. Based on WHO (2012), the statement in the section 3.1 of the guideline state that every country should have a national blood policy which defines the principles and strategies for blood donor recruitment, selection and deferral, blood screening, confirmatory testing, notification, counselling and referral and the suggestion that

notification and

This system is relevant to be applied in Indonesia because the health facilities needed for this system is already established and the system for counseling in

blood

established.

donor A

center

have

modification

been

proposed

makes the effectiveness and feasibility of this system is become more promising.The system

proposed

only

requires

the

coordination of Blood Donor Center (PMI) and

community health

care centre

(puskesmas) to reach the patient in a step 3 notification system. PMI as the center of notification system already has 514 units in 33 province and its capability to screen HIV and the existence of doctor for counseling make this system can widely applied

(Infodati

PMI,

2015).

The

existence of 9,655 primary health care that

12

will help to reach the patients also

the likelihood of progression to AIDS,

supporting the feasibility of this system to

delayed

run in Indonesia (.

secondary outcome, improve quality of life

Concerning the problems of cost and facilities, Indonesia’s status as a developing countries doesn’t make this system impossible to be implemented. The fact that 16 developing countries already applied such system through law and Standard

Operation

Procedure

(SOP)

incidence

of

primary

and

and prolong life. These changes will lead to significant long-term cost savings including lower care costs, in addition to the financial benefits of people avoiding activities that put others at risk, such as unprotected sex and injecting drug use (Grinsztejn et all, 2014).

means this system have high compatibility

Blood donation center as the one

and very applicable to developed country

who managed the blood will also get

and even developing countries (WHO,

benefit from the notification system, the

2011). It’s because this system did not

counseling process that suggest the HIV

need a high amount of money to be run

positive patient will reduced the number of

off. A person that’s in charge for making

wasted blood because of HIV infection as

the letter, the cost and facility to send the

much as 7,900 bags each year (infodatin

letter are the only additional components

PMI,2015). This will efficiently reduce the

needed for this system. A high amount of

unnecessary cost for blood screening and

postal services with relatively cheap prices

blood bag to those bags and reduce the

in Indonesia support the feasibility of this

unnecessary extra works for screening it.

system.

For the blood recipient, this mean it will

Benefit of post-donation service system

reduce the chances of false negative screening bag to be transferred to their body and increase the safety of each

The

existence

of

notification

individual.

system will benefit not only the HIV infected person but also the blood donor

Conclusion :

center and the blood recipient. For HIV

This system is able to decrease HIV by

infected person, a clear benefit will be

notifying HIV positive blood donors to

gained through early treatment which is

increase their awareness of self-status and

the end results of the post-donation service

counseling through behavioral strategies

system. Early treatment of HIV will reduce

approach, to sustain safer sexual behavior

13

and

so

avoid

further

and even as standard operation procedure.

highly

On a final note, implementation of this

recommended for this system because

system need to take place on a urgent

many countries, both developed and

basis.

transmission.Indonesia

is

developing have applied law enforcements References 1. Attia, S., Egger, M., Müller, M., Zwahlen, M., & Low, N. (2009).

Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. Aids, 23(11), 1397-1404.

2. Australian Red Blood Cross. (n.d).

Blood Testing and Safety.

Retrieved from http://www.donateblood.com.au/eli gibility/blood-testing-and-safety 3. Boonstra, Heather D.(2008).

Making HIV Tests ‘Routine’: Concerns and Implications.

Guttmacher Institute, 11(2), 13-18.

4. Centers for Disease Control and Prevention (CDC). Evolution of HIV/AIDS Prevention Programs-United States, 1981-2006. MMWR Morb Mortal Wkly Rep. Jun 2 2006;55(21):597-603.

5. Delage, G., Myhal, G., Grégoire, Y., & Simmons‐Coley, G. M. (2014). Donors' psychological reactions to deferral following

false‐positive screening test results.

Vox sanguinis, 107(2), 132-139.

6. Gorbach PM, Drumright LN, Daar ES, Little SJ. Transmission Behaviors of Recently HIV-Infected Men Who Have Sex With Men. J Acquir Immune Defic Syndr. May 2006;42(1):80-85.

7. Grinsztejn, B., Hosseinipour, M. C., Ribaudo, H. J., Swindells, S., Eron, J., Chen, Y. Q. HPTN 052ACTG Study Team. (2014).

Effects of early versus delayed initiation of antiretroviral treatment on clinical outcomes of HIV-1 infection: results from the phase 3 HPTN 052 randomised controlled trial. The Lancet. Infectious Diseases, 14(4), 281–290. http://doi.org/10.1016/S14733099(13)70692-3.

8. Guidelines for blood donor counselling on human immunodeficiency virus (HIV).

Geneva, International Federation of Red Cross and Red Crescent Societies/ World Health Organization Global programme on AIDS, 1994.

14

9. Guidelines for the blood

14. Metsch LR, McCoy CB, Miles CC,

transfusion services in the United

Wohler B. Prevention Myths and

Kingdom. Stationery Office. 2002.

HIV Risk Reduction by Active

10. Isnarti, T. (2015).

IMPLEMENTASI PERATURAN MENTERI KESEHATAN

Drug Users. AIDS Educ Prev. Apr 2004;16(2):150-159.

15. Morin SF, Koester KA, Steward

REPUBLIK INDONESIA NOMOR

WT, et al. Missed opportunities:

21 TAHUN 2013 TENTANG

Prevention With HIV-Infected

PENANGGULANGAN HIV DAN

Patients in Clinical Care Settings. J

AIDS DI KABUPATEN SRAGEN

Acquir Immune Defic Syndr. Aug

(Doctoral dissertation, Universitas

1 2004;36(4):960-966.

Sebelas Maret).

11. Kotwal, U., Doda, V., Arora, S., &

16. National AIDS Commission.

(2009). Republic of Indonesia

Bhardwaj, S. (2015). Blood donor

Country Report on the Follow up

notification and counseling: Our

the Declaration of Commitment on

experience from a tertiary care

HIV-AIDS (UNGASS) Reporting

hospital in India. Asian Journal of

Period 2008-2009. National AIDS

Transfusion Science, 9(1), 18–22.

Commission.

Retrieved from

17. Public Health England. (2014).

http://doi.org/10.4103/0973-

PHE publishes the latest statistics

6247.150941

for HIV in the UK. The figures

12. Marks, G., Crepaz, N., & Janssen,

highlight the need to increase both

R. S. (2006). Estimating sexual

the number and frequency of HIV

transmission of HIV from persons

tests. Retrieved from

aware and unaware that they are

https://www.gov.uk/government/ne

infected with the virus in the USA.

ws/hiv-infections-continue-to-rise

Aids, 20(10), 1447-1450.

13. Mayer KH, Safren SA, Gordon

18. Skarbinski, J., Rosenberg, E., PazBailey, G., Hall, H. I., Rose, C. E.,

CM. HIV Care Providers and

Viall, A. H., ... & Mermin, J. H.

Prevention: Opportunities and

(2015). Human immunodeficiency

Challenges. J Acquir Immune

virus transmission at each step of

Defic Syndr. Oct 1 2004;37(Suppl

the care continuum in the United

2):S130-132.

States. JAMA internal medicine, 175(4), 588-596.

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19. Timberlake, S., & Heywood, M. (2000). Opening up the HIV/AIDS epidemic. Guidance on encouraging beneficial disclosure ethical partner counselling and appropriate use of HIV casereporting.

20. World Health Organization, Centers for Disease Control and Prevention. (2011). Inter-regional Workshop on 'Blood Donor Selection and Donor Counselling' for Priority Countries in the African and Eastern Mediterranean Region.

21. World Health Organization.

(2012). Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples: recommendations for a public health approach.

22. World Health Organization. (n.d).

HIV/AIDS. Retrieved from http://www.who.int/topics/hiv_aids /en/

16

National Disease Prevention Insurance (NDPI): Redirecting Health Funds in Focusing on The Early Detection and Prevention of Disease in Indonesia Felix Lee, Andre Elton Heryanto, Jaspal Singh AMSA-Universitas Indonesia

Abstract Introduction and objective: Medical health care is a privilege for every citizen in Indonesia to get. Badan Penyelenggara Jaminan Sosial (BPJS) has been developed since the January 1st, 2014 as the initial step taken by the government to achieve equality and to give medical health care services that are accessible to anyone without the worry of the medical expenses.

Despite the intervention given to improve the health condition in Indonesia, preventive measures and anticipation for early detection of diseases are still low and as a matter of fact, health promotion and disease prevention have a much greater impact compared to treatment of a disease at a late stage. Therefore, there should be a new intervention to improve the health promotion and disease prevention situation in Indonesia. This will help Indonesia achieve her goal of increasing the quality of the existing healthcare system so as to attain a world standard.

Methods: A literature review was conducted to find a new solution for the underlying problem. Literatures were obtained from various search engines such as PubMed, Cochrane and Google Scholar.

Results: Studies and literatures have shown that prevention programs like early screening, medical checkups and education, are less costly and more effective as they significantly lower the risk of acquiring a disease compared to curative measures, as shown in some countries which have applied the program.

Conclusion: Regarding this, the writers would like to implement a new program called National Disease Prevention Insurance (NDPI), which will include prevention and screening of the four most death-causing diseases (cardiovascular disease, chronic respiratory disease, diabetes, cancer), in order to improve health promotion, thereby reducing the incidence of these diseases in Indonesia.

Keywords: Badan Penyelenggara Jaminan Sosial, disease prevention, health promotion, National Disease Prevention Insurance

National Disease Prevention Insurance (NDPI): Redirecting Health Funds in Focusing on The Early Detection and Prevention of Disease in Indonesia Felix Lee, Andre Elton Heryanto, Jaspal Singh AMSA-Universitas Indonesia

Abstract Medical health care is a privilege for every citizen in Indonesia to get. Badan Penyelenggara Jaminan Sosial (BPJS) has been developed since the January 1st, 2014 as the initial step taken by the government to achieve equality and to give medical health care services that are accessible to anyone without the worry of the medical expenses. Despite the intervention given to improve the health condition in Indonesia, preventive measures and anticipation for early detection of diseases are still low and as a matter of fact, health promotion and disease prevention have a much greater impact compared to treatment of a disease at a late stage.

Therefore, there should be a new intervention to improve the health promotion and disease prevention situation in Indonesia. This will help Indonesia achieve her goal of increasing the quality of the existing healthcare system so as to attain a world standard. A literature review was conducted to find a new solution for the underlying problem. Literatures were obtained from various search engines such as PubMed, Cochrane and Google Scholar. Studies and literatures have shown that prevention programs like early screening, medical checkups and education, are less costly and more effective as they significantly lower the risk of acquiring a disease compared to curative measures, as shown in some countries which have applied the program. Regarding this, the writers would like to implement a new program called National Disease Prevention Insurance (NDPI), which will include prevention and screening of the four most death-causing diseases (cardiovascular disease, chronic respiratory disease, diabetes, cancer), in order to improve health promotion, thereby reducing the incidence of these diseases in Indonesia.

Keywords: Badan Penyelenggara Jaminan Sosial, disease prevention, health promotion, National Disease Prevention Insurance

Introduction The current health care program in Indonesia is BPJS Kesehatan, which has been implemented since 2 years ago. BPJS Kesehatan, which stands for Badan Penyelenggara Jaminan Sosial Kesehatan or known as the social health insurance organization in Indonesia, is a state-owned enterprise that were specially commissioned by the government to administer healthcare benefits for all Indonesian citizens, especially for civil servants, pension recipients civil servants, police, veterans, independence pioneers and their families and other business entities or commoner.1 BPJS Kesehatan together with BPJS Ketenagakerjaan (formerly called as Jamsostek) is a government program under one union of the National Health Insurance (JKN), which was inaugurated on December 31, 2013. BPJS Kesehatan has begun operating since January 1, 2014, while BPJS Ketenagakerjaan has begun its operation since July 1, 2014.1 BPJS Kesehatan, which was previously known as the Asuransi Kesehatan (Askes), is managed by PT. Askes Indonesia (Persero). However, according to UU No. 24 year 2011 on BPJS, PT. Askes Indonesia has turned into BPJS Kesehatan since January 1, 2014.1 BPJS Kesehatan is a national health insurance most programs of which only cover the treatment of patient’s disease in hospitals that are registered for this scheme. In the Indonesian BPJS health program, all the health funds from the government are directed to the treatment for Indonesian citizen who get sick or ill. However, as a matter of fact, health promotion and prevention show greater impact than treatment or curing of a disease. It is highly advantageous to promote health for every individual and to maintain good health of the healthy ones and prevent disease from occurring rather than waiting until the disease has occurred and then curing it.2 Therefore, it is important to have a health program in Indonesia that covers mostly for the health promotion and disease prevention for Indonesian citizens.

In the United States of America, the government has implemented enormous amount of money and effort for the prevention as mentioned by CDC (Centers for Disease Control and Prevention). This program has been proven to be of advantage for all groups of people and age, as demonstrated in children. When they are well promoted to healthy lifestyle such as doing regular exercise and having healthy environment, there is significant increase in

productivity in learning as demonstrated by their marks at school. It is also mentioned that this implementation gives benefit from prevention of chronic disease in their future such as cardiovascular disease, diabetes, and other chronic disease.5 The productive age group also gain substantial amount of benefit by being promoted of good health and having healthy life. This is showed by a research in USA that annual increment of income could reach $200-$440 per individual. This is proven by declining number of patient suffering from chronic diseases such as asthma, obesity, smoking, and hypertension.5 Promotion and prevention of good health is a must as part of a good healthcare system and health program, which can empower the nation. This is also true in the case of elderly patient.

The benefit of health promotion in elderly is shown to be effective in keeping the independency of the seniors in life and maintaining healthy mental health.5 The government health funds currently are more focusing on the BPJS Kesehatan. However, if these funds is also mainly used for a health program that covers mostly in health promotion and disease prevention, it will give substantial amount of beneficence and costeffective, since if we focus more on promoting health and preventing disease, the incidence and severity of the disease can be decreased . In addition, carrying out health promotion is much more cost effective compared to treating a disease, especially for chronic disease.

One article written by Kartari DS., MD., MBBS., MPH state that Indonesian model of health care should be changed into a health care model that is more focus on prevention, rather than treatment or curative action, particularly in geriatric case in her article case. And the article further state that screening test is one of the most significant component of a public health program, in which the focus is give more on the prevention.3 Thus, early detection, screening test and medical check-ups is important as one of the prevention act program and the government health funds need to be more focused on this health sector so that to ensure every Indonesian citizen to be health-promoted and detected earlier if there is any disease in the patient so that could be managed earlier, which therefore increase the chance of recovery and reduce mortality rate.

Indonesia has a population of 247, 000, 000 and the mortality rate or death rate in Indonesia is also high. According to World Health Organization (WHO), there are four noncommunicable diseases that cause the highest death tolls in Indonesia for both sexes, which are cardiovascular disease, cancers, chronic respiratory disease, and diabetes. Cardiovascular disease accounts for 37% of the total death in all ages and sexes, which followed by cancers (13%), diabetes (6%), and chronic respiratory disease (5%).4 Most of these diseases are chronic and mostly hard to be recovered or cured completely. Therefore, if we can prevent these diseases from occurring earlier by health promotion program or even if we can detect earlier, the mortality rate could be decrease.

In conclusion, the writers propose a new health care program that should be implemented in Indonesia, which called as National Disease Prevention Insurance (NDPI). This insurance program, which supported by the government health funds, will cover the health promotion, early detection, screening and prevention measures of diseases for every Indonesian citizens, especially for cancer, diabetes, cardiovascular, and chronic respiratory diseases.

Objectives General Objective: To enhance the quality of existing health care system in Indonesia to be the world standard throughout introducing a new preventive system program, called as National Disease Prevention Insurance (NDPI).

Specific Objectives: 

To decrease the number of patients suffering from diseases, especially chronic diseases.



To decrease the fund needed for curative therapy and the overall health care in the future.



To increase productivity and life expectancy of every Indonesian citizens.



Empowering the nation to live their life as healthiest as possible.

Methods

The writers review systematically from literature, journals, books, and other reliable sources.

Literatures and journals are obtained from reliable search engine like PubMed, Cochrane and Google Scholar. After collecting all the new information from variable of sources, the writers carry out analysis of all the elements and think reasonably and logically for a new innovative solution to solve the problem stated in the scientific paper.

Results Cardiovascular Diseases: A cohort study in Catalonia, Spain, was conducted to observe the efficacy of intensive prevention program of coronary heart disease. The study included 983 patients with coronary heart disease, followed for 5 years. The age was around 30-80 years and they were divided into 2 groups: The intervention and control groups. The intervention group was examined by their general practitioner, who was responsible to control the cardiovascular risk factors thoroughly and implement life style changes. The prevention program was conducted twice a year that included checking of patient’s weight and blood pressure along with laboratory tests for each visits. Patients in the control group received usual care and the differences in the outcome was observed.6 Mean standard deviation of age was 64 and 74.5% were men. During the follow ups, 235 patients suffered some non-fatal cardiovascular recurrence: 109 vs. 126 in the control and intervention group respectively with a p value of 0.84. 45 patients died from cardiovascular recurrences: 23 vs. 22 in the control and intervention group respectively with a p value of 0.57. Ratio between total cardiovascular event and total mortality in intervention group was 1.01 and the control group had 0.92.6 Based on the results of this study, the reinforced preventive measures implemented on the intervention group did not yield any prospect for the prevention of cardiovascular recurrences or mortality at 5 years.6 On another study, a systemic review was conducted to observe the effectiveness of primary health education and intervention programs in rural women about cardiovascular diseases.

The inclusion criteria for participants were women with age of 16-65 years that lived in rural areas. Interventions included were educations (counseling, educational materials and discussing the risk factors), lifestyle modifications (reduced daily salt intake, fruits and

vegetables, decreased fat intake, exercise, and decreased level of smoking), health assessment (body weight, cholesterol levels, and blood pressure). 9 trials are included in the review, with 3 trials to observe the effects of interventions on physical activity, 1 trial with the one that smokes and the remaining 5 trials with multiple risk factors. Even though physical activity could be sustained for up to a year and a decrease in the blood pressure was achieved within 6 months, studies for 5 years showed no decrease in the blood pressure.

Dietary modification also showed no sustainable effect. The conclusion was lifestyle interventions yielded a slight benefit in low-risk people and it was better to use the resources onto high-risk people.7 Nevertheless, primary prevention may be the option to lower the risk. A study revealed that the intervention with lower costs and higher effectiveness is dietary changes based on the model.8 Respiratory Diseases: A study conducted in the Respiratory win, Department of Medicine, Bangabandhu Sheikh Mujib Medical University to evaluate the efficacy of spirometric screening for the early detection of chronic obstructive pulmonary disease in Bangladeshi population. Using the spirometry screening based on the Global Initiative for Chronic Obstructive Lung diseases (GOLD) criteria, a total of 400 participants with 200 smokers among them were in the study and based on the result, spirometry was an effective and easy to use method in obtaining reliable results for the detection of COPD in risk group population.9 Cancer: Based on the data collected throughout in Indonesia from the period of 1988-1991, the 5 major anatomical sites for cancer diseases are cervix, breast, lymph node, skin, and nasopharynx.10 For cervical cancer, World Health Organization (WHO), United Nations Populations Fund (UNFPA), International Union Against Cancer (UICC), International Federation of Gynecologists and Obstetricians (FIGO) and other organizations have recommended the use of Human Papillomavirus (HPV) vaccines as an effective cancer prevention option, especially for developing countries where cervical cancer is prevalent.11 For breast cancer, the most cost-effective strategy is mammography starting at age 50 years.12 Diabetes:

Multiple factors play a role in the high prevalence of undiagnosed diabetes. One of the aspect is the physicians who fail to screen eligible patients as not all patients have been screened with glucose test. Additionally, lack of insurance decrease the testing even further.13 Discussions Medical health insurance in Indonesia may have improved through the development of BPJS.14 All Indonesian citizens are eligible for administration for this insurance, regardless of economic status. Almost all kinds of diseases are covered by BPJS, including cardiovascular diseases, cervical and breast cancer, diabetes, and chronic pulmonary diseases.15,

16

However, consultation and routine screening checks and preventive

medications are still limited and not covered yet. For example is the HPV vaccine that has not been included in the BPJS nationally and only covered for 2 provinces due to the relatively expensive vaccine.17As many people are still having insufficient resources about progression of diseases, many people come to the clinic at a late stages. Even though treatment and management are still covered by BPJS, the costs onto the national financial resources are heavily burdened, yielding an ineffective utilization of the financial resources.

Example of this case is the nasopharyngeal cancer, which is ranked fourth among cancers in males in Indonesia. Case report from Ear, Nose, and Throat department at Dr. Cipto Mangunkusumo Hospital (RSCM) stated that patients were generally referred at late stages.

This result a complex, not cost-effective treatment and caused economic burden to the patients.18 BPJS has served as the citizens’ main resources for medical support when medical attention is needed. However, this kind of system means that it serves as a curative program that helps to restore one’s health from a disease. Based on World Health Organization in 2014, the top specific diseases which cause high mortality rates are cardiovascular diseases, chronic respiratory diseases, cancers and nutritional condition (diabetes).19 These types of diseases are more effective if we have some sort of a medical interventions during the development of the diseases. The initial step in achieving this is the development of a new health care program that covers prevention and medical checkup that can detect early signs of a disease so that medical health providers can do early intervention to delay or halt the development of the disease. This will be very cost-effective as the cost of treatment is more expensive that early detection of a disease. Unfortunately, BPJS have not yet covered the expenses of

medical checkup in Indonesia. Laboratory examination can only be granted if there is an indication of a disease and patients themselves do not have the privilege to request an examination on their own, only with doctor recommendations will the BPJS cover the expenses.20 Medical checkup is a tool to determine the current health status and detect any health problems that are still asymptomatic. It is not something that BPJS should also cover as even almost all private insurances do not cover medical checkup as it is not something that is urgently needed.20 Being said so, cardiovascular diseases ranked as number one disease that causes death with a mortality rate of 943.5 per 100 000 population in Indonesia and the prevalence rose sharply at age 25 and 45 years.21 Medical checkup to determine high risk population can be a step to do early detection and the early start in anticipating the risk factors that may involve in the development and progress of the disease. As it is the leading cause of death, being able to anticipate the disease may be a big step in creating better outcomes for high risk people. Not just cardiovascular diseases, respiratory diseases, cancer and diabetes are also in the top list causes of death and medical checkup may be the key to reduce the total amount of patients administered to hospitals for treatment when the diseases have developed.

Therefore, the writers plan to implement a new national health care program in Indonesia called as National Disease Prevention Insurance (NDPI). This new health care program will be funded from the government health funds and will cover all Indonesian citizens. This new program that the writers want to implement is on a fundamental of early detection and prevention of the progression of diseases, which is not included in BPJS. The writers want to create a free medical checkup in NDPI program for only some of the dangerous diseases for the first trial, which are: 1. Cardiovascular diseases 2. Chronic respiratory diseases 3. Cancers: Breast, cervical and nasopharyngeal cancers 4. Nutritional diseases, especially diabetes mellitus These 4 categories of diseases might be a good set of example of diseases to be set onto the new system for evaluation of the success.

For cardiovascular diseases based on articles regarding preventive measures, routine intensive medical care does not show beneficial effects onto the outcomes when compared to a controlled group.6 This means that routine medical checkup is not the best solution to anticipate the diseases. For early detection of the determining risk, the best cost-effective way is to do blood pressure, cholesterol level and body weight measurement as well as some history taking about the possible other risks.6 For the education part, the best solution might be some lifestyle changes and dietary changes are the most cost-effective based on an article mentioned.8 Based on American Heart Association, checking of cholesterol level should have started at the age of 20 every 5 years.22 This can be used as a routine period for cardiovascular medical checkup to ensure that early anticipation can be achieved.

Chronic respiratory diseases are also one of the major diseases in Indonesia. Based on the GOLD standard where WHO also agree on, spirometric screening can detect early condition of chronic obstructive pulmonary disease along with GOLD’s criteria.9 After screening, education to the patients can also be conducted to increase awareness of the risk factors that may cause Chronic Obstructive Pulmonary Disease (COPD) or other respiratory problems.

Cancer is also one of the leading causes of death and the writers will be focusing more onto the cervical and breast cancer as they are both can be detected with some screening techniques and preventive vaccines. Indonesia has a population of 93.15 million women with 15 years of age and older those are at risk of developing cervical cancer.23 With this alarming statistic, CDC recommends HPV vaccination at the age 11 and 12 years old. From the age of 13 to 26 who have not been vaccinated, it is also recommended to be vaccinated.

Additionally, HPV vaccination can be even started at 9 years old. Therefore, in the medical checkup for cervical cancer, which are VIA (Visual Inspection with Acetic Acid) and Pap test that will covered by NDPI. In addition, HPV vaccination can be followed if the candidate is suitable for vaccination and will be included in this NDPI program. Even though it is quite expensive, the cost for treatment of cervical cancer is more expensive. Hence, preventing the development of the cervical cancer should be prioritized, just like the vaccination of BCG and others. For breast examination, the writers choose the self-breast examination and by health professionals as the most cost-effective method for screening breast cancer, followed by mammography at the age of 50.12 For the last one diabetes, it is found that diabetes often not diagnosed on eligible patient by health professionals and even insurance that does not support glucose testing regularly may

decrease the likelihood of diagnosing early progression of diabetes.13 Therefore as a part of NDPI, the writers would like to implement when doing the medical checkup of fasting plasma glucose and/or glycated hemoglobin (A1C) for type-2 diabetes performed every 3 years for patients at the age starting from 40 or for patients at high risk.14 As this is adding new health programs for citizens to enjoy free medical checkup and screening, difficulties will still occur. In patient prospective, having additional free medical checkup is going to be beneficial. The main problem lies in the distance travelled to reach the health facilities. Based on a data in 2010, the number of beds for hospitals every 1000 citizens in Indonesia are still low compared to other countries. More information can be viewed in the figure below:25

Figure 1. Table showing the comparison between other countries in terms of number of beds for hospitals every 1000 citizens in each respective countries.25 For health professionals, difficulty may rise in the addition of workload. With the current BPJS, there is an increase in patients in hospitals and this may increase more burden to medical health professionals. Additionally with this new health care program, NDPI, every health professionals need to cooperate and work together to record the patients data, do the medical checkup that may involve more than one health professionals and do the education part of the features. This means that cooperative working needs to be trained further to avoid many unprofessionalism between coworkers when working together as a team.

Besides, the government also needs to re-examine the geographical distribution of health facilities to ensure that every provinces in Indonesia has health facilities for the medical checkup and routine screening to work.

One of the solution for these difficulties could be medical students can take part in this new program, NDPI, and even act as a place to practice to face patients and educate them.

Medical students undergoing clinical years can be assigned to do part of the medical checkup and screening programs such as blood pressure, VIA, etc. With this, medical students can already contribute to the society and to other health professionals.

The medical checkup and screening programs will not only help to improve the quality of life in Indonesia, it will improve conversation skills in medical health professionals, improve cooperation between health professionals, improving geographical medical facilities availability that are easily accessed, and play a role as part of the medical education program to help improve medical students in dealing with patients to be professional doctors in the future.

Conclusion Despite the implementation of a health care program, BPJS, which launched by the government of Indonesia in 2014, there are still many issues need to be administered. One of the effective measure proposed by the writers is create a new health care program called National Disease Prevention Insurance (NDPI) as a prevention methodology for diseases of cardiovascular, pulmonary, cancer (breast and cervical), and nutritional imbalance (diabetes) since the incidence are among the highest in Indonesia. This method is proven to be cost effective and increases the overall quality of life. The proposed prevention program of cardiovascular disease is through regular check-up of blood pressure, cholesterol, body weight, combined with thorough history taking, and education of lifestyle. For the respiratory disease, the effective prevention measure is using spirometric screening and education of healthy lifestyle. For the cervical cancer, HPV vaccination is proposed to be an effective measure and the cost of this vaccine is way more cost-effective compared to the curative treatment of advance cervical cancer. For breast cancer prevention program the writers proposed regular physical examination combined with mammography and education of SADARI. In the case of diabetes, fasting plasma glucose and glycated hemoglobin A1C every 3 years from 40 years old should be performed in this program. NDPI must also be

supported by the government through increasing the accessibility of health care itself in the peripheral and central. This can be implemented by increasing the number of primary health care and the number of bed in the central referral hospitals.

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Retrieved 9 January 2016, from http://www.ncbi.nlm.nih.gov/pubmed/18457617 7. Crouch R, e. (2016). A systematic review of the effectiveness of primary health education or intervention programs in improving rural women's knowledge of heart disease... - PubMed - NCBI. Ncbi.nlm.nih.gov. Retrieved 9 January 2016, from http://www.ncbi.nlm.nih.gov/pubmed/21884451 8. Lindgren P, e. (2016). Cost-effectiveness of primary prevention of coronary heart disease through risk factor intervention in 60-year-old men from the county of Stockholm... - PubMed - NCBI. Ncbi.nlm.nih.gov. Retrieved 9 January 2016, from http://www.ncbi.nlm.nih.gov/pubmed/12649048 9. Mosharraf-Hossain KM, e. (2016). Detection of chronic obstructive pulmonary disease using spirometric screening. - PubMed - NCBI. Ncbi.nlm.nih.gov. Retrieved 9 January 2016, from http://www.ncbi.nlm.nih.gov/pubmed/19377418

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Japanese Journal of Clinical Oncology, 32(1), 17-21. Doi: 10.1093/jjco/hye123 11. Basu, P., Bhattacharya, C., Biswas, J., Singh, P., & Banerjee, D. (2013). Efficacy and safety of human papillomavirus vaccine for primary prevention of cervical cancer: A review of evidence from phase III trials and national programs. South Asian Journal Of Cancer, 2(4), 187. http://dx.doi.org/10.4103/2278-330x.119877 12. Melnikow J, e. (2016). Program-specific cost-effectiveness analysis: breast cancer screening policies for a safety-net program. - PubMed - NCBI. Ncbi.nlm.nih.gov.

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22. (2015, September 16). Top 10 myths about cardiovascular disease. Retrieved from: http://www.heart.org/HEARTORG/Conditions/Top-10-Myths-about-CardiovascularDisease_UCM_430164_Article.jsp#.VpCvzI9OJMs 23. (2015, December 18). Human papillomavirus and related cancers, fact sheet 2015.

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Abstract A Modification on Koperasi Unit Desa (KUD): Literature Review for Creating the Potential Way to Optimize the Financing for Health Care and Health Promotion in Indonesia for Rural People Achmad Januar Er Putra1, Rendra Dwi Putra2, Muhammad Rafif Alfian Dita3 1,2

Second Year Medical School Student, Faculty of Medicine Universitas Airlangga

3

First Year Medical School Student, Faculty of Medicine Universitas Airlangga 1

achmad.januar.er-2014@fk.unair.ac.id 2

ren.dwi.putra-2014@fk.unair.ac.id

3

muhammad.rafif.alfian-2015@fk.unair.ac.id

Introduction: We are suffering double burden problem. Both infectious and degenerative diseases are rising now. Example, the survey shown that there is an increase on the mortality rate caused by cigarette-related disease in rural area from 41.75% in 1995 become 59.7% in 2007. (Kementerian Kesehatan RI, 2015). By this paper, we are trying to suggest the coverage the financial needs of people in village to get the medical care. Methods: Through the literature review from several journals and official reports which was taken from valid sources. The data taken than synthesize and modified to create and modify a bureau in Indonesia that is Koperasi Unit Desa as the financing sources for rural people. Results: From two countries (i.e. South Korea and Japan) financing system, both of them are using small amount of government allocation. South Korea’s largest contribution is coming from insured which comprises 50% of total. While for Japan, the biggest portion of financing is coming from the social security expenditure (i.e. assurance). Indonesia itself try to fulfill the health financing through money sharing between central government and local agencies through special allocation money, which is relatively small in percentage compared with other country. That allocation only fulfill 46.5%, which it was the needy person that comprises 34.2 % of total population in 2008. Koperasi, which is a special bureau from Indonesia are having numerous members, especially Koperasi Unit Desa. Conclusion: From the result we have discussed, we can modify Koperasi Unit Desa as a health-insurance agent for rural people as the money savings for their health care and promotion, while we are waiting the application of National Health Assurance. They can pay the ‘insurance’ using their crop results as a deposit. It is possible for them to rent the money also if there is not enough money for that case and pay back using the crop.

Keywords: financial resources, health care, Koperasi Unit Desa, rural people, health financing

A Modification on Koperasi Unit Desa (KUD): Literature Review for Creating the Potential Way to Optimize the Financing for Health Care and Promotion in Indonesia for Rural People Achmad Januar Er Putra1, Rendra Dwi Putra2, Muhammad Rafif Alfian Dita3 1,2

Second Year Medical School Student, Faculty of Medicine Universitas Airlangga

3

First Year Medical School Student, Faculty of Medicine Universitas Airlangga 1

achmad.januar.er-2014@fk.unair.ac.id 2

ren.dwi.putra-2014@fk.unair.ac.id

3

muhammad.rafif.alfian-2015@fk.unair.ac.id

I.

Introduction and Objectives Indonesia is an agricultural country that has a large territory and diverse population. It causes Indonesia become a country which has a high population density. Every year, the population continues to grow and grow and it makes the density become higher than before. In 2015, it is estimated that Indonesia's population reached 255 million people (BPS, 2014). This population spread unevenly in town and village. As much as 53.4% of the population in Indonesia lives in city and 46.6% of the population in Indonesia lives in village (BPS, 2014). With that population, Indonesian government has not been able to guarantee the health care for the entire population.

Next, as a tropical country, Indonesia were rich of diseases. It is stated that Indonesia is suffering from double burden conditions, caused by infectious and non-infectious diseases. The tendency to get an infectious disease is higher than the previous decades.

Not only the infectious diseases, the non-infectious and degenerative diseases are extremely injured many people in Indonesia. Those main diseases are hypertension, diabetes mellitus, cancer, and Chronic Obstructive Pulmonary Disease. A surprising result also come from the cigarette-related diseases. The mortality rate which is caused by cigarette-related diseased is increasing from 41.75% in 1995 becoming 59.7% in 2007. (Kementerian Kesehatan Republik Indonesia, 2015). It is important to secure the health condition of Indonesian people despite from the double burden case shown.

Health insurance is one of many things that is so important to increase the health quality of people in Indonesia and to increase the welfare in Indonesia. Indonesian Government has been doing many effort to increase the health insurance in Indonesia, like BPJS. But it is still cannot guarantee the health care of the entire population in

Indonesia. In 2015, people who used BPJS only reached 156 million people (BPJS, 2015), approximately 61% of the population in Indonesia has used BPJS and 39% hasn't used BPJS. Those 39% of population in Indonesia are not guaranteed the health services. It is caused by many factors, like the lack of public ignorance about BPJS although Indonesian government has do many thing to inform people about BPJS (Pambudi, et. al., 2014, p. 6). Especially people in villagers who are lagging information.

Village in Indonesia usually dominated by farmer because it's their main livelihood.

In Indonesia, there is approximately 102 million people in Indonesia who become a farmer (Sensus Pertanian, 2013). To work productively, a farmer need a good health, but in fact farmers have relatively low health quality. It is because farmers have a high work intensity, their health hygiene are relatively low, and the use of chemicals in their work. ). More, from the number mentioned before, based on National Economic Survey 2006, it is stated that villagers are using 12.6% of their salary to consume the cigarette. (Kementerian Kesehatan Republik Indonesia, 2015). As we know also, the villagers mostly work as farmer. To prevent or maintain the health of farmer, a farmer must have sufficient income. But, in fact, in Indonesia, farmers have relatively low income, as example in Sragen, 2011, the average income of farmers ranged from Rp 2,094,100.00 to Rp 8,051,870.00 with their average outcome for production ranged from Rp 1,499,999.00 to Rp 3,499,999.00 (Damanik, 2014). With that income and outcome, it is hard for farmers to keep their health. This led farmers become unproductive.

Our objective is to cover the financial needs of people in village to get the medical care. With the fulfillment of health needs in the village, it will increase the health quality of people in village and indirectly, it will increase the productivity of people in village and improve the welfare of Indonesia.

II.

Methods We are using the literature review at this scientific paper. The literatures were founded at the physical copies such as from journal magazines. The journal which were using are the valid journal at the form of pdf. Not only journal, we also use the official report from the government-related bureau to analyze and synthesize the data.

Those journal and official report were searched through the specific web-provider, those are Google scholar, Lancet, and PubMed. In deducing a conclusion within this scientific paper, we are using the related

information from the journals and official report. Those information then summarize into several important data. In this case, we review the health financing strategies from two countries those are South Korea and Japan. We analyze the health financing ways from those countries and compared to the condition of our countries.

Additionally, we are focusing on the rural people which create almost half of total Indonesian citizen. While from the BPJS, a government bureau which focus on health payment system, only cover more than half of total population, we are trying to modify one of the bureau from Indonesia that is Koperasi Unit Desa by modifying several financing system from two countries mentioned before.

III.

Results South Korea Financing System for Health Almost all of the South Korea’s citizen are coverable by the National Health Insurance Program. This program has three sources of funding, those are: contributions, government subsidies, and tobacco taxes or surcharges. The contributions provides the biggest portion of funding which is cover 50% of the total.

The contributors, or later will be discussed as the insured are divided into two group, those are the employee insured and private insured. For the employee insured, the insurance will cover the spouse, descendants, brothers or sisters, and direct lineal ascendants. The insured employee should pay 5.08% from their average income.

Several criteria such as private property, age, gender, and motor vehicles are considered. For the self-employed insured category will cover the people from excluded category of employee insured. The government provides 14% of the total funding. While tobacco surcharges donate 6% for the funding. (Song, 2009, p. 207208) From the financing above, it will be develop into a health care system which is known as the consumer cost sharing. This is to make sure that there is a very little consumption of the services and the budget available. But, this cost-sharing system is frequently changing from time to time. After 2008, the cost-sharing tends to change from the combination of co-payment and co-insurance. Co-payment system at South Korea also persuade the insured to pay several number of money which is different from one another due to the different level of care and type of the hospital used. Here, they are exempted from the next payment if they can pay more than the lower bound of money (3 million won) for 6 months continuously. The co-payment tends to

decrease, while the co-insurance increases. There is also an informal payment, but in a very little amount. South Korea also not receive any external payments from other country. (Chun, et. al., 2009, p. 58-61) Nowadays, the South Korean also provide the Long Term Medication Program as the health prevention. This will provide the geriatric care for them whose age more than 65 years old or below if they are suffering from the age-related disease such as Parkinson. The financial sources are coming from the insured, government subsidies, and beneficiary co-payments. The government provides 20% for total long-term insurance which is based from the co-payments system, and the users will provide vary from 15% for in-home services till 20% for institution services. (Song, 2009, p.

