Physical inactivity kills 5.3 million a year globally

cbc.ca - Lack of physical activity could be causing as many deaths worldwide as smoking and obesity do, say researchers who are calling on people to take at least a 15-minute brisk walk each day.

This week's issue of the medical journal The Lancet includes a series of studies leading up to the London Olympics to highlight how little physical activity most people worldwide actually get and how dire the health consequences are.

I-Min Lee from Brigham and Women's Hospital in Boston and her co-authors estimated that worldwide, physical inactivity causes six per cent of the burden of disease from coronary heart disease, seven per cent of Type 2 diabetes, 10 per cent of breast cancer, and 10 per cent of colon cancer.

What's more, physical inactivity was blamed for nine per cent of premature mortality — more than 5.3 million deaths of the 57 million deaths globally in 2008.

Eliminating physical inactivity could increase life expectancy by 0.68 years. That may seem small, they said, but the gains are for the whole population, not just inactive people who start moving more.

Canadian health authorities recommend that adults get 2½ hours of physical activity a week.

Tanya Berry holds a Canada Research Chair in physical activity promotion at the University of Alberta in Edmonton. Berry said her research suggests half of Canadians think they're moving enough, but they're mistaken.

"If you actually put a little accelerometer or pedometer on people, something that actually objectively measures how active they are, it's closer to 15 per cent are actually active and 85 per cent of Canadians are not active enough to achieve health benefits."

The Lancet researchers said people need to be told about the dangers of being sedentary, rather than just the benefits of exercise. They urged governments to find ways to make physical activity more convenient, affordable and safer.

"This series emphasizes the need to focus on population physical activity levels as an outcome, not just decreasing obesity," Harold Kohl, a professor of epidemiology at the University of Texas and one of the Lancet authors, said in a release.

Kohl recommended prioritizing physical activity across sectors including health, transportation, sports, education and business.

Min-Lee and her co-authors acknowledged that not everyone is capable of being physically active.

"This summer, we will admire the breathtaking feats of athletes competing in the 2012 Olympic Games," the researchers concluded.

"Although only the smallest fraction of the population will attain these heights, the overwhelming majority of us are able to be physically active at very modest levels — 15 to 30 minutes a day of brisk walking — which bring substantial health benefits.

Fighting Depression, One Village at a Time

Nytimes.com - What is the most burdensome disease in the world today? According to the World Health Organization, the disease that robs the most adults of the most years of productive life is not AIDS, not heart disease, not cancer. It is depression.

This is especially true in places that have experienced war, disaster or crushing deprivation. Yes, in many poor countries the bonds between people are much stronger than they are in wealthier, more individualistic societies, and this is a good thing for mental health. But it can hardly counteract the fact that a lot of people have an awful lot to be depressed about. Violence — whether war or high rates of crime — produces widespread post-traumatic stress. The constant worry that a crop failure or serious illness will throw a family into poverty is a source of extreme anxiety. Seeing your children go hungry creates paralyzing guilt.

According to the World Health Organization, three-quarters of the world's neuropsychiatric disorders are in low-income or low-middle income countries.

In troubled places, depression's impact is more severe. Most families have no cushion or safety net — they are running very hard just to stay in one place. A parent who is too depressed to work can bring a family to ruin.

In wealthy countries, we grasp how debilitating mental illness can be, and we treat it. (Unevenly — the disparity in access to mental health care between rich and poor in America is enormous.) In poor countries, attention to mental health has been close to zero. The conventional wisdom is that treating depression in countries where there are myriad other problems is a luxury. Besides, how could it be done? Drugs are expensive, and the vast majority of poor countries have virtually no psychiatrists or psychologists outside of private clinics.

Until a few years ago, no one was even asking this question. Today, not only is mental health getting global attention, mental health care is successfully expanding in many poor countries, including India, which announced a new national mental health care plan at the end of June. The strategy is the same one that is preventing and curing disease all over the world where health care professionals are few: task shifting. That means training and supporting people with lower levels of education to do the work of doctors and nurses.

~~~~~

Amadi was inside her hut, sitting in the semidarkness, when C.N. came to her door to invite her to do something that would have been unheard-of in her Ugandan village before: join a therapy group for depression. She was 59, and had lost five of her nine children in the last 10 years, three of them to AIDS. She was numb and passive, sad and irritable. She could not care for her family, work in her garden, or do her mat-weaving.

At first Amadi had no use for any therapy — "all the treatment in the world won't bring my children back," she told C.N. But at C.N.'s urging, she joined the group.

The group consisted of eight women, with C.N. as facilitator. They met weekly, first spending their time describing their problems, but gradually comforting one another and suggesting steps to take. Together they visited the graves of their loved ones and held a formal mourning service. The women all became active in the community, and each talked to her own family members about H.I.V. infection and how to prevent it.

All the