209) Japan Financing System for Health For three decades, Japan’s health care system has effectively controlled the cost usage which is caused by: 1) predominantly private sector delivery system, 2) payment by fee-for-service, and 3) no gatekeeper function by family doctors. There are two explanations related to the financing system. The first explained that Japanese use outpatient services greater than inpatient care. This happens because of the historical condition of Japan: almost all of the hospital built as the longer hand of physician’s practical place. The outpatient care condition even shared a large quantity at tertiary hospital. This will provide the absence of functional differentiation and gives an effective referral between hospitals and clinics. The people at Japan also have cultural preference for less invasive care, which is shown by the lower usage of surgical activity. From then on, the financial payments from the patient will be lower compared to the other country. (Hashimoto, et. al., 2011, p. 1174-1175) The second explanation is about the payment system. Japan has multiple payers for the insurance (i.e. about 3500 insurers) for insured person, but from these insurers, they have only one payment system which is applied across the insurers. The supplyside cost control is provided by the government whose can be revised at both the global condition and the item level. The fee scheduled will control the money from the plans to most of the providers. These two explanations of financing can act as the social source of payment since their function to provide the lower costs for Japanese.

Though it seems that there are numerous insurers, the system still regulated by the government and revised biannually. The revision process were regulated by several ministries, those are Ministry of Finance, Ministry of Health, Labor and Welfare and

Cabinet. They are trying to make sure that the net effect of health financing will at least equal or similar with global condition. The insurance rate at 2008 was decreased by 0.82%, while at 2010 fiscal year, the rate was increased by 0.19%. After the regulation were dealing, the decision are officially made by the Central Social Insurance Medical Council, which is composed by several members of payers, providers, and people as the representative of public interest, appointed by Ministry of Health, Labor and Welfare. (Hashimoto, et. al., 2011, p. 1175-1176) Although the Japanese already conduct the financing system for health, by 2010, they already adopt the concept that Japan has to strategically increase their role in the global health policy through their Ministry of Foreign Affairs. Because the internal financial system was developing through the social payments (i.e. insurance), they were setting the goal to donate their US$ 5 billion over 5 years to another countries.

While declaring their commitments in the global health’s policy, Japan still hasn’t any regulation to control the usage and distribution of money used for internal or external.

Each ministry, government bureau, and domestic agency are developing their own policy on financing the health system. Because of that, Japanese has no clear vision for their own national health financing policy or even the global health’s policy.

(Sugiyama, et. al., 2013, p. 2) Sistem Kesehatan Nasional Indonesia (Indonesian Health System) at Common Indonesia’s National Health System was built through the observation of primary health care revitalization, which is cover: 1) fair and equity’s scope of health care, 2) citizen-oriented health care providing, 3) health building policy, and 4) leadership.

National Health System also arranged through a deep observation to a wide range of health building execution, also with the referral system. (Departemen Kesehatan RI, 2009, p. 4) At the health financing sector, Indonesia’s allocation on health year by year is increasing. At 2005, the national expenditure for health is 0.81% from the Gross Domestic Product (GDP). The number is increasing at 2007, which is the expenditure rises to 1.09% from the GDP. This number is still lower compared to the recommendation from World Health Organization (WHO), which is 5% from the total GDP. Government allocation comprises 2.6-2.8% from the total money allocated in a year (about 19.75 trillion in 2007). The health expenditure always increase from year to year, while the government contribution is small, which is 38% from the financial allocation for health in a year. (Departemen Kesehatan RI, 2009, p. 8)

Furthermore, the government through the Ministry of Health Affairs develops the strategic plan for increasing and making an effective financing. The government hopes by the end of 2019, the health allocation from GDP will be 5% from the total GDP at that year. The improvement in the amount of money allocate for health will be supported financially by the local government, private sectors, insured citizen, and taxation/tariff from tobacco cigarette. The financial resources then projected through the Special Allocation Money. (Kementerian Kesehatan RI, 2015, p. 95) To achieve that financial improvement, the government prior to increase the access and quality of health care for poor people through a program called JKN (Jaminan Kesehatan Nasional) – National Health Assurance. More, government also try to strengthen the public health at isolated region; outer island; border within another country; and the sub-system at National Health System to reduce the number of Mother Mortality Rate, Infant Mortality Rate, increase the public nutritional status and disease control through public sanitation. From then on, at local level, the government projected to increase the portion of Special Allocation Money, Deconcentration, Social Charity and another activities that is provided for the local agencies. (Kementerian Kesehatan RI, 2015, p. 95) Moreover, the financial resources proportion which come from the government is still not optimizing at the health promotion and prevention. The allocation used for the curative only. About 46.5% of the citizen is getting the health care assurance scope at 2008. That amount was coming from social responsibility for the needy person at 76.4 million citizen or 34.2% from the total population at most. (Departemen Kesehatan RI, 2009, p. 9) BPJS at a Glance BPJS or known as Badan Penyelenggara Jaminan Sosial, a bureau which is taking responsibility for providing the financial resources for Indonesian people through JKN-Jaminan Kesehatan Nasional, National Health Assurance. This assurance is projected to cover the health financing for all Indonesian people step by step. There are three criteria to be the member of this program, those are the civil and private servants, entrepreneur, and the poor people who can’t afford the minimum standard for a healthy life. (Dinkes Surabaya, 2013) Koperasi Unit Desa (KUD) Explanation Koperasi is an organization that has been provided by the government in order to assist the running of the Indonesian economy. There are many types of koperasi in

Indonesia, such as KSU (Koperasi Serba Usaha), KUD (Koperasi Unit Desa), KSP (Koperasi Simpan Pinjam).

Koperasi Unit Desa is cooperation in rural areas are engaged in the provision of community needs related to agricultural activity. KUD can also be regarded as an economic organization characterized by sociality and is a forum for the development of various economic activities of rural communities organized by the society and for society itself. KUD can also be referred to as a KSU (Koperasi Serba Usaha) efforts as trying to meet a variety of fields such as savings and loans, consumption, production, marketing and services. (Anggraeni, et. al., 2012, p. 2-3) KUD can obtain the capital according to UU No. 25 1992 article 41 by: capital derived from the equity capital and debt capital.

1. Equity capital comes from: a. Principal; b. Compulsory savings; c. Deposit reserve; 2. Debt capital comes from: a. Member; b. Koperasi lain (other cooperation) and / or its members; c. Banks and other financial institutions; d. Issuance of bonds and other debt securities; e. Other legitimate sources.

Principal is the amount of money that must be paid to the members of the cooperative at the time of entry into members. The amount of principal for each member of the same and cannot be taken as long as a member of the cooperative.

Deposit required is a certain amount of money that must be paid by the member to the cooperative in a certain time and opportunity, for example, every month for the same amount. A compulsory saving can’t be taken by the member for still become cooperative members.

Voluntary savings deposits same as above, but can be taken at any time. Grant is a sum of money or capital goods that can be valued by money received from the other party that is giving non-binding. (Kementerian Koperasi, 2015).

IV.

Discussion From several results we have found and synthesize at the previous chapter, hereby we discussed several points related to the appropriate theme. As we look from the figure below, we could discuss and explain that Indonesian financing allocation is still low if we compared to Republic of Korea (South Korea) and Japan. Our percentage is still about 2.5% from the total Gross Domestic Product. More, the government expenditure were still comprises half of total financing. The social security expenditure and government-source expenditure in Indonesia is still mixes also though JKN, National Health Assurance. From these sources of finance, Indonesia can only cover 46.5% of the total population. By the coming of BPJS, this percentage is increasing to be 61% of total population. But, the rest 39% is still not covering by the financing allocation yet, especially for them who live in rural area. The rural people itself also potentially suffer from the diseases, such as cigarette-related diseases

which

tend

to

increase

year

by

year.

Figure 1. Public and Private Mix of Health Expenditure for Several Countries in Asia Pacific. (Kwon, 2011, p. 653) By this problem of health and financing strategy, we are trying to modify one of bureau which is already known by the rural people in Indonesia that is Koperasi Unit Desa to provide the new function as a health-insurance agent. Koperasi Unit Desa’s benefit or that we are familiar with KUD is one of the facilities to help the economy of the villagers. Nowadays, KUD only play roles in (1) Funds and capital, (2)

Providing agricultural tools, (3) Provide fertilizer, seed and other planting needs at a low price, (4) Providing information and guidance on how to plant the good so that the results can be maximal. And even today, KUD is getting dimmer. Many functions of KUD itself that are not performing well. (Kementerian Koperasi, 2015) With the overcast of the KUD functions and the number of cases found in rural health, KUD function could actually take over the functions of the health insurance and BPJS for several periods of time while we are waiting the universal implementation of National Health Insurance. We believe that to cover all of Indonesian people through National Health Insurance will take a long time if we know that our country is not secure enough. While we are waiting, our country now is suffering from the double burden condition that need a fast action to secure all of the citizen, especially for them in rural area who are still not covered by any health insurance such as BPJS. With little development and modification, KUD may provide additional facility for its members. Members could get health insurance without paying a premium. The flow of fund will be like KUD in general, we just add a special bookkeeping function of each member, in which the results of their crops benefit not only to develop KUD itself, but as a health insurance that will be used in the local area.

The members, which were usually a farmer can save their crops after they are harvesting as the deposit reserve. If someday they are suffering from a disease which is needing a huge amount of money, they can take their savings or deserve to pay their health care. If their money is not enough, they can lend the money from Koperasi Unit Desa, through a system like cross-subsidy using others saving which is not used yet. After that, they can re-pay it again to pay the debt.

For the health promotion issues, they can use the conference at every year’s end. This conference, which is known as Rapat Sisa Hasil Usaha, will also welcome the health practitioner to come to their conference and give the health promotion. The money to hold this conference and health promotion is getting from the profit of cooperation.

The profit will also use to print and reproduce several health posters and buying some preventive materials such as Abate (Mosquito killer) to be distributed to the Koperasi Unit Desa’s members.

This modification of Koperasi Unit Desa’s function is based on the South Korea and Japan financing strategy that is coming from the insured (a people who pay several money to secure their health). This modification will be potentially executed in

Indonesia while we are waiting for the JKN (National Health Assurance) to be practiced holistically in Indonesia several times later.

V.

Conclusion From the result we have discussed, we can modify Koperasi Unit Desa as a healthinsurance agent for rural people as the ‘money’ savings for their health care and promotion, while we are waiting the application of National Health Assurance. They can pay the ‘insurance’ using their crop results as a deposit reserve. It is possible for them to rent the money also if there is not enough money for that case and pay back using the crop. The Koperasi Unit Desa can also provide several function as the health promotion agent. The activities has been mentioned at the previous chapter.

This modification for cooperation system can be used as the solution for rural people which were still not coverage by the BPJS. At the future, it is hoping that this system could be included as a system of National Health Assurance because we know that mostly rural people in Indonesia are the members of Koperasi Unit Desa.

VI.

References Anggraeni, Nova; Retnadi, Eko; Kurniawati, Rina. (2012). Perancangan Sistem Informasi Simpan Pinjam di KUD Mandiri Bayongbong. Jurnal Algoritma; 09(05):2-3.

BPJS.

(2015).

Jumlah

Peserta.

Retrieved

from:

http://www.bpjs-

kesehatan.go.id/bpjs/index.php Chun C-B, Kim S-Y, Lee J-Y, Lee S-Y. (2009). Republic of Korea: Health system review.

Health Systems in Transition; 11(7):58-61.

Damanik, J. (2014). Analisis Faktor-Faktor Yang Mempengaruhi Pendapatan Petani Padi Di Kecamatan Masaran, Kabupaten Sragen. Economics Development Analysis Journal; 3(1):212 - 224.

Departemen Kesehatan Republik Indonesia. (2009). Sistem Kesehatan

Nasional.

Jakarta: Departemen Kesehatan Republik Indonesia.

E-Health Team Dinkes Surabaya. (2013). Selayang Pandang Mengenai BPJS: Menuju Indonesia

Sehat

dan

JKN

yang

Bermutu.

Retrieved from:

http://dinkes.surabaya.go.id/portal/index.php/artikel-kesehatan/selayang-

pandang-

mengenai-bpjs/

Hashimoto, Hideki; Ikegami, Naoki; Shibuya, Kenji; Izumida, Nobuyuki; Noguchi, Haruko; Yasunaga, Hideo; Miyata, Hiroaki; Acuin, Jose M; Reich, Michael R. (2011). Cost Containment and Quality of Care in Japan: Is there a trade-off?

Lancet 2011; 378:1174-82.

Kementerian Kesehatan Republik Indonesia. (2015). Rencana Strategis Kementerian Kesehatan Tahun 2015-2019. Jakarta: Kementerian Kesehatan Republik Indonesia.

Kementerian Koperasi. (2015). Pernanan Keuntungan Koperasi Unit Desa: Keberadaan Koperasi Unit Desa Menguntungkan para Petani. Jakarta: Kementerian Koperasi Republik Indonesia.

Kementerian Koperasi. (2015). Modal Koperasi Berasal Dari Mana. Jakarta: Kementerian Koperasi Republik Indonesia.

Kwon, Soonman. (2011). Health Care Financing in Asia: Key Issues and Challenges.

Asia-Pacific Journal of Public Health; 23(5):653.

Pambudi, A.; Ahdiyana, M.; Winarni, F.; Fitriana, K.N.; Wirawan, E.W.; Septiana, R. (2014). Sosialisasi Program Jaminan Kesehatan Nasional (JKN) Melalui Badan Penyelenggara Jaminan Sosial (BPJS) Kesehatan Di Desa Trimulyo Kecamatan Jetis

Kabupaten

Bantul.

Retrieved

from:

http://staff.uny.ac.id/sites/default/files/pengabdian/marita-ahdiyana-sipmsi/laporan-ppm-sosialisasi-program-jaminan-kesehatan-nasional-jknmelalui-bpjs-kesehatan-desa-trimulyo-.pdf Ritongan, Razali. (2014). Kebutuhan Data Ketenagakerjaan Untuk Pembangunan Berkelanjutan. Jakarta: BPS. Sensus Pertanian. (2013). Jumlah Petani Menurut Sektor/Subsektor dan Jenis Kelamin Tahun

2013.

Retrieved

from:

http://st2013.bps.go.id/dev/st2013/index.php/site/tabel?tid=23&wid=0 Song, Young Joo. (2009). the South Korean Health Care System. JMAJ; 52(3):207- 208.

Sugiyama, Haruko; Yamaguchi, Ayaka; Murakami; Hiromi. (2013). Japan’s Global Health Policy: Developing a Comprehensive Approach in a Period of Economic Stress. Lanham: Rowman & Littlefield Publishers, Inc.

BPJS Still Unable to Bridge the Deficit Shielda Natasha Shidarta; Almira Thalita Ulima; Edwin Setiawan AMSA-Maranatha Christian University

Abstract According to the Law No. 24/2011, BPJS is a public agency established to implement the social security program. It consists of the BPJS for Health and the BPJS for Manpower. The BPJS for Health is expected to commence on 1 January 2014, which replaces PT Askes Indonesia. Indonesian citizens and all residents of Indonesia, including long term expatriate employees, are required to join.

Based on literature review, BPJS for Health has been stricken by financial difficulties since 2014, suffering from a deficit of claims it has paid against premiums it has received. In 2015 Rp 5.85 trillion, meanwhile in 2014 Rp 1.54 trillion.

Some of solutions are considered, such as increasing subscriber premiums, transparency in system, making strict sanctions, and building a good relationship with DPRD. Keywords: BPJS, BPJS for Health, JKN

BPJS Still Unable to Bridge the Deficit Shielda Natasha Shidarta; Almira Thalita Ulima; Edwin Setiawan AMSA-Maranatha Christian University

Introduction and objectives The Healthcare and Social Security Agency (BPJS) for Health is one of public sub agencies of BPJS that concerned in health through the National Healthcare Insurance (JKN) program. From Article 14 of Law No. 24/2011 on the BPJS stipulates that all residents, including foreign nationals who have been living in the country for more than six months, are required to participate in social security programs. By participating in the JKN a patient, at the time of treatment, only needs to follow established procedure and show a membership card to receive needed health service.

Under presidential regulation (Perpres) No. 111/2013, there are three types of JKN’s participants: 

First, low-income participants, known as contribution assistance recipients (PBI) whose premium is paid by the government



Second, wage-earning workers whose premium is paid by the employers from wage cuts.



Third, informal workers and non-employee.

The table below summarizes the contributions and healthcare accommodation

levels by member type:

Source: The Mandatory Health Insurance Scheme from Insurance Newsletter, February 2015, http://www.ey.com/Publication/vwLUAssets/ey-the-new-mandatory-health-insurancescheme/$FILE/ey-the-new-mandatory-health-insurance-scheme.pdf

Two years since the implementation of the JKN program, the program continues to face financial difficulties and has recorded a deficit as a result of the high number of claims made by insurance beneficiaries in comparison with amounts of the premiums it has received.

BPJS for Health reports that the 2015, the deficit stood at Rp5.85 trillion.

However, back in 2014, the deficit stood at Rp1.54 trillion, with Rp42.6 trillion paid out in claims and Rp41.06 trillion received in premium payments.

Although BPJS for Health reported that it currently had over 142 million participants in the program, representing more than half the country’s population, the cause of low income of the premiums allegedly comes from participants: 

The number of PBI is still not clear. It is reported that there is a lot of lowincome participants are unregistered and some of PBI are already died.



Informal workers and non-employee are unsupervised for paying their premium. They are investors, employers, and more.



Many participants do not register for the national healthcare program until they are sick, when instructed to by hospitals. They can stop paying premiums when they are recovered. This paradigm is called moral hazard.

Methods We use literature review to observe and analyze our research. We collect our information from newspaper and BPJS’ regulation No.1/2014.

Results As part of efforts to address the deficit urgently, BPJS for Health asks for injecting funds as a part of the establishment of a state-owned enterprise (BUMN).

The House of Representatives agree with it, then injecting Rp1.54 trillion into BPJS for Health. This solution seems good, but it is only temporary and decrease budget for other sector in prosperity target listed in the 2016 State Budget (APBN), making less efficient to improve people’s welfare.

The challenge looks daunting. A recent study by the University of Indonesia (UI) public health department predicted BPJS for Health would have an accumulated deficit by Rp173 trillion ($12.5 billion) by 2019 if the government continued with the current payment scheme for the JKN program.

Discussion As concerned grows over the financial sustainability of JKN program, experts have urged the government to look for innovative ways to pay for the program.

The most solution to be offered is increasing subscriber premiums. Health Minister Nila F. Moeloek, confirmed that PBI rate would be raised from the current Rp19,225 to Rp23,000 in 2016; while non-PBI fees are still negotiation. But it is lowering the income of participants, effecting economic activity that is feared to be less passionate. Impact magnitude is the weakening of rupiah against dollar.

To address financial difficulties, considering Indonesia has high rate of corruption, it is good to be reevaluate the system. Administrators even the director that suspicious to do corruption should be replaced. So the transparency in the system plays an important role.

Disciplining participants for paying premiums, not only when it is needed, BPJS for Health can make strict sanctions, such as putting fine.

In addition, it necessary to build a good relationship between BPJS for Health and the Provincial Legislative Council for provinces (DPRD), so the amount of participants can be counted well, not only the predictive amount.

Conclusion BPJS for Health is a new hope for every people in Indonesia to get comprehensive

health

care

covering

promotive,

preventive,

curative,

and

rehabilitative services with affordable cost through the insurance system. The major problem of this program is financial that still deficit since the implementation in 2014.

Some of solutions are considered, such as increasing subscribers premiums, transparency in system, making strict sanctions, and building a good relationship with DPRD.

References 

Peraturan BPJS No. 1/2014 tentang Penyelanggaran Jaminan Kesehatan



Himawan A. 2015. Komisi IX DPR Bingung BPJS Kesehatan Harus Nombok Rp 5,85 Triliun. Suara.com. 30 December. http://www.suara.com/bisnis/2015/12/30/142547/komisi-ix-dpr-bingung-bpjskesehatan-harus-nombok-rp585-triliun.



Kirana K. 2015. Tantangan BPJS Kesehatan: Moral Hazard atau... Kompasiana. com. 27 July. http://www.kompasiana.com/kriskirana/tantangan-bpjs-kesehatanmoral-hazard-atau_55b5c7af397b617f05db111f



2015. Thejakartapost. com. 29 April http://www.thejakartapost.com/news/2015/04/29/bpjs-kesehatan-needs-morecash.html

52

The application of Iron Fortification in Eradicating Iron Deficiencies Anemia in Northern Maluku Intan Kautsarani, Januardi indra Jaya, Ryan Janardhana AMSA-Universitas Brawijaya

Abstract Iron deficiency anemia is anemia resulting from the reduced supply of iron for erythropoiesis, because depleted iron stores that eventually resulted in the reduced of hemoglobin formation.

It’s one of the disease that is still high in Indonesia especially in Northern Maluku. To solve the core problem of this disease, mode of literature review were used to find the best method of solving it through fortification. Salt fortification were proposed with some technical requirement in order to make its effectiveness and feasibility become higher. This study found that distribution of fortified salt, with iodine fortified salt as reference, shows a high compatibility for this double fortified salt to be applied. Some research that were conducted in several countries also support the effectiveness of this method. In the end this method will give a big impact toward the effort of eradicating iron deficiency anemia in Northern Maluku Keywords : Iron, Anemia, Fortification, Northern Maluku

The application of Iron Fortification in

In 2011, South-East Asia, Eastern

Eradicating Iron Deficiencies Anemia in

Mediterranean and African Regions had the

Northern Maluku

lowest

mean

blood

haemoglobin

Intan Kautsarani, Januardi indra Jaya, Ryan

concentrations and the highest prevalences

Janardhana

of anaemia across population groups5. The

AMSA-Universitas Brawijaya

national prevalence of anaemia in Indonesia is about 21.7%6. There are 20 provinces in Indonesia which has higher prevalences

Background

than the national prevalence. Based on data

Iron deficiency anemia is anemia

from Riskesdas, 2007, North Maluku has

resulting from the reduced supply of iron

the highest anemia prevalence, which is

for erythropoiesis, because depleted iron

24.4% on the group of both male and

stores that eventually resulted in the

female adult, and on children6.

reduced of hemoglobin formation.1 Iron

Northern Maluku Province is a

deficiency anemia is the most severe stage

relatively new province in Indonesia. BPS

of iron deficiency, which is characterized

(Badan Pusat Statistik) survey showed that

by general fatigue, weakness, pale skin,

income per-capita of this province is under

shortness of breath, dizziness, strange

five million rupiahs, and GDB-per capita

cravings to eat items that aren’t food, such

which only contribute about 0,13% from

as dirt, ice, or clay, cheilosis(stomatitis

total summation province in Indonesia, it

nail)2.

shows that Northern Maluku is a province

While the condition may be common, a lot

which has the lowest income in Indonesia7.

of people not realize that they have an iron

The geographical condition of this province

deficiency

to

which consist of 395 islands caused higher

experience the symptoms for years without

cost on primary needs compared to other

ever knowing the cause3. If anemia or iron

island, like Java8. Population Census 2010

deficiency is untreated, it can lead to other

of education segment state that people who

health

reduced

graduated from senior high school/equal in

work

Northern Maluku is about 18,74%9. The

of

expensive logistics costs, low education,

maternal and child mortality and reduced

and high poverty rate conduct on increasing

children growth. It is one of the disease that

the risk factors of low iron intake and also

angularis),

koilonychias

anemia.

problems,

cognitive performance

It’s

(spoon

possible

including

performances, endurance,

lower increase

is embed in the cycle of poverty 4.

increasing incident of an Iron Deficiency

The method of data analysis literature

Anemia10.

conducted through two approaches, namely:

With those geographical and socio

1. Method of exposition, that the presented

economic condition, government yet have

data and facts that may ultimately sought

to solve the problem of Iron deficiency

correlations between these data.

because of its role in the poverty cycle. One

2. Analytic methods, namely through the

of the common method to tackle a

analysis of data or information by giving

micronutrient problem in a huge scale with

the argument through logical thinking and

geographical and socio economical problem

were then taken to a conclusion.

is by fortified the micronutrient to the staple food or product11. This paper will analyze

Results

the application of fortification to solve the

Fortification

problem of iron deficiency anemia in

micronutrient to a specific substance,

Northern Maluku.

commonly staple food, in order to eradicate

is

a

process

of

adding

a certain micronutrient problem. One of the Method

fortification in Indonesia that has been run

This scientific paper was based on literature

and show a promising result is iodine

review through comparative study on the

fortification using salt as its vehicle.

effort

Northern

of

eradicating

micronutrient

Maluku

with

its

people’s

deficiencies especially iron deficiencies and

condition that are in poverty, low education

its long term effect. Some methods and

and have a geographical problem makes

program were carefully examine in order to

fortification method is the most suitable

find

iron

method to end the problem of iron

Maluku.

deficiency. Salt fortification is chosen as it

the

right

fortification Socioeconomic

method

on

for

Northern and

the

characteristic

of

shows a successful distribution and suitable

mentioned region were considered in order

for

to meet the right methods for the program

distribution of salt fortified with iodine that

proposed.

reach 98%6.The salt fortification that we

Data collection methods in this study

propose is the fortification of iron into salt

conducted by the method of literature

without eliminating iodine component in it,

(literature review) based on issues, both

because iodine fortification is still needed,

through digital and non-digital information

and make the double fortification salt with

from literature such as journals and reports.

Northern

Maluku

as

shown

in

iron

and

iodine

as

the

fortified

effectiveness and feasibility of this program

micronutrient.

and in order to anticipated for technical and

Some technical supports that will be done

practical barriers that may arise that can

including:

give the utmost benefit to people in

1. Making an obligation / having contract

with

salt

production

company that distribute salt to

Northern Maluku11.

Fig.1. Process of fortified food to target population

Northern Maluku.

2. Giving some fund to the company for

the

research

and

technical

support 3. Making a strict rule that the only salt that can be distribute in Northern Maluku is the one with double fortification 4. Socialization

and

education

to

Northern Maluku people 5. Involvement of regional government

may be faced

and other governmental bodies 6. Involvement of NGO and any organization in Northern Maluku in the

effort

of

distributing

and

socializing the benefit of double fortified salt and 7. Evaluation and control toward the quality of double fortified salt and its effect to society, including but not limited to toxicity causes by double fortified salt, iron over dosage, and its effect to reduce the prevalence will be regularly done.

All of the mention technical support were performed

in

order

to

ensure

Fig.2. Technical and practical problem that

the

Discussions

by everyone, consumption of salt is

The effectiveness of double fortified salt

fairly stable throughout the year, salt production is usually limited to a few

Compared to other strategies used

for

the

prevention

of

iron

geographical another

areas

(1).

Although,

suggested

food

for

iron

deficiency anemia, food fortification is

fortification, like wheat flour- this food

a safe, affordable and effective method

has recently been confirmed in an

of upgrading the micronutrient status of

efficacy study in Thailand, cocoa

a population. It requires no medical

product, maize, and soy sauce. But, the

infrastructure, or any specific action by

food is not food that is often eaten by

the consumers, and is often much more

the population in Northern Maluku.

cost-effective4.Unfortunately, effective

Northern Maluku is not one of

fortification programs require a food

the 9 provinces in Indonesia which has

vehicle that is universally consumed, at

a salt production center and also has no

approximately

rate,

iodized salt producer, which requires

independently of economic status. Salt

this province to entirely rely on the salt

consumption

uniform

produced in any other areas of this

within societies, and it is not home

country. On 2013, 91.4% households in

produced,

centralized

Northern Maluku have already been

fortification 4.Indeed, over the past 20

distributed by iodinized salt3. This data

years infrastructure for salt iodization

can show us that fortified salt in

has been developed, and iodized salt

Maluku Utara can be well distributed,

now reaches 5 billion people – with a

highly

dramatic decrease in iodine deficiency

competitors to cover almost all areas in

diseases. Food fortification regarded by

Northern Maluku. Salt is highly used in

nutritionists as a strategy the most

food seasoning, which contributes to a

practical, economical and effective way

widely use of salt. Also, double

to need meet daily intake of iron.

fortified salt is far cheaper compared to

the is

same

relatively

allowing

for

accepted

and

have

less

. Salt is an ideal carrier of

any other food containing high iron,

micronutrients, from the successful

such as red meat and poultry. This

experience of salt iodization program.

leads to a wide consumption of salt,

Salt known as a micronutrients that is

even for people with low-income and

one of the few commodities consumed

increase the effectiveness of the system

proposed.

Therefore, the addition of

of iron deficiency anemia in the DFS

iron

iodized

great

group decreased from 35% at baseline

expectations can be used to address two

to 8% at 40 week (P < 0.001). This

The

in

means that double fortified salt will not

Indonesia as well, which is due to

disturb the iodine fortification program

iodine deficiency disorders (IDD) and

and it also proof the effectiveness of

iron deficiency anemia.

double fortified salt in reducing the

to main

salt

nutritional

has

problem

of

prevalence of IDA4.The effectiveness

double fortified salt to the iodine

of iron fortification to reduce the

content, double fortified salt is proven

prevalence of iron deficiencies anemia

to not disturb the ionizing program.

is also demonstrated by the fall of

According to a randomized, double-

prevalence

of

blind, controlled trial mean salt intake

developed

countries

in school-age children was 7â&#x20AC;&#x201C;12 g/d,

Venezuela, chili and china that applied

after storage for 20 week, the , double

iron fortification in various staple food4.

Concerning

the

effect

fortified salt and iodized salt were not

The

anemia

successful

in

some

like

US,

of

iron

significantly different in iodine content,

fortification also shown in India, the

and color stability was acceptable when

countries that has a similarity of

the compounds were added to local

demographic and socioeconomic status.

meals 12. This study also show that the

According to World Bank in 2015 both

efficacy of both substance that is

countries has status as a lower middle

significantly improved. urinary iodine

income countries. India and Indonesia

concentrations and thyroid volumes

also have many similar problems, both

improved significantly (P < 0.001)

country

from baseline. At 40 week, mean

populations and high poverty. India has

hemoglobin concentrations in the ,

implemented double fortification iron

double

and iodine in salt product in 2004,

fortified

salt

group

had

have

Tamil

volume

Nadu

of

increased by 14 g/L (P < 0.01), and

produced

serum ferritin, transferrin receptor, and

Corporation introduced in mid-day

zinc

concentrations

school meals in the state in 2008, a

were significantly better (P < 0.05) in

community-based study in Bangalore,

the , double fortified salt group than in

India proves the efficacy of Double

the iodized salt group. The prevalence

Fortified Salt in raising hemoglobin

protoporphyrin

by

gigantic

Salt

levels and addressing iron deficiency among primary school children

13

.

Another trial has been conducted to

potential of conflict and rejection reflected by a lot of company already fortified its products.

search for the efficiency of double fortified salt to improve the iron status

Moreover many researches on

in rural women of reproductive age

double fortified salt have been held

from northern West Bengal, India. This

since the 1980s12. Most of them

study

double

indicates positive results, also on

fortified salt is an efficacious approach

animal and human trials. The National

to improving iron status 14.

Institute of Nutrition has conducted a

demonstrated

that

With all the evidence and the geographical

and

research towards the bioeffectivity and

socio-economical

safety of long-term feeding of common

character of Northern Maluku, double

salt fortified with iron and iodine

fortified salt distribution is the most

(double fortified salt) in rat. The result

effective method to eradicate the iron

is that the iron provided through double

deficiencies anemia.

fortified salt is bioavailable and showed no evidence of any toxicity due to the

The feasibility of double fortified salt

long

programs

containing 1000 ppm iron, 30 ppm In

fortification

has

Indonesia, been

iron

mandatory

term

iodine

and

consumption 1%

hexametaphosphate

of

DFS

of

sodium

This

research

5

imposed on some food products such as

backup will help government and other

instant noodles, milk powder and flour.

health institution to communicate about

Through the Minister of Industry No.

the benefit of this program and make

29/M/SK/2/1995 has required that salt

the rejection from society is less likely

product must conform the provision

to occur.

SNI(Standar Nasional Indonesia) each product contain in the form of KIO3 min.

30mg/kg.

This

shows

Monitoring and Evaluation :

the

System of monitoring and

technology and knowledge for iron

evaluation of fortification program is

fortification is reachable. It also shows

very important. These systems should

that government mandate to require a

be designed in such a way that the

company to do fortification has less

information provided by monitoring

and evaluation is used effectively for

Government as a decision makers, must

decision-making

frequently monitoring and evaluation.

and

for

overall

program management.

Monitoring can be done every time, and evaluation at least once per year.

There are two main categories of monitoring, regulatory monitoring and individual

monitoring.

Future Benefit:

Regulatory

Iron deficiency is a disease

monitoring consist of internal, external,

categorized as cycle of poverty, its

and commercial monitoring. Internal

effect

monitoring includes quality control and

performance and work performance

quality assurance, external monitoring

endurance

includes

and

important factors that determined and

technical auditing by government food

affect individual prosperity. Applying

control unit. Commercial monitoring

this

includes

legal

prevalence of iron deficiencies anemia

food

means

factory

inspection

verification

compliance

by

of

Government

toward

the

which

system

both

that

can

eradicating

two

cognitive are

reduce

two

the

important

control unit and corroboating trials in

factors that drag Northern Maluku into

retail stores. Individual monitoring

poverty.

includes

prosperity,

assessment

of

provision

This

will

means

increase

their

increasing

their

utilization and coverage in all Northern

income and affordability to purchase

Maluku people. Impact evaluation also

meat, fish, vegetables and other healthy

should be done after monitoring.

foods, that can help to eradicate the

Impact evaluation is useful for assess

Iron deficiencies anemia with a natural

the goals of food fortification. There

means, as well as helping them in

are many ways to make impact

fulfilling

evaluation design. Habicht et al. (344)

micronutrient.

have

devised

a

useful

way

their

needs

for

other

of

classifying the various approaches to

Conclusion : Based on analysis on the

evaluating public health interventions.

characteristic of Northern Maluku and

There are three levels of inference are

salt distribution in Indonesia, we can

identified: adequacy, plausibility and

conclude that double fortification salt is

probability evaluation.

the best method to eradicate iron

deficiency

anemia

with

high

BAHAN PANGAN POKOK (MARET 2014).pdf. 2014. p. 23.

effectiveness and feasibility.

9.

Kehutanan D. Provinsi Maluku Utara. 2006;583â&#x20AC;&#x201C;98.

10.

SMERU Research Institute.

Child Poverty and Disparities in Indonesia: Challenges for Inclusive Growth. 2013;

1. Cafasso, Jacquelyn, Nall, Rachel.

2015. Iron Deficiency Anemia. (online) http://www.healthline.com/healt h/iron-deficiencyanemia#Overview1 on January 4th 2015 at 12.35 pm

11.

Uauy R., et al. Iron Fortification of Foods : Overcoming technical and Practical Barriers.

2. American Society of Hematology. http://www.hematology.org/Pati ents/Anemia/IronDeficiency.aspx on January 4th 2015 at 12.35 pm

based on Low Scientific Evidence.

References References

3. http://www.mayoclinic.org/diseasesconditions/iron-deficiencyanemia/basics/complications/con -20019327 on January 4th 2015 at 12.35 pm

4. WHO, FAO. 2006. Guidline on food fortification with micronutrients 5. WHO. The global prevalence of anaemia in 2011. Geneva: World Health Organization; 2015.

6. Badan Penelitian dan Pengembangan Kesehatan Departemen Kesehatan Republik Indonesia.

Riset Kesehatan Dasar 2007. Jakarta.

2008 December.

7.

Samiun MZM. Analisis Perekonomian Prov. Maluku Utara. 2008;233.

8.

Perdagangan D. ANALISIS MONITORING PERKEMBANGAN HARGA

12. Kapil U, Sareen N. Implementation of Double Fortified Salt in India is

Indian J Comm Health. 2014;26, Suppl S2:99-101 13. K. Madhavan Nair, Ph.D., B. Sesikeran,

MD.,

S.

Ranganathan,

B.Sc., B. Sivakumar, Ph.D. Bioeffect and safety of long-term feeding of common salt fortified with iron and iodine (double fortified salt) in rat.

Nutrition

Research

January

1998

Volume 18, Issue 1, Pages 121â&#x20AC;&#x201C;129.

14. Jere D. Haas,4 * Maike Rahn,4 Sudha

Venkatramanan,5

Grace

S.

Marquis,5 Michael J. Wenger et al.

Double-Fortified Salt Is Efficacious in Improving

Indicators

of

Iron

Deficiency in Female Indian Tea Pickers1â&#x20AC;&#x201C;3. J. Nutr. June 1, 2014 vol.

144 no. 6 957-964

5-STAR (Specialized To Assess Revitalization) Strategies of Indonesian Health Care Sector To Face Todayâ&#x20AC;&#x2122;s Challenge After Jaminan Kesehatan Nasional (JKN) and ASEAN Economic Community (AEC) : Systematic Review Priscilla Christina Natan 1, Chrisandi Yusuf 1, Khrisna Rangga Permana 1 1

AMSA-Universitas Medicine Brawijaya ABSTRACT

Introduction and Objectives : Indonesia, one of ten member countries, has a role to the success of ASEAN Economic Community (AEC) particularly to promote free trade and service across boundaries. Indonesia undoubtedly provides opportunities for both locals and foreigners to participate in the growth of the health care sector industry. This paper has objective to provide both insights about health care system in Indonesia and ASEAN Economic Community and revolutionary strategies to prepare Indonesian health sector to face those challenges. Methods: This scientific paper is based on systematic review research method. This is done by synthesizing the results of several studies which uses transparent procedures to find, evaluate and synthesize the results of relevant research. Results: There are 5 sectors Indonesia lacks; health care coverage, hospital shortage, qualification of physicians, local and government investment, and foreigner investment. On the other hand, to achieve UHC, JKN programs have some issues and It seems that Indonesia will probably miss that 2019 goal and It seems not promising to succeed AEC. Based on those issues, authors propose 5-STAR (specialized to assess revitalization) strategies. These strategies consist of utilization mainly on 5 sectors Indonesia lacks. The strategies consist 4 steps including building partnership, determining targets, 5-STAR strategies, and evaluation. Conclusion: 5-STAR strategies can be used as strategies for Indonesian health sector to face todayâ&#x20AC;&#x2122;s challenge based on reliable facts from trusted data. It is hoped It will invite a further research and lead to better improvement of JKN and contribute to the success of AEC.

Keywords: ASEAN Economic Community (AEC), Indonesia, Jaminan Kesehatan Nasional (JKN), Universal Health Coverage (UHC), 5-STAR Strategies

5-STAR (SPECIALIZED TO ASSESS REVITALIZATION) STRATEGIES OF INDONESIAN HEALTH CARE SECTOR TO FACE TODAY’S CHALLENGE AFTER JAMINAN KESEHATAN NASIONAL (JKN) AND ASEAN ECONOMIC COMMUNITY (AEC): SYSTEMATIC REVIEW

by: Priscilla Christina Natan Chrisandi Yusuf Khrisna Rangga Permana

FACULTY OF MEDICINE BRAWIJAYA UNIVERSITY AMSA BRAWIJAYA MALANG 2016

ABSTRACT 5-STAR (Specialized To Assess Revitalization) Strategies of Indonesian Health Care Sector To Face Todayâ&#x20AC;&#x2122;s Challenge After Jaminan Kesehatan Nasional (JKN) and ASEAN Economic Community (AEC) : Systematic Review Priscilla Christina Natan 1, Chrisandi Yusuf 1, Khrisna Rangga Permana 1 1

Faculty of Medicine Brawijaya University, Malang, Indonesia

Introduction and Objectives : Indonesia, one of ten member countries, has a role to the success of ASEAN Economic Community (AEC) particularly to promote free trade and service across boundaries. Indonesia undoubtedly provides opportunities for both locals and foreigners to participate in the growth of the health care sector industry. This paper has objective to provide both insights about health care system in Indonesia and ASEAN Economic Community and revolutionary strategies to prepare Indonesian health sector to face those challenges. Methods: This scientific paper is based on systematic review research method. This is done by synthesizing the results of several studies which uses transparent procedures to find, evaluate and synthesize the results of relevant research. Results: There are 5 sectors Indonesia lacks; health care coverage, hospital shortage, qualification of physicians, local and government investment, and foreigner investment. On the other hand, to achieve UHC, JKN programs have some issues and It seems that Indonesia will probably miss that 2019 goal and It seems not promising to succeed AEC. Based on those issues, authors propose 5-STAR (specialized to assess revitalization) strategies. These strategies consist of utilization mainly on 5 sectors Indonesia lacks. The strategies consist 4 steps including building partnership, determining targets, 5-STAR strategies, and evaluation. Conclusion: 5-STAR strategies can be used as strategies for Indonesian health sector to face todayâ&#x20AC;&#x2122;s challenge based on reliable facts from trusted data. It is hoped It will invite a further research and lead to better improvement of JKN and contribute to the success of AEC. Keywords: ASEAN Economic Community (AEC), Indonesia, Jaminan Kesehatan Nasional (JKN), Universal Health Coverage (UHC), 5-STAR Strategies

INTRODUCTION AND OBJECTIVES Indonesia is a country geographically located in Southeast Asia and demographically whose the number of population in Indonesia in 2014 253,609,643 with 0.95% population growth rate per year. It is gradually increased when compared to the population in 2010 that 237,641,326 people (CIA, 2014).

The increasing number of people in Indonesia might bring unfavorable impact, the burden of development including development in health. Indonesia, one of ten member countries, has a role to the success of ASEAN Economic Community (AEC) particularly to promote free trade and service across boundaries. To transform ASEAN into a single market production base, a highly competitive economic region, a region of equitable economic development, and a region fully integrated into the global economy are the four pillars of AEC. Indonesia undoubtedly provides opportunities for both locals and foreigners to participate in the growth of the health care sector industry. The health care landscape in Indonesia provides investors with both an interesting economic opportunity and the chance to make a way by improving the living standards of many people.

Investors can make a major difference in Indonesia through strategic investments, bringing in expertise, finding innovative solutions and putting down the foundations of a robust health care system for the future (World Bank, 2015).

On January 1, 2014, Indonesia launched its Universal Health Coverage (UHC) program, locally known as Jaminan Kesehatan Nasional (JKN) via Badan Penyelenggara Jaminan Sosial (BPJS) Health, to improve access to basic health care for Indonesians and to help achieve the United Nations (UN) Millennium Development Goals (MDGs). On Febuary 2015, 617 private hospitals (44%) have already registered with BPJS Health as of February 2015. Meanwhile, BPJS Health stated that 51 private insurance companies (35.8%) had registered as of February 2015, and the number is rising. On April 2015, about 142 million participants or approximately 56% of the population already registered. The Indonesian Government envisages that UHC will cover all citizens, residents (who have lived in the country for at least six months) and all hospital registered

by January 1, 2019 (Ministry of Health, 2015).

On the other hand, to achieve UHC, the population of Indonesia covered by health insurance is approximately 60%. It remains low compared to other ASEAN countries which already covers almost entire population by social health insurance and technically the entire population can use public health services funded via general taxation and low user charges. However, the key financial constraint to achieve UHC is low level of government spending and overall spending on health. Indonesia relatively spends little on health services. Indonesia allocated 3% (less than 5%) of the gross domestic product (GDP) as expenditure on health in 2012; and Out of Pocket (OOP) is 45%. The World Health Organization (WHO) argues that it is very difficult to achieve UHC if OOP as a percentage of total health spending is equal or greater than 30% (WHO, 2012).

AEC and JKN, both tremendously, influence Indonesian health care sector.

More and more professionals, including foreign doctors, will come to Indonesia and have practices here. The AEC will remove substantially all boundaries on trade so that ASEAN will become a region with liberated movement of services, investment and skilled labor, including in the healthcare sector. Eventhough, now, health sector cooperation in AEC is still in process revolving around knowledge exchange, standardisation and accreditation for health centers, that will happen soon. Government also needs to consider the health budgets to not only achieve, but also maintain of UHC. There is a disparity in health care infrastructure and doctor numbers between developed and less developed regions. It also believes there are regulatory weaknesses that exclude certain population groups from UHC. For example, newborn babies and unregistered low-income citizens are not automatically covered. Some those issues also suggest that Indonesia will probably miss that 2019 goal (IMTJ, 2014).

Based on those issues, authors propose 5-STAR (specialized to assess revitalization) strategies for Indonesian health sector to face todayâ&#x20AC;&#x2122;s challenge.

These strategies consists of utilization mainly on 5 sectors Indonesia lacks; health care coverage, hospital shortage, qualification of physicians, local and government investment, and foreigner investment.

This paper has objective to provide both insights about health care system in Indonesia and ASEAN Economic Community and revolutionary strategies to prepare Indonesian health sector to face those challenges. It is hoped that knowledge of how health care system works within it and the context of society, health care provider, and government will invite a further research and lead to better improvement of JKN and contribute to the success of AEC.

METHODS This scientific paper is based on systematic review research method.

Systematic review has increasingly replaced traditional narrative reviews and expert commentaries as a way of summarising research evidence. This is done by synthesizing the results of several studies. A systematic review uses transparent procedures to find, evaluate and synthesize the results of relevant research.

Procedures are explicitly defined in advance, in order to ensure that the exercise is transparent and can be replicated. This practice is also designed to minimize bias.

Studies included in a review are screened for quality, so that the findings of a large number of studies can be combined. Peer review is a key part of the process; qualified independent researchers control the author's methods and results..

Data collection methods in this study conducted based on issues, both through digital and non-digital information from literature such as journals or medical books or other realiable and trusted data from government or nongovernment organizations. The method of data analysis literature conducted through two approaches, namely: 1. Method of exposition, that the presented data and facts that may ultimately sought correlations between these data.

2. Analytic methods, namely through the analysis of data or information by giving the argument through logical thinking and were then taken to a conclusion.

RESULTS Indonesia Country Profile Geography and Cultural Profile Indonesia is a country geographically located in Southeast Asia, archipelago between the Indian and Pacific Ocean. It is approximately 17,508 islands and administratively divided into 33 provinces and approximately 500 districts (Figure 1). Indonesia lies between latitudes 11°S and 6°N, and longitudes 95°E and 141°E. The largest are Java, Sumatra, Borneo, New Guinea, and Sulawesi.

Indonesia shares land borders with Malaysia on Borneo, Papua New Guinea on the island of New Guinea, and East Timor on the island of Timor. Indonesia shares maritime borders across narrow straits with Singapore, Malaysia, the Philippines, and Palau to the north, and with Australia to the south. The capital, Jakarta, is on Java (CIA, 2016).

Indonesia has many ethnics group and more than 700 languages are used.

Indonesia is the world’s largest Muslim country, but strongly espouses freedom of religion. Hindu, Christian or Buddhist is small sections. Indonesia’s motto of ‘strength in diversity’ reflects the Republic’s multiculturalism. Despite the diversity of cultures, Indonesia is united by one language, Bahasa Indonesia, and by the national philosophy of Pancasila (Gimon, 2011).

Figure 1. Map of Indonesia

Demography Profile Age structure of population can be depicted graphically in the form of the population pyramid, which males shown on the left and females on the right (Figure 1). This pyramid shows the population also by age group. It can be seen that the large group of population is young population (0-14 years) although the birth rate 17.04 births/1,000 population in 2014 is lower than the birth rate in 2012, which was 17.76%. That number tells the needs to invest more in schools.

Meanwhile, the rapid growth of population from 25-59 years, which is a working group that indicates the needs to provide more job opportunities; and the high percentages ages 65 and over need to invest more in health sector (BPS, 2015).

Indonesia has achieved substantial and sustained progress in increasing life expectancy at birth rate, which is increased from 71.05 in 2010 to 72.17 years (male: 69.59 years and female: 74.88 years) in 2014. It shows the better overall quality of life in the country (BPS, 2015). The infant mortality rate also has fallen greatly from 62 deaths/1,000 live births in 1990 to 25.16 deaths/1,000 live births in 2014 (male: 29.45 deaths and female: 20.66 deaths/1,000 live births); and maternal mortality rate made some progress from 600 deaths in 1990 to 220 deaths/100,000 live births in 2010. Nonetheless, the government needs to work harder in decreasing the rate of infant mortality and maternal mortality.

Figure 2. Pyramid of Indonesian Population

Indonesia’s Concerns Related to ASEAN Economic Community (AEC) With a total population of 600 million, ASEAN has grown rapidly to be one of the largest economies in the world with a combined GDP of over USD2.1 trillion. With the directives from the ASEAN Economic Community (AEC) gradually coming into effect, intra-ASEAN Foreign Direct Investments (FDIs) and trade have grown tremendously as corporations across the region continue to keep pace whilst enabling new economic opportunities. Intra-ASEAN trade crossed USD500 billion in 2011, whilst intra-ASEAN FDIs increased by 30% to reach USD12 billion in 2010 (Aldaba, 2013).

Indonesia joins AEC not without preparations. Indonesia has some strengths and weaknesses. Indonesia has some strengths. Indonesia has such as having the largest population in ASEAN, with 254 million inhabitants which Indonesia’s vast population is an indisputable strength (Figure 3), as are its favorable demographics, with the average age being 29.2 years; The 2014 Indonesian Government’s gross debt, as a proportion of GDP, is just 25.0% compared to the G8 average of 108.6% (Canada, France, Germany, Italy, Japan, Russia, UK and US); Exports represent around 30% of GDP; Natural resources; Strategic location; and Indonesia’s current economic growth is forecast to be above five percent per year until 2020 (Figure 4) (World Bank 2015).

Figure 3. Population of ASEAN member states in 2014

Figure 4. Indonesiaâ&#x20AC;&#x2122;s Economic Growth Besides those strengths, Indonesia also has some weaknesses that should be well corrected. Those are infrastructure deficiencies, instable politics, corruption, risk of natural disaster, severe environmental pollution, language barriers, diverse population, complicated bureaucracy, poor education levels/educational system and stagnating productivity, Current account deficit due to imports outstripping exports (Figure 5) which puts high pressure on the currency with a trend of a weaker Rupiah (World Bank, 2013).

Figure 5. Indonesiaâ&#x20AC;&#x2122;s Current Account

Indonesiaâ&#x20AC;&#x2122;s Health Care System Universal Health Coverage On January 1, 2014, Indonesia launched its Universal Health Coverage (UHC) program, locally known as Jaminan Kesehatan Nasional (JKN) via Badan Penyelenggara Jaminan Sosial (BPJS) Health, to improve access to basic health care for Indonesians and to help achieve the United Nations (UN) Millennium Development Goals (MDGs). Indonesia is engaged in the process of ensuring effective decentralization, which is implemented since 2001 to district level.

Decentralization is the process of delegating authority from central government to local government. The type of decentralization is the implementation of the regional autonomy, which is widely given to the local government of regency and a city. Through decentralization, it is expected that government can improve health services as well as the welfare of the community as is stated in Law No. 32 of 2004 on Regional Government of Indonesia (Minh et al., 2014).

On Febuary 2015, 617 private hospitals (44%) have already registered with BPJS Health as of February 2015. Meanwhile, BPJS Health stated that 51 private insurance companies (35.8%) had registered as of February 2015, and the number is rising. On April 2015, about 142 million participants or approximately 56% of the population already registered. The Indonesian government envisages that UHC will cover all citizens, residents (who have lived in the country for at least six months) by January 1, 2019. It is important that the discussions between BPJS Health and the private insurance industry are moving forward, because the absence of a clear regulation passes too much reimbursement risk to private hospitals. The issue is that BJPS Health wants to collect premiums first and then pass the appropriate proportion on to private insurances. However, private insurances are concerned that the chronic underfunding of BJPS Health might lead to a collection risk for private insurers (IMTJ, 2014).

UHC operates a cashless referral model (Figure 6). Members must choose a primary care facility from BPJS Health, usually a public health center such as an Indonesian Government-mandated community health clinic, locally known as Puskesmas. The first treatment must occur here unless it is an emergency.

Secondary care is by referral from the first level public health care facility, usually to a public hospital. UHC has sparked complaints from participants, due to its rigid referral system that decreases flexibility in choosing health care facilities and reduces employees’ productivity. Travel costs can be high for employees who work in remote areas but are registered at only one distant first level public health care facility. Health risks can also result from delayed treatment, which can be driven by inefficient processes (BPJS RI, 2014).

Figure 6. BPJS Claim Procedure Hospital Shortage Indonesia currently has about 1,562 public and 666 private hospitals (2013).

Most of the hospitals are located in Java and Bali (1,219), Sumatera (511), Sulawesi (182) and Kalimantan (142); together, these hospitals will serve 93% of the projected 255 million population in 2015 (Figure 7).

While Indonesia’s ratio of hospital beds to population is the lowest in ASEAN and among the lowest in the world, the average bed occupancy rate (BOR) of 64% in 2015 was significantly below the Indonesian Ministry of Health’s ideal ratio of between 80% and 85%. BOR is used as a measure of quality and is an operational target; a ratio exceeding the ideal percentage

indicates poor hospital safety and efficiency. A higher BOR also reduces the speed of admitting patients with higher care needs and increases the risk of crossinfection in overcrowded wards, as patients are less likely to be assigned toward divisions dedicated to their specific diseases (Rokx, 2014).

The BORs presented in (Figure 8) are indicative. Despite uncertainties as to the accuracy of BORs, the message is clear: highly populated regions such as Java and Bali have BORs above the ideal rate, which indicates a need for additional beds (Guinto et al., 2015).

Figure 7. Regional Hospital Infrastructure

Figure 8. Number of Hospitals and Beds by Region

Qualified Physicians Shortage Indonesiaâ&#x20AC;&#x2122;s health care system is currently unable to serve its more than 250 million citizens and residents adequately. Public health care infrastructure is severely underfunded, public hospitals are overcrowded with long waiting times and the quality of service is low. A lack of qualified physicians is the major challenge which currently 1 physician serves 3333 people in ratio (Figure 9).

Government whose target is to achieve 1 physician per 1,000 nationally by 2019 as recommended by WHO (Suwandono et al., 2015).

Figure 9. Physician-People Ratio The challenge being faced by Indonesia government is deploying and retaining health workers in rural and remote areas. 13 The gap between urban and rural areas remains very large. There is only 20 percent of physicians are based in rural areas. 18 On the other hand, there is approximately 60% of graduating physicians are female who may be facing particular barriers to deployment in rural and remote areas, particularly if there are limited schooling for their children or security concerns. Moreover, lack of salary and late budgeting are the other factors due to decentralization, which lead medical staff to have dual practice, and is allowed by government to compensate the low government salary. On the other hand, high number of Indonesian is mostly going abroad to have medical

treatment. Singapore is often referred as medical help abroad, which some 30-40 percent of foreign patients in Singapore at any one time are Indonesian (WHO, 2015).

In line with that, the number and location hospitals; and medical schools are also factors influencing the unequal distribution of physician, especially specialist physician. For examples, large number of internal medicine specialists stays in urban hospitals, especially in Java compared to remote Maluku, Papua, and West Sulawesi; and the medical school, mostly 72 medical schools are located in provincial capital city in 2011. There are a few schools provide special programs for recruiting students from rural areas. It is also worsened by long physician supply chain (Anderson et al., 2014) (Figure 10).

Figure 10. Physician Supply Chain Local and Foreigner Investments Indonesia undoubtedly provides opportunities for both locals and foreigners to participate in the growth of the health care sector industry. Indonesia allocated 3% (less than 5%) of the gross domestic product (GDP) as expenditure on health in 2012; and Out of Pocket (OOP) is 45%. Investors can make a major difference in Indonesia through strategic investments, bringing in expertise, finding innovative solutions and putting down the foundations of a robust health care system for the future (DPLLN, 2011).

The Indonesian middle class has become a major focus for investors due to its sheer size, increasing buying power and the fact that Indonesians are among the most confident consumers in the world. There are different ways to define the middle class in Indonesia. Despite these different definitions, the McKinsey (Figure 11) and BCG (Figure 12) studies both show that the middle class in Indonesia will continue to grow, after a strong increase between 2003 and 2010.

This rising middle class with its increased buying power, combined with basic health coverage provided by UHC, will drive the demand for affordable quality public and private health care in Indonesia. Health care spending in Indonesia has not followed macroeconomic trends. Total public and private spending on health care, as a percentage of GDP is significantly behind the average for ASEAN member countries (World Bank, 2013) (Figure 13).

Figure 11. Rise of the â&#x20AC;&#x153;consuming classâ&#x20AC;? as Forecast by McKinsey

Figure 12. Rise of The Middle Class as Estimated by BCG (2012 and 2020F)

Figure 13. Private and Public Health Care Expenditure (% of GDP) in 2013

DISCUSSION Review in Health Care Coverage Sector As authors described before, to achieve UHC, the population of Indonesia covered by health insurance is approximately 60%. It remains low compared to other ASEAN. It is expected that government should pay more attention to UHC by raising allocation for health services in Indonesia from 3% to at least 5% of GDP. It is also suggested that government should decrease OOP from 45% to 30%. Because World Health Organization (WHO) argues that it is very difficult to achieve UHC if OOP as a percentage of total health spending is equal or greater than 30%. Government also needs to consider the health budgets to not only achieve, but also maintain of UHC. It also believes there are regulatory weaknesses that exclude certain population groups from UHC. For example, newborn babies and unregistered low-income citizens are not automatically covered. The UGM study also predicts that only 7 of 33 provinces are expected to have full UHC by 2019, including Greater Jakarta, Yogyakarta, South Sumatera, West Sumatera, Central Java, East Java and South Sulawesi. The government has to make some good regulation regarding automatic coverage for newborn babies and low-income citizens especially in remote area. If we can manage it well, It also suggests that Indonesia will probably achieve that 2019 goal.

Review in Hospital Sector Private hospital operators could help to develop the health care infrastructure and upgrade the skills of physicians by collaborating with faculties of medicine, as well as by opening their own training centers. However, these initiatives remain a drop in the ocean. In Indonesia, hospitals that are owned by the Indonesian Government, regional governments and any nonprofit legal entity fall into the public hospital category. Anything profit-based is considered as a private hospital. Hospitals are further grouped into general hospitals and specialized hospitals. The majority of hospitals in Indonesia are classified as public (70%), with the remaining being private hospitals (30%) (Figure 14).

Figure 14. Number of Hospitals in Indonesia (2011â&#x20AC;&#x201C;2013) Around 77% of private hospitals offer general services while 23% of private hospitals provide specialized services. In theory, an increasing number of private hospitals registered by JKN will be beneficial for public patients as Ministry of Health Regulation No. 56/2014 requires private hospitals to reserve at least 20% of their beds for public patients. However, even though the Ministry of Health monitors compliance with this requirement, in practice we understand that often the quota is not met, as poor to near-poor patients are often not aware of their rights or not confident enough to visit private hospitals (PODES, 2013).

Review in Physician Sector Compared with other ASEAN countries and developed markets, Indonesia is facing a massive undersupply of specialists, general physicians, and beds.

Quantity is not the only issue: the lack of qualified staff is equally critical.

Hospitals widely admit that their No.1 issue is finding and retaining qualified medical personnel. The uneven geographical distribution of medical professionals is a challenge, as in other countries, as doctors can be reluctant to practice in rural areas. Nearly 50% of total health care professionals in Indonesia practice in Java and Bali. Long chain supply of physicians also contributes.

Review in Local and Government Investment Indonesia undoubtedly provides opportunities for both locals and foreigners to participate in the growth of the health care sector industry. The health care landscape in Indonesia provides investors with both an interesting economic opportunity and the chance by improving the living standards of many people.

The new Indonesian Government has recently introduced a new way to make it easier to start a business. However, opening and operating new hospitals and clinics without a local partner remains a challenge in Indonesia. Local partners often have much to offer, especially in terms of knowledge of the industry and the client base. For foreign investors, what is more important than investing capital into the venture is to bring in much-needed hands-on hospital management capabilities. Lack of experienced management teams in this fastgrowing market provides great opportunities for an investor who has this capability and experience to bring in: a good management team will be able to unlock a wealth of unrealized pro ts through better utilization of capital, negotiating better terms with suppliers and better cost management.

Review in Foreigner Investment At the end of 2015, ASEAN is due to launch the ASEAN Economic Community (AEC) which will push the region toward further economic integration. Indonesiaâ&#x20AC;&#x2122;s health care sector is relatively open for foreign investment.

The Indonesian Government revised the foreign investment regulation in 2014 to encourage foreign direct investment (FDI) from other ASEAN member countries in health care, in line with its commitment to the AEC. Overall, the legal framework to support foreign investment in health care, especially for ASEAN investors, has been adjusted favorably. A supportive legal framework on foreign ownership is expected to further drive growth of FDI. Foreigner investors could support this. Investors can make a major difference in Indonesia through strategic investments, bringing in expertise, finding innovative solutions and putting down the foundations of a robust health care system for the future.

5-STAR (specialized to assess revitalization) Strategies Actually, there were many attempts attended by local governments, such as through the mass information media or health worker intervention. However, none of them seems to give a satisfying result in purpose to succeed JKN and AEC. This study proposes a new approach by enhancing the performance of the preexisting health system. The suboptimal performance of JKN achievement and AEC challenge may serve as the principal causative agent for the inefficacy of the past methods. The technical details of the 5-STAR (specialized to assess revitalization) strategies proposed solutions largely take place mainly on 5 sectors Indonesia lacks; health care coverage, hospital shortage, qualification of physicians, local and government investment, and foreigner investment. This study was only equipped with a prototype model and are next to be described in a crude concept below (Figure 15).

Figure 15. Stages in 5-STAR Step 1. Building Partnership Before executing the full function of the prototype, such a permanent organization or structural base seems to be necessary to ensure a long lasting, constant process, at least till the final target of 5-STAR all regions. Whenever a stable number is reached, another form of governmental council can be established in order to maintain a steady state. First of all, the role of government who have already acquired an appropriate amount of power in health care regulations and managing both local and foreigner investments.

On the other side, faculty of medicine in every university in Indonesia, which has function to support the need of qualified physicians. Consequently, medical students who are in turn to have the in targeted area will be the next organizer and still in the scope of academic programs. Private hospital also will give beneficial partnership with the support both local and foreigner investors.

Step 2. Determining Targets A full achievement of this strategies is initially determined by the targets which are having need of immediate fixing, those of the moderate need, and the last for the most developed area. Adjustments which are specifically made on 5 main sectors we already discussed.

Step 3. 5-STAR Strategies The technical details of the 5-STAR (specialized to assess revitalization) strategies proposed solutions largely take place mainly on 5 sectors Indonesia lacks; health care coverage, hospital shortage, qualification of physicians, local and government investment, and foreigner investment after we determining the targets.

By increasing the budget for UHC, government is expected could bring its potential to its fullest. Financial issue is not the only problem here, the shortage of hospital and physicians even make it worse. By building partnership with private hospital and investors, It could help to develop the health care infrastructure and upgrade the skills of physicians by collaborating with faculties of medicine and schools of nursing, as well as by opening their own training centers.

Authors propose and advice on how hospitals can attract and retain talented physicians by cooperating with universities and take on doctors before they graduate. Cooperating with reputable medical schools to arrange an early uptake of doctors before graduation, which helps to reach the pool of new doctors. By providing access to high-quality medical equipment and training. Small hospital operators may not have the resources to do this, but doctors are attracted by stateof-the-art equipment and regular training. Apart from retention considerations, exibility may help to upgrade the quality of specialists.

Step 4. Evaluation Evaluating the program can be performed through progress report and intenal meeting among the committees of the program. It is performed merely to discuss disadvantages and obstacles observed in daily management and performance. Readjustment should be made whenever there are mismatch between the basic need of a certain sector and the dominance of program phase held over it.

CONCLUSION Indonesia, one of ten member countries, has a role to the success of ASEAN Economic Community (AEC) particularly to promote free trade and service across boundaries. Indonesia undoubtedly provides opportunities for both locals and foreigners to participate in the growth of the health care sector industry. On the other hand, to achieve UHC, JKN programs have some issues and It seems that Indonesia will probably miss that 2019 goal.

Based on those issues, authors propose 5-STAR (specialized to assess revitalization) strategy strategies for Indonesian health sector to face todayâ&#x20AC;&#x2122;s challenge based on reliable facts from trusted data. These strategies consist of utilization mainly on 5 sectors Indonesia lacks; health care coverage, hospital shortage, qualification of physicians, local and government investment, and foreigner investment. The strategies consist 4 steps including building partnership, determining targets, 5-STAR strategies, and evaluation.

This paper has objective to provide both insights about health care system in Indonesia and ASEAN Economic Community and revolutionary strategies to prepare Indonesian health sector to face those challenges. It is hoped that knowledge of how health care system works within it and the context of society, health care provider, and government will invite a further research and lead to better improvement of JKN and contribute to the success of AEC.

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Minh HV, Pocock NS, Chaiyakunapruk N, et al. 2014. Progress toward universal health coverage in ASEAN;p9-10.

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IMSTC 2016

Tel-Meds Project: Direct Implementation and Integration Between Palapa Ring, 4G Technology, And Medicine For Health Approach In Rural Area In Indonesia Adrian R Sudirman, Heri Khiputra, Felix Kurniawan AMSA-Universitas Indonesia (AMSA UI)

Abstract A midst an array of problems faced by Indonesia healthcare system, the lack of healthcare workers which included specialist still exist. The low number of graduates and the unbalance distribution of specialist contributes to the overall low quality of healthcare services, especially towards the people in rural areas. The government has tried several measures to ensure that the distribution could be even out but to no avail. An alternative proposed by the writers is to integrate the upcoming Palapa Ring project which aims to cover all parts of Indonesia with fiber optic network to assist the development of telemedicine in Indonesia.

The advancement of telecommunication devices and the rapid progression of 4G LTE network has made consultation and diagnosis through long-distance communication possible.

This study is a literature review of various journals searched through Google Scholar with keywords of

“telemedicine”, “Indonesia rural areas”, “Palapa Ring”, “telemedicine in

Indonesia”, “specialist distribution in Indonesia”. With the completion of the ring and its integration with 4GLTE, people would have easier access to tertiary care thus lessening the burden of unbalance distribution faced by Indonesia healthcare system.

Keyword telemedicine, 4G LTE, palapa ring, rural area

IMSTC 2016

Tel-Meds Project: Direct Implementation and Integration Between Palapa Ring, 4G Technology, And Medicine For Health Approach In Rural Area In Indonesia Adrian R Sudirman, Heri Khiputra, Felix Kurniawan AMSA-Universitas Indonesia (AMSA UI)

Introduction and Objectives

and remote areas but it turns out to be

One of the goal of a developing country is

ineffective as there still exist a huge gap

to increase the quality of its healthcare

between the number of specialist serving

services, and Indonesia not excluded.

in cities and in rural areas. The ratio of

Sadly the healthcare system and policy

specialist per 100,000 people in Jakarta is

implemented by the government has not

46.95 while in West Sulawesi the ratio is

successful in addressing the needs of the

as low as only 0.69. While the specialist

people. The number of healthcare worker

keeps increasing in number to the point of

in Indonesia still cannot reach the target.

overcrowding the cities, the rural areas

That includes the number of specialist.

lack definite appeal to catch the interest of

Based on an analysis done in 2013, the

said specialist that come from the cities.

number of specialist needed was 31,000

According to a research, the factors that

while the total number of specialist only

serve as determinant for specialist to

amounted to 24,000. With a negative

consider working at rural areas are

margin of 7,000 specialist and only 300

financial incentives and the level of

graduates per year, Indonesia is still far

infrastructure development. The result is

from being able to meet the needs for

of course the overall quality of healthcare

healthcare in terms of quantity. (Pusat

services lessened due to the unfulfilled

Perencanaan dan Pendayagunaan SDM

demand

Kesehatan, 2013).

(Priyatmoko, dr. Lutfan Lazuardi, & dr.

The problem is made worse by the fact

Mubasysysir Hasanbasri, 2014)

that there is an unbalance distribution of

An alternative to the problem is, instead of

specialists in Indonesia. The government

tackling down the problem of unbalanced

has once tried to implement a program

distribution, the government could try to

which forces healthcare workers to rural

apply

and

unbalanced

telemedicine.

distribution.

Telemedicine

is

defined as “the use of information and

The project called Palapa Ring actually

communications technology to provide

was called Nusantara 21 but was then

health care services to individuals who are

called off due to the economy crisis that

some distance from the health care

happened in 1998. On January 2005, the

provider”. With telemedicine, connecting

government

specialists and patient through long-

project with another name. Palapa Ring is

distance

a project with the objectives of building a

communication

is

possible.

decided

to

continue

the

(Roine, Ohinmaa, & Hailey, 2001)

fiber optic network that covers 440 states

The concept of telemedicine itself is not

in

unfamiliar to Indonesia as in 1987, an

completed, the network will encircle the

experiment using satellite was conducted

whole archipelago thus the name ‘ring’.

as a part of project called Satellite for

Although this project is intended for the

Health and Rural Education. The usage of

people at Eastern Indonesia to be able to

telemedicine for development of maternal

enjoy the telecommunication service they

care in rural Eastern Indonesia was done in

deserved, it is undisputable that the

1997 by three institution. Right now

completion of Palapa Ring will contribute

telemedicine

towards the development of telemedicine

has

gone

beyond

tele-

Indonesia.

education and has been used to transmit

in

image or even patient’s haemodynamic

Wijayanti, n.d.)

status for diagnosis and for treatment.

The

Telemedicine

telecommunication

will

improve

as

Indonesia.

When

second

the

project

(Pambudi,

biggest

is

Sugito,

&

development

in

field

is

the

4G

telecommunication improve so this is a

technology. This technology has reached

great asset for developing countries like

other nations in Asia and soon Indonesia

Indonesia with its rapid development in

will follow. The most widely known is

wireless communication. The availability

Long Term Evolution (LTE) which will

of the equipment which could satisfy the

become the pivot of 4G connection in

minimum requirement for sending medical

Indonesia due to the support given by

images and data has not reached an

multiple mobile operator. As the successor

adequate amount yet. That is why the

of

integration of Palapa Ring is deemed

compared to its predecessor. It has wider

important. (Suksmono, Sastrokusumo, Tati

coverage, bigger capacity, faster data

L.R. Mengko, Pramudito, & Oktowaty,

transfer speed, lesser operational cost and

2004)

could be integrated to currently existing

3G,

LTE

has

many

advantages

technology. The last trait is important

facilities

because with this the integration of Palapa

36.000 kilometers. This project consist of

Ring with 4G is not only deemed to be

seven small fiber-optic ring, which are in

possible but also favourable. (Suyuti, Rusli,

Sumatra,

& Syarif, 2011)

Tenggara, Papua, Sulawesi, and Maluku

Based on those explanation, there is a big

and a backhaul to connect every ring into

potency

of

one integrated system. The implementation

telemedicine which are completed by

of this project will be able to reach 400

Palapa Ring project and 4G technology.

rural districts across Indonesia.

Project we called Tel-Meds project will

project will bring the integration between

enable patient in rural area get the proper

new network and existing network that

services and connected with advanced

focused on every networks in East

doctor such as specialist doctor in the city.

Indonesia. The government has declared a

This implementation

regulation to make a consortium consist of

of

the

implementation

will bring

new

throughout

Java,

Indonesia

along

Kalimantan,

telecommunication

provider

Nusa

This

dimension in providing standardization

all

in

health services in Indonesia.

Indonesia to support the implementation of this project. At the end of the day, this

Method

project

will

bring

revolutions

in

The method used in this paper was

communication

literature and systematic review studies.

disclosure could give the good impact for

The literature studies took the data and

the nation with integrated communication

information from various researches and

system which enable the government and

literatures, such as journals, textbooks, and

society connected to one another in order

reviews about every topic related to Palapa

to information sharing and feedback for a

Ring Project,

better system.

Telemedicine,

and

4G

technology which play roles in providing better health approach in rural area in Indonesia

industries.

Information

Telemedicine is a trend that focused on medical information exchanged between one person to another using electronic communication to provide better health approach and improve patientâ&#x20AC;&#x2122;s clinical

Result Palapa

ring

is

defined

as

telecommunication infrastructure project that construct and establish fiber optic

health status. In addition, it holds great potential for reducing the variability of differential diagnoses, improving clinical

management,

and

better

health

care

Nowadays,

telemedicine

has

been

delivery by enhancing access, efficiency,

advocated in situations where the health

quality, and cost-effectiveness. The main

professional on duty has little or no access

attraction regarding this trend includes

to expert help. The implementation have

growing variety of services and application

been shown to directly and indirectly

using two-way video, wireless tools, and

reduce the number of referrals to off-site

other

telecommunications

facilities and reduce the need for patient

technology. The purpose of telemedicine is

transfers. Remote care and diagnosis via

an extending care and approach to patients

telemedicine

in remote areas. The reason behind is

developed countries bring benefits to both

because of the limitation of decent

patients and health care system by

healthcare

reducing

parts

of

services

and

facilities

the

in

less-economically

distance

travelled

for

availabilities. This issue become the

specialist care, related expenses, time, and

unsolved problems in Indonesia. A large

stress. Furthermore, it has the potential to

area become another issue that has to be

motivate rural practitioners to remain in

overcomed first before the government can

rural practice with augmentation and

solve those issues. Providing populations

opportunities for continuing professional

in these undeveloped

development and personal support.

countries

with

purpose to have adequate access health

It has been proven that telemedicine will

care has the potential to help meet

bring great promises in health care sector

previously unmet needs and positively

in developed country. For example is the

impact health services, without location

implementation

and time barriers. The implementation of

promote maternal and newborn health in

telemedicine can overcome distance and

remote provinces

time barriers problems between health-

project aim to reduce infant and maternal

care providers and patients. In addition, it

mortality while addressing the gap in rural

will

health care services. There are a total of

bring

benefits

to

important

telemedicine

to

of Mongolia. This

families,

health

598 cases referred in 2009, which consist

health

system

of 64% obstetrical, 21% gynaecological

including educational opportunities and

pathology, and 15% neonatal pathology.

enhanced patient-provider communication

From 598 cases, only 36 of these cases

in better way.

were reffered to urban health-care facility

practitioners,

patients,

socioeconomic

of

and

the

in Ulaanbaatar (capital city of Mongolia)

for treatment following the diagnosis.

workers assigned to the area, especially

From this situation, telemedicine could

specialists. This problem actually has been

saving and contributes to protecting people

realized by the government and the

in

risks

government itself has made an attempt to

urban

deal with this problem by modifying the

healthcare service in order to obtain

system of PTT (Pegawai Tidak Tetap or

tertiary level maternal and newborn care.

contracted

The other success stories of telemedicine

workers are given more incentive wage if

has

The

they agree to be placed in remote areas and

implementation of this project aim to

even more if they are placed in very

reduce the breast cancer mortality rate in

remote areas. They also earn reduction in

women between the ages of fifty to sixty-

the duration of the PTT program. This

nine. The result of this project is the

move do give remote areas more doctors

increased number of national screening

since it attracts more freshly graduated

rates from 7.2% in 2007 to 21.6% by 2012.

medical doctors to serve there. The

In Indonesia, the government need to

problem is, the doctors only stay there for

improve and develop network and internet

the given duration of stay and most of

facilites in rural area, which has been

them refuse to prolong their service there

included in Palapa Ring project. Due to

as the attachment is not strong enough.

challenges with internet connectivity, the

Another problem is, the PTT program

government

telecommunication

mostly only covers general practitioners,

provider has solved it using the fiber optic

but not specialists. As of 2010, only 60

connectivity in Palapa Ring Project. Based

and 20 specialists are registered as

on those facts, it is very feasible to

contracted workers in remote and very

implement this project in Indonesia.

remote

rural

associated

been

areas

from

with

shown

and

financial

travelling

in

to

Mexico.

Discussion

workers).

area

The

respectively.

contracted

Specialists

provide tertiary care which is an essential part in health sustaining. Thus, it is very

Every people needs adequate access to

important to increase the number of

healthcare, this is an obvious statement.

specialists or make the access to tertiary

However in Indonesia, it is only a

care easier. (Efendi, 2012)

privilege for those living in urban area.

People living in remote (rural) and very remote area in Indonesia only have limited access to healthcare due to lack of health

Telemedicine could be the solution of this issue. Telemedicine can be described as the

distribution

of

healthcare

where

distance

is

a

problem

by

using

Palapa Ring is

a telecommunication

technologies for exchanging information

infrastructure project in the form of fiber

related to the diagnosis of a case, or in

optic

short, distant healing. It facilitates people

Indonesia through the length of 36.000

living in remote area to get adequate

kilometers. It consist of seven smaller fiber

tertiary care. There are four things related

optic rings in each of Sumatra, Java,

to telemedicine, which are: providing

Borneo, Nusa Tenggara, Papua, Celebes,

clinical support, intended to overcome

and Maluku area and a bigger network to

distance or geographical barrier, involving

connect the seven rings. Palapa ring

various

and

connects the already existed ring in the

and

western area and the new ring in the

improving health outcomes as the final

eastern area of Indonesia. By adopting

result. (World Health Organization, 2009)

fiber optic, this Palapa Ring is very

Telemedicine has actually been established

promising. It can covers the network

or has piloted in some area in Indonesia

needed for advanced telemedicine so

such as National Cardiovascular Center

transmitting video communication will not

Harapan Kita and Cicendo Eye Hospital

be a problem in the integration of

which both located in big cities like

telemedicine

Jakarta

(Kementrian Komunikasi dan Informatika

types

of

communication

or

information

technologies,

Bandung.

It

shows

that

network

construction

and

all

Palapa

over

Ring.

Indonesia is ready to adopt telemedicine in

RI, 2013)

its healthcare system. (World Health

The Palapa Ring project is also growing to

Organization, 2009)

become bigger and wider. So, once the

The remaining problem was remote areas

Palapa

in Indonesia hadnâ&#x20AC;&#x2122;t got sufficient network

integrated, the progression of Palapa Ring

access so for telemedicine to reach these

will automatically affect the growth of

areas was still difficult. However, this

telemedicine in Indonesia. This will result

condition has changed, the Palapa Ring

in the increasing easiness of access to

project has been established and its

healthcare, especially tertiary care, in rural

integration to telemedicine could solve all

or remote areas. People living even in the

of the previously stated problems. The

most remote area will be able to consult

Palapa Ring project is actually still

their problem to a specialist in the center

growing and the second project of it is

hospital in Jakarta once the Palapa Ring

currently being built.

Ring

and

telemedicine

are

reaches

all

part

of

Indonesia

with

1. American

Telemedicine

telemedicine integrated to it.

Association.

The fiber optic provided by Palapa Ring

Telemedicine.

will allow information to be transmitted to

January

rural areas and then further transmitted via

http://www.americantelemed.org/a

4G broadband through 4G-transmitting

bout-telemedicine/what-is-

tower. Thus, people living even further

telemedicine#.VpOt_sZEnIU

away from one of Palapa Ring’s points can

2. Dobson,

(2016).

What

Retrieved 2016,

A.,

is 11

from

McLaughlin,

D.,

still get the benefits of telemedicine

Vagenas, D., & Wong, K. Y.

through their local healthcare centers.

(2010). Why are death rates higher in rural areas? Evidence from the

Conclusion 1. The

Australian Longitudinal Study on distribution

of

healthcare

Women’s Health. Australian and

workers, especially specialists, are

New Zealand Journal of Public

not even between urban and rural

Health,

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Community Approach: Accessing Knowledge of HIV/AIDS from Further Developed AIDS Digital for Early Diagnostic and Prevention Keisha Deandra Christie, Steven Jonathan, Irvania AMSA-Universitas Kristen Krida Wacana University

Introduction and objectives: HIV/ AIDS has been a major problem in every developing and developed countries in the world for the last decades. Although Indonesia is not high in prevalence, but the transmission does not stop. The objective is to suggest government to develop and re-introduce AIDS digital as an instrument to educate the society and to support governmentâ&#x20AC;&#x2122;s effort on early diagnostic and prevention of HIV/ AIDS in Indonesia.

Methods: This study is a literature review cited from journals and articles from national and international government website regarding HIV/ AIDS and AIDS digital application, which consist of several steps such as reviewing about HIV/ AIDS situation in Indonesia today, listing government attempts on combatting the disease, discovering potential attempts on solving the problems on conducting early diagnostic and prevention of HIV/ AIDS in Indonesia, searching on reasons why the instrument currently failed to be utilized effectively and developing concepts in order to re-introduce the instrument.

Results: Ages of high risk people range from 20-39 (49,67%) and 30-39 (29,8%). This groups of population generally considered to have fair knowledge of technology based health application. In 2012, government launched AIDS digital to approach the high risk people.

But, the prevalence rates still risen sharply up to 2013. Actually, the application does have several helpful options for People Living with HIV (PLHIV), but havenâ&#x20AC;&#x2122;t been used much. It can be seen from its website, mobile applications and facebook.

Conclusion: The AIDS digital application is a potential instrument, but its socialization still overpowered by the stigmas in community. Besides that, AIDS digital only post news updates few times in a year. To educate people, the application needs to be updated routinely

and get supports from government, health workers and also medical students to help socializing it to society.

Keywords: HIV/ AIDS, AIDS digital, technology based health application

COMMUNITY APPROACH: DEVELOPING AIDS DIGITAL CONCEPT TO SUPPORT PREVENTION OF HIV/ AIDS IN INDONESIA

Keisha Deandra Christie, Steven Jonathan, Irvania

ASIAN MEDICAL STUDENTS‘ ASSOCIATION UNIVERSITAS KRISTEN KRIDA WACANA JAKARTA 2016

Introduction Acquired Immune Deficiency Syndrome (AIDS) is caused by a retrovirus called Human Immunodeficiency Virus (HIV). It is transmitted through blood, semen, anal mucous, vaginal fluids, breast milk, and transplacental from HIV positive mother to her fetus. HIV can be identified by screening on CD4 cells count which depict the number of T helper cells.

Person with HIV has lower immune system that more susceptible to opportunistic infection compared to normal people. Actually, AIDS patient usually die because of the opportunistic infection and not by HIV itself directly. (Pohan H. T., 2006)

HIV/ AIDS has been a major problem in every developing and developed countries in the world for the last decades. Considerable efforts have been deployed since the first time it was identified in 1980s. Although Indonesia is not high in prevalence rates, but the transmission does not stop. According to Renstra (Rencana Strategis/ Strategic Plan) of Ministry of Health of Indonesia there was a sharp increase on HIV prevalence rates in 2009 to 2013. In 2009, the prevalence of people ages 15-49 is only 0,16%, then in 2013 it increased to 0,85%. The CFR (Case Fatality Rates) of AIDS which inversely proportional with its incidence rates, is also decreased from 13,65% in 2004, 0,85% in 2013, and still decreasing (Figure 1). From the data, it can be concluded that the transmission is more rapid than the case management. From 1987 up to September 2014, Ministry of Health recorded a total of 150,296 HIV positive patient, mostly infected by heterosexual infection (61,5%), injection drug users (IDU) in the amount of 15,2%, and homosexual infection (3,4%), the rest 17,1% with unknown risk factors (Figure 2).

Voluntarily Counselling and Testing (VCT) is the major important step to get early diagnostic and prevention of HIV. VCT has 3 phase: pre- and post-test counseling and an HIV test. VCT can only be started with the patientâ&#x20AC;&#x2122;s approval.4 All HIV testing services must include the 5 Câ&#x20AC;&#x2122;s recommended by WHO: informed Consent, Confidentiality, Counselling, Correct test results and Connection (linkage to care, treatment and other services). From 2007 to 2008, the number of facilities offering VCT increased 35% globally.

In December 2011, the Ministry of Health reported 500 active VCT sites in 33 provinces in

Indonesia. Unfortunately, Basic Health Research Indonesia recorded that peopleâ&#x20AC;&#x2122;s knowledge regarding to VCT existence was very low, about 6,2% of all population in 2010.

Indonesian government has indeed provided potential facilities on effort to manage HIV/ AIDS cases, which consists of qualified patient management, sufficient health professionals in several areas, health care (hospital, community health center), and also medical laboratory.

At least, there is four laboratories accredited with third level Biology Safety Laboratory (BSL 3), i.e. Agency for Health Research, Institute of Human Virology and Cancer Biology University of Indonesia, Tropical Diseases Institute University of Airlangga, and Eijkman Institute for Molecular Biology (Ministry of Health, 2015). These potential facilities have not been accessed optimally because of the lack of knowledge and awareness, which resulting in late diagnostic and treatment.

In 2012, Ministry of Health Indonesia has attempted to develop an application called AIDS digital that can be downloaded in variance operating systems in gadgets with purpose to educate people about HIV/ AIDS. There are several useful toolkits provided on the application, i.e. HIV testing, ARV therapy, People Living with HIV/ AIDS (PLHIV) support groups, sterile syringes, methadone, prevention of parent-child, reference AIDS hospital, sexually transmitted infections. It even provided the addresses of hospital, community health center or the places for various needs (test, treatment, syringes, etc.) in all over Indonesia, which shows huge potentials in helping more PLHIV with their needs either inward or physically, if the applications can be used optimally. Unfortunately, the fact that the applications was last updated in 2014 indicates that it has not been accessed on wide range people and the usage is not yet optimized. Moreover, the articles updated is less convincing because there is no writerâ&#x20AC;&#x2122;s identity and source.

The purpose of this study is to re-introduce fellow medical students and people about potential instruments related to the technology era to educate people regarding the importance of HIV testing and also to build platform for PLHIV to get their needs fulfilled by connecting them to government provided facilities to maintain their health by executing early diagnostic and prevention.

Methods This journals cited from journals and articles from national and international government website regarding HIV/ AIDS and AIDS digital application, which consist of several steps such as reviewing about HIV/ AIDS situation in Indonesia today, listing government attempts on combatting the disease, discovering potential attempts on solving the problems on conducting early diagnostic and prevention of HIV/ AIDS in Indonesia, searching on reasons why the instrument currently failed to be utilized effectively and developing concepts in order to re-introduce the instrument.

Results The study suggests that the utilization of AIDS digital application is a highly potential approach to reach HIV/ AIDS patient within the technology society. Nowadays, people who use internet to look for health information online keep increasing, especially in mid-high socioeconomic (MSE) community. A survey conducted shows that more frequent users of the internet were more likely to place the internet in their top five source of health information. The heightened use of online health information suggests that online information is likely to be a more important future source. By using formal applications that run under the Ministry of Health, it will reduce the searching time and opt out untrustworthy sites which can lead to misguided information.

Furthermore, AIDS digital was developed for high risk people ranging from 20-29 and 30-39 which generally have a fairly good understanding on handling technology based media.

AIDS digital application is designed through cooperation between the Ministry of Health and Indonesia Aids Coalition (IAC). This application can be accessed through website (i.e., www.aidsdigital.net) or smartphones with Blackberry AppWorld, Apple Store, and Play Store.

According to Hind et al. in 2011, as Indonesia progresses economically toward a middleincome country, it is expected to eventually lower its dependence on foreign financing for

the health sector. As foreign funding will decline in the near future, it is necessary for Indonesia to strengthen its national mechanisms, improve coordination among service providing agencies, and improve HIV/AIDS related service delivery at local levels. Agung Laksono, the Coordinating Minister for People’s Welfare also states, that, above all, Indonesia needs “good leadership and governance” in order to prevent “1.2 million new HIV infections by the year 2025” (Laksono, 2010).

Several attempts have been conducted by governments in solving HIV/ AIDS towards the future challenges: 1. Increasing coverage of HIV testing (including towards pregnant women) to reach more people on early diagnostic and prevention effort. The Ministry of Health provided 1.8 million HIV test reagents to be used in regions.

2. Increased condom use among the clients of sex workers, monitored by 428 health centers and hospitals.

3. Decreasing loss to follow-up numbers simultaneously in order to improve assistance to those eligible to participate and receive CD4 check.

4. Improve coverage of Anti Retro Viral (ARV) directly without checking CD4 counts, so that it doesn’t sacrifice the quality of effectiveness of coverage.

5. Minister of Health’s policy for regional autonomy which has become an opportunity for sustainable and effective AIDS prevention.

Even with all the attempts, the epidemic of HIV still risen sharply, caused by missing links between the facilities and the community itself. To utilize the facilities (i.e., treatment), the first step would be to do VCT. Several major clashes that hindered government’s current effort on rising number of people who are willing to do VCT for early diagnostic and prevention are lack of knowledge and awareness, also stigmas and discrimination of HIV/ AIDS patient inside the society. Actually, all the problems intricate to the lack of knowledge.

In Indonesia, education level is still low (i.e., people with high intelligence prefer to study abroad and stay) and most people believes what media says even if it is not true. Even, a non-medical fresh graduate’s knowledge about health cannot be guaranteed. Moreover, the medical knowledges that are hard to get is (not understandable for general people) lacking

socialization from the authorized institutions. Being hampered by the lack of knowledge makes people ignorance and becomes unaware of the risk, resulting in majority of patients got their test already being accompanied by severe symptoms such as candidiasis, pulmonary infections and neurological problems. A Cohort study in United States shows that people below the high school education had a 53% greater risk of death than their counterparts (Cunningham et al., 2005).

Earlier diagnostic and treatment will prevent the disease from progressing, and it can only be actualized when the person decided to do VCT, which can only happen if they were educated and informed about HIV/ AIDS, and sufficient enough to make them aware and make the decision. If people were to be socialized with AIDS digital, using analogy case e.g., go-jek application (i.e., AIDS digital) in Indonesia has been helping so much non-vehicle users (i.e., HIV/ AIDS patient) since the first time they were published. It has variance of helpful choice for the users, e.g., it escorts users to desired place (i.e., hospital or health center), it bought user’s desired things (i.e., sterile syringe, methadone), etc. The operation begins from Jakarta with small number of drivers, then started spreading as soon as everybody promoted and supported it (i.e., supports from government, PLHIV, health workers). Even when it gets known and developed to other cities (i.e., Bandung and Bali), the applications did not stop and was updated with more variance of choice and news, which makes go-jek a competitive application even when other new applications popped in. It can be seen how the development of go-jek application influenced other applications to popped in one by one. Moreover, gojek application developed transparency to its users which is the most important point in gaining the user’s faith, which is still lacking in AIDS digital application’s articles and make it less convincing to the society.

Although VCT services may have increased in number, there are still many people left out there not wanting to take the test or remain unaware of their HIV status. The main reason is because there is stigma and discrimination related with HIV/AIDS people inside the society in Indonesia. The WHO cites fear of stigma and discrimination as the main reason why people avoid to get tested, they don’t want others to know their HIV status because consequences of stigma and discrimination are wide-ranging. People were afraid to be shunned by the community, their peers, and even family. The unwillingness to take an HIV

test means that the person would be diagnosed late, when the virus may have developed to AIDS phase and gets too late to be treated. This situation created less effective treatment which results in being contagious to others and can causes early death (“What is HIV/AIDS”, 2015). In Indonesia HIV/AIDS related stigma and discrimination is considered to be a serious problem because less people really understands about HIV/ AIDS itself. Cases of violence against people with HIV/AIDS in Indonesia executed by members of police and health professionals have reported. Moreover, people with HIV/AIDS often shunned by people around them and may not be able to get a proper job. Such discrimination being thrown makes people with high risk or HIV/ AIDS patient avoid visiting health centers and do VCT. Apart from affecting the physical well-being of PLHIV, such stigmatization affects their psycho-social life and sooner or later they would feel worthless and unwanted (“Stigma, discrimination and HIV”, 2015).

The core problem on stigmatization is also lack of knowledge. Non PLHIV or people who feels that they do not belong to HIV/ AIDS high risk group would have less concerned and attention to the disease. This will cause them to generate bad perspectives which comes from the stigma which already have rooted within the society. Therefore, this problem can also be solved if the AIDS digital manage to be introduced and also updated constantly with information about HIV/ AIDS (i.e., a statement that can straighten the stigma).

Discussion Society nowadays is full of network, that means a society constructed around personal and organizational networks powered by digital networks and communicated through the internet and know no boundaries. Academic research has established that internet does not isolate people, internet actually increases sociability. Study by Michael Willmott showed that internet use empowers people by increasing their feeling of security, personal freedom, and influence, all feelings that have a positive effect on happiness and personal well-being.

Internet helps women as the center of the network of their families to organize their lives and helps them to overcome their isolation, particularly in patriarchal societies (Castells M., 2014).

After reviewing the usage of the internet, looking at it functions and facilities provided, AIDS digital application with more reliable source has high utility value, particularly for PLHIV. However, after several years had passed since it was launched this application becomes inactive (i.e., no new news updates, no review from the users on website which can be seen from Figure 3). Whereas on 6 days after AIDS Digital was first launched, about 700 people has downloaded the application, but up until now there has not been any significant changes on it. AIDS digital application which currently inactive, actually hides a great potential within the field of HIV / AIDS if it used optimally. This application helps to simplify PLHIV’s life who are already in hardships suffering HIV/ AIDS. As mentioned before, there are several services in the application such as HIV testing, which provides the address of hospitals which available in 33 provinces in Indonesia along with the phone number. However, AIDS digital currently still hasn’t provide information from all of the hospital in Indonesia. Several probabilities on why this application is currently inactive (i.e., looking at the application’s website) are it lacks socialization towards the society either the application on mobile devices, its facebook page or its website.

Such conclusion taken because the result of searching on google search engine with keywords "AIDS digital" and “Kemenkes” (Kementrian Kesehatan/ Ministry of Health) which led to a result that the socialization and introduction that was conducted on this application were just booming at the beginning of the official launch of this application in July 2013. From 39.800 search results about the promotion of this application, the promotion only occurred about 30 results and by each passing year the results inclines. Supposedly, application that actively being used normally have feedbacks from the users, just like go-jek application.

The suggestion to government are to develop and update the AIDS digital with new improvements that is more interesting and update news routinely about HIV/AIDS situation in Indonesia, because the current AIDS Digital application only update news few times in a year (Figure 4). Such application that has high potential in approaching the high risk groups should be used optimally. Moreover, AIDS Digital application is the first application in Asia Pacific with HIV/AIDS basis. Supports from government, health workers, medical student and the users of AIDS digital are needed to maintain continuity on this potential application.

Socializing or re-introducing the application can be done at certain health event such as World AIDS Day on December 1st, or displayed at one of the Ministry of Healthâ&#x20AC;&#x2122;s advertisement so that the application can reach out and be trusted by the society.

Furthermore, we are living in a condition where media is saturated in our environment and it is indeed an important instrument to deliver government policies and thoughts to the society.

The media that used properly can reach out and give a positive impact to the community.

Reports on the influence of media in United States can be seen in Figure 5.

Conclusion 1. HIV/ AIDS has been an unsolved problem for Indonesia. The core problem is HIV/ AIDS is epidemic and fast to spread, still increasing at sharp pace from 2009 (0,16%) to 2013 (0,85%). Two groups with highest risk to HIV/ AIDS are 20-29 (49,57%) and 30-39 (29,8%), with the most HIV accumulation infections in DKI Jakarta according to Ministry of Health 2014 reports (Figure 6). If there is no significant action being taken, Indonesia will reach 1.2 million new HIV infections by the year 2025. Moreover, there will be decrease of funds in HIV/ AIDS case because Indonesia is now stepping towards the middle income country category. Indonesia needs good governance and leadership with plan that can make progress to achieve our goal, which is getting to three zeroes: zero new HIV infection, zero stigma and discrimination, zero AIDS related death and the SDG-3 in time (i.e., 2030).

2. Up until today, government has provided facilities like qualified patient management, sufficient health professionals in several areas, health care (hospital, community health center), and also four medical laboratories accredited with third level Biology Safety Laboratory (BSL-3). Unfortunately, it is hardly accessed by the high risk people or the society because there are several barriers between the society and governmentâ&#x20AC;&#x2122;s facilities. Which are the lack of knowledge and awareness, stigmatization and discrimination. Government cannot force the society to do VCT, unless the person had developed AIDS symptoms which means early diagnostic and treatment failed to be conducted.

3. To achieve early diagnostic and treatment, the most important step should be doing Voluntarily Counseling and Testing (VCT) which consists of 5Cs according to WHO e.g., informed Consent, Confidentiality, Counselling, Correct test results and Connection. Last report in 2010, society’s knowledge about VCT is still very low (6,2%) and it still needs approach to reach more people.

4. AIDS digital were one of the attempt conducted to combat HIV by the Ministry of health coordinating with Indonesia Aids Coalition (IAC). It was designated to achieve MDG-6 which already finished in 2015. The application was published in 2012, but officially launched in 2013 on the Ministry of Health’s website. This application can be accessed through website and also smartphones, available in three operating system platform e.g., Blackberry z10, iOs and Android (i.e., Blackberry AppWorld, Apple Store, and Play Store. The target of this app is groups of high risk people, especially the adolescence whom considered generally to have fair understandings towards the technology based health application.

5. AIDS digital application consists of several useful services, e.g., HIV testing, ARV therapy, People Living with HIV/ AIDS (PLHIV) support groups, sterile syringes, methadone, prevention of parent-child, reference AIDS hospital, sexually transmitted infections. It is a potential instrument in approaching today’s technology society. But it needs supports from every concerned parties (i.e., government, authorized institution, health workers, PLHIV itself) to actualized its functions. Unfortunately, it has been lacking supports and promotion (i.e., it didn’t even pop in when it was searched in google because it was lack of updates), which results in lack of people knows the existence of the app which caused only a little or even nobody used it anymore with the application’s facilities left with no reviews and has stopped updating in 2015.

6. Today, the applications either on website or smartphones haven’t been getting any updates anymore. The smartphone’s application was last updated in 2014 with only 1 updates per year. As the analogy has been said before (i.e., go-jek analogy),

application updates were crucial thing that keeps customer interests to make decision to keep using the application.

7. To reach SDG-3 and our main goal that aims for all people well-beings and especially for our commitment aims for three zeroes, we can further develop the applications and re-introduce it to public. Several variance of choices can be updated to reach wider range of people. On adolescence and adults, the apps need socialization more (i.e., show the testimony/ feedback), more news updates about HIV/ AIDS today. And then, not only to reach adolescence and adults, but also to reach children by developing simple games that teach them about HIV (i.e., retrovirus attacking white blood cells, love PLHIV by giving hug) and it can teach them even better than words. This will further inform our new generation at an early age to maintain and continue our achievement later up until 2030.

8. The application itself should look for opportunity to re-introduced once more by taking chance to be socialized in special days (e.g., AIDS day), with help from medical studentâ&#x20AC;&#x2122;s campaign. (it can be launched in local Jakarta first, then when it already got the faith from the users it can be spread like go-jek application)

9. A potential instrument that does not used is a waste. The suggestion is for the government to update and re-introduce it to the society with the help of mass media through advertisement on television, health campaign with our help as a medical student. Empowered by all the partiesâ&#x20AC;&#x2122; support together, the applications will succeed in approaching the society to do VCT. References 1. About

HIV/AIDS.

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6).

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5).

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Retrieved from http://kominfo.go.id/index.php/content/detail/3980/Kemkominfo%3A+Pengguna+Int ernet+di+Indonesia+Capai+82+Juta/0/berita_satker#.VpDowlly3IV 9. Peluncuran Aplikasi AIDS Digital: HIV dan AIDS Information Right on Your Hand.

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publik/Renstra-2015.pdf 12. Responding to HIV and AIDS [PDF document]. (2012, October). Retrieved from http://www.unicef.org/indonesia/A4-_E_Issue_Brief_HIV_REV.pdf

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Figures Figure 1. AIDS Case Fatality Rate 2000-2014

Figure 2. AIDS Percentage Based on Risk Factor 1987-2014

Figure 3. AIDS Digital Website Review

Figure 4. AIDS Digital Mobile Display with Rarely Updated Articles

Figure 5. Accumulation of HIV Infection 1987-2014

Figure 6. Penetration of Select Media in the United States, 2010

118

CIGACARD AS THE NOVEL CONCEPT IN SUPPORTING THE SURVEILLANCE OF TOBACCO USE AND DISTRIBUTION IN INDONESIA Stefina Gunawan, Kezia Joselyn, Ayudhea Tannika AMSA-Universitas Kristen Krida Wacana

ABSTRACT Introduction: Tobacco consumption in Indonesia has increased significantly in the last two decades due to several factors. This alarming situation prompted us to improve public policy.

Several efforts have been implemented in Indonesia in the last 15 years. But, we can still see a lot of disobedience in society. The objective of our paper is to suggest a novel concept named CigaCard to support government regulations regarding tobacco distribution surveillance in Indonesia.

Methods: This study is conducted by several steps such as discussing several ideas regarding tobacco control, searching the official reports and articles associated to tobacco survey in Indonesia, reviewing what kind of prevention has been done in tobacco surveillance, looking for the potential concept in controlling tobacco access and distribution among people, and constructing certain steps in enacting new regulation in tobacco control.

Results: Current smoking habit in Indonesia is more prevalent in the middle-age people in rural areas. It has the highest prevalence among those with less than primary school education.

In the matter of tobacco productsâ&#x20AC;&#x2122; varieties, kretek is the most commonly purchased by Indonesian smokers. It has been demonstrated that tobacco use has serious negative health effects for nearly every organ in the body. Government regulations regarding tobacco control donâ&#x20AC;&#x2122;t seem to work well, and still seem weak compared to other countries. On the other hand, there has been reluctance of the government to combat cigarette consumption in Indonesia.

Conclusions: The surveillance on tobacco use by Indonesian government are still sorely lacking. CigaCard system aims to restrict purchases and consumptions of cigarettes. By doing so, it may prevent uncontrolled sales and therefore helps the government in controlling

tobacco use in society. However, this concept still needs considerable reviews, researches, and trials before it is implemented in our community.

Keywords: CigaCard, cigarette, kretek, tobacco control

CIGACARD AS THE NOVEL CONCEPT IN SUPPORTING THE SURVEILLANCE OF TOBACCO USE AND DISTRIBUTION IN INDONESIA

Stefina Gunawan, Kezia Joselyn, Ayudhea Tannika

ASIAN MEDICAL STUDENTS‘ ASSOCIATION UNIVERSITAS KRISTEN KRIDA WACANA JAKARTA 2016

INTRODUCTION AND OBJECTIVES Tobacco consumption in Indonesia has increased significantly in the last two decades due to several factors, such as the growth of the population, the relatively cheap price of cigarettes, and aggressive marketing of tobacco industries. This alarming situation prompted us to improve public policy, to plan a comprehensive tobacco control program and to propose more strict laws and regulations. Several efforts have been implemented in Indonesia in the last 15 years, including periodic increase of tobacco tax, expansion of smoke free areas and working places, public transport facilities; requirement to put the health warning on cigarette packaging and restriction on broadcasting time of electronic advertisement.

Right now, tobacco control in Indonesia is regulated in Government Regulation (Peraturan Pemerintah) No. 109 in 2012 about Security of Ingredients Containing Addictive Substance in Tobacco Products for Health Benefits. This regulation is a derivative of the Act No. 36 of 2009 on Health.

This regulation is organized with the aim to protect the health of people from the dangers of materials containing carcinogens and addictive substances in tobacco products that can cause disease, death, and lower quality of life; protect the population of childbearing age, children, adolescents, and pregnant women from environmental encouragement and influence of advertising and promotion of tobacco products; increase public awareness about the dangers of smoking and the benefits of living without smoking; and to protect public health from passive-smoking.

But, despite the detailed regulation regarding production, distribution, and promotion of tobacco products, especially cigarette, we can still see a lot of disobedience in society.

The objective of this study is to provide a platform for medical students to exchange knowledge regarding national policies on tobacco control and to introduce fellow medical students and people about potential concept in surveillance and prevention against tobacco use in Indonesia.

METHODS The method used for this paper is literature review. This study is conducted by several major steps such as discussing several novel ideas regarding tobacco control, searching the worldwide websites, official reports and articles associated to tobacco survey in Indonesia, reviewing what kind of prevention has been done in tobacco surveillance, looking for the potential concept in controlling tobacco access and distribution among people, and constructing certain steps in enacting new regulation in tobacco control.

RESULTS In August 2006, the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC) convened an expert consultation to discuss adult tobacco surveillance and make recommendations for the development of a standard survey protocol.

The expert consultation also recognized the challenges of limited funding and methodological complexities when conducting systematic adult tobacco surveys, and identified a lack of comparability in ongoing national surveys.

Indonesia, the Tobacco Country Indonesia is the fifth-largest producer of tobacco leaf. It is among the five topmost producers and exporters of cigarettes. Indonesia is the fourth-largest cigarette consuming country. It ranks third in the number of men smokers and 17th for women smokers. In 2008, cigarette consumption in Indonesia was 225 000 000 billion sticks. The country is the third-largest cigarette consumer in the world.

Kreteks (pronounced “cree-techs”) are clove cigarettes. Kreteks are popular in Indonesia, and typically contain a mixture consisting of tobacco, cloves and other additives. Broadly speaking, there are two types of manufactured cigarettes in Indonesia–kreteks and white cigarettes. Indonesian kreteks, both machine-manufactured and hand-rolled, have a higher tar level than white cigarettes (more than 10 mg tar). The most common tar level for “mild” kreteks is 14 mg tar and 1 mg nicotine. Indonesia is one of the world's most attractive cigarette markets and international companies have been keen to establish themselves. The major cigarette manufacturers are Gudang Garam, HM Sampoerna (PMI), Djarum, Bentoel (BAT) and Nojorono.

Prevalence of Tobacco Smokers in Indonesia

Table 1 gives the prevalence of smoking tobacco by “current tobacco smokers” and “nonsmokers”. Current tobacco smokers include “daily smokers” and “occasional smokers”.

Non-smokers include “former daily smokers” and “never daily smokers”. The overall prevalence rate of current smokers is 34.8%. It is particularly high among men (67.0%), who have 30 times the prevalence rate of women (2.7%). Non-smokers account for 65.2% of the overall adult population. Among them, only 3.3% are former daily smokers and 61.9% are never daily smokers. The proportion of never smokers among women is 95.3% while that among men is 22.0%.

Table 1. Percentage of adults ≥15 years old, by detailed smokeless tobacco use status and gender – GATS Indonesia, 2011

Current smoking is more prevalent in the age group of 25 – 44 and 45 - 64 years as compared to the younger (15–24 years) and older age groups (65+ years). Kretek smoking is more prevalent in the age group of 25–64 years as compared to the younger (15–24 years) and older age groups (65+ years), while hand-rolled cigarette smoking showed a definite increasing trend with age. White cigarette smoking did not differ by age.

Table 2 presents the estimated number of adult smokers corresponding to the prevalence estimates presented on smoking status in Table 4.1 by gender. The estimated number of adult smokers in Indonesia is 59.9 million (57.6 million men and 2.3 million women). The number of daily smokers is 50.3 million and the number of occasional smokers is 9.6 million). The estimated number of non-smokers is 112.2 million, of whom 5.7 million are former daily smokers and 106.6 million are never daily smokers.

Table 2. Number of adults ≥15 years old, by Detailed Smoking Status and Gender – GATS Indonesia, 2011

Smoking is more prevalent in rural areas as compared to urban areas. Kretek and hand-rolled cigarette smoking is more prevalent in rural areas as compared to urban areas. White cigarette smoking is more prevalent in urban areas. Other smoking products did not differ by residence. The prevalence rate of any smoked tobacco product is highest among those with less than primary school education (38.0%) and lowest among those with college or university education(27.6%). Kretek smoking did not show any difference by educational category, while hand-rolled cigarette smoking was higher among the less educated (less than primary, and primary) as compared to those who were more educated (high school and college/university educated). White cigarette smoking is higher more in college/university educated people as compared to less educated people (primary or less than primary).

Table 3 gives the average number and percentage distribution of any type of cigarette smoked per day among daily smokers. The overall figure is 12.8 sticks per day. About 34% of daily smokers smoke 10–14 sticks per day, and only 6.3% smoke 25 or more sticks per day. For men, the overall average is 13.0 sticks per day and for women it is 8.1. Among men smokers, the highest proportion smoke 10–14 sticks (34.7%), while among women smokers it is 5–9 sticks (36.6%). There are no women smokers who smoke 25 or more sticks per day, as against 6.5% among men smokers. The overall average numbers of cigarettes smoked per day is similar for all age groups, ranging between 11.4 and 13.2 sticks. In the adolescent age group (15–24 years), the highest proportion of average cigarettes smoked per day (26.8%) is 15–24 sticks per day.

The average number of cigarettes smoked per day in rural areas is 13.3 as against 12.3 sticks in urban areas. The highest prevalence (34.7%) in both urban and rural areas is 10–14 sticks per day and the lowest (4.4%) is 25 or more sticks per day.

Table 3. Average number and percentage distribution of cigarettes smoked per day among daily cigarette smokers ≥15 years old – GATS Indonesia, 2011

Based on the educational level, those with college or university-level education smoke the most every day (13.7 sticks). Among them, 46.2% smoke 15–24 sticks per day. The highest average number of cigarettes smoked daily for all other educational levels is 10–14 sticks.

By occupation, the highest average number of cigarettes smoked per day is among those who are self-employed (13.5 sticks) and the lowest average number is smoked by home-makers (7.6 sticks). More than half of the smokers in the home-maker group (58.7%) smoke 5–9 cigarettes per day and none smoke 25 or more per day. The self-employed group has the highest percentage of smokers who smoke 25 or more cigarettes daily (8.2%).

Table 4 shows that overall, kretek cigarettes were most commonly purchased at kiosks (79.8%) and at stores (17.6%). The largest proportion that purchased the cigarettes at kiosks was men (79.9%), those in the age group of 15–24 years (81.1%), and rural dwellers (80.6%).

The other sources of purchase (2.6%) included street vendors, duty-free shops, outside the country and from another person.

Table 4. Percentage distribution of kretek cigarette smokers ≥15 Years Old, by the source of last purchase of kretek cigarettes and selected demographic characteristics – GATS Indonesia, 2011

Impacts of Smoking on Health Cancers are responsible for one-third of these deaths, and cardiovascular and chronic respiratory diseases are each responsible for 30 percent of deaths. These projections find that smoking will kill 50 percent more people in 2015 than HIV/AIDS, and will account for 10 percent of all deaths globally. Estimates show that tobacco consumption causes up to 200,000 deaths annually in Indonesia. The main causes of tobacco attributable mortality in Indonesia — similar to the causes in global estimates — are heart diseases, stroke, cancers, and respiratory illnesses, particularly chronic obstructive pulmonary disease. It has been demonstrated that tobacco use has serious negative health effects for nearly every organ in the body.

Secondhand smoke is carcinogenic to humans. Secondhand smoke kills about one nonsmoker for every eight smokers that die from active smoking. Multiple studies have demonstrated increased risk of serious diseases caused by exposure to secondhand smoke.

Nonsmoking women exposed to secondhand smoke in the home have a 25 percent increased risk of lung cancer, with longer exposure corresponding to higher risk. Studies among nonsmoking Indonesian women with smoking husbands demonstrated higher risks of lung cancer compared with nonsmoking women with nonsmoking husbands.

Other studies have demonstrated a 23 to 25 percent increased risk of heart disease from exposure to secondhand smoke. Even low levels of exposure increase the risk of heart attacks and heart disease. Significantly reduced coronary flow velocity reserve has been reported in nonsmokers after 30 minutes of exposure to secondhand smoke, indicating loss of endothelial function that leads to vascular diseases. This suggests that even short periods

of exposure to secondhand smoke could have long-term negative health effects. More than 97 million nonsmokers in Indonesia are routinely exposed to secondhand smoke. Exposure to secondhand smoke leads to serious illnesses for children, including a higher risk of sudden infant death syndrome (SIDS), acute respiratory infections, ear disease, and severe asthma.

Among school children in Jakarta and Java, between 76 and 82 percent report exposure to secondhand smoke in public places. Some 70 percent of all Indonesian children less than 15 years of age are regularly exposed to secondhand tobacco smoke.

Relationships between Health and Economic Productivity Based on the established theories of health as a form of human capital, Bloom and Canning describe four ways in which health contributes to economic prosperity. First, healthy people are physically and cognitively stronger, leading to longer working hours, fewer sick days, and higher productivity at work or in school. Second, healthy people have longer life expectancies. This creates incentives for investments in health, education, and other forms of human capital. Third, greater longevity induces higher levels of retirement savings during working life. Foreign investors look to economies with a healthy labor force. Fourth, a healthier population reduces demand for children via lower mortality rates. The changes from high to low mortality and fertility lead to increases in the proportion of working age adults â&#x20AC;&#x201D; a key determinant of economic growth. Whereas better health promotes a countryâ&#x20AC;&#x2122;s economic performance, the reverse is also true. Poor health can inhibit economic growth. In the case of tobacco, smoking reduces physical strength and lung capacity. In addition to other serious long-term conditions, tobacco consumption diminishes overall immune function, which leads to higher rates of general infections among smokers.

Government Regulations regarding Tobacco Control in Indonesia Chapter I article 1 of the regulation states that non-smoking area is a room or area that is otherwise prohibited to production, sales, advertising, promotional and/or use of cigarettes.

And chapter III article 50 states that non-smoking area includes public places, health facilities, workplaces and places specifically use as learning area, the arena of children's activities, places of worship and public transport. However, in reality people are still smoking in these places without any consequences. In August 2015, The Jakarta Environmental Management Agency (BPHLD) has disclosed that 90% of malls and shopping centers that they inspected in Jakarta were in violation of Gubernatorial Regulation

No. 88/2010 on no-smoking areas. Also, a survey shown that there are cigarette advertisement found in 85% of school in Indonesia. Another survey found that 70% of students started smoking because the influence of such advertisement.

Chapter 4 article 14 states that every form of advertisement has to mention danger of smoking and include pictorial health warning (PHW). But, as of June 2014, only 13,45% cigarette packs have included PHW. The Faculty of Public Health, University of Indonesia coordinated a survey in the last week of August 2014 – the end of the extended implementation period – to assess the progress of compliance at points of sales (POS). No cigarette brand variants assessed in the survey fully complied with the PHW requirement at all POS sites. Between 40-60% of brand variants were non-compliant (had no PHW at all), and 4-5% were partially compliant (had a PHW, but with other violations of the law such as excise stamps obscuring the warning on the packs). In addition to pictorial health warnings, information is also required on all packs to advise that there is “no safe level” of tobacco use and that cigarette smoke “contains more than 4,000 hazardous chemicals and more than 43 cancer-causing agents”. No domestic brands of the top five manufacturers provided this information. Five of the largest tobacco companies, which collectively control 90% of the market, showed low compliance.

And sadly, even when pictorial health warnings “created strong reactions from smokers”, people’s common reaction was to look for packs with no warnings at all, or to choose “the least scary picture” — one which shows a ‘smoking man’ with a skull background instead of the horrific images of charred lungs and throats.

Overall, these regulations don’t seem to work well, and still seem weak compared to other countries. Chapter III article 25 states that tobacco products aren’t to be sold to children under 18 years old. But we can see obvious violation of the regulation. Smoking among minors is consider a normal thing in Indonesia, many would even consider it a right of passage. At kiosks, cigarettes can be bought by the stick rather than in packs, making them even more affordable for children. Lisda Sundari, deputy director for education and advocacy at the local children NGO Lentera Anak, said the number of children aged 10 to 14 who smoke has doubled over the past 20 years, and has at least tripled for 5- to 9-year olds.

On the other hand, there has been reluctance of the government to combat cigarette consumption in Indonesia. For instance, Indonesia is one of 8 countries, and the only one left in Asia that has not ratified the Framework Convention on Tobacco Control (FCTC) of the World Health Organization (WHO). This treaty aims “to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke" through a set of universal standards stating the dangers of tobacco and limiting its use worldwide.

DISCUSSION Roles of Health Workers in Tobacco Use Prevention and Cessation in Indonesia In May 2015, The Indonesian Minister of Health, Prof. Dr. dr. Nila Farid Moeloek, Sp. M (K) said that every health care facility has opened various services for smoking cessation. At the first level of health care facilities, the smoking cessation program includes counseling, building motivation, and creating a supportive environment, while at the advanced level, smokers will be given further counseling and treatment from health specialists.

In addition, medical students from all over Indonesia has been conducting anti-smoking actions. The actions include days without cigarettes, seminars, giving posters, banners, and stickers. There are some concrete examples performed by medical students throughout Indonesia. Students from several medical schools in Malang held “Aksi Damai Tanpa Rokok” in 2014 to mark No Tobacco Day.5 They did the campaign with posters, banners, and stickers depicting the dangers and risks for active and passive smokers. These activities are expected to increase public awareness of the dangers of smoking. Another unique activity is created by the Student Association of Public Health Department, Faculty of Health Science State Islamic University of Alauddin Makassar. They held a selection of “Anti-Smoking Ambassador” every year. The chairman of this committee, Irzan Yusfa Randa, hoped the chosen Ambassador of Anti-Smoking could reduce the number of smokers among students and staffs at the State Islamic University of Alauddin Makassar, and also could empower other students and people in community to join anti-smoking action.

Indonesian Pulmonologists Association (Persatuan Dokter Paru Indonesia) in collaboration with the Faculty of Medicine University of Sebelas Maret and the Faculty of Health Science

University of Muhammadiyah Surakarta, organized a seminar to mark World No Tobacco Day in June 2015. The seminar is entitled "Tobacco smoking vs. Electric Cigarettes". In 2015, they also set up a Tobacco Control Center named Tobacco Control Initiative to mark World No Tobacco Day in collaboration with university students in Solo.

CigaCard System Surveillance and prevention against tobacco use from Indonesian government and health professionals are still sorely lacking. We see people could buy cigarettes freely as many as they want without any age limit and with a cheap price. It gives great access for the public, including students. This makes us think of CigaCard system.

CigaCard is a cigarette card consists of barcode which contains the identity of its owner and the records of cigarette usage. CigaCard system aims to restrict purchases and consumptions of cigarettes in society. Each card has a limited purchase of cigarettes in a month. If the purchase exceeds the limit, the card owner has a right to choose either to buy or not. People who choose to buy above the limit must pay more expensive than the normal price.

However, this CigaCard system only runs if cigarettes are sold in supermarkets which use computers for every transaction. Therefore, government must watch every cigarette companies strictly â&#x20AC;&#x201C; companies may disregard this system and sell the cigarettes outside supermarkets. This system manages the purchase of cigarettes easier and controlled, because controlling supermarkets including its employees are much easier than stalls and kiosks.

Restricting the purchase of cigarettes may reduce people to sell cigarettes in their stalls, so it prevents uncontrolled sales. Though this system is ignored, Indonesian tends to break the rules - the purchase by the public, especially the middle and low class, will be decreased, seeing stallsâ&#x20AC;&#x2122; and small shopâ&#x20AC;&#x2122;s owner will raise the price to make profits. In addition, the limitation in this cigarette card makes people forced to reduce tobacco use in a day.

The freedom to buy cigarettes over the limitations hopefully reduce the protest which come from cigarette companies. According to the Ministry of Health of the Republic of Indonesia in 2010, the prevalence of smokers with low education and low income are higher than people with good education and high income.9 Therefore, increasing the price of cigarettes

that exceeds the limit is effective to reduce the rate of tobacco use in the population of middle and low class.

When a person wants to make a CigaCard, he must go to a counter near a supermarket. He must show his identity (ID) card to the officer. Then, the officer will enter the data from his ID card using a computer that connected to the central database. Every data has a different barcode which is on a cigarette card. Then, he must pay for the card.

Terms and conditions of CigaCard ownership are as follows. First, the tobacco companies must sell cigarettes only in supermarkets such as Carrefour, Alfamart, Indomart, etc. The employees must be obedient to the rules. Second, people can only buy cigarettes by having a CigaCard. CigaCards are available at the card counters which are built near the supermarkets to ease smokers having this card. The officers in each counter must be from the government to prevent rule-breaking. Third, people who want to make a cigarette card must be aged over 18 years by showing their identity (ID) card. A person only get one card, cannot be more.

Every card is recorded in the central database, along with data of the person it belongs to, to prevent somebody having more than one card. Fourth, the identity in a cigarette card must match the ID card, so it is not transferable. Fifth, there is no validity period for a cigarette card. Lastly, people must pay for the cigarette card (around Rp 15.000,00) â&#x20AC;&#x201C; because government needs money to produce cards. Fig 1 will show you the steps to get a CigaCard.

You are >18 years old + have ID card

Go to a CigaCard counter near supermarket

Show your ID card

The officer submits your data

Pay Rp 15.000,00

Get your CigaCard

Go to the nearest supermarket

Show your CigaCard and ID card to the cashier

The cashier checks and scans your ID card and CigaCard

You can only get 8 packs in a month.

Pay Rp 50.000,00 for each more

You get your cigarettes

Fig 1. How to Buy Cigarette Using CigaCard

CigaCard Terms and Conditions Terms and conditions of CigaCard usage are as follows. First, any people who wants to buy cigarettes must give a cigarette card and his ID card to the cashier. The cashier will check the suitability of those two cards after scanning the barcode on a cigarette card. Second, each card has a limit to purchase cigarettes (8 packs a month). Though US Surgeon General said, â&#x20AC;&#x153;There is no risk-free level of exposure to tobacco smoke, and there is no safe tobacco productâ&#x20AC;?, the safe nicotine concentration limit in cigarettes to the body is three cigarettes a day (According to the Agency of Forestry and Plantation of Bojonegoro). And the maximum number of cigarette packs allowed in each purchase is 2 packs (based on Ministry of Health of the Republic of Indonesia, 52.3% of Indonesian people consume 1-10 cigarettes a day).

If it exceeds the limit, the price of the cigarettes will be increased by 3 times than normal price (about 50.000 rupiah). Third, cigarette transactions are initiated by scanning a

CigaCard. Once connected to the central database, the computer screen will display the identity of its owner, number of purchases that have been made, and the remaining amount of purchases available. If it exceeds the limit, the cashier shall notify the consumer and ask if he wants to continue purchasing. If the consumer decides to continue the purchase, the consumer is obliged to pay higher prices according to the price that has been determined.

Fourth, the number of purchases on each cigarette card are managed by the government and cannot be contested. Last, if one of the officers or the cashiers is caught breaking the rules, he or she, along with the related supermarket will be penalized.

CONCLUSION As the third-largest cigarette consumer in the world, Indonesia has more challenges and obstacles in controlling tobacco, either it is in monitoring tobacco use and prevention policies, protecting people from tobacco smoke, or enforcing the bans on its promotion and advertising. The surveillance and prevention against tobacco use from Indonesian government and health professionals are still sorely lacking. CigaCard system aims to restrict purchases and consumptions of cigarettes, so by restricting the purchase of cigarettes may prevent uncontrolled sales and therefore helps the government in controlling tobacco use in society. However, this concept still needs considerable reviews, researches, and trials before it is implemented in our community.

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“OPTIMIZING HEALTH MANAGEMENT AND PROVIDE A BETTER HEALTH CARE TOWARDS CULTURE AND SOCIAL DIVERSITY” participate in IMSTC 2016

by AMSA-Indonesia

Arranged by :

Muhammad Zuhal Darwis

(110 2014 0085)

Andi Muh. Ariansyah Nazaruddin

(110 2014 0021)

Indah KurniaRamadhani M

(110 2014 0079)

FACULTY OF MEDICINE UNIVERSITAS MUSLIM INDONESIA 2016

137

ABSTRACT ANDI MUH. ARIANSYAH N., PRAMULIANSYAH HAQ, INDAH KURNIA RAMADHANI. 2016.â&#x20AC;? Optimizing Health Management And Provide A Better Health Care Towards Culture And Social Diversityâ&#x20AC;?

Background: Condition of health services industry is growing and full of dynamics problems. Health problems in Indonesia at this time was also full of good issues of quality of service, HR service providers, service management.

Health services in the future getting quite serious challenges, including in Indonesia. The first challenge, health care services are required to provide services at low cost (read: cheap) but must provide high quality services. Delivery of health services should be done with the full calculation and correct economic principles so that efforts issued by health service providers to be efficient. Health care providers are required to continuously improve service quality both from the aspect of satisfaction, comfort and safety of patients so that health care becomes effective. The second challenge, health care today is not only related to medical problems (technical medical) and health but also a matter of law (policy), economic and social. Beside that, Diversity that means something different to each and every person. The changing demographics and economics of our growing multicultural world and the long-standing disparities in the health status of people from culturally diverse backgrounds have challenged health care providers and organizations to consider cultural diversity as a priority.

Objective: To Optimizing Health Management And Provide A Better Health Care Towards Culture And Social Diversity. Method: This study is a research library, which is the writing that is implemented using the literature (literature), either in the form of books, records, and reports the results of previous studies.

Conclusion: By paying attention to the elements of the seven elements such as; 1) Legality, 2) Human Resources, 3) Facilities and Infrastructures, 4) Standardize, 5) Marketing, 6) Rates, and 7) Information Systems and then to achieve and qualified the human resources needs cultural competence which are: cultural Desire, cultural awareness, cultural knowledge, cultural skill and cultural encounters that can create and optimize health management which can be providing better health care.

Keywords: Health management, cultural diversity

138

A. Introduction Condition of health services industry is growing and full of dynamics problems. Health problems in Indonesia at this time was also full of good issues of quality of service, HR service providers, service management. Health services in the future getting quite serious challenges, including in Indonesia. (Burke., 2004) The first challenge, health care services are required to provide services at low cost (read: cheap) but must provide high quality services. Delivery of health services should be done with the full calculation and correct economic principles so that efforts issued by health service providers to be efficient. Health care providers are required to continuously improve service quality both from the aspect of satisfaction, comfort and safety of patients so that health care becomes effective. (Burke., 2004) The second challenge, health care today is not only related tomedical problems (technical medical) and health but also a matter of law (policy), economic and social. Health care providers today must understand the different kinds of rules or policies either in the form of regulations, guidelines, technical instructions of health services. Health care providers must understand the conceptand rules in the field of economics, including financial management, accounting, taxation. Health care providers must also understand the conditionsand social characteristics of the people in the working area of â&#x20AC;&#x2039; â&#x20AC;&#x2039;

the

delivery of services so that the provision of health services is inseparable from the norms, valuesand the prevailing culture in the local community. 209 Indonesian Health Administration Journal Volume 1 Number 3 July-August 2013 The third challenge, health care financing is done by the health insurance system (health coverage). The rate of increase in health care costs incurredgovernment and society to encourage the need for universal health insurance system (universal health coverage). That is, not a single soul in the world that does not guarantee health care costs. (Burke., 2004)

Indonesia has targeted the implementation of universal health financing system (universal health coverage) beginning in 2014. Expected in 2019 the entire populace in Indonesia has shaded universal health financing system.

Enactment of universal health financing system requires good preparation of the various elements. Enactment of universal health financing system (universal health coverage) in Indonesia is housed within several key policy 1) Law no. 40 of 2004 on National Social Security System and 2) of Law no. 24 of 2011 on the Social Security Agency. Further strengthened by 3) Regulation of the Minister of Health no. 001 of 2012 on Individual Health Services Referral System. (UU no.24., 2011)

B. Objectives â&#x20AC;&#x153;How Optimizing Health Management And Provide A Better Health Care Towards Culture And Social Diversity ?â&#x20AC;?

C. Methods This study is a research library, which is the writing that is implemented using the literature (literature), either in the form of books, records, and reports the results of previous studies. In this study has been carried out the data collection, the data were analyzed to obtain conclusions, forms a technique in data analysis techniques.

D. Results and Discussion Elements That Needs To Be Prepared To Provide Better Health Care There are at least 7 (seven) elements that must be organized and prepared a clinic in order to meet the era of BPJS 2014 among other things: 1) Legality, 2) Human Resources, 3) facilities, Infrastructures, 4) Standardize, 5) Marketing, 6) Rates, and 7) Information Systems. (Peraturan Menkes., 2012)

1) Legality As mentioned at the beginning that the health sector is not only intersect and dealing with the technical aspects of medicine, but also should consider the legal aspects (legality). In accordance with the mandate in 2011 on the 28-year Permenkes Clinic, the clinic can be a business entity. Forms of business entities are recognized, among others, the Company,Foundations or CV. Especially for major clinics offer only outpatient services, clinics ownership may individually bewithout having to form a business entity. (Peraturan Menkes., 2011) 2) Human Resources The readiness of human resources, especially human resources (personnel) health for medical personnel, nursing staff and non-medical personnel is an important element to consider in the implementation of the clinic. Readiness of human resources is the most important aspect of competence include: 1) knowledge, 2) the ability, 3) skills and 4) legality. Health professionals, especially medical personnel should have knowledge of the interrelationships between biological, social and emotional diseases faced (Ministry of Health Decree No. 039 of 2007).

Therefore, in providing services should utilize a holistic approach (holistic approach). In addition, energy must master the ability of medical and diagnostic skills, and the ability to refer to a reliable (Health Ministerial Decree No. 039 of 2007). The existence of the Regulation of the Minister of Health No. 001 of 2012 on Individual Health Services Referral System will only succeed when supported medical personnel with the ability to refer reliable.

(Peraturan Menkes., 2011) Not only the ability that we needed to create a better human resource but we also need a cultural

competence to handle patient form different culture and social diversity.

Diversity, It is a word that means something different to each and every person. The changing demographics and economics of our growing multicultural world and the longstanding disparities in the health status of people from culturally diverse backgrounds have challenged health care providers and organizations to consider cultural diversity as a priority. However, health care providers must realize that addressing cultural diversity goes beyond knowing the values, beliefs, practices and customs of African

Americans,

Asians,

Hispanics/Latinos,

Native

Americans/Alaskan Natives, and Pacific Islanders. In addition to racial classification and national origin, there are many other faces of cultural diversity. Religious affiliation, language, physical size, gender, sexual orientation, age, disability (both physical and mental), political orientation, socio-economic status, occupational status and geographical location are but a few of the faces of diversity. It will talks more the concept of cultural competence, describe a model of cultural competence that can be used in the delivery of health care services to address the many faces of diversity, and present a mnemonic to help in asking questions whose responses will facilitate culturally competent care.

(Harwood., 1981).

2.1

Culture and Cultural Competence The literature is saturated with many definitions of culture. Krober and Kluckhohn (1952/1978) cite over 164 definitions of culture. Late in the 1800s, Tylor (1871) defined culture "as that complex and whole which includes knowledge, belief, art, morals, law, custom, any other

capabilities and habits acquired by man as a member of society" (p. 1).

Cultural values give an individual a sense of direction as well as meaning to life. These values are held on an unconscious level. There is a direct relationship between culture and health practices. In fact, of the many factors that are known to determine health beliefs and behaviors, culture is the most influential (Harwood, 1981).

To meet the needs of culturally diverse groups, health care providers must engage in the process of becoming culturally competent. Cross, Bazron, Dennis, & Isaacs (1989) define cultural competence as "a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals and enables that system, agency or those professionals to work effectively in cross-cultural situations" (p. iv). The word competence is used because it implies having the capacity to function effectively.

2.2

A Model of Cultural Competence The Process of Cultural Competence in the Delivery of Healthcare Services Model is a model of cultural competence that defines cultural competence as "the process in which the health worker continuously strives to achieve the ability and availability to effectively work within the cultural context of a client individual, family or community" (Campinha-Bacote,1998, p. 6). This process requires health worker to see themselves as

becoming

culturally

competent,

rather

than being culturally competent. It includes consideration of cultural desire, cultural awareness, cultural knowledge, cultural skill (conducting culturally sensitive assessments) and cultural encounters (Campinha-Bacote, 2002a). This model of cultural competence is pictorially depicted as a volcano, which symbolically represents that it is cultural desire which stimulates the process of cultural competence.

When cultural desire erupts, it gives forth the desire to enter into the process of becoming culturally competent by being humble to the process of seeking cultural awareness, by obtaining cultural knowledge, by genuinely seeking cultural encounters, and by conducting culturally-sensitive assessments (showing cultural skill). To fully understand this model, each construct will be defined and discussed with examples coming from the many faces of diversity.

Figure 1 : Cultural Desire divided into 4 types

2.3

Cultural Desire

Cultural desire is defined as the motivation of the health worker to "want to" engage in the process of becoming culturally aware, culturally knowledgeable, culturally skillful, and seeking cultural encounters. It stands in contrast to the feeling of "having to" participate in this process (Campinha-Bacote, 1999). Cultural desire is the pivotal and key construct of cultural competence, for it is the nurse's desire that evokes the entire process of cultural competence. This desire must come from one's aspiration, and not out of one's desperation.

Cultural desire involves the concept of caring. It has been said that people don't care how much you know, until they first know how much you care (CampinhaBacote, 1998). Cultural desire includes a genuine passion to be open and flexible with others, to accept differences and build on similarities, and to be willing to learn from others as cultural informants. This type of learning is a lifelong process which has been referred to as cultural humility (Tervalon & Murray-Garcia, 1998).

Cultural desire also involves the commitment of the nurse to care for all clients, regardless of their cultural values, beliefs, customs, or practices. This may be difficult when caring for challenging patients or patients who engage in behaviors that may be in direct moral conflict with the health worker (e.g., abortion, substance abuse, spouse abuse, sexual addiction). An example of such a situation might arise when a health worker is asked to care for an Arab patient whose political and/or religious beliefs are in direct contrast to his/her beliefs. In this case, too,

commitment to the process of cultural desire requires the nurse to be available to care for patients, even when there may be a natural instinct to resign oneself from the nursepatient interaction. (Tervalon & Murray-Garcia, 1998).

One suggestion is to see the patient as a unique human being. We all come from the same race - the human race, with similar basic human needs. Our goal in providing culturally responsive care is to find common ground. Berlin and Fowkes' (1982) LEARN Model can assist the nurse in this process. The mnemonic LEARN, represents

the

process

of

listening,

explaining,

acknowledging, recommending and negotiating. The health worker must first listen to the patient's perception of the problem. This listening must be done in a non-judgemental manner, using encouraging comments such as, "Tell me more." The second step is for the health worker to explain his/her perception of the problem. The next key step is for the health worker to acknowledge not only the differences between the two perceptions of the problem, but to acknowledge the similarities. In developing a culturally responsive approach to care, the health worker must recognize differences, but build upon the similarities.

The fourth step is to make recommendations which involve the patient. Finally, the health worker is to negotiate a treatment plan, considering that it is beneficial to incorporate selected aspects of the patient's culture into the plan. (Fowkes., 1982) 2.4

Cultural Awareness

Cultural awareness is the self-examination and indepth exploration of one's own cultural background (Campinha-Bacote, 1999). This process involves the recognition of one's biases, prejudices, and assumptions about individuals who are different. Without being aware of the influence of one's own cultural values, there is risk that the health worker may engage in cultural imposition.

Cultural imposition is the tendency to impose one's beliefs, values and patterns of behavior upon another culture (Leininger, 1978).

One example of a culturally diverse group for which the health worker may want to closely examine his/her biases and beliefs, is the group of patients with disabilities. "Disability rights advocates often criticize health professionals, citing erroneous assumptions and failure to understand the perspectives of disabled persons" (Treloar, 1999, p. 358). Treloar further states that many health care providers practice from an illness-based model of disability and are unaware of the shift toward looking at disability as a problem that exists within the environment rather than the person. Some health worker haves used the term physically-challenged to capture this contemporary shift. Treloar asserts that effective interactions with people affected by disability begin with a personal awareness of one's thoughts and feelings surrounding disability, and encourages the nurse to ask the following questions: "Do my actions support stigma, isolation, and devaluation of people with disabilities? Am I sensitive to cultural differences in response to and support of this population?".

(Treloar, 1999, p. 358)

2.5

Cultural Knowledge Cultural knowledge is the process of seeking and obtaining a sound educational foundation about diverse cultural and ethnic groups (Campinha-Bacote 1998).

Obtaining cultural knowledge about the patient's healthrelated beliefs and values involves understanding their world view. The patients' world views will explain how they interpret their illness and how it guides their thinking, doing, and being. For example, although deafness can be defined physiologically as a loss of hearing, the majority of deaf people define it culturally, not physiologically (Stebnicki & Coeling, 1999). They believe that the most important quality of deafness is not the lack of hearing, but rather participation in the Deaf culture that is based on the American Sign Language and that values pride in this culture. Knowing the cultural values of the Deaf can help these clients use their usual coping responses in the midst of illness.

Treatment efficacy is another issue to address in the process of obtaining cultural knowledge. This involves obtaining knowledge in such areas as ethnic pharmacology.

Ethnic pharmacology is the study of variations in drug metabolism among ethnic groups. There are several factors that are involved in determining responses to a specific drug in ethnic groups. These factors include genetic, environmental, structural, and cultural variation in ethnic groups. For example, therapeutic ranges of lithium differs among ethnic groups. Lin, Poland, and Lesser (1986) reported that the therapeutic range of lithium for manic

patients in Japan and Taiwan to be 0.4 - 0.8 mEq/L, as compared to 0.6 - 1/2 mEq/L for patients in the United States.

In seeking knowledge about specific cultural groups, Campinha-Bacote (1998) and Purnell (1998) identified

four

stages

through:

unconscious

that

a

incompetence,

nurse

goes

conscious

incompetence, conscious competence and unconscious competence. Unconscious incompetence is not being aware that one is lacking cultural knowledge. This health worker has no awareness that cultural differences exist between themselves and the patient. Conscious incompetence is the awareness that one is lacking knowledge about another culture. The health worker may have recognized this incompetence by attending workshops on cultural diversity, reading articles or books on the topic, or having direct cross-cultural experiences with patients from culturally diverse backgrounds. These health worker posses "the ‘know that’ knowledge, but not the ‘know how’ knowledge" (Campinha-Bacote, 1998). They know that culture plays an important role in caring a patient, but do not know how to effectively use this knowledge.

Conscious competence is the intentional act of learning about the patient's culture, verifying generalizations and providing culturally responsive nursing interventions.

Unconscious competence is the ability of the health worker to spontaneously provide culturally responsive care to patients from diverse cultural backgrounds. The timing of an unconsciously competent nurse appears to be "a natural"

when observing their interacting with patients from diverse cultures (Campinha-Bacote, 1998).

In obtaining cultural knowledge, it is critical to remember the concept of intra-cultural variation - there is more variation within cultural groups than across cultural groups. No individual is a stereotype of one's culture of origin, but rather a unique blend of the diversity found within each culture, a unique accumulation of life experiences, and the process of acculturation to other cultures. Therefore, the health worker must develop the skill to conduct a cultural assessment with each patient.

(Stebnicki & Coeling, 1999) 2.6

Cultural Skill Cultural skill is the ability to collect relevant cultural data regarding the patient's presenting problem as well as accurately performing a culturally-based, physical assessment (Campinha-Bacote, 1999). Leininger (1978) defines a cultural assessment as a "systematic appraisal or examination of individuals, groups, and communities as to their cultural beliefs, values and practices to determine explicit needs and intervention practices within the context of the people being served. Cultural skill is also required when performing a physical assessment on ethnically diverse clients. The health worker should know how a patient's physical, biological and physiological variations influence their ability to conduct an accurate and appropriate physical evaluation (Purnell, 1998).

The literature provides the nurse with several cultural

assessment

tools

(Giger

&

Davidhizar,

1999; Kleinman, Eisenburg, & Good, 1978; Purnell, 1998).

However,

the health

worker

must remember that

conducting a cultural assessment is more than selecting a tool and asking the patient questions listed on the tool. The health worker 's approach must be done in a culturally sensitive manner. A situation in which the nurse would need to be very culturally sensitive might arise when the health worker is collecting data regarding the sexual orientation of a patient. In such a situation the nurse can avoid offending the patient by increasing his/her skill in addressing this question with all patients, by listening with interest, and by remaining non-judgmental regarding any responses given by the patient. The health worker may need to have many encounters with patients from this cultural group in order to formulate questions that are culturally sensitive. (Giger & Davidhizar, 1999; Kleinman, Eisenburg, & Good, 1978; Purnell, 1998).

2.7

Cultural Encounters Cultural encounter is the process which encourages the nurse to directly engage in face-to-face interactions with

patients

from

culturally

diverse

backgrounds

(Campinha-Bacote, 1998).

Interacting with patients from diverse cultural groups will refine or modify one's existing beliefs about a cultural group and will prevent stereotyping. However, the health worker must be cautious and recognize that interacting with only three or four members from a specific

ethnic group does not make one an expert on the cultural group. It is possible that these three or four individuals may or may not truly represent the stated beliefs, values, and/or

practices

of

their

specific

cultural

group.

(Campinha-Bacote, 1998) Cultural encounters also involve an assessment of the patient's linguistic needs. Using a formally trained medical interpreter is necessary to facilitate accurate communication during the encounters. The use of untrained interpreters, friends, or family members may pose a problem due to their lack of knowledge regarding medical terminology and disease entities. This situation is heightened when children are used as interpreters. One glaring example of the failure to used a formally trained interpreter comes from the authorâ&#x20AC;&#x2122;s experience. The case involved an obstetrical health worker who needed to communicate to her patient that she was going to deliver a stillbirth. The health worker did not speak Spanish and used the patient's 6 year old daughter to interpret to the mother that the baby was dead. (Campinha-Bacote, 1998) Service delivery does not meet the policy (rules, regulations) regarding the referral criteria will not be verified by the administering body and will not be covered. Policies on individual health care referral system should be well understood by health personnel employed by clinics that do not harm the clinical management. Intense communication necessary for the implementation of individual health care referral system is good for service providers (clinics and health workers) and service users (patients and society). (Peraturan Menkes., 2011)

The entire facility, facilities and infrastructure owned clinic should be equipped with permits and standards set by the authorities. Standards that must be considered include quality standards ,safety

standards and safety and air worthiness

standards. The provision of facilities, standardized infrastructure willing crease the "bargaining power" with the BPJS when negotiating a cooperation contract. 214 Indonesian Health Administration Journal Volume 1 Number 3 July-August 2013 Completeness infrastructure owned clinic is an effort facility health in achieving standardization of services. (Peraturan Menkes., 2011) 3) Facilities (Facilities and Infrastructure) In accordance with Regulation of the Minister of Health No. 28 of 2011 on the clinic, clinic location requirements should follow the Spatial Plan (RTRW) administered by the local government. Location clinic as a business unit (due to its status as an entity) then it should comply with the designation RTRW as a business area. Location clinics that do not fit his RTRW designation would be risky to move the location by the local government, or at least will not be granted permission to set up a clinic. Shaped permanent clinic building required and should not be joined residence and qualify a healthy environment. This requirement was a good goal, but the consequences are huge costs for the clinic manager primarily related to taxes and utility costs (water, electricity, telephone. The entire facility, facilities and infrastructure owned clinic should be equipped with permits and standards set by the authorities. Standards that must be considered include quality standards, safety standards and safety and airworthiness standards. The provision of facilities, infrastructure is standardized increase the "bargaining power" with the BPJS

when negotiating a cooperation contract. Completeness of facilities and infrastructure owned clinic is one of the efforts to achieve standardization of health facilities services. (Peraturan Menkes., 2011) 4) Standards Service Facilities clinic as a health care provider must provide standardized services. Medical care is one of the services provided by the clinic. The provision of medical services in Indonesia is regulated in the Regulation of the Minister of Health No. 1438 of 2011 on Standards of Medical Care. In the policy, the provision of medical services is required to refer to the clinical practice guidelines (hereinafter referred PPK) are set in a care facility health. Clinic must immediately prepare a document for the CO as guidance services include: Guidelines for Diagnosis and Therapy, Clinical Pathways, and formulary. For the sake of standardization better, be more efficient if all the clinics in the region to discuss the joint KDP so that the provision of medical services at the clinic in a region becoming increasingly standardization.(Peraturan Menkes., 2011) To achieve the standardization of services should be supported by the Minimum Service Standards (hereinafter referred to as SPM) and Standard Operational Procedures (hereinafter referred to as SPO). Clinics must have service indicators as a tool for quality control of services provided to the patient. In order to achieve the indicator (SPM) that has been set, it takes SPO as operational steps and activities of the service providers. In general, the SPO document may include: 1) SPO Services, 2) SPO Administration, 3) Technical SPO, and 4) SPO Safety and Security.(Peraturan Menkes., 2011)

5) Marketing The scope of the clinical management are essential to be prepared is marketing. Marketing function plays an important role in the industryhealth services. Marketing functions to be performed by the clinic are not just doing the promotion and advertising. According to Kotler et al (2001), marketing as: "A social and managerial process by the which individuals and groups Obtain what they need and want though creating and exchanging products andvalue with each other ". Referring to these definitions, the clinic should be able to create and deliver the product as well as the value of the product. Thus, the clinic should perform the function of STP (Segmenting-Targeting-Positioning). Clinics should have an overview of the existing market in the region (business area), both from the aspect of geographic, demographic and psychographic. After having further illustrate the clinic will choose potential markets to be targeted as 215 Indonesian Health Administration Journal Volume 1 Number 3 July-August 2013 the target market. The next clinic will position itself through the provision of appropriate serviceswith the needs of its target market.

To be able to perform positioning with both the need to consider the concept of 5-P (People, Product, Place, Price, Physical Evidence).(Peraturan Menkes., 2011) 6) Rates In the era BPJS regulatory mechanisms in health care facilities have also been provided for in Article 11 of Law No. 24 of 2011 on BPJS that reads "made a deal with a major health facilities regarding the payment of health facilities which refers to the standard rates set by the Government". In Article 24 of Law No. 40 of 2004 on the Social Security also arrange payment mechanism, which reads "The amount paid to health facilities for

each region shall be determinedby agreement between the Social Security Agency and the association of health facilities in the region ". Thus the service will become standard fare between each clinic in the region, except for services that are not managed by BPJS. Clinic can not control pricing in full, because it must be based on an agreement with the BPJS. Therefore, the clinic must immediately calculate the unit cost (unit cost) of service as a basis for pricing. Resultthe calculation of unit costs is also a matter of negotiation with BPJS to reach an agreement of the rates. Under article 27 of RegulationHealth No. 28 of 2011 on the clinic, the rates component based on the clinical care services and services facilities.Component services include: 1) consulting services, 2) service action, 3) services medical support, 4) the cost of pharmacy services, 5) treatment room (special clinics with hospitalization), 6) administration, or 7) other components supportingservice. Component means services include: 1) the cost of using the means and facilities clinic, 2) the use of pharmaceutical preparations (medical consumable materials), 3) the cost of other means of support services.(Peraturan Menkes., 2011) 7) Information Systems Clinics and medical personal who work at the clinic is required to make the recording and reporting. One form of recording andThe reporting is done is in the form of medical record documents. In the document there are many medical records as well as the amount of datainformation related to the provision of services (medical, nursing and medical support). The modern clinic management practices must be based on evidence (evidence based practice). 216 Indonesian Health Administration Journal Volume 1 Number 3 July-August 2013, to be able to

manage the amount of data recorded in the medical record documents needed toolsin the form of Information Systems (IS).

Therefore the need to develop evidence-based clinical information system (EBIS). EBIS is the backboneas a management decision support system (Decission Support System). In the era of information technology is growingso fast, the clinics need to use information technology (IT) to support the EBIS. EBIS through the existence of the modern IT support the clinical management is expected to be more effective and facilitates the management process.(Peraturan Menkes., 2011)

E. Conclusion By paying attention to the elements of the seven elements such as; 1) Legality, 2) Human Resources, 3) Facilities and Infrastructures, 4) Standardize, 5) Marketing, 6) Rates, and 7) Information Systems and then to achieve and qualified the human resources needs cultural competence which are: cultural Desire, cultural awareness, cultural knowledge, cultural skill and cultural encounters that can create and optimize health management which can be providing better health care.

F. References Berlin, E., & Fowkes, W. (1982). A teaching framework for cross-cultural health care.The Western Journal of Medicine, 139(6), 934-938.

Burke FJT., Freeman R.,2004. Preparing Dental Practice. Oxford. London.

Campinha-Bacote, J. (1998). The process of cultural competence in the delivery healthcare services: A culturally competentm Model of care (3rd ed.). Cincinnati, OH: Transcultural C.A.R.E. Associates. (Available from www.transculturalcare.net) Campinha-Bacote, J. (1999). A model and instrument for addressing cultural competence in health care. Journal of Nursing Education, 38(5), 203-207.

Campinha-Bacote, J. (2002a). The process of cultural competence in the delivery of

health care services: A model of care. Journal of Transcultural

Nursing, 13(3), 181-184.

Campinha-Bacote, J. (2002b). Cultural competence in psychiatric nursing: Have

you "ASKED" the right questions? Journal of the American Psychiatric Association, 8(16), 183-187.

Campinha-Bacote, J. (in press). Cultural desire: The development of a spiritual construct of cultural competence. Journal of Christian Nursing.

Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care. Volume 1. Washington, DC: CASSP Technical Assistance Center.

Dolnick, E. (1993). Deafness as a culture. Atlantic, 272(3), 37-53.

Giger, J., & Davidhizar, R. (1999). Transcultural nursing. St. Louis: Mosby Year Book.

Harwood, A. (1981). Ethnicity and medical care. Boston: Harvard University Press.

Kleinman, A., Eisenburg, L., & Good, B. (1978). Culture, illness and care. Annals of Internal Medicine, 88, 251-258.

Kotler P., 2008. Create, Communicate, Deliver The Value to The Target market at a Profit. Diunduh dari: www.londonbusinessforum.com Kroeber, A., & Kluckhohn, C. (1978). Culture: A critical review of concepts and definitions. NY: Krauss Reprint Co. (Original work published in 1952).

Leininger, M. (1978). Transcultural nursing: Concepts, theories, research, & practice. NY: John Wiley & Sons.

Leuning, C., Swiggum, P., Wiegert, H. ,& McCullough-Zander, K. (2002).

Proposed standards for transcultural nursing. Journal of Transcultural Nursing, 13(1), 40- 46.

Lin, K., Poland, R. Lesser, I. (1986). Ethnicity and psychopharmacology. Culture, Medicine, and Psychiatry, 10,151-165.

Peraturan Menteri Kesehatan No. 001 Tahun 2012 tentang Sistem Rujukan Pelayanan Kesehatan Peraturan Menteri Kesehatan No. 1438 Tahun 2011 tentang Standar Pelayanan Kedokteran.

Peraturan Menteri Kesehatan No. 28 Tahun 2011 tentang Klinik Perorangan.

Purnell, L. (1998). Transcultural diversity and health care. In L. Purnell and B. Paulanka (Eds.), Transcultural health care: A culturally competent approach. Philadelphia: F.A. Davis.

Stebnicki, J., & Coeling, H. (1999). The culture of the deaf. Journal of Transcultural Nursing, 10(4), 350-357.

Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125.

Treloar, L. (1999). People with disabilities - the same, but different: Implications for health care practice. Journal of Transcultural Nursing, 10(4), 350-357.

Tylor, E. (1871). Primitive Culture. Volume 1. London: Bradbury, Evans and Co. Undang-undang no. 24 tahun 2011 tentang Badan Pengelola Jaminan Sosial.

Undang-undang no. 40 tahun 2004 tentang Sistem Jaminan Sosial Nasional.

Keywords: The National Health Insurance Program (Jaringan Kesehatan Nasional=JKN); Sustainability in financing; Health Services Infrastructure; Qualified Health Workers and Competency of JKN Management.

162

163

Post-donation Donor Notifications and Behavioral Strategies Counseling Approach to Decrease Outspread of HIV Mochamad Naufal Bachtiar, Tsaniya Rizqina, Januardi Indra Jaya AMSA-Universitas Brawijaya

Abstract

The Human Immunodeficiency Virus (HIV) is a retrovirus that infects cells of the immune system, destroying or impairing their function and already become a concern to a lot of countries including Indonesia. The government's efforts to prevent the spread of HIV is still lacking. One of the way to stop the outspread of HIV is to perform early detection and it regularly been done to a healthy person is in the blood donor center. Therefore, we propose a system for optimizing the function of blood donors in an effort to suppress the outspread of HIV. The method used in this paper is literature review, and the materials are relevant scientific journals.The system is a post-donation service system which including post-donation notification, counselling and treatment referral. Blood donor will receive a notification letter after the blood screen test is positive. If the donor does not call in two weeks, a second similar letter is sent, followed by a telephone call. If it's not answered , clinicians with HIV or counselling background from community health care centre (Puskesmas) will be sent to donor house. Patient is recommended to hospital after received positive result from repeat testing.

The application of the post-donation service can detect more than 7,900 HIV positive person each year. This system is able to decrease HIV by notifying HIV positive blood donors to increase their awareness of self-status and counseling through behavioral strategies approach, to sustain safer sexual behavior and so avoid further transmission.

165

Re-empowering Infirmary as health mental revolution innovation through platform-er genre game Kevin Dimas S, Enrico J. Hartono, Brian mahendra AMSA-Universitas Hang Tuah

The independence of healthy life, that is one of the missions of the school health unit or Infirmary which teaches students to learn to stay healthy and independently. not many of us understand the significance effect of the existence of INFIRMARY at school, so we always race to create a system, to make an innovation and solutions that make the people of Indonesia is getting healthier but it turns out we forgot, the best solution of the problem has been around since 1956 right in our schools. annually, the budget for health in Indonesia currently only 1.5 percent of the National Budget, In comparison to government budget per year could reach 10.5 percent of Indonesia's National Budget. This fact can be used to divert a little funding from education to help the health program through Infirmary. There would be a lot of parties supporting this based on the Mission and Vision of the Infirmary which is aligned with the Vision of The President of Indonesia , Which is Mental Revolution Game is one of innovative ways to energizing and reactivate Infirmary vision at school.

Game uses students weakness to â&#x20AC;&#x2DC;brain washingâ&#x20AC;&#x2122; with a fundamental basic health principle to make better health Indonesia.

167

The application of Iron Fortification in Eradicating Iron Deficiencies Anemia in Northern Maluku Lia Wijaya, Januardi indra Jaya, Himmah Islaura AMSA-Universitas Brawijaya Abstract Iron deficiency anemia is anemia resulting from the reduced supply of iron for erythropoiesis, because depleted iron stores that eventually resulted in the reduced of hemoglobin formation.

Itâ&#x20AC;&#x2122;s one of the disease that is still high in Indonesia especially in Northern Maluku. To solve the core problem of this disease, mode of literature review were used to find the best method of solving it through fortification. Salt fortification were proposed with some technical requirement in order to make its effectiveness and feasibility become higher. This study found that distribution of fortified salt, with iodine fortified salt as reference, shows a high compatibility for this double fortified salt to be applied. Some research that were conducted in several countries also support the effectiveness of this method. In the end this method will give a big impact toward the effort of eradicating iron deficiency anemia in Northern Maluku Keywords : Iron, Anemia, Fortification, Northern Maluku

169

Orderliness in Medical Treatment's Cycle :

Upgrades to Prevent Ethics Violation Gilbert Renardi Kusila, Yohanes Setiawan Bramantyo, Vincentius Dennis Prabaniarga AMSA-Universitas Gadjahmada

Background of The Study Since several years, Indonesia’s government is always arguing in order to achieve the targets of MDGs. However Indonesia’s preparation is not enough, especially in health scope. One of the main difficulties in Indonesia’s health problems comes from cycle of medical treatment that consists of 3 major actors. Those are doctor, pharmacy, and the patient. The first problem is doctors who are receiving gratification from the pharmaceutical industry. This condition is getting worst because the second problem; that is most of Indonesia’s patients are less educated about medicines, for example, there is perception that generic medicines are not as good as the branded ones (Dewi S.L., 2014), this create opportunities for doctor to write unnecessary medicine in the recipe. The third problem is the pharmacy. There are drugstores that sell “special” medicines even when buyers don’t have medical recipe. These problem are linked to each other in order to hurt Indonesia’s health, especially in drug’s price and distribution.

Based on problems in that cycle, the maker of this poster would like to find the solution and inform it to the public.

Materials and Method We use literatures searching from journals, newspapers, and government’s report Results The gratification to the doctor had been regulated in Kode Etik Kedokteran Indonesia (KODEKI) chapter 3. It’s written that the doctors are not allowed to receive gifts such as money, car, dan other material things. In the other hands, the role of pharmacist is also found in PMK 2014 number 35 chapter 1, that they should obey the medical recipe form the doctors, but also give the information about the medicine to the patient detailedly, as written in chapter 3. In this position, pharmacists are the supervisor of medical treatment. However, if there is collusion with doctors, the problem occurs; this

can be trigged by economic problem. If the government can manage the salary, aid, and subsidy equitably; this problem can be prevented. We also found that one of the best solution is to educate the patient by giving the medicine’s information on BPOM’s website. So far, BPOM’s website just informs the name of the product, shape, and the produced factories. It’ll be better if there is also the information about how to use, how drugs work, and other important information to increase patient knowledge about medicines.

Conclusion The problems in this medical treatment cycle can be overcome with good education and distinct law.

172

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GOBGYN: Application of Rising Awareness of Medical Students towards Social Responsibilities on Pregnancy to Overcome Maternal Mortality Tamara Audrey Kadarusman and Kenneth Reyner Agoes AMSA-Universitas Airlangga

Background of the Study Maternal mortality has been a great issue in Indonesia. Approximately 126 per 100,000 mothers die every year during labor in Indonesia, caused mostly by late diagnosis of prenatal conditions. This can be caused by low initiative or low education in women to consult their pregnancy to the health provider. Community-based links are needed to give special concerns towards maternal mortality issues.

Material and Methods Woman has critical phase during pregnancy, each with its own risks and consultation to health-care provider is needed through some medical check-ups. Community-linked maternal death review (CLMDR) is an effective way to figure out maternal death before it happens and is proven effective to decline high maternal mortality rate.

Results GOBGYN is a smartphone application aimed at medical students who will register voluntarily. Each of them has a responsibility of one woman, from the first trimester of the pregnancy until labor. Their responsibilities include accompany her to monthly consultation, take a regular monitor to her physical condition (body weight, height, blood pressure, and heartbeat), remind her to have a healthy lifestyle, such as eat nutritious food and control her physical activity. They will report their progress to the program instantly for every check.

This program will be attended by medical students from different regions in Indonesia. For each region, there will be a obstetry-gynecology specialists to control their activity, both in real life and online. Through this program, medical students will rise their awareness towards maternal mortality and help from the first hand to reduce it. This will also be the first step of medical students towards society services.

Conclusion Health of a country is also determined by the rate of maternal mortality. Many factors cause the high rate of maternal mortality in Indonesia, and one of them are minimal awareness of mother to consult to the health provider. GOBGYN is a smartphone application synthesized to make a group of medical students, where they can take a responsibility of one pregnant women, from her first trimester until labor, then report their progress in that application. Each medical student must take several responsibilities. With a strict concern from medical students, as their first step to social services, and the pregnant woman, the rate of maternal mortality should be declined.

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Optimizing financial resources through COB BPJS implementation Ediva Pradiptaloka, Ivy Wenanto Tjandra, Michael Jonathan Tan AMSA-Universitas Katholik Atma Jaya

Abstract Since January 1st 2014, Indonesiaâ&#x20AC;&#x2122;s public entity who execute the National Health Security (Jaminan Kesehatan Nasional) serves as BPJS (Badan Pelaksana Jaminan Sosial); Indonesian social insurance system. Data obtained since August 8th 2014 shows the total member of National Health Security has reached 126,487,166 people and some have more than one insurance. To prevent over-payment that exceeds available health services and facilities, it has to be coordinated between institutions to achieve its purpose. This corresponds to Presidential Regulation No.12 of 2013; BPJS Kesehatan is allowed to cooperate with health insurance administrator regarding coordination procedures. Government is cooperating with private health care service institutions, forming the Coordination of Benefits BPJS (COB). COB allows planning that provide health coverage for a person with BPJS to determine their respective payment responsibilities, which insurance plan holds the primary payment responsibility and the extent to which the other plans will contribute when one is covered by more than one plan.

The main problem is there are only 30

private insurance institutions which have officially cooperated with COB so far.

Private insurance institutions, government, and citizens in Indonesia are still less exposed to the information and unaware of the advantages of COB. We have analyze the benefit of COB from the perspective of Indonesia-Health-Care's financial resources, and from literature review, we found out that Indonesiaâ&#x20AC;&#x2122;s financial resources in health care program is very low. The Government is not able to cover 50% of the health care outcome. This new program, Coordination of Benefit, will be a win-win solution for the government, patients, and insurance company. The problem lies in the implementation of COB in Indonesia, one of which because there is still no COB authorized guideline. Therefore, to achieve high-quality, well-coordinated COB, some changes need to be considered from different aspects.

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Cost Effectiveness Analysis of Cardiovascular Disease Interventions: A Systematic Review Michael Nathaniel; Sallie Naomi AMSA-Universitas Katholik Atma Jaya

Introduction and Objectives Due to the high demand of health services through BPJS Kesehatan and high prevalence of cardiovascular in Indonesia, itâ&#x20AC;&#x2122;s important for health care provider to provide patient with the most cost-effective cardiovascular intervention.

The objective of this study is to review the most cost effective interventions for national health insurance program policy makers on resource-allocation decisions to reduce the burden of CVD. Methods A literature search was conducted through ProQuest. The initial search resulted 17 studies. After applying the inclusion criteria, we conducted a full text review for the remaining studies (n=5). No studies were excluded and a total of 5 studies were included in the final analysis of this review.

Results Most cost effective CVD interventions were divided into 3 groups: prevention, diagnosis, and treatment. Cost effective interventions are: (1) Prevention program in targeting modifiable risk factors; (2) Prevention program through KardiPro individualized prevention program; (3) generic anti hypertensive drugs were cost effective with a wide range of population covered; (4) Cardiovascular magnetic resonance (CMR) +coronary angiography (CXA) is a cost effective diagnosis combination; (5) naturopathic approach in prevention program of CVD should be considered Conclusion Cost effective interventions result from the studies ranging from prevention, choice of drugs,

and diagnosis could be well implemented with further adaptation in the

decision making of cardiovascular disease intervention in users of the national health insurance system.

Keywords Cardiovascular Disease, Cost-effectiveness Analysis, Decision Analysis, National Health Insurance

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Electronic Cigaratte: A Trend yet to be Regulated Nadia Novita Wijaya, Hoo Felicia Davina, Clarissa AMSA-Universitas Katholik Atma Jaya

Intro: E-cigarettes are battery powered devices that vaporizes liquid solution for users to inhale. (Mascarelli, 2014) Self-reported use of this cigarette sub-culture has increased seven times during 2010 to 2013 from 1% to 7%. (Gravely et al., 2014) Available in attractive flavors, e-cigarette targets young consumers. (Farsalinos et al., 2013) E-cigarette also creates the perception of a healthy cigarette, an aid to give up conventional cigarette addiction.

(Mascarelli, 2014) A study involving 75,643 students aged 13–18 years found in total 9.4% students ever used e-cigarette with 1.4% being e-cigarette-only users, and 8.0% being dual users with conventional cigarette.( Lee et al., 2013) It was also reported in the study that current e-cigarette users smoke more conventional cigarette than never or former e-cigarette users. With the rising popularity, we need to look further about the actual impact of ecigarette and the proper response to it as e-cigarette may not be as harmless as it seems.

Method: The method of this study is literature review of various studies published during the year 2004 to 2015. ProQuest and Google Scholar are the medical search engine and database tools used in this review. As much as 1212 articles were found and 45 of it serve the purpose of this study.

Result: A study found 10 out of 28 products claimed to be “nicotine free” and among those ten, seven contained nicotine in the range of 0.1-15 μg/ml. In some products, propylene glycol and glycerol were being replaced by ethylene glycol (Hutzler et al., 2014) Every e-liquid contains propylene glycol and/or glycerol carriers that consists of nicotine, flavors, and other toxic like nitrosamines, metals, carbonyls, volatile organic compounds, polycyclic aromatic hydrocarbons that may also be produced as emission (Lukasz et al., 2014) and promotes infection in the respiratory tract. (Sussan et al., 2015) Right now, public health professionals like WHO has issued warnings about the use of ecigarette, even as nicotine replacement therapy. (“WHO | Electronic cigarettes (e-cigarette) or electronic nicotine delivery system,” n.d.) Efforts to regulate e-cigarette are done to prevent harms towards users and potential bystanders. (“WHO | Backgrounder on WHO report on regulation of e-cigarettes and similar products,” n.d.)

Conclusion: Seeing as e-cigarette has similar qualities as conventional cigarette, government need to take a firm stance against e-cigarette and put a clear regulation to raise awareness about the harm of this product.

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The Role of People in Health Sector in Optimizing Health Strategies to Overcome Multimorbidity Muhammad Prima, Ririn Puspita, Rizka Febriana Fitrie AMSA-Universitas Sriwijaya Multimorbidity is a condition when an individual suffers from multiple chronic diseases. Nowadays multimorbidity is the ultimate challenge facing healthcare systems worldwide, but health systems available now are largely focused for individual diseases rather than multimorbidity.

We do a literature review from several articles and journals, then summarize the data.

We continue by drawing some ideas that can be used by people in the health sector to optimize the strategy to overcome multimorbidity.

People involved in the health sectors include medical professionals and patients, government, medical students and society. Those people in the health sector could contribute through several ways.

This study concludes that people in health sector, starting from medical professionals and patients can contribute by implementing patientâ&#x20AC;&#x2122;s health goal orientation rather than disease goal orientation and coordinating each other in the decision making. An approach from the government is making health policy, such as establishing electronic health records to facilitate clinical decision making for patient with multimorbidity and stimulating multidisciplinary healthcare teams to involve in improving health service. While medical students and society have responsibilities in generating and developing research to achieve patientâ&#x20AC;&#x2122;s health goals.

Keywords: multimorbidity, health strategies, people in health sector

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5-STAR (Specialized To Assess Revitalization) Strategies of Indonesian Health Care Sector To Face Todayâ&#x20AC;&#x2122;s Challenge After Jaminan Kesehatan Nasional (JKN) and ASEAN Economic Community (AEC) : Systematic Review Priscilla Christina Natan 1, Chrisandi Yusuf 1, Khrisna Rangga Permana 1 1

AMSA-Universitas Brawijaya

Background: Indonesia, one of ten member countries, has a role to the success of ASEAN Economic Community (AEC) particularly to promote free trade and service across boundaries. Indonesia undoubtedly provides opportunities for both locals and foreigners to participate in the growth of the health care sector industry.

Material and Methods: This scientific paper is based on systematic review research method. This is done by synthesizing the results of several studies which uses transparent procedures to find, evaluate and synthesize the results. Results: There are 5 sectors Indonesia lacks; health care coverage, hospital shortage, qualification of physicians, local and government investment, and foreigner investment. On the other hand, JKN programs have some issues and It seems that Indonesia will probably miss that 2019 goal and not so promising to succeed AEC. Based on those issues, authors propose 5-STAR (specialized to assess revitalization) strategies. These strategies consist of utilization mainly on 5 sectors Indonesia lacks. The strategies consist 4 steps including building partnership, determining targets, 5-STAR strategies, and evaluation. Conclusion: 5-STAR strategies can be used as strategies for Indonesian health sector to face todayâ&#x20AC;&#x2122;s challenge based on reliable facts from trusted data. It is hoped It will invite a further research and lead to better improvement of JKN and contribute to the success of AEC. Keywords ASEAN Economic Community (AEC), Indonesia, Jaminan Kesehatan Nasional (JKN), Universal Health Coverage (UHC), 5-STAR Strategies

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Gratification of medical Presciption Dicky Zulfa Firman Kurniawan, Denny Arvi Makhrifandi, Ngurah Bagus Raditya S.D AMSA-Universitas Hang Tuah

Recently, cases about gratification involving prescriptions from pharmaceuticals to doctors increasingly discussed. A total of 2125 doctors receives money with a value between 5 million - 2.5 billion Rupiah. They are spread over five provinces, which is Jakarta, West Java, Banten, East Java, and South Sulawesi.

However, these cases are becoming lengthier after the Ministry of Health appealed against the case. The question is , is the gratification of medical prescription is legal under the law ?

The current dilemma, physician are not satisfied with their low salaries. the low regulation of the law in Indonesia causes an opportunity to some pharmaceutical parties to grant gratuities the opportunity for collusion with the rule of law that is low in Indonesia causes gratuities.

According to the Law of Republic Of Indonesia On article 12 Number 20 of 2001, gratification, including money, goods, rebate (discount), commissions, interest-free loans, travel tickets, lodging, travel, free medical treatment and lodging facilities, tours, free medical treatment and other facilities.

Gratuities are well received at home and abroad also it carried out by using electronics or without electronic means. However, as it stated in the Law of the Republic of Indonesia Number 20 of 1999 on Article 12 B about the Corruption Eradication clearly stated that any gratuity to an official or state officials are considering bribery, when the gratification is against the law with the obligations or duties. Before doctor carries out the duty of serving the patient or medical practitioner, the physician must first obtain a doctor's permission and registration letter (RL). This letter was published by the Indonesian Medical Council.

Therefore, physicians are included in part of gratuities set forth in the Anti-Corruption Act. it is clear that the gratification of the prescription made by the pharmacies to the physician is illegal. The Perpetrators of this act can be charged with criminal penalties of life imprisonment or a minimum imprisonment of 4 (four) years and a maximum of 20 (twenty) years, and fined at least Rp 200,000,000.00 (two hundred million rupiah) and at most Rp 1,000,000,000.00 (one billion rupiah).

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Legal component in free medical Healthcare of Social act in Medical Faculty of Surabaya.

Enrico J.Hartono, Kalista Wahyu, Rusda Syawie AMSA-Universitas Hang Tuah

Many cases of legal disputes in the medical practice causes the medical workers to be extra cautious. patients can sue the medical workers if they felt thereâ&#x20AC;&#x2122;s inelegant nor dissatisfied with the health care process . not limited on places, it may also occur on free health care in social event . this problems need more-in-depth research to find out whether the treatment process at Social Act already meet the elements of a therapeutic contract , Then is there any kind of gap that will make a room of error by the law The method of data collecting is research using a questionnaire given to the Chairman of Commed ( Community Medicine ) at Student Council Organization (BEM) at the Medical Faculty On Airlangga University, Hang Tuah University, and Wijaya Kusuma University .

Research also uses literature review on the legal materials that gave us a normative data. and there still lot of erorr through the healthcare process that need to be covered up before they meet a legal problem.

Background School Health Unit / Infirmary (UKS) The independence of healthy life, that is one of the missions of the school health unit or Infirmary which teaches students to learn to stay healthy and independently. not many of us understand the significance effect of the existence of INFIRMARY at school, so we always race to create a system, to make an innovation and solutions that make the people of Indonesia is getting healthier but it turns out we forgot, the best solution of the problem has been around since 1956 right in our schools. annually, the budget for health in Indonesia currently only 1.5 percent of the National Budget, In comparison to government budget per year could reach 10.5 percent of Indonesia's National Budget. This fact can be used to divert a little funding from education to help the health program through Infirmary. There would be a lot of parties supporting this based on the Mission and Vision of the Infirmary which is aligned with the Vision of The President of Indonesia , Which is Mental Revolution.

The Infirmary aims to educate so they can live healthy and independently. Arguably, this would include a massive Promotive and Preventive efforts in health education that provided due to the large amount of students in Indonesia. Of course, we can feel the benefits if we already are aware of the benefits and potential of utilizing the infirmary since 60 years ago.

But, the current situation is that the program activities are less vary and less innovative makes the Infirmary lost it strength. We need to create an innovation to make Infirmary more interesting so we can feel the beneficial effect of Infirmary

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Cost-effectiveness of Rotavirus Vaccine throughout ASEAN Developing Coutries: A Systematic Review Koe SA, Aristya L, Huang F AMSA-Universitas Indonesia

Background: Rotavirus infection could present deadly diarrhea in children <5 years and in 2012 accounted for 5,8% deaths of children <5 years in Indonesia, more than AIDS and measles combined. Although Ikatan Dokter Anak Indonesia (IDAI) has recommended vaccination as a preventive solution, rotavirus vaccination has not been covered by the government as part of its national immunization program. Costeffectiveness of rotavirus vaccine is one of its major considerations. This systematic review was conducted in order to provide an overview regarding cost-effectiveness of rotavirus vaccination.

Material and Methods: Literature searching was conducted systematically in 4 databases: Science-Direct, EBSCO, Cochrane, and Google Scholar. It used predefined search criteria with selection of inclusion and exclusion. Journals published prior to 2006 were selected by their relevance based on title, abstract, and full-text assessment. Articles included in the review were summarized and discussed to draw a conclusion based on the objective of the review.

Results: Rotavirus vaccination proves to be cost-effective in reducing the severity, duration of illness, and incidence of rotavirus diarrhea. Findings in Indonesia prove that the rotavirus vaccination will be highly cost-effective with 3-dose vaccination at USD15,5. Rotavirus vaccination has proven to be cost-effective with vaccination at USD5 and below USD10 per dose respectively in Vietnam and Thailand. Overall vaccination coverage cost plays a crucial role in determining its feasibility as part of cost-saving national immunization program.

Conclusion: Rotavirus vaccination program has been proven to be a cost-effective intervention in several developing countries in ASEAN. However, further research is

needed in the field of economics and other aspect required to successfully implement rotavirus vaccination as part of the national immunization program.

Keywords: Rotavirus Vaccination, Cost-effectiveness

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CIGACARD AS THE NOVEL CONCEPT IN SUPPORTING THE SURVEILLANCE OF TOBACCO USE AND DISTRIBUTION IN INDONESIA Stefina Gunawan, Kezia Joselyn, Ayudhea Tannika AMSA-Universitas Kristen Krida Wacana

ABSTRACT Introduction: Tobacco consumption in Indonesia has increased significantly in the last two decades due to several factors. This alarming situation prompted us to improve public policy.

Several efforts have been implemented in Indonesia in the last 15 years. But, we can still see a lot of disobedience in society. The objective of our paper is to suggest a novel concept named CigaCard to support government regulations regarding tobacco distribution surveillance in Indonesia.

Methods: This study is conducted by several steps such as discussing several ideas regarding tobacco control, searching the official reports and articles associated to tobacco survey in Indonesia, reviewing what kind of prevention has been done in tobacco surveillance, looking for the potential concept in controlling tobacco access and distribution among people, and constructing certain steps in enacting new regulation in tobacco control.

Results: Current smoking habit in Indonesia is more prevalent in the middle-age people in rural areas. It has the highest prevalence among those with less than primary school education.

In the matter of tobacco productsâ&#x20AC;&#x2122; varieties, kretek is the most commonly purchased by Indonesian smokers. It has been demonstrated that tobacco use has serious negative health effects for nearly every organ in the body. Government regulations regarding tobacco control donâ&#x20AC;&#x2122;t seem to work well, and still seem weak compared to other countries. On the other hand, there has been reluctance of the government to combat cigarette consumption in Indonesia.

Conclusions: The surveillance on tobacco use by Indonesian government are still sorely lacking. CigaCard system aims to restrict purchases and consumptions of cigarettes. By doing so, it may prevent uncontrolled sales and therefore helps the government in controlling

tobacco use in society. However, this concept still needs considerable reviews, researches, and trials before it is implemented in our community.

Keywords: CigaCard, cigarette, kretek, tobacco control

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Implementation of National Health Insurance through BPJS program to improving Public Health Service in Village of Mungli, Kalitengah, Lamongan Susi Anggawati, Ria Setiawati, Apriliana Puspitasari AMSA-Universitas Airlangga

Abstract : This study aims to access the effectiveness of the implementation of National Health Insurance through BPJS program of the peoples of Mungli Village. The method was used by interviews with officuals of Mungli Village. From the interviews it is knoen that the implementation of National Health Insurance through BPJS progran for peoples of Mungli Village has not been effective. It is because lack of information of the peoples. So, the next it is need advocacy and sozialitation to peoples of Mungli Village due to for optimalization Health Program from government. To facilitate of implementation BPJS program, officials of Mungli Village divide all peoples become three category that are Pre-Prosperous Society, Prosperous Society, and Prosperous Plus Society.

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A comprehensive approach towards Indonesia New Healthcare System: An Analysis of BPJS Progression in Achieving Universal Health Coverage 2019 Iin Tammasse* and Khumaira* *AMSA-Universitas Hasanuddin ABSTRACT

The Indonesian government is committed achieving universal health coverage (UHC) by 2019 to cover a projected population of 257.5 million. Challenges to UHC in Indonesia include a

fragmented

health

financing

system,

decentralization,

demographic transition, high out-of-pocket spending and low levels of government spending on health. Despite these challenges, Indonesia has made substantial progress on UHC through the establishment of a clear policy framework. The purpose of this study is to assess and analyze the progress of the newly established Indonesia Medicare under BPJS using a comprehensive approach. BPJS is a public agency established to implement the social security program. The health insurance prepared through BPJS is in the form health protection for participants. The rate of health insurance tuition that must be paid regularly by participants, employers, and/or the government are vary. The study is a literature review of various journals retrieved from Google Scholar with keywords of “BPJS”, “UHC”, “SJSN” and “Indonesia Medicare System”. This study recognize the barriers and opportunities of BPJS progress. Total expenditure on health in Indonesia has already grown significantly, To keep it balance, BPJS Health will need to ensure its financial sustainability. In addition another issue is the long time undersupply of healthcare service. Nonetheless, there are also several opportunities. The existence of growing middle class population who tend to choose better healthcare could lowering government expenditure. Also another potential coming from Pharmaceutical and Med-tech to fulfill the demand that fit the demand of BPJS. In summary, we found that there are several obstacles and also potentials that may affect healthcare policy. However, it can be negotiated and integrated in implementing BPJS in Indonesia in order to achieve the Universal Health Coverage by 2019.

Key words: “BPJS”, “UHC”, “SJSN” and “Indonesia Medicare System”

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The Effect of Education and Health Facilities Availability to Increased Public Satisfaction in Doris Sylvanus Hospital Palangka Raya, Central Kalimantan Dita Ayu Pertiwi, Fia Delfia Adventy, Luh Ade Gina Andriyani AMSA-Universitas Palangka Raya

Abstract Along with improving the quality in the era of globalization, the demand for health services is also increasing in many regions of Indonesia, including Central Kalimantan.

Central Kalimantan Governor initiated the slogan "Kalteng Barigas" to improve public health with primary health care system improvement of quality and affordable. According to Government Institution Performance Accountability Report of Central Kalimantan Province of Doris Sylvanus Hospital Central Kalimantan in 2014 pictured on patient satisfaction index in 2014 with a target of 90, but realized only 75.5. This shows that the public has not been fully satisfied with the health services obtained. According to

the data from the

Ministry of Health Year Strategic Plan 2015 - 2019, in terms of the readiness of the service indicates that the achievements have not been satisfied. The unpreparedness due to incomplete medication, tools, medical equipment, lack of health workers and inadequate quality of service. Assuredness facilities, comforts of life as well as the availability of facilities and infrastructure affect the quality of health services from health workers that will affect the improvement of people's satisfaction with health services. Implementation of Health Insurance in Indonesia stipulated in Indonesian Presidential Regulation No. 12 Year 2013. However, in practice raises many new problems between the community and health professionals. minimal level of public knowledge and education are less than tanaga cause disagreement between the public health and health workers so as to make the rise of legal cases involving both sides.

Keyword : Indonesia,Central Kalimantan,Public Health Service, People Satisfactory, Health Insurance, health workers, knowledge, education

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ASK MORE, MAKE IT EASIER Priscillia Imelda AMSA-Universitas Gadjah Mada

ASK MORE, MAKE IT EASIER Priscillia Imelda AMSA-Universitas Gadjah Mada

Every people wants healthy life but when they are sick, sometimes they do not immediately seek for medication. There are many reasons, such as economic, sociocultural, education, and transportation, but sometimes someone does not want to be bothered with health service because they think that it takes many regulations or they confused with that regulations. Finally, people choose to neglect their sickness and assume it will be selflimiting.

Now days, health service is everywhere, even extended to remote villages. There is health insurance program which facilitate low-middle economic people to get health service.

Health promotion has been done in many places. Actually the way to access health service is easy. People do not need high education to understand. The problem is the willingness to ask when they do not understand is still low.

This picture was taken in Primary Health Care in a village, in sub-district Tanjung Raja, South Sumatra. This Primary Health Care is the only one health care for that area and its surroundings. In that picture, we can see that health providers are serving patient who wants to ask about how to access health insurance. Health providers seem pleasure to give information and patient seems understands with their explanation.

The objective of this picture is to persuade people to raise their willingness to ask more if they confuse or do not understand about health service or health insurance or else so it will easier to access health service.

Queues at the ER Alvin Saputra AMSA-Universitas Airlangga

Queues at the ER Alvin Saputra AMSA-Universitas Airlangga

This photo was taken on Sunday, January 10th, 2016 in Dr. Soetomo General Hospital Emergency Room. Camera: NIKON D7000, no editing.

From the subtheme about optimizing financial resources in health care and health promotion to face today’s challenge, we know that Indonesia has too many weakness about its health care management. We can see from this photo there are too many queues at the Emergency waiting room Dr. Soetomo General Hospital. Those people are waiting for ordering some lab test, performing CT scan/MRI, and more physical examination. If we can optimize our countries financial resources such as fixing the flow of BPJS covering to our citizens maybe there is not this queues anymore because there is better health care management too if there are more financial support from our country. From this photo we can see the written sentences “Semoga Cepat Sembuh” in Bahasa and it means “Get well soon” in English, Why? Because, however lack of funds from the government for health care, but we as doctors will still try our best to save the patient with minimal amenities and wishing all the best for the patient to get well as soon as possible.

Longer, Suffer More Nadia Fadhilah AMSA-Universitas Brawijaya

Longer, Suffer More Nadia Fadhilah AMSA-Universitas Brawijaya

Content and Background : This photo was taken at Puskesmas Lawang, Malang. It shows an issue of Indonesian health system. The patients must increase their suffering with a long queue and queue up in an uncomfortable place. So that they can catch the disease from other patients. This photo aims to raise this issue back and reminded that health problems are not over yet.

Improvement of the health system needed to address this problem.

Thankyou Nurudin AMSA-Universitas Hang Tuah

Thankyou Nurudin AMSA-Universitas Hang Tuah

Bright smile appeared on an 73 old man, Mr. Kusnan, when he told his change had change because of the government program, especially health aspect, BPJS. "i do not have to pay the doctor beacuse all is free. now i am not afraid to go to doctor again when i got sick."

The man who every morning collecting wood at Arca lanang, Trawas, said that he could save more money, and allocated to others because all is free. "thanks to Mrs. minister and Mr. President for this service. thats really helpful especially for people like us."

Rangkang ( a Relaxation Hut ) from RSUDZA for All Patientâ&#x20AC;&#x2122;s Family Aqil Yuniawan Tasrif AMSA-Universitas Syiah Kuala

Rangkang ( a Relaxation Hut ) from RSUDZA for All Patientâ&#x20AC;&#x2122;s Family Aqil Yuniawan Tasrif AMSA-Universitas Syiah Kuala

Health is a prosperous state of body, soul, and social allows anyone to live socially and economically productive. In realizing this healthy concept, it takes 3 aspects of support, which one of them is the Health Facilities. Culture in Indonesia itself is when one of a family member fall sick, the big family would come to the hospital. Not intended to visit, but to accompany other families. This may causing new problems, which family members are not getting a room for sleeping will sleep at the facilities that should not be used to sleep like floor. The hospital authorities has been warned not to sleep around that place. However, the family ignored it. The park at the hospital is supposed to be a place for a brief rest, in fact converted into a place to rest of the patient's family. This problem raises new problems that the environment around the hospital become into a slum even like unkempt. To mitigate this, the hospital authorities need to strictly enforce the rules to the patient's family. In addition, the hospital authorities need to provide facility like guest house, which serve to accommodate patient's family who come far - far from the hometown. For example, several years ago, at the General Hospital of Zainoel Abidin, Banda Aceh, once provided guest house for the families of patients. It is in fact able to minimize the number of families of patients who were not in the proper place. However, the increasing number of patients in RSUDZA, made the guest house is converted into inpatient rooms. Therefore, the awareness of patient's family is needed about this. Also, awareness of city government about this, considering the hospital is a place for the healing process, not a place for new emerging diseases that inhibits the healing process itself.

What Would we do If Money were not exist?

Immanuella Yosephine Sirait AMSA-Universitas Trisakti

What Would we do If Money were not exist?

Immanuella Yosephine Sirait AMSA-Universitas Trisakti

Backgorund:

Before I start I would like to tell an old joke about the doctor whose son graduates from medical school and joins his practice. After a while the son tells his father, “You know old Mrs. Jones? You’ve been treating her rash for years and she never got better. I prescribed a new steroid cream and her rash is gone!” The father responds, “You idiot! That rash put you through medical school.”That’s just a joke. It doesn’t reflect reality, but there’s a common misconception that doctors care more about their own income than about their patient’s outcome. That accusation is demonstrably untrue.There’s a lot misconception of people accusing doctors of being money-oriented. They say “Doctors are only out to make money.” Or “Doctors are greedy people only interested I our money.” Or as one of the people I ask about what he thinks about doctor and he said: “First do no harm. Second ?

Third, profit ”Some have even made the ridiculous accusation that doctors have found the cure for a lot of disease but keep the information so as to keep people sick and increase their business. If profit were really their primary motivation, doctors would have to be astoundingly clueless, because they keep doing things that are guaranteed to reduce their profits. Those people, who have made up their minds that doctors are money oriented can always find a lot of examples to reinforce their belief: confirmation works really well to support preconceived beliefs. But if you want to ask whether the claim is true, the trick is to look not for confirming examples but for disconfirming ones. I don’t deny that there are bad apples in the medical barrel, but they are vastly outnumbered by the overwhelming weight of disconfirming examples.

Finally, You Come Hanifan Nugraha AMSA-Maranatha Christian University

Finally, You Come Hanifan Nugraha AMSA-Maranatha Christian University

This photo was taken, back then when my university was doing the free social service in one of village in Bandung. There, we as the medical students were giving the job to do the anamnesis and general checkup, after that the patients was delivered to the doctor. This patient, the one in the picture that talking to the doctor, was the one I handled that time.

Surprisingly, when we had conversation, he said “I.. never want to go to the doctor, although my neighbors already told me hundred times, I don’t want, there’s a reason, and not only me boy, there are lot that just like me.” And I asked “Why ?” and he explained it, he said the reason are such as cost, distance, disability to mobile, frightened to go to the doctor, thinking the alternative is better, and lot more.

So, the point that I want to deliver here is. To improve our nation in health sector, we need to do things like this more often. Because of what, sometimes we are the one that need to approach them, sometimes they afraid to go to us. It’s a burden for them, to waiting for us to come. We as the medical students can’t just rely in senior health worker to improve our nation health sector. We can do things such like this. Sometimes, as the health workers, we only think that “aaah, it’s the peoples fault that they don’t want to go to the doctor!” we only ask them to come to the health center or else. But, have we already do the best to approach them ?. They waiting, and sometimes, the one that come are not us, but the death.

Reachable Health Care Access for Society Stefanie AMSA-Universitas Kristen Krida Wacana

Reachable Health Care Access for Society Stefanie AMSA-Universitas Kristen Krida Wacana

Health care is expanding better and greater day by day. Facilities and treatment for the people varies across countries in better quality and bigger quantity. As diversity exists amongst people, there are many different ways of handling cases in health division, especially in several emergencies. Culture and social diversity hold important roles to individualsâ&#x20AC;&#x2122; health. However, the strategies used in most countries, including Indonesia, have not been fully accomplished due to lack of financial improvement and geographical establishment. Right now, access to health care is easier to reach among people with middle to high income. This matter is mostly influenced by their good condition-living environment.

While for people with middle to low income, there lies some difficulties in accessing health care provided, mainly because the health care facilities only exist in limited areas, majoring in big cities while many are left unreached. Having difficulties to access health care is a huge issue as individual health becomes unstable, moreover if it is a matter of emergency. The photograph taken brings the effective solution atmosphere for people with difficulties to access health care. Some areas remain unreached while in fact they are in need of medical help. The existence of an ambulance becomes an open pathway to get medical treatments immediately. The fact that the ambulance is available in a secluded areas can be a good strategy and an effective solution in improving medical care system in Indonesia and even across countries. By enforcing this policy there will be less challenges in maintaining public health facing nowadays culture and social diversity.

Smoking is A Ghost for Children Agustin J Nanda Deniro AMSA-Universitas Airlangga

Smoking is A Ghost for Children Agustin J Nanda Deniro AMSA-Universitas Airlangga ABSTRACT Cigarettes contain many toxins that can harm health. In the enjoyment of a cigarette, also saved a lot of danger which very dangerous chemicals contained in cigarettes. More than 1000 kinds of dangerous chemicals contained therein.

In everyday life even where cigarettes can be found in almost any shops or stalls and supermarkets. As well as the users of cigarettes, can buy cigarettes and use it freely. Even some smokers do not want to heed the ban on smoking in some places, such as in the children's playground. The impact of the cigarette is not only people who inhale the smoke directly. But also those around him who also breathe the air around the smoker, or so-called passive smokers. As a result, losses caused by cigarette smoke is almost unknown by passive smokers .So many innocent people who feel the negative impact of these cigarettes is a health problem in the short and long term.

Struggling for Health Fenska Seipalla AMSA-Universitas Airlangga

Struggling for Health Fenska Seipalla AMSA-Universitas Airlangga

In this picture, we can see that many people are queuing to register health insurance, which is BPJS at the BPJS office place in Surabaya. As already stated in the banner that citizen can sign up BPJS online without the need to queue but the reality is people keep struggling for health. So, why it becomes a problem? Why people keep queuing to get health insurance?

The problems are the online system become complicated and have frequent errors, for example, frequent loss of data that has been entered. Therefore, people prefer to manually register directly at the BPJS office than online. To Optimizing financial resources in health care and health promotion to face todayâ&#x20AC;&#x2122;s challenge, there should be cooperation between the government and the citizen itself. From a technology perspective, as the server, the government should fix the online health insurance problem in their website. They also can create BPJS mobile application to register BPJS program. From a lifestyle perspective, they can maximize the availabilities of BPJS transportation, which is the use of BPJS cars across the nation to make easier way for citizen to register insurance health. The awareness of citizen to cooperate with government policy to not believe perpetrators who often deceive people to register BPJS in shortcut way is also important to improving the nationâ&#x20AC;&#x2122;s health in Indonesia.

Littering Maria Yolanda Felicita AMSA-Universitas Airlangga

Littering Maria Yolanda Felicita AMSA-Universitas Airlangga

Health is priceless, we can not buy it. But, we can maintain it for ourself or for everyone else. The easiest way is to keep our environment clean and not to litter it. Many people knew about it, but still there are some people who ignore it. There are people who litter everyday and not care about their health and everyone around them. Letâ&#x20AC;&#x2122;s us not litter, because littering is the start of being unhealthy.

Public Smoking Triagung Arif Pratama AMSA-Universitas Airlangga

Public Smoking Triagung Arif Pratama AMSA-Universitas Airlangga

Smoking is a common habit in for most people today, especially in Indonesia who included in one of the top countries to produce tobacco. But as we learn form scientific research, we found that smoking is bad for health and it is worse for the people around smokers which we called as passive smoker. Many nation already have law enforced to stop smoking in open public area, instead they can smoke in the smoking area. But unfortunately habit is a habit, which after addicted to smoking we have this great feeling of urge to smoke at any time. This photo taken to increase people awareness of smoking law and prohibition, so they can stop smoking publicly or to remind people who smoke in public to see the â&#x20AC;&#x153;do not smokeâ&#x20AC;? sign first before they smoke.

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BPJS-Equalization Health and Further Promote to Impoverish People Yohanes Krisnantyo Adi Pinandito AMSA-Universitas Airlangga

BPJS-Equalization Health and Further Promote to Impoverish People Yohanes Krisnantyo Adi Pinandito AMSA-Universitas Airlangga

ABSTRACT At December 31st 2013, Indonesian Minister of health launched a new agency of health which contributes as guarantor for all people who live in Indonesia whether they are Indonesian or not. The new agency is BPJS Kesehatan (Badan Penyelenggaraan Jaminan Sosial Kesehatan) or in English is Health Social Security Agency. BPJS Kesehatan ensure financial for people who sick in some of primary service clinic in their area. Actually, before BPJS Kesehatan, there was an agency which ensured Indonesian health, PT. Askes.

But, in Askes, only for members of Askes who had ensured. BPJS Kesehatan has vision to equalization health for all people in Indonesia, especially for impoverish people.

In realization, BPJS Kesehatan hadnâ&#x20AC;&#x2122;t does the vision well. BPJS card does not distributed well. Some BPJS card owners are well-heeled people. And there are many people who work in Informal sector, hadnâ&#x20AC;&#x2122;t registered in BPJS Kesehatan. Even though, Informal worker has higher risk from accident or sickness in their works. BPJS Kesehatan, Minister of Social and Minister Health need to further promote BPJS Kesehatan to poverty people, so they can feel benefit from BPJS Kesehatan, mostly when they are in sickness, they will get the best service for health.

Some people in poverty think BPJS Kesehatan only for the have people who pay every month for BPJS dues. Not all Indonesia know about principle how BPJS Kesehatan equalization health for Indonesia. There are two type of BPJS member, Dues and not dues (PBI-Penerima Bantuan Iuran) or receiver helps of dues. BPJS Kesehatan, Minister of Social and Minister Health need to further promote the PBI for poverty people in Indonesia such as beggar, and collaboration with the head of neighborhood(RT) to get data of poverty people and worthy to get PBI in BPJS Kesehatan service system.

Stop smoking-would you do if you already know?

Amy Tryabto AMSA-Universitas Hassanudin

Stop smoking-would you do if you already know?

Amy Tryabto AMSA-Universitas Hassanudin

Abstract "Quit smoking", "smoke kill", "stop smoking for a review of the lungs the healthy" is a few examples of warning signs that we find in every been used general society. Rarely did not even conducted socialization to review stop smoking. The level of knowledge society and felt that the hearts any different cigarettes contain hazardous substances that may endanger yourself and others are enough.

But all things whether the true ability to make 'stop people smoking? The answer is no. Photo capturing the phenomenon successful husband looks a hospital visitors the permanent smoke, although with clearly visible signs stop smoking. Wants to convey hearts husband photo is very simple, that effort away 'society from danger cigarette not be only conducted with only install alerts. An effort is needed to review more thing can realized.

It seems that the problem has been realized posted initials also hospital officials with establishment of the regulation the regulation confirms the smoking ban. But the realization of such regulation was not maximum yet to be realized in society, posted therefore expected that future regulation concerning a smoking ban not just be a discourse, but can with neither realized under strict supervision for a review of health the 'society in the future.

Appreciate the Rest Time Muh. Arham Harun AMSA-Universitas Hassanudin

Appreciate the Rest Time Muh. Arham Harun AMSA-Universitas Hassanudin

Abstract The key for the recovery of the patient is not only determined by the proper care from the doctor, but also by the conditon of the hospital when the patient need time to rest. And this condition can only be achieved if there is a good cooperation between the hospital, the doctor, patient, and also the family of the patient One way to make sure this happen is by making a schedule to visit the patient when they still in the hospital. The purpose is to make sure that the patient have enough time to rest, that really needed to ensure the recovery of the patient How to make sure this can happen? This photo show you how. You can see that the security is try to prevent the visitor that want to visit he patient outside the schedule that already being placed in the door. What we want to show you that these rules will not work without good cooperation from all the stake holders. We hope these can be implemented in every hospital so we can make sure that the recovery of the patient will be good

BPJS, Health Facility in Public?

Robertus Erik Kantona, Imelda, Yudistira Wardana AMSA-Universitas Sriwijaya

BPJS, Health Facility in Public?

Robertus Erik Kantona, Imelda, Yudistira Wardana AMSA-Universitas Sriwijaya

BPJS is a legal entity which formed to organize social security program in Indonesia (Act No. 24 of 2011). BPJS consists of Health BPJS and Employment BPJS. Health BPJS formed to hold health insurance program form of health protection so that participants receive health care benefits and protection to meet basic health needs are given to every person who has paid dues or dues paid by the government.

BPJS Health will pay the first-level health facilities with capitation. For advanced level referral health facilities , Health BPJS pay with a INA CBGâ&#x20AC;&#x2122;S package system. Health BPJS obliged to pay health facilities for services provided to the participant no later than 15 days after the claim is received with complete document. The amount of payments to health facilities is determined by agreement between the association BPJS Health and Health Facilities in the region with reference to the standard rate set by the Minister of Health .

Unanticipated expenses such as individuals exposed to severe illness with a mortality risk of demanding stabilization routine as operating costs are very high make use of one's income to be disrupted. It is certainly causing economic hardship for themselves and family. Through DPA Consideration No. 30 / DPA / 2000 , dated October 11, 2000, states should immediately set up a National Social Security Agency in order to realize a prosperous society.

Universal health insurance is expected to start gradually in 2014 and 2019.

Expected that all citizens of Indonesia already have the health insurance. Health Minister Nafsiah Mboi stated BPJS Health will be sought to endure all kinds of diseases by conducting efficiency efforts.

This Is for You, MOM Cut Lia Listiani Fatmala Putri AMSA-Universitas Syiah Kuala

This Is for You, MOM Cut Lia Listiani Fatmala Putri AMSA-Universitas Syiah Kuala

Breastfeeding is necessity that have to be loaded by every mother who have a child in 0-2 years. Itâ&#x20AC;&#x2122;s not only as nutrition resource but also as the immune system for the body and to be psychological bone tighten between the children and their mother. The necessity of breastfeeding is not looking at the time, and mother activities to reach it. But the problem there is mothers that confront to certain problems such as, their husband or their parents are hospitalized that oblige the mothers to take care over them. And this problem make their child fussy because breastfeeding unsatisfied that cant annoy other patients in the same room.

So to overcome the problem, dr. Zainoel Abidin University Hospital (RSUZA) as type A of health attendance have provided a corner to breastfeed. And it is a good solution to overcome the problem, but itâ&#x20AC;&#x2122;s not enough to accommodate all mothers and not enough accessible from the other rooms that far enough. However, it must capable to provide in another some points in RSUZA that consider many patients and their family. And for the next, itâ&#x20AC;&#x2122;s not only type A hospital that have breastfeeding corner, but also can be provided in every type of hospital.

Hygiene is Considered Trivial Alfattah Nandayu Setiawan AMSA-Universitas Palangka Raya

Hygiene is Considered Trivial Alfattah Nandayu Setiawan AMSA-Universitas Palangkaraya

Hygiene sometimes is still lacking in the community even though the place looks clean. Even when food that fell to the floor just a few seconds. Many communities when the food he wants to eat accidentally fell to the floor, if not 5 minutes then the food was still clean and still very healthy to come back consumption. These habits are still very much in the community. The lack of knowledge seem trivial but can cause various diseases. If the public was aware that any food that fell on the floor or fall wherever exposed to contact foreign bodies lack of cleanliness and hygiene level, it is a place for bacteria and germs stick.

Imagine if this trend continues. The level of selfishness and concern for others to tell that it is not well done also exists only in on oneself without being able to revealed. Everything is still need more knowledge and education the provision of that habit as it slowly must be removed, so that the disease caused by bacteria and germs that invade the body will be minimized. As we know that a reflection of what the disease will be suffered can be seen from what foods are consumed and the level of cleanliness of the food.

Keyword: Hygiene, clean, food, floor, habits, bacteria, knowledge and education

The Proper Use, The Patient is Healthier Anggini Tsamaratul Qolby AMSA-Universitas Palangkaraya

The Proper Use, The Patient is Healthier Anggini Tsamaratul Qolby AMSA-Universitas Palangkaraya

Antibiotics are used to prevent and treat infectious diseases. Not infrequently found negligence on the actual antibiotic function. Antibiotics in the form of medicines and injections on the condition that was not caused by bacteria not a few are found in everyday practice and in hospitals. Some errors were found to actually cause a weak influence of infections to antibiotics. In fact, the use of antibiotics in excess doses can also cause bacterial resistance. Required evaluate whether or not the patient has an allergy to antibiotics.

Moreover, before injecting the patient, medical personnel need to pay attention to some principle that is right patient, right drug, right dose, right timing, right route of administration, correctly giving information about the patient's medication, right about the history of the use of drugs by patients, right about history drug allergy in a patient, right about the reaction of some of the administration of different drugs when administered together, and correct documentation of drug use. If there is a dubious infection will require a more specific examination to ascertain the type of bacteria that cause without ignoring the established procedures. Accuracy and compliance principles to deal with patients is no exception to the injections should be used whenever and wherever in order to avoid losses.

Keyword: Injection, antibiotic

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DONâ&#x20AC;&#x2122;T BE AFRAID TO SEE YOUR DOCTOR! Kriswahyu Yudo Wirawan, I Putu Aditio Artayasa, Verrell Christopher Amadeus AMSA-Universitas Gadjah Mada

One of the indicators of the welfare of society is the level of health. Over the times, the challenges in the health sector are increasingly difficult. High population and the emergence of new diseases add to the difficulties. Therefore, it required the active efforts of governments, health professionals and the public to improve the quality of health.

One health problem in Indonesia is the tendency of some people to choose nonmedical treatment as their first option when they are sick. But the fact, mosts of nonmedical treatments have no scientific basis so often the patient does not recover, and their diseases get worse. This is compounded by the existence of non-medical treatment that is both fraudulent and unprofessional. Perhaps this is also due to the uneven distribution of physicians, so communities are not familiar with medical equipment such as syringes and there is a fear of an expensive fee to the doctor.in some people.

So we need to sensitize the public to prefer medical treatment because it has been clinically tested and treated by a trained and professional doctor. In addition, we, as future health professionals, should be closer to the community and establish a good image so that would be ingrained in the public mind that the doctor is the first person they encountered when they are sick.

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YOU EAT JUNK FOOD, JUNK FOOD WILL EAT YOU BACK Nafisa Naaz Nisha, Priscilla Christina Natan AMSA-Universitas Brawijaya

In the 21st century and "junk food" has gone global. For better or for worse, junk food is now available all over the world. We see it most everywhere we go -- in grocery and convenience stores, fast-food restaurants, on television -- usually looking very appealing. But just what are the facts about junk food?

"Junk food" generally refers to foods that contribute lots of calories but little nutritional value. One problem with junk foods is that they're low in satiation value -- that is, people don't tend to feel as full when they eat them -- which can lead to overeating. Another problem is that junk food tends to replace other, more nutritious foods. When people drink lots of soda, for example, they are usually not getting plenty of low-fat dairy or other healthful beverages like green tea or orange juice. When they're snacking on chips and cookies, they're usually not loading up on fruits and vegetables.

While people in developed countries are already fighting the childhood obesity epidemic, most Indonesian parents, even the best educated ones, are unaware of the problem.

Most parents still worry more about raising a malnourished child than they do about the threat at the other end of the scale.

Indonesians are beginning to recognise that obesity can lead to problems like diabetes mellitus, cardiovascular disease. Not only that, the study determined that people who eat junk food are 51 percent more likely to develop depression than those who eat little to no junk food. It was also found that the more junk food study participants consumed, the more likely they were to develop depression. A junk food diet could also affect your brainâ&#x20AC;&#x2122;s synapses and the molecules related to memory and learning, according to a study published in the journal Nature. Animal tests have shown a similar effect. Rats fed a steady diet with over half the calories from fat (similar to a junk food diet) for just a few days had trouble completing a maze they had previously mastered in a 2009 study.

So simply said that eating junk food means you destroy your own body. Because people who eats junk food will get addicted with it and make junk food as their daily food which makes them having low nutrient and unhealthy lifestyle.

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4 Minimum Check-Ups to Save the Future Edelyne Chelsea, Suripto AMSA-Universitas Indonesia

Indonesia is one of the countries with high rate of births. However, it is really sad to know that the rate of maternal mortality in Indonesia is still high. According to WHO, 228 of 100,000 women die from giving birth. This high rate of maternal mortality is related to the knowledge of Indonesian women about pregnancy. Due to the local cultures and beliefs in Indonesia, they have improper knowledge about how to take care of themselves and the babies. Let alone going to the hospital, most women who live in the village still prefer going to the traditional birth attendant (dukun) to going to the community healthcare centre (puskesmas).

The purpose of this poster is to increase the awareness about the importance of Antenatal Care (ANC) amongst people, especially pregnant women in Indonesia. Antenatal care itself is a program consisting of observation, education, and healthcare for pregnant women.

Indonesia really needs to optimize the ANC program considering the high rate of maternal mortality. The Ministry of Health (MoH) requires that every woman do at least four checkups during the nine months of pregnancy: once during the first trimester, once during the second trimester, and twice during the third trimester. ANC does not have to be done at the hospital. Women who live in the village can get help to do the ANC from community healthcare centre (puskesmas), midwife or even community healthcare volunteers (kader).

Letâ&#x20AC;&#x2122;s increase this awareness and save the future!

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VACCINATION = PROTECTION Devina Talitha AMSA-Universitas Padjadjaran

Abstract Immunization is the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine. Immunization has been proved to be an effective tool for controlling and eliminating life-threatening infectious diseases and is one of the most cost-effective health policies. Sixty-five countries out of one hundred (and) sixty-four which are members of WHO still has a DPT (Diphtheria, Pertussis, Tetanus) immunization range below the 90% global target. Indonesia is one of those 65 countries.

Indonesia also has what is called an “immunization gap”. Immunization gap simply means that there are still certain areas where children are still susceptible to certain infection or diseases that could be prevented through immunization. WHO’s theme in 2015’s World’s Immunization Week, “Close the Immunization Gap, Vaccination for All”, brought awareness to the problem that Indonesia and 65 other WHO members are facing.

Overcoming geographical barriers, raising awareness, and governmental intervention are the key factors towards closing the immunization gap and reaching the global target. Indonesia geographical condition is a barrier in distributing not only the vaccine itself but also the human resources in distributing the vaccine to an area of need. Inequality and incompatible delivery of message to certain areas where access and level of education or even language is different form other more urban parts of Indonesia is one of the reasons for the gap. In order to have a wide and even impact on the people, governmental involvement is crucial for funding and cooperation with the local government. The three factors are interconnected, if those key factors can work in harmony Indonesia’s future in immunization will surely reach it’s target and it will have a directly positive impact on Indonesia’s health as a whole.

Sources WHO ; depkes.go.id

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OPEN THE WAY FOR GOOD SAMARITAN LAW IN INDONESIA Camelia Ijaya, Nabila Fauziah Ramadhani AMSA-Universitas Brawijaya

Good Samaritan Law is a way to enforce protection for good samaritan. A good samaritan refers to someone who renders aid in an emergency to an injured person on a voluntary basis. They are people who want to help but in the other side society will blame them, even they will be jailed if they make a mistakes. This is certainly not fair for them, because helping shouldn’t be a crime. Under the good samaritan laws which grant immunity for good samaritan, if the good samaritan makes an error while rendering emergency medical care, he/she cannot be held legally liable for damages in court. Any other country such as USA, Canada, China and many more have imposed Good Samaritan Law. This poster has two objectives which are, first, to raise public awareness towards medical care issues from universal perspective. There’s still a lot of cases in Indonesia which contrary blame the good samaritan, because up until now we still don’t have specific policy to protect them. The second objective is to propose strategies how general public can participate in improving medical care system in Indonesia from universal perspective. By applying this law, public can contribute to medical care to their fellow people by giving an emergency aid to those in need. There are some important key points of Good Samaritan Law such as, they should be protected from civil and criminal liability, suitably rewarded by government, and no demand for medical expenses.

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IT’S OUR TIME TO SAVE OUR GENERAL PRACTITIONERS! I Putu Aditio Artayasa, Kriswahyu Yudo Wirawan, Verrell Christopher Amadeus AMSA-Universitas Gadjah Mada

Nowadays, to become a general practitioner, a person must pass in Undergraduate Medical Education Program, which is famous for the cost is very expensive when compared to another undergraduate study program. It is not included professional education and internship to obtain Permit Practice that prolongs studying time. Doctors also are lifelong learners to keep up to date about medicine Seeing from the education process, we can think that the income of a general practitioner should be feasible and appropriate. But what is the reality? Compared with other professions such as employee taxes, the salaries of doctors is very little. The salary of a new general practitioner in Indonesia is only about Rp 2-3 million per month. Whereas in other countries, as a comparison in Malaysia, a general practitioner paid Rp 15 million per month, not including commissions. Moreover, the ratio becomes more ironic if we compare it with developed countries like the United States and the United Kingdom.

Not quite up there, a general practitioner, who primarily work in hospitals, often to have working hours in excess of what it should be, which makes their workload becomes very heavy. Not to mention, with the passing of new legislation now, few mistakes made by doctors, can immediately take them to jail.

Seeing this, of course we need to make people aware that the general practitioner needs special attention in today's era. We must respect the general practitioner, realized that the profession is very important in people's lives. We must act and support the movement in the struggle for justice and the welfare of doctors, so doctors can work safely and peacefully, in order to reach an optimal performance, because it is unattainable to reach “Healthy Indonesia”, without any optimal role of general practitioners in it.

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Internship Program, has it done well?

Ana Silvi Niâ&#x20AC;&#x2122;ma, Novita Oktaviana AMSA-Universitas Airlangga Internship is a program for doctors who have completed professional education. The goal of this program is to apply the ability or competence of the doctors at choosen region in Indonesia for one year. In Indonesia, Internship program has been started since 2003. The implementation of the internship program is set on the Indonesian Medical Council Regulation No. 1 / IMC / PER / 1/2010.

But in 2015, there were 3 cases in internship program. The cases are the death of dr.

Dhanny Elya Tangke on May 13, 2015 in Jayapura, the death of dr. Dionisius Giri Samudra on 11 November 2015 in the Aru Islands, Southeast Maluku and the death of dr. Afriandi Naufan on December 15, 2015 in the Aru Islands, Southeast Maluku.

Of the three cases above, in general these deaths are caused by illness and the delays in treatment. This is because there is no official rules that regulate both of rights and obligations of internship doctors, so there is no adequate protection in internship program.

Internship doctors need a policy that regulate their rights and obligations based on Law No. 20 of 2013 concerning medical education, Section 1 of Article 3 which states: Operation of Medical Education is based on: a. scientific truth b. responsible c. benefits d. humanity e. balance f. equality g. relevance h. affirmation i. professional ethics To achieve a better internship program, the government should issue anofficial rules that regulate the rights of internship doctors. Some rights are: 1. Guarantee the health of both central and local government 2. Life insurance 3. Vaccination and other protection

4. Ability to survive 5. Organization of the medical profession who always supervise the implementation of the internship program 6. Adequate transportation 7. Completeness of drugs 8. Review of the area to be occupied

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GO SAGO! Marselno Tatipikalawan AMSA-Universitas Pattimura

Objectives: 1. To introduce sago as a local food that can help stabilizing blood glucose level 2. To engage the Moluccans to go back consuming sago as a local food

Key words: Sago, blood glucose, local food

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Price for Health F.X. Krisnawan Soharto AMSA-Maranatha Christian University

“Health is Priceless”. That was a saying we have heard a thousand times, yet that saying still remain a mere words for many people. We live in a strange era, we have global problems of overweight and underweight at the same time. Some people fill themselves with overpriced drinks, foods or item which actually doesn’t cost that high while some people are struggling to eat a spoonful of rice each day. And with this, comes many health problems, the poor and the rich suffer the same and need medical care with different cost.

Our nation has Health Insurance Policy to help on economy factor. But somehow, there are people who abuse to this policy. With very limited budget it is common for Health Workers, especially doctor to meet demands from patients, starting from medicines, fullbody check up, lab examination etc., and when the Health Workers are struggling with the funds. There are peoples who felt they deserve more than they actually bargain for. Pity, people pay 50K for coffee willingly but reject when health workers can’t give maximum service with low budget. With this poster I want to raise public awareness that optimum service has its cost, and we need to ask ourselves. Do coffee really worth more than a life ?

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SAVE THE LIVE-SAVER WITH GOOD SAMARITAN LAWS Nabila Fauziah Ramadhani, Camelia Ijaya AMSA-Universitas Brawijaya

A good samaritan law defines a law that exempts from legal liability persons, sometimes only physicians, who give reasonable aid to strangers in grave physical distress. In addition, some states extend Good Samaritan liability protection to cover business and nonprofit entities acting during an emergency. This law will usually be applied with two following conditions: 1. The aid must be given at the scene of emergency, and 2. The volunteer didnâ&#x20AC;&#x2122;t has other motives such as the hope of being paid a fee or reward. Several countries such as Canada, China, Ireland, United States and many more have imposed the Good Samaritan Laws.

This work of public poster has few objectives. First objective is to raise public awareness towards medical care issues from universal perspective. People nowadays mostly afraid of giving an emergency aid to those in need because if things get worse, the civilizations will accused them guilty. But if this law imposed, people donâ&#x20AC;&#x2122;t have to worry anymore to help because, unless they have bad motives, the law will protects them from criminal liability. the second objective of this poster is to propose strategies on how general public can participate in improving medical care system in Indonesia from universal perspective. By enforcing this law, the death probability of injured people will significantly decreased because of the undergoing emergency aid people gave to the others in need. Thus, medical care system in Indonesia will be improved by public participation, automatically along with restoration in faith of humanity.

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Stop Elephantiasis Nuansa Firgie Paraimtha, Aâ&#x20AC;&#x2122;ifatin Venysya, Karina Shofyana AMSA-Universitas Brawijaya

In Indonesia, the efforts to eradicate filariasis has been implemented since 1975, especially in the highly endemic areas of filariasis. In 2014 there were more than 14 thousand patients with chronic elephantiasis which has been spread in Indonesia. More than 120 million of Indonesian occupation occupy the area at high risk of contracting filariasis.

Elephantiasis disease or Filariasis is a chronic infectious disease caused by a filarial worm that attacks channels and lymph nodes. Filariasis patients is someone that the examination of blood result containing the microfilariae with positive antigen detection test or had clinical symptoms of filariasis. Filariasis is a contagious disease that is spread most of Indonesia, and can cause lifelong disability.

Filariasis prevention is all activities or actions aimed at reducing the prevalence (microfilaria rate) as low as possible to reduce the risk of transmission of filariasis in the region. Filariasis Dispensing Prevention Bulk called POMP. Filariasis is the administration of drugs to kill microfilaria performed simultaneously to all target populations in endemic areas of filariasis. Drugs that are currently used for mass treatment is based on a global agreement under the direction of WHO is Diethylcarbamazine (DEC) plus Albendazol, given in a single dose once a year and repeated once every year for five years in the endemic areas of filariasis. In the history of Filariasis Bulk Drug Prevention (POMP) in Indonesia, DEC is always used as the drug of choice for filariasis. This medication kills the microfilariae, but its effect on adult filaria still questionable. Albendazole is used to kill adult filarial. Albendazole during a counter drugs used to treat intestinal worms investment.

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We Care, We Aspirate Nadia Fadhilah, Raras Ambarjati S AMSA-Universitas Brawijaya

Lately in our beloved country, Indonesia, there have been a number of cases that show how our health services in remote areas are lack of concern from our government.

There is this case where a young doctor called dr. Dhanny Elya Tangke who died in Jayapura, Papua because of malaria. He suffered from recurrent malaria and was late to evacuate from Community Health Centre for a few days due to bad weather. In the meantime if the evacuation was done faster, his life could be saved. But despite of the evacuation, drugs for malaria should be available in Community Health Centre if the area is included as endemic malaria.

This one example above open our eyes about what is it actually the role of society to a better health service. If we examine further, there are actually three roles of society to a better health service. The first is actively participate in criticize and informed the government about the lack of health service in some remote areas. The second is contributing in keeping the facilities. And the last is helping the poor to get the same service as everyone in the country.

The small thing we can do from three roles that explained above is actively participate in criticize and informed the government about what are the things which are less, either from transportation, drugs, as well as facilities. So, from now on let us aware about every health services problem in Indonesia and give the government the information, critics and suggestions so that there wonâ&#x20AC;&#x2122;t be any more lives taken.

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Prevent the Antimicrobial Resistance (AMR) by Introduce 4R 1A (Right Dose, Righ Patient, Right Drug, Right Indication and Aware to Side Effect) to Community Amalia Ayu, Farhana Sutomo, Chrisandi Yusuf R AMSA-Universitas Brawijaya

The issue of antibiotics not only in Indonesia but also globally are becoming a problem that is quite complicated and must be handled together. Even though the death rate, tucked away from the case of deaths in hospitals, such as death caused by heart attack, stroke, pneumonia. If at the track in the medical record it turns out, there are resistant germs are not reported, because the reporting system is not referring to microbes. Sales of antibiotics freely in pharmacies, shops, also keeps a reserve antibiotic in the house, forcing the doctor to ask for written prescription of antibiotics, that’s all problem that occurs in the community. This can lead to antibiotic resistance in humans.People often buy antibitoik haphazardly without knowing what exactly their diseases and often buy without a prescription. Also people who already buy prescription antibiotics often consumed the antibiotic without right indication as doctor say. The Indonesian government has issued guidelines for the use antibiotics wisely and rationally. It is the government's efforts to reduce the incidence of resistance in Indonesia.

It

is

listed

in

“Peraturan

Menteri

Kesehatan

Republik

Indonesia

Nomor

2406/MENKES/PER/XII/2011 Tentang Pedoman Umum Penggunaan Antibiotik”. But in reality, many people who do not know and have not implemented the use of antibiotics in accordance with the guidelines. Public awareness of antibiotic resistance is still low.The reason why this public poster chose the title to introduce the public how to use antibiotics properly and rationally and to inform that cases of antibiotic resistance is not a trivial thing. It can cause increased morbidity and causes of death, increasing the cost and duration of treatment, increasing the side effects of multiple drug use and high doses.

282

Vaccines don’t harm your children, your refusal does Anugerahaning Salsabila, Rara Ayuningtyas, Vidya Ananda AMSA-Universitas Gadjah Mada

In 2013, our former Ministry of Health released a regulation (Permenkes 42 tahun 2013), which said all parents are obliged to get their newborn baby Basic Complete Immunization (Imunisasi Dasar Lengkap). But in 2015, according to Health Department, roughly 13,2% children in Indonesia don’t use their rights to be vaccinated. This means 13,2% children can suffer —or even worse— die, from preventable infectious diseases. This means parents have violated the children’s right to be protected by vaccines, and neglected their obligations to vaccinate the children. This is dangerous, as vaccine acts as “shield” for the children. Indonesian Pediatrics Alliance in 2011 reported as the number of babies who get MMR vaccination were increased, the number of MMR cases found were decreased significantly.

Why does some parents refuse to get their children vaccinated? We believe money is not the issue, as BCI is completely free, supported by the BPJS system. Turns out that there are some false rumours circulating in the society and anti-vaccine campaigns that actively support that beliefs.

Examples are: vaccines can turn the children into autists; not allowed in certain religion; the children are healthily safe and sound, so why need vaccines? Advanced and updated researches had succesfully proved those rumours wrong, and Indonesian Council of Ulama had stated that vaccines are safe to use. Vaccines are safe and much needed as the first-line protection towards infection that can attack anytime during their childhood.

Therefore, the purpose of our poster is to raise awareness of the parents that vaccines are included in one of children's right to be protected, and an obligation of the parents to get their children vaccinated. We hope the raising awareness of the importance of vaccines will increase the general health quality in Indonesia. Vaccines don’t harm our future generation, our refusal does.

284

YOU ARE WHAT YOU EAT Atika Nurul Haniyyah, Azura Nabila Putri, Ignatia Rosalia Kirana AMSA-Universitas Gadjah Mada

Government has policies which are applied in Indonesia. One of the policies is about health.

Indonesia government wants to reach Indonesia’s universal health care. In this poster we want to propose you the idea of improving nutritions for Indonesian people to reach universal health care One of indicator how developed a country is from healthy life of the society. Healthy life can be accomplished if we have a healthy lifestyle. We can start having healthy lifestyle from what we eat. As we know, all diseases come from tummy that consist unhealth food. If we want to prevent the disease, we can start by maintaining composition of food we eat. The food we eat should consist carbohydrates, proteins, fat, vitamins, minerals, etc. We can get all of those components from eating good food in our meal. What kind of food is eaten can also be an indicator how wealthy people are.

A country can be developed if all the components support it to develope. We show you from this poster there are people from all ages, which depicts that Indonesian people are famous with its culture – helping each other. This poster describes all components should involve and help each other in making a policy. We could not deal with a policy if one group disagree with the policy. So, all people should involve in making a policy. We also show you Tumpeng, it is one of traditional food that has a complete nutrition according to Indonesian’s culture.

In our mind, we can improve Indonesian people’s health by improving what food is in their body. Good foods have good nutritions for having good health.

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BE PREVENTIVE, STEP ON Petrus Gandi Purwosatrio, Indah JP Devrin, Arif Abdur Rohman AMSA-Universitas Gadjah Mada

A. ABOUT THE TITLE Why we choose this perspective?

ALL AT RISK Preventive healthcare. Just as health condition encompasses a variety of physical and mental states, so do disease and disability, which are affected by : 1.

environmental factors,

2.

genetic predisposition,

3.

disease agents,

4.

lifestyle choices.

Health problems, disease, and disability are the result of dynamic processes which begin before individuals realize they are affected. TRUTH. Each year, millions of people die of preventable deaths.

1.

A research showed that about half of all deaths in the U.S. in 2000s were due to preventable behaviors and exposures (leading causes were cardiovascular disease, diabetes). Same study estimates that 400,000 people die each year in the U.S. due to poor diet and a sedentary lifestyle. TRUTH.

B. OBJECTIVE “OUR” AIM Regarding from that reason (above), preventive healthcare do it’s job by finding and treating disease as soon as possible. Some sort of illness hits everyone eventually, but many, many diseases – when caught early – can be nipped in the bud and full health returned quickly.

To share this perspective : By Exercising regularly (3-5 times a week @30-45 min) You get Clear and well-being mind The shape you always want Prevent The two major killers (CV disease and diabetes) WE get Efficiency on cost management (Universal Coverage fundings should be more prevalent (re: merit) in ALL areas (as on MDGs)) Better health care, better patient’s health outcome and satisfaction

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Increasing People Participation on Optimizing Health Insurance Program Resty Puspita Sari, Hermanuaji Sihageng, Tania Prima Auladina AMSA-Universitas Gadjah Mada

Jaminan Kesehatan Nasional or JKN (National Health Insurance) is the most influential health policy nowadays. Since January 1st 2014, JKN is handled by Badan Penyelenggara Jaminan Sosial Kesehatan or the Social Security Management Agency for the Health Sector (BPJS Kesehatan) to provide wider coverage of health insurance for all of Indonesian people.

Although this program is meant for all of Indonesian people, public awareness towards this program is still low. This is proved by low number of JKN participants which is 156.790.287 of 255.993.674 Indonesian people or only 61.2%. This is still far from the governmentâ&#x20AC;&#x2122;s target which is 100% participation of Indonesian people. Moreover, JKN principle is gotong royong or mutual cooperation where the healthy ones should help those who are sick and those who are rich should help the less fortunate without differentiating social status or ethnicity. So, if people participation is still uneven, the principle of mutual cooperation will not work well and can even cause BPJS loss. On the other side, many of JKN participants still do not know the procedure of JKN service so some of them feel that they are not well served.

Based on the facts stated above, we made this public poster in order to gain public awareness towards the importance of being JKN participant. Besides, we also would like to invite the public to be proactive in gaining information regarding the procedure of JKN service so that there will be no more miscommunication between the service provider and the JKN participants. Along with the increasing of public participation, health care service can be done more systematically. We also hope that those who already understand JKN well can be the agent of socialization in the community so that the information can be conveyed well.

292

Health care provider without health care providing instrument, can it work?

Robert, Yohanes Leonard and Kevin Setiawan AMSA-Universitas Gadjah Mada

Indonesia, a beautiful country with tremendous number of islands, finds it difficult to manage its health issue, one of them being evenly distributed health care providers but lacking in distribution of medical instrument. To evenly distribute the young doctors across the country, the government has made a program called internship which obligates young doctors to apply their knowledge in society. In one side, Internship is a good way to manage Indonesia’s health issues but on the other hand, Internship is really a loss for medical students. Remembering a long time which is spent for them to graduate from medical school and in addition to internship program, they must be spending more money until graduation.

By applying a law which obligates young doctors to spread over the entire country with hope of improving the country’s health. Unfortunately, this distribution of young doctor is not balanced with the distribution of the medical instrument. In spite of sacrificing medical students, government still can’t manage health issues in Indonesia. The government has made the program so it will be nice if there’s a way to optimize this program and optimizing internship program can be achieved by supplying medical instrument evenly.

294

Oh My God, This is BPJS! Ikhlasul Amal Abdal, Rizky Nur Caesaria AMSA-Universitas Halu Oleo Abstract In constitution number 36 years 2009 about health stated that everyone have the same right to get the health service with safety, quality, and reachable price. On that reason, the government of Indonesia create two govern bodies which BPJS (Social Security Agency), there’re BPJS for health and for labour. BPJS for health is the legal govern body which manage the healthcare programs and has been published on 1st January 2014.The aim of BPJS for health is giving the same right in health service to all of the citizens in Indonesia, include the service of prevention, curative, and rehabilitation service. Include the medicines and the medical treatment according to patient’s need.

One of the target from BPJS is to give the health service for the poor. In general, the poor susceptibility to have healthcare degree lower than, because they can’t to access it that cause economy problem to get the health service. In BPJS program, the poor put into group that call PIB (Receiver of Aid Insurance) where government pay out the insurance as healthcare service participants.

From the ministry of health data showed the number of people that join in any healthcare insurance was 151,6 million people. But in reality, data on 30th June 2014 showed that the number of participants who have joined in BPJS healthcare program just around 124,5 million people, including the poor around 86 million people.

Therefore, to maximize program of BPJS, it takes the promotion of this programs. In order to make everyone join this program, to registered themselves before they get sick and bring to society that able to be healthy and productive.

296

“The Price To Be Healthy” Muhammad Afdhal Ruslan, Firman Riansyah Kasman, Nurul Dwi Ratih AMSA-Universitas Halu Oleo

Abstract Urban youth are familiar with snacks such as fried chicken, french fries, hamburgers, pizza and drinks such as soft drinks, cola drinks, ice cream, milkshakes, and so on. The food is indeed very cool drinks easily found in shopping malls, plazas and shops in the center and suburbs. And seems to have entrenched elite and a meal, especially for urban youth. Urban consumer culture has already hit too young, Who does not feel wah and "slang" if lunch or dinner at McDonalds or KFC or Pizza Hut or Dunkin 'Donuts? Usually there is no denying.

Besides it tastes delicious, the atmosphere is also pleasant and prestigious restaurant. But we know that the types of food offered in top restaurants including as junk food? junk food with nutritional content is very low or too high calories and only rely on its good taste.

Economically, the price is very expensive, while the very low nutritional value. So it should be enough to buy healthy foods such as fruits, vegetables, and beverages such as milk that are cheap and affordable and has many nutritional benefits for the body. To be healthy is not expensive, therefore don’t waste your money to make you sick but use it for make you healthy.

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Hernia Paints Dian Riftya, Dina Marcelina, Edgar Enca AMSA-Universitas Hang Tuah

Everything instant is always gaining a popularity, who doesnot want any practical things in their life? Our society was already being treated in a practice way, including health issue. People tend to looking for a fastest, easiest and simplest way to cure their health problem.

Nowadays, we can easily find many kind of alternative medication advertisement which offers wide range of simple way to manage diseases so patients can freely choose which medicine that worked best on them. From the sophisticated until the traditional one have its own enthusiasts. One of which is hernia pants. Thepants is quite popular in Indonesia as one of alternative medication for hernia, which the mechanism is wearing the pants to prevent hernia going down because its structure is tight and firm. Hernia itself is one kind of disease which made testicle or intestine going down from where it should be.

Hernia pants is one of Indonesians phenomenon who is lack of healthcare education because mainly they want something simple for their pain to become less. They are completely fine if they do not feel any painful again even though actually the hernia does not disappear.

Because hernia pants didnot cure, it just gave a comfort sensation to the patients. The only one treatment for hernia is surgery.

300

UNIVERSITY OF HANG TUAH SURABAYA Medical Faculty

Drugs are Basically Poison, Take it Properly Dicky Zulfa Firman Kurniawan

Abstract Rational medicine is practice of medicine based upon actual knowledge. According to WHO, rational use of medicines requires that "patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community". However, in May 31st 2011, kompas.com stated that â&#x20AC;&#x153;Indonesian people are surrounded by thousands brands of drug. Believe it or not, more than 40 percent of drugs that distributed in Indonesia are irrational. More than it's harmful to health, it's also a wastingâ&#x20AC;?. Even General Chief of Indonesian Pharmology Society and Grandmaster of Pharmacology Medical Faculty of Gadjah Mada University, Prof. dr. Iwan Dwiprahasto, M.MedSc, PhD, also giving his concern about this problem. However, there are several things that an individual can do to prevent this from continuing, as we cited from WHO website on March 2012. You can prevent it by using approved clinical guidelines, perform supervision, audit, and feedback on drugs usage, or increase your knowledge by attending public education about medicines.

Keywords: rational medicine, irrational, prevention.

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Registering Into BPJS is Easy, Why wait Dina Marcelina S, Mutya Syntya, Samiaji Gilang A AMSA-Universitas Hang Tuah

By 2019, every single citizen should applied for BPJS in Indonesia. rather than you protest about the long waiting list, itâ&#x20AC;&#x2122;s more better to register now , because there arenâ&#x20AC;&#x2122;t many queues and many people are quite lazy to register themselves right now, Also there are many beneficial effect from BPJS , So why we should wait and suspend something that will bring a good impact for us.

304

Go exercise Mutya syntia, Dian Rifta, Agnis Rahmi AMSA-Universitas Hang Tuah

Many herbs and traditional medicines havenâ&#x20AC;&#x2122;t been proven or tests in evidence based medicine for the benefits and the side effect were relatively dangerous. It's good to keep the body to stay healthy and fit , it can be done by Exercise regularly and Eat based on Nutritional Status.

306

Condom, A Trigger?

Suripto, Felix Kurniawan, Koe Stella Asadinia AMSA-Universitas Indonesia

As we all know, Indonesian health ministry did give out free condoms to society.

This policy raised both pros and cons from the people. While it is an effective way to prevent sexually transmitted diseases, many people see this move as an encouragement to free sex. If this continues to be perceived as such, people may eventually develop the wrong mindset, resulting in increasing practice of free sex.

“Condom Doesn’t Mean Can-Do” is saying that easy and free access to condoms does not mean you can have sex freely and without responsibility. Practice of free sex leads to not only sexual transmitted disease, but also psychological problems. Condoms are there to prevent transmission of sexually transmitted diseases, or in short, to protect someone physically. Alas, condoms cannot protect the user psychologically. This makes free sex a big threat for people’s mind, especially the young generation’s.

308

IMPROVING PROSPERITY, IMPROVING QUALITY Billy Jonathan, Bernadet Yulyanti AMSA-Universitas Kristen Krida Wacana

Doctor is a noble profession responsible in sustaining the public health sector. Doctor s dedicate their life to help people. Doctors give their best effort starting from the promotive s tage of health service, throughout the preventive and curative, all to the rehabilitative stage. T here are uncountable amount of time, effort, and money they spend to provide the best servic e for people. However, we can see that these days the welfare that is the right of all health-car e providers, especially doctors, is no longer obtained properly. There are so many policies pro blems and issues, reflecting how the prosperity of doctors are no longer considered important.

Doctor's salary given by goverment is at the minimum amount, many would even say it's ina dequate compared to the effort and work that they do. Moreover, doctors experience tardiness regarding their payroll schedule. And this lateness could take weeks, or even months. Of co urse this condition would affect their walfare and consequently the quality of their work. Mor eover, because of the stigma that being a doctor equals to being rich, this kind of issue often g oes unnoticed. Government, as the policy maker, should pay more attention in creating and ru nning new policies that will ensure the prosperity of health workers. And the community sho uld also take notice regarding these issues, and try to erase their stigma and perception regard ing doctor's welfare.

310

ONE PLACE TO SMOKE, ONE CHILDREN CAN BE SAVED Chaifung Carolline, Calysta Nadya Wijaya, Jessica AMSA-Universitas Kristen Krida Wacana

Objectives Tobacco use is growing the fastest in Indonesia. There are over 61 million tobacco users in Indonesia and it is causing 225.000 death annually. However, active smokers are not the only one affected. Passive smoking also has serious and fatal health consequences. The Tobacco Advisory Group of the Royal College of Physicians says that children are particularly vulnerable to secondhand smoke exposure, mostly at home. Unlike adults, they have little control and are therefore unable to remove themselves from areas of passive smoke exposure. Because of this, many children die because of the effects of secondhand smoke.

Actually, PERPU RI (Peraturan Pemerintah Republik Indonesia) number 19 in part VI verse 22 states that smokers can’t smoke in public areas such as school, public transportation, etc. But, why is the number of children’s death cause by exposure to secondhand smoke keep increasing? Because, people who stop smoking in nonsmoking area, are in fact, still smoking at home while their children is in the vicinity.

So what should we do? We propose that the government build a place to smoke near public area and civil houses. Smokers may only smoke in these places by showing their ID and paying some fees. This might reduce the number of smokers who are unwilling to pay. Other benefit is to protect passive smoker from second-hand smoke.

Public should realize the danger of passive smoking and protect the children’s future because they are the nation’s successor.

312

Better Knowledge to Prevent Sickness Ferdy Bahasuan, Jonathan B. Gilbert, Un Gerry Namyu AMSA-Universitas Krsiten Krida Wacana

There are a lot of problems that occured in medical field that is happening in this era of modern health, moreover this problem is caused by the people themselves.For example there are a lot of disease that are caused by the unclean environtment. These problem can become a serious problem if there are no people who have the will to change their surrounding. Doctors can be more active by guiding people on how to protect and prevent them from getting sick, in order to achieve healthy lifestyle. In Indonesia, the government made the primary health care doctor program to realize that task. The definition of primary care doctor itself forth in the Law No. 20 of 2013 on Medical Education. In Article 8, paragraph 3 of Law No. 20 of 2013 states that primary care doctor is a new education that can be taken after medical profession program and internship program, equivalent to a specialist profession. The title of which will be given to doctors who have passed the primary care doctor education program is SpFM (specialist Family Medicine). Primary care doctors are expected to act as a looker and

keeper that will handle the majority of cases in the

community. Primary care doctor are expected to provide a service that is holistic, preventive and promotive than curative. On the other hand, primary care doctor should also be oriented towards family medicine, occupational, community, managerial, and leadership. In this case, the difference between primary care doctor with a general doctor because of the conduct of the duties of primary care doctors prefer the preventive and promotive rather than curative.

Because the program still in development, the obstacles of this program caused by the lack of primary care doctors graduate so the implemented task of primary care doctors havenâ&#x20AC;&#x2122;t fully achieved.

314

Water Matters Vina Cyrilla, Grace Elizabeth Claudia, Franklin Wijaya AMSA-Universitas Kristen Krida Wacana

Safe and readily available water is important for public health, whether it is used for drinking, domestic use, food production or recreational purposes. However, not all available water on earth are good for human health. Indonesian government through the Minister of Health No. 416/Menkes/Per/IX/1990 concerning Requirements Water Quality Monitoring provides a definition of healthy water is the water used for daily consumption of which quality meets the requirements of health and be able to drink if it has been cooked. According to UNICEF and WHO, Indonesia is categorized as one of ten countries with two-third of its population, crisis for healthy water. Various diseases can arise as a result of the use of contaminated water, such as diarrhea, cholera, dysentery, typhoid and polio. Contaminated water is estimated to cause 502,000 diarrhea deaths each year. One of Indonesia govenment's program in providing healthy water is PAMSIMAS (Water Supply and Sanitation Community Based). The aim is increasing the number of facilities to the residents in rural and suburbs. However, there are some problems in implementation of its program such as intersector coordination, finding the source of water, the climate change and people unhealthy behavior on the riverbanks. Some people use the river for a toilet and at the same time they use the water to drink and wash their clothes too. Imagine the heavy pollution of river water by household and industrial waste is threatening the health of people who is living on the riverbanks. We can work together to keep the water clean so the plants, animals, and people who depend on it remain healthy such as using environmentally friendly detergents, not pouring oil down drains, reducing pesticides, and throwing garbage to its place. Start by yourself, we can make pollution less of a problem and the world a better place.

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COMMUNITY HEALTH IMPROVEMENT EFFORTS Dewinsya Medisujiannisa MS Idris AMSA-Universitas Muslim Indonesia

Objective

:

To Share the Effective solutions towards medical care issues from universal perspective

Health is an investment to support economic development as well as having an important role in poverty reduction efforts. Health development should be viewed as an investment to improve the quality of human resources. In the measurement of Human Development Index (HDI), health is one of the main components in addition to education and income in Law No. 23 of 1992 on Health determined that health is a state of body, soul and socially to enable more people to live productive socially and economy.

General condition of health is influenced by various factors such as environment, behavior, and health services. While the health service is influenced by various factors such as the availability and quality of health care facilities, medicines and medical supplies, health personnel, finance and health management. Basic health care facilities, the health center which is reinforced by the health center and health center circumference, have been established in almost all regions of Indonesia.

Currently, the number of health centers throughout Indonesia is 7,550 units, 22 002 units of sub health center and health center around 6132 units. Although basic health care facilities are located in all districts, but equity and affordability of health care is still an obstacle. This facility is not fully accessible by the public, especially in relation to cost and distance of transport. Other health care facilities Hospital is contained in almost all the districts / cities, but individual health care referral system can not run optimally.

The availability of quality, safety of drugs and medical supplies are still not optimal and can not be reached easily by the public. In terms of health personnel, Indonesia deficient in almost all types of health personnel needed. SDM is a major problem of the inefficiency and ineffectiveness of human resources in tackling health problems. Although the ratio of health human resources has improved, but still far from the target of Healthy Indonesia 2010 and the variations between regions are still sharp. With the production of health human resources of educational institutions at this time, the target is difficult to achieve.

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PATIENT’S INFORMATION "DONT’T AFRAID TO TELL, DOCTOR WILL KEEP YOUR SECRET” Muhammad Aiman AMSA-Universitas Muhammadiyah Palembang

The process of Diagnose is not simple. As a Doctor we must give a right diagnose to our patient, a right diagnose is important to help doctor choose a right treatment for patient.

Because of that as a doctor, a patient’s information is so important.

Patient’s information like your daily habits such as a smoker, alcoholic, drug addict, sex addict, patient allergic, family condition, operation history, and other, will guide the doctor to choose the patient disease.

However, patient nowdays, sometimes afraid to tell their doctor, they choose to hold back and keep important information that can be lifesaving. Many of them are embarrassed to share certain personal information with their doctor. And think the doctor will not keep it secret.

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Fight Towards Tuberculosis Ardhin Martdana, Lidya Pertiwi Suhandoko, and Nuzula Fikrin Nabila AMSA-Universitas Airlangga Abstract According to World Health Organization (WHO), Tuberculosis (TB) is top infectious disease killer worldwide. In 2014, 9.6 million people fell ill with TB and 1.5 million died from the disease. In 2014, an estimated 1 million children became ill with TB and 140 000 children died of TB The bacteria, mycobacterium tuberculosis can live in dorman form inside humanâ&#x20AC;&#x2122;s organ especially lung. Unfortunately only few people who aware that they could have been infected by the bacteria. This makes transmission of the disease is more widespread.

However, Tuberculosis is a preventable and a curable disease if detected and treated early. Understanding of its transmission can help people to prevent them and people interacting with them to be infected.

Taking easy steps (prevent-test-treat) as represented in our poster is aimed to help the audience understand the strategy to fight against tuberculosis, and the most important thing is giving them a picture that about a half of person in the world (represented by 2,5 out of 5 persons) might have been infected and also show them how the disease is transmitted.

Many medical care issues emerge because of people misunderstanding toward tuberculosis, few societies tend to keep their belief that this disease is a curse thus they keep away from universal perspective and medication. In order to change their mindset, 5 persons in our poster represent different race. To inform them that many persons in the world also have the same disease and they can be cured in a same way.

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Help Us to Help You Dyah Ratri Widyati, Alvin Saputra, Meilia Dwi Cahyani AMSA-Universitas Airlangga

Living as a healthcare provider, especially doctor, requires a high dedication and commitment. Professions in the medical field are mostly filled with high-pressure circumstances- which no doubt cause the people involved to develop stress. It is important to make sure that healthcare provider are given the proper regulations to make sure that they are protected by law when they are working. People who work in the medicine field are facing high-risk situations everyday and have to take responsibility on every medical decisions they made. In Indonesia, it is very common to see that these regulations are still facing quite a lot of problems. We can see this through a number of cases that happened lately. Doctors are sued because the patients outcome are not as what they expected. However, it is important to note that health care provider are only responsible for giving a proper treatment according to the guidelines available, but not for making sure that everyone will be fully recovered. It is important for the law and regulations maker to know how medical world nowadays look like and how things are in the eyes of a healthcare worker. This way, the regulation maker can help healthcare worker to make them feel safer at work, in which this will make them perform better. This is because they know they are protected by law when they are helping others. A better regulation will also prevent the defensive medicine trend in which the healthcare provider retreats from doing a high-risk medical treatment or overusing the diagnostic tools available. So, â&#x20AC;&#x153;We hope that you can help us to help you.â&#x20AC;?

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Between Conventional & Alternative Medicine Lidya Pertiwi Suhandoko, Williana Suwirman, and Fenska Seipalla AMSA-Universitas Airlangga Abstract Alternative medicine is any practice that is believed to be able to cure diseases, but is not evidence-based. Recently, alternative medicine has been a problem to medical care because of its non-evidence-based nature, making it unreliable. Even worse, some alternative medicine practices gives wrong and misleading information on their advertisements. Despite its nature, a lot of patients still prefer alternative medicine to conventional medical treatment. This is caused by the price of alternative medicine usually being significantly lower than conventional medicine. Some patients choose alternative medicine because they are afraid of surgery and other conventional medicine healing methods. The fact that people have little information about the unreliability of alternative medicine makes us medical professionals harder to get the facts straight to them. This is why this public poster is made. We believe that people need to understand that they shouldn't risk their own health and life by undergoing non-reliable healing methods. In our opinion, production and distribution of drugs should be strictly observed by the National Agency of Drug and Food Control (NADFC). A law regarding alternative medicine practice should be made. We believe that Indonesia can be a better place.

326

Not Just a Tool for “Money Generator” Meilia Dwi Cahyani, Alvin Saputra, Dyah Ratri Widyati AMSA-Universitas Airlangga

Living as a healthcare provider, especially doctor, requires a high dedication and commitment. As a medical student we’re going to be a doctor in the future but, in Indonesia there are so many complicated medical problems related with politics and law about the doctor’s rights and obligations. This issue alone is a major issue unresolved until now even though there are few qualified doctors. But now, Indonesia has too many medical faculties. It has sporadic development. There are 76 certified medical faculties, but only 17 faculties received “A” for the accreditation. So there are differences were visible from the doctor depends on his/her ability to pass from which university they are in. Nevertheless, the Indonesian government never paid special attention to this issue until now and because of that the development of new medical faculty is uncontrolled. Many new. Many construction of a new medical school indicating that a lot of certain parties who want to take advantage of this position. So many people who are actually not qualified for admission to medical school, but is included for the purpose of money taken hundreds of millions for the sake of special interests and not think about the future of Indonesia. Now, we have to think of it. So, what will the government do to this? Don’t they want to make a move to correct this? Are we treated now as a “Money Generator” or a future health care provider? Let’s think of it and decide it.

328

Doctor Is Human, Not A Robot Michael Jonatan, Fenska Seipalla, Henry Timothy AMSA-Universitas Airlangga

Abstract

Healthcare workers, especially doctors, are exposed to high tension of work, long hours of work and the burden of the job. More than 40% of doctors were having burnout and 25% of them had suicidal ideation (Shanafelt., et al, 2012). Our poster entitled “Doctor Is Human, Not A Robot” are aimed to encourage and raise awareness of the implication of burnout among doctors and suggest the need to limit healthcare workers’ work hours.

Romani and Ashkar (2014), long hours of work is the main cause of burnout. It makes doctors unable to recreate itself, release their stress and recharge energy. The burden then accumulate and results in burnout. Burnout is dangerous and psychologically deadly. It is also dangerous for the patients.

Burnout has 3 dimensions, emotional exhaustion, depersonalization, and low personal accomplishment. It affects the psychologically status of the doctors. Moreover, burnout is implicated with higher risk of medical errors and patient safety. Burnout also impair the relationship between doctors and patient, results in lack of communication and malpractice.

In Indonesia, most doctors work more than 80 hours a week without limitation. It seems that doctors are permitted to work as long as they can. And believe it or not, maybe that’s why Indonesian doctors are having trouble in communicate with their patient, because they experience the burnout.

We suggest that there is a need to make a legal regulation about duty hour standard for Indonesian doctors. That regulation are meant not only to protect the physician, but also to protect the patient, which results in protection for our country’s health. By limiting work hours, doctors will have time to relax and recreate themselves, it will impact on their good and healthy life and in the end will reduce the risk of medical error and improvement of patient safety.

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STOP DOCTOR CRIMINALIZATION! Nuzula Fikrin Nabila, Nila Novia Putri, Novia Nurul Faizah AMSA-Universitas Airlangga

Criminal prosecution of doctors due to medical malpractice, gratification, and other prosecution has created controversy. More malpractice cases have been heard in court. people tend to blame the doctors and accuse them of malpractice if someone death in the hospital treatment, even if the death is due to natural causes. Fear of criminalization due to malpractice case may lead to the practice of ordering excessive and unnecessary medical tests and procedures to avoid potential malpractice lawsuits. This poster aims to encourage people to act wisely and feel concern for Indonesian medical service. People should know that doctors are in a profession that emphasizes the process rather than the result. Law enforcers should really learn about medical issues because doctors do not intentionally hurt someone.

The media should be more balanced in viewing malpractice cases, thus the image of Indonesian doctors will be kept good.

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Changing Public Habit in Antibiotic Usage: Key to Fight Antibiotic Resistance Winona May Hendrata, Andi Yasmin Wijaya AMSA-Universitas Airlangga Antibiotic resistance is one of health challenge we face today. Microbe strains are changing, developing resistance to antibiotics. Antibiotic resistance is going on like a snowball effect, where more resistance developed in one strain of bacteria could be transferred to another and creates a more resistant strain. Human habit has significant contribution to antibiotic resistance development. This poster frames public carelessness in antibiotic usage. The actions of people cannot be fully controlled by health workers, so the public need to be aware of impact of their actions toward antibiotic resistance. Antibiotic resistance occurs naturally, but its growing can be decelerated.

First problem is that people sometimes assume they donâ&#x20AC;&#x2122;t need to take more of the medicine when they feel better, or forget to take it. Stopping and delaying routine intake of antibiotics gives time to microbes to mutate and create resistance toward the antibiotics. This may be caused by lack of trust from the patient to the doctor, and that is why developing trust is the first step to prevent antibiotics resistance. Patient should also understand that the prescribed drugs are only for personal use and not to be shared with anyone, even if the other person develops the same symptoms of illness. Antibiotics with degraded quality cannot effectively treat disease; instead it acts as stimuli for microbe to create resistance. Keeping antibiotics free from exposures such as sunlight could maintain the quality of the antibiotics and could still be effective as medication. The most important thing is to stay healthy.

Preventing infections and illness is the best way to prevent the acceleration of antibiotic resistance, and keeping people away from accelerating it.

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Saving the Money for Health Insurance Falensia Dwita Lestari, Nurizki Meutiarani M

AMSA-Universitas Hasanuddin

Objectives: When people talk and then offered an insurance product, most people will avoid it. It is because the stereotypes of insurance agents in the past which is identical to the the person who seem less accommodating their customers and also the procedure was complicated. But nowadays, there are a lot of insurance companies that compete to offered their product with their best service and easier procedure, which is, give more benefit toward their customer.

It has been said that nothing is more important than your health, and there is a lot of truth to that saying. Among other things, a loss of health can mean a loss of earnings if you are not able to work, and it can also mean medical bills that are extremely expensive.

The importance of having health insurance should not be dismissed or underestimated.

Health insurance can covers the unpredictable moments in life. It is the guarantee of being seen when ill and to have that medical treatment on a pay scale based on coverage. Rising medical costs can wipe out a lifetime of savings with just one major medical event. Even the most routine of surgeries can cost tens-of-thousands of dollars, and more sophisticated procedures can easily run into the hundreds-of-thousands of dollars. Health insurance can help pay those skyrocketing cost and help save you from financial ruin. It can also help individuals to lead more healthy lives by paying for preventive measures such as regular check ups and immunizations to name just two.

We could imagine that when uninsured, we receive less medical care and less timely care and these seem to be the people that experience the worse health problems. So, saving your money for health insurance is the better option.

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Face The New World Together Fenska Seipalla, Michael Jonatan, Henry Timothy AMSA-Universitas Airlangga

Abstract Effective on December 31st 2015, AFTA (Asean Free Trade Area) has been implemented all over ASEAN countries, including Indonesia. Our poster entitled “Face The New World Together” are aimed to encourage everyone to raise their awareness about the challenge in healthcare sector.

According to Union Contre la Cancre Meeting on April ’99, in the new era there must be some improvement, which are 1) Doctors must be fast learner and adopt to a new technologies, and the government should provide the necessary technology; 2) Doctors must work within the system and in team; and 3) Building communication and trust between doctors and people. The relationship should be a deliberative model, patient should aware and well informed.

Yet, Indonesian Medical Association stated that the challenge are 1) Our healthcare is lack of technology and doctors are lack of quality and confidence and the healthcare system in Indonesia mostly based on free market system and profit; 2) Our doctor has been always a solo player rather than a team player; and 3) lack of communication and trust.

So we suggest Indonesian doctors to 1) Be a team player; 2) be a fast learner and 3) communication is the key for survival. And to survive in AFTA era, Doctors need to AFTA which are Analyzing (Analyze the current challenge and problems); Finding (Find the suitable solution for the challenge); Taking Risk to apply the solution to solve the problems; and finally Achieving a Goal, which is improvement of the quality of Indonesia Healthcare System.

By doing AFTA and the suggestion above, we believe that the future of Indonesian people will be amazing. It is either we do it together (Government-Doctors-People) so we can win big, or we lose against another foreign country. Choose wisely and face the new world together.

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Doctor vs. Witchdoctor Nadya Eunice S. & Imanuela Yoel B., AMSA-Univeritas Hasanuddin

Indonesia is rich in cultures which vary according to local tradition that passed from generation to generation. Even in health area, it is believed that a person that called “smart person” or witchdoctor has an ability to heal without doctor’s help. Besides of the cheaper cost, the traditional medication and therapy are easier to be reached, especially for those who living in isolated village. In this condition, is doctor no longer needed?

According to SSEN 2004, 72,44% of the population prefer to do self-medication and 32,87% tried traditional medication. Whether it is safe or not is the problem. How do we know if this witchdoctor could really heal without any side effect? And is it trusted or is it just a luck that people that come to the witchdoctor heal themselves?

According to Darmajdi Ismono, there is a significant increasement of disablement of limb caused by fracture from 1998-2000 to 2003-2007 as 150 patients. 22 of them have infection that tought to be caused by inaccurate therapy by witchdoctor that worsen the patient's condition. At the end, they will come to doctor to cure their problem. Why don't they come to the doctor in the very first place? The goverment has already authorized the BPJS anyway.

A doctor has experience more than 5 years education in health and medicine that is certified and already pass through the exit exam, how can we compare it with a person that is being famous just by heal a person accidentaly or maybe not, but they do not know about our body, our body’s anatomy! Through this poster, we want to raise public awareness about how important is it to come to the doctor than a witchdoctor.

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Protect Your Child Give a Shot of Vaccines Falensia Dwita Lestari, Nurizki Meutiarani M

AMSA-Universitas Hasanuddin

Objectives: Vaccines help develop immunity by imitating an infection. This type of infection, however, does not cause illness, but it does cause the immune system to produce Tlymphocytes and antibodies. Some people believe that naturally acquired immunity (immunity from having the disease itself) is better than the immunity provided by vaccines.

However, natural infections can cause severe complications and be deadly. It is impossible to predict who will get serious infections that may lead to hospitalization.

Vaccines are recommended for very young children because their immune systems are not yet fully mature. When a baby is developing in the mother's womb it is in a sterile environment. The baby's immune system goes into action at birth, as the child confronts bacteria outside of the womb. But our bodies are an amazing creation with an immune system that is ready to go to work from the moment that we are born. Infants begin to immediately develop an active immune response to these bacteria -- an immune response that prevents these bacteria from entering the bloodstream and causing harm.

Doctors and other public health experts have worked hard to come up with the optimal vaccination schedule, affording the most complete and safest protection possible. It is not advisable to skip or delay vaccines, as this will leave the child vulnerable to disease for a longer period of time.

Diseases that vaccines prevent can be dangerous, or even deadly. Vaccines greatly reduce the risk of infection by working with the bodyâ&#x20AC;&#x2122;s natural defenses to safely develop immunity to disease. This is how vaccines can protect our child with producing immunity.

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Health Without Hassles Jessica Clara, Kesih Kalua, Rima Sisca Fanuela AMSA-Universitas Katolik Atmajaya

Objective: Indonesia as the biggest country that has 252.370.792 of people can not deny that pover ty is one of the biggest challenge which have been faced by Indonesia for years. The po verty becomes a problem which reduces the quality of public health, beside the lack of proper education and awareness for the healthy environtment. Based on the data of BPS (Badan Pusat Statistik), there are 11,13% poor people of total number of Indonesia pop ulation that have been reported in September 2015. Indeed, there are more than 930.00 0 people dies of illness and diseases in a year.

By the time, Indonesia has successfully expanded its health care system to improve qua lity and access for people, and promote the equity towards social diversity among Indo nesian. On January 1st, 2014, the health ministry officially introduce the Indonesian nat ional health insurance programme as known as JKN (Jaminan Kesehatan Nasional). Re cently, BPJS Health (Badan Penyelenggara Jaminan Sosial Kesehatan) is the agency w hich manage and implement this programme. It is an idea that goes beyond the limits of ordinary people who may just think of solutions for today only, but our government is able to provide a solution which would be useful in the future. Under this programme, a ll citizens are now being able to access the health service provided in wide range by pu blic facilities. Furthermore, people who financially underprivileged can now experience better healthcare. Our government is impressive because it has put forward an idea like this.

In some cases, BPJS Health found to had given the positive impact to the growth of hea lth care system in Indonesia. According to independent survey, member satisfaction rea ch 81%. The BPJS Health has received 133,4 million of membership in the first year of its implementation. More recently, there are conveniently accessible payment online an d offline. Through optimizing this beneficial programme, it is expected to be universall y applicable in 2019. Although, the education of the importance using BPJS Health has not been spread evenly through all social classes in Indonesia. Meanwhile, people with low competency and the system management have been the issues of unequal access a

mong public.

Therefore, the need for education about how to use this health facilities is very importa nt. In addition, the colaboration of government and public as the role of people who hav e more knowledge about this programme is very important in order to educate people w ho do not have sufficient knowledge or even people who do not have notice at all about how this programme would bring out benefits and the scheme of reachable administrati on.

References: http://www.beritasatu.com/ekonomi/337807-selama-6-bulan-penduduk-miskin-berkura ng-80000-orang.html http://infobpjs.net/kelebihan-dan-keuntungan-ikut-program-bpjs-kesehatan/

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What can we do?

Syafaat Zulkarnain Sp. AMSA-Universitas Muhammadiyah Makassar

Indonesia health budget of no more than three percent of the total state budget this year, which

amounted to Rp 1.000 trillion. In addition to the low budget allocation is the

most major health used for health measures per puppets, such as the cost of the sick and pay the salaries of employees in the health units.

The budget of our health has never exceeded three percent since Indonesia's independence. In fact, the World Health Organization (WHO) recommends health budget the lowest five per cent health budgets are small impact on public health efforts, especially in the implementation of the Clean and Healthy Lifestyle (PHBs).

In fact, behavior contributes significantly to the health of the community, namely 40 percent, while 30 percent contribute to environmental, genetic factors contribute 20 percent, and access to healthcare contributed 10 percent.

Government health budget allocated in the state budget in 2016 was Rp 109 trillion (5.05 percent of the budget) or ride than 2015 Rp 75 trillion (3.45 percent of the state budget).

That includes tuition fees beneficiaries of the National Health Insurance (JKN) managed by the Social Security Agency (BPJS) Health. While the budget of the Ministry of Health in 2016 to Rp 74.8 trillion (3.7 percent of the state budget).

However, the number of state finances has not been able to fully be able to improve the welfare of Indonesian people who occupied the world's fourth largest. The budget has not been able to cover the health needs of Indonesian society such as facilities, pharmaceuticals and others.

What we do with the financial health of this kind only provide counseling to prevent morbidity and mortality for the funds used this bit is given to people who are in need. Health promotion to the society either directly or indirectly that increased awareness of the importance of health to social and economic productivity. Demanded the government to keep raising the budget to the health budget as recommended by the WHO.

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Title: Medical Check-Ups. Spare a little time for your health Enita Harianti AMSA-Universitas Jambi Objectives: To raise public awareness towards the importance of medical check-ups.

Health is expensive, but sickness costs more. Therefore, prevention is better than cure.

As a precautionary measure, medical check-ups can be done to determine the health condition, as well as to detect a disease early. But, people nowadays tend to ignore the medical check-ups with many excuses. One of the examples is they are afraid of knowing what illness they have. They donâ&#x20AC;&#x2122;t know how important medical check-ups to detect illness at an early stage, or better still prevent illness occurring in the first place. It is surprising how many conditions are picked up on routine medicals such as diabetes, stroke, hypertension, and etc. Medical check-up required by women and men, both young and the elderly. Even people who look healthy need to do medical check-ups, especially to check the health condition as well as the possibility of a serious disease that has not shown any symptoms.

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THE IMPORTANCE OF PUBLIC PARTICIPATION TOWARDS BPJS PROGRAM TO OVERCOME NATIONAL HEALTH PROBLEMS Amalia Ramadhani AMSA-Universitas Padjadjaran

OBJECTIVES Indonesia is a welfare state, and thus has the responsibility to create a social safety net and also to overcome health problems. One of the problems is the lack of access to health care due to the low-economic factor. BPJS is a program that is made by the government to provide a national health insurance for the whole population to get health care and coverage in order to fulfill their basic health needs. By participating into this program, the public has an important role to reduce the incidence of diseases and raise the national health indicator, especially for the low-income population since they contribute most to the indicator rather than the middle- and high-income populations. This poster was made to raise public awareness to the BPJS program and thus overcoming the national health problem.

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REFERRAL SYSTEM STAGES TO MAXIMIZE HEALTH SERVICE Rana Zhafira, Talitha R. Ayuningtyas AMSA-Universitas Padjadjaran

A good referral system is needed in order to make a good Universal Health Coverage. A referral can be defined as a process in which a health worker seek the assistance of a better or differently resourced facility in order to give best treatment for patients.

Based on WHO, An effective referral system can ensures a close relationship between all levels of the health system and helps to ensure people receive the best possible care closest to home.

It also assists in making cost-effective use of hospitals and primary health care services. This system is functioned as a filter, to give the best care to whom it’s most needed first.

As a matter of fact, the government actually has developed referral system through health care regulation since long time ago, but the system has not functioned properly, particularly in the urban area. Considering the majority of people spend their health care cost by out-of-pocket payment, so they are not obliged to follow the referral system. Primary-level care service does not function as a guard in health system, except for those who are covered with health-insurance.

One of Government’s new programme, BPJS, could be a good breakthrough for a good referral system. In this programme, people in society will be covered by insurance. It makes referral system will be mandatory for all of the people in community.

This poster’s purpose is to informed the public more about referral system, and their stages.

And for health-worker, it acts as a reminder, in order to support this system. Health-worker is required to know more about the system itself, mainly about decision-making to refer patient.

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Optimize The Distribution of Health Personnel in the Islands in Indonesia!

Imas F Rahadita S AMSA-Universitas Pattimura Objective : Public poster aims to Promote and Enhance Health Care Access in Disadvantaged Areas, Border, and remote islands in Indonesia were hit on the situation and geographical conditions that are difficult to reach, limited health facilities and infrastructure, as well as the availability and quality of health human resources is low. This is caused by the lack of interest of health workers who would be placed in Region DTPK (Disadvantaged Areas, border and island areas) is contributing to the public health status is low.

In this regard, effort and commitment of all components ranging from central and local government, legislative, business, society and customs in developing some special programs or strategies that can support access to health services in DTPK, among others Improved ketersediaan, equity and quality of health personnel in the islands in Indonesia, Improved infrastructure health services for example Hospital circumference, Service flying Doctor, Support Health Care Financing, eg Operational Support Health (BOK), then support increased access to services such as the procurement of drugs and medical devices, in addition , Community empowerment in DTPK through Posyandu activities, prepared village, Medicinal Plants Family and PHBs and Procurement of medical training for health personnel.

Health care efforts in DTPK need special attention to improving people's access to quality health services and is responsible in DPTK can be immediately fulfilled. Thus, Healthy Indonesia in 2016 we can achieve together.

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Optimizing Health Worker’s Role to Prevent Mothers’ and Newborns’ Death.

Patricia Arindita Eka Pradipta AMSA-Universitas Sebelas Maret

Objective To share the effective solutions towards medical care issues from universal perspective.

Abstract Facing the facts that mothers’ and newborns’ death is increasing lately, I found WHO issued an article that could prevent this problem effectively. I thought by taking this topic on my poster will help people to know better about the prevention and by the simple and to-thepoint poster will help people to understand it easily. With those easy steps, we can decrease the number of mothers’ and newborns’ death. I got all the material from WHO guideline and represent it into a public poster. All the materials refer to the copyright of WHO. (http://www.who.int/reproductivehealth/topics/maternal_perinatal/en/)

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Story Behind a Medic’s Smile Bianca Theodeanna, Siti Shalihah Ramadhani Novizar, Siti Rokoyah Rezkylia AMSA-Universitas Sriwjaya

An internship doctor in DKI Jakarta’s income is about 2.5-3 million Rupiahs per month, while constructions workers have the wage of 2.4 million Rupiahs per month. As for our fellow internship doctors in remote areas, they only get around 1.2 million Rupiahs per month. Let alone the intern doctors wage, other health workers (e.g. nurse, pharmacist, etc.) seems to be in similiar condition.

This incoherent condition represents the poor management towards our health workers’

payment system. Hence, government and health institutions should

strengthen the law enforcement for health workers’ welfare.

Despite of the wages polemic, doctors have to improve their skills and update their knowledge through seminars, workshops and trainings, based on UU Republik Indonesia no 29 year 2004 clause 51 point e. These series of trainings are sometimes very costly, ranging from hundred rupiahs to millions rupiahs. The idea is, trainings and seminars will be paid by the institution where the doctors are working. This might help the doctors to enhance their capability in order to meet people’s satisfaction.

In the other hand, people satisfaction for health services in Indonesia is far beyond perfect. This is caused by lacking of health workers, compared to the amount of people in Indonesia, especially in rural areas. Based on the Health Department of Indonesia, the ratio between medics and population in Indonesia currently is 1:4000, while the ratio is expected to be 1:1000. We belief that if our government and society pay more attention towards health workers’ prosperity, this number will be achieved soon.

The purpose of this poster is to raise people’s awarness towards Indonesian health workers’ issues, in order to improve the quality of health service in Indonesia. We hope this piece of art can improve the welfare of medics as well as people satisfaction.

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Reaching The Best Healthcare Criteria Achievement by The Optimal Using of the National Financial Resources Hilda Nadhila Hasbi, Amalia Dienanti ,Muhammad Fahmi AMSA-Universitas Sriwijaya The national financial resources are limited while necessities for humans are infinite. Thus, the amount of paramedics and healthcare facilities are limited while demand in health care increases.

The financial resources in health is crucial because its correlation with economy and healthcare. Illness will cause several negative impacts in doing every single daily activity. Better health allows people to achieve productive life and bad health leads to high living cost.

To overcome those things, optimizing the national financial resources for health care and promotion is urgently significant. As the reflection, we may mimic the Australiaâ&#x20AC;&#x2122;s health-service regulations. Australiaâ&#x20AC;&#x2122;s healthcare systems include overseeing the

regulation of pharmaceutical and therapeutic goods and appliances,

managing international quarantine arrangements, and regulating the private health insurance industry.

By following these criteria, we can reach the efficient and equitable healthcare and health promotion goals: 1. Requirement is the quantity of goods or services that usually determined by a physician, but the quality of education depends on physician preference, equipment, and competence.

2. Demand is the actual goods or services purchased by the patient. Demand is influenced by the medical opinion of the physician, as well as other factors such as income and the price of drugs.

3. Desire is the desired goods which considered the best for the patient, its goal is discovering the needs of people by improving the doctor's decision to bring the desire.

4. Efficiency is where the healthcare providers achieve productive efficiency when producing output or person treated quantity with a minimum input quantity, or input quantity available.

5. Justice (equity) is not the same as the similarity (equality).

6. Life insurance optimization is a strategy that may protect families from the financial consequences of the financial risk of life's events including personal insurance, liability insurance, and life insurance.

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STOP FRAUD! PROTECT, DETECT, REPORT! Monica Djaja Saputera, Regina Eda Tanjuan AMSA-Universitas Tarumanegara

Health Care Fraud According to Legal Information Institute, fraud is a type of white-collar crime that involves the filling of dishonest health care claims in order to turn a profit. Whereas according to Regulation of Minister of Health No. 36 year 2015 on The Prevention of Fraud in the Implementation of Health Insurance Program on National Social Security System, fraud is action taken deliberately to get financial benefits from Health Insurance System (BPJS) in National Social Security System through fraudulent act that doesnâ&#x20AC;&#x2122;t comply with the provision. Fraud in implementation of BPJS can be done by participants, BPJS for health officers, health providers, and or medicine and health device providers. In 2014, fraud on the BPJS system began to emerge characterized by budget deficit until 6 billion rupiahs. The budget deficit was occurred as a result of service procedures that were not needed so the services for patients did not comply with the quality standard. The purpose of this poster is to provide information for public and general practitioners regarding to fraud in health system.

Hopefully with this poster, the incidence of fraud can be prevented and health services for patient can be carried out in accordance with quality of services.

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The Benefits of Albumin in Behau ( Channa striata ) for Post-Surgery Wounds Fia Delfia Adventy, Nadilla De Putri AMSA-Universitas Palangka Raya

Abstract Albumin is a blood plasm protein synthesized in the liver and most commonly found in the human body, which is about 55-60%. Albumin is used to overcome various diseases mainly caused by reduction the amount of blood protein, such as post-surgery wounds. Snakehead fish (Channa striata), which has another name "behau" (in Central Kalimantan) is one of the highest food sources containing albumin. In a study entitled Albumin and Zinc Content of Snakehead Fish (Channa striata) Extract And Its Role In Health from IEESE International Journal of Science and Technology (IJSTE), in every 100 mL the extract of behau contains 2,17g albumin which has the potential to improve albumin serum in post-surgery patients. The enhancement of albumin serum has a positive correlation in the process of wound healing . Albumin in behau have a better quality than albumin in egg. With giving the extract of behau obtained from 2 kilos of fish every day increases the albumin to normal levels (3.5 to 5.5 g / dL) and the wound healed for 8 days without effects.

The Government of Central Kalimantan Province enact policies to spreading, developing, and processing behau to several districts through Instruction of

The Governor of Central

Kalimantan Number : 188.54 / 4/2012 on April 13, 2012 about The Cultivation of Behau (Gabus) in the Central Kalimantan Province and Regional Secretaries Document Number : SB1 / TU.256 / 2012.K on April 2012 about The Support Activities Aquaculture of Behau.

With this policy , the health promotion is realized and the public are expected not only to know but also frequently consume the behau that has been the mainstay of Central Kalimantan .

Keywords : Albumin, behau, post-surgical wounds, Central Kalimantan, health promotion

368

Break the Chain of Genetic Diseases, Be Healthy for the Next Generation Azka Rizky Pamula AMSA-Universitas Palangka Raya

Genetic disease is a condition caused by abnormalities of one or more genes that cause a clinical phenotype condition. One reason is the defective genes inherited from the parents or one of the family members. By this time there are about 4,000 genetic diseases have been identified. Genetic disease may often we hear in the community are diabetes mellitus, heart disease, asthma and many other diseases anymore. If the someone has a family history that has a hereditary disease, is actually a hereditary disease as above so could prevent, by optimizing the promotion of good health in the hope of targets that we are headed also has a desire to break the chain of genetic diseases such as changing the pattern of his life into a lifestyle better again and regularly check the condition of his health. One simple way to do in order to break the chain of the disease is by doing a health promotion campaign that is primarily located in the nearest sphere around us for example to our own family first. After conducting health promotion complete with components up to the provision of education, we must also give a positive response to the target that we aim. If health promotion has been implemented, is expected to target that we are going to want to change the pattern of his life into a healthier lifestyle again. Basically all it can be prevented, nothing may happen.

Everything was very easy, just choose to or not. If you want to break the chain, a hereditary disease can be prevented and it certainly did not decrease to the next generation.

Keyword : Genetic disease, Health promotion campaign

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Vacination: Child’s Best Protector Dimas Muhammad, Heike Esfandari Hatoyama, Pretika Prameswari AMSA-Universitas Trisakti

Objectives

:

Our aim in this poster is to promote combination vaccine especially to mothers who doubt its efficacy. As we know vaccine is one of the best way to provide steady defense from diseases for the children as the nation's future. Therefore we think it is very important if we can change people’s bad preception about vaccine. As stated in Indonesia’s law, children deserves to get vaccinated to prevent life-threatening diseases. Because prevention is better and less expensive than treating a deadly disease. We chose a superhero to be our icon as a metaphor that vaccine optimize child’s immunity system owning to the fact its doing its job as a protector just like a superhero. Thus, this poster is made as we strive to promote combination vaccine for children in hope of a better future for the nation. Based on RISKESDAS (Riset Kesehatan Dasar) 2013 the number of children who gets complete based vaccination reached 60%. This shows an increase from the last reseach that stands at 54%.

Expected from this poster, we hope to contribute to reach the optimal precentage of children who gets complete based vaccination and open their minds that vaccination is child’s best protector.

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Raise for Prosperity Laksmita Dwana AMSA-Universitas Trisakti

The purpose of this study is to deliver information of a system approach to face today’s challenge and share the effective solutions towards medical care issues in improving, promoting and optimizing national financial resources in health care and health promotion.In 2009, the society demands for their welfare, then a regulation about health insurance were assigned eventually. The aim of this is to guarantee people’s lives by giving a health service. On the other hand, this event will need a budget. Indonesia’s health budget in 2015 was Rp 71.1 trillion and this value keeps increasing constantly each year. The matter is that the utilization of the budget is not quite optimized. The current issues are (1) the health services given are not equal compared to each other, by means there is no settled standardization, (2) people nowadays do not understand the SOP of getting BPJS-JKN and (3) the registration is not fully supported by the facilities. Moreover, based on an evaluation taken from society’s opinion on the system, dissatisfaction towards either the system and/or the service is clearly shown. The solutions that could be offered to face today’s challenge are (1) settling down a fixed standardization for implementing a valid and acceptable health services for every hospital in Indonesia, (2) enforcing an easy-to-understand Standard Operating Procedure for public, and (3) revise and refine the database supervision and management to make a better pace in serving people the best health service.

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Map of Nutrition Syifa Nabila Putri, Sari Riastiningsih, Laksmita Dwana AMSA-Universitas Trisakti

Malnutrition in Indonesia is not a strange word we could have heard. It is a condition where the lack of energy and protein consumed in daily meal so that it doesn’t fulfill nutritional adequacy rate. In Indoesia, especially in Eastern districts, a lot of victims is dead because of malnutrition. This case usually occurs with children or toddlers, but this doesn’t mean that it would not affect adults. To overcome this issue, the government accompanied by several institutions offer some help which are health and nutrition education, along with additional healthy meal to the children in Nusa Tenggara Timur. Unfortunately, event though Indonesia is renowned by its rich farm land, yet still too many cases of malnutrition and import rice from another country. Each year, a significant increase of malnutrition case is developing. The lack of knowledge about malnutrition, citizen’s behaviour that doesn’t realize the importance of health and nutrition are the problems. That is why a good coordination between the government and the citizen is needed to overcome this case.

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BPJS REFERRAL PATHWAY Nadya Tripuspa Berlinda, Birrandry Diva Pradhista AMSA-Universitas Padjadjaran

Objective: to improve people knowledge about BPJS referral pathway One of the points SDGs in promoting peace and prosperity is to improve the health aspects that mentioned in the third point â&#x20AC;&#x153;good health and well beingâ&#x20AC;?. Based on Ministry of Health Republic of Indonesia vision and mission, one of the health strategies in 2016 to realize the third point is by improving equitable, affordable, quality and justice health service, as well as evidence-based; majoring in promotive and preventive.

BPJS Kesehatan or Badan Penyelenggara Jaminan Kesehatan believed to be the organizer of a national health insurance. BPJS been trusted since January 1st, 2014. Everyone can seek treatment and get decent facilities, not only the middle and upper classes, but also help the lower classes to receive treatment with the best service and facilities.

Based on the data in March 2015, BPJS Card owner soared to 140 million, increased by the end of 2014 recorded 133 millions owner. However, based on survey, one of BPJS biggest problems that still being complained by the people is BPJS service flow is too complicated, which also because some people does not know enough about the flow of treatment using BPJS Card.

Therefore, it is fundamental to educate people about the steps. This poster will help people to understand how BPJS Card works and keep the public from view that BPJS is complicated, to help the government realize the third point of SDGs and together improve Indonesian welfare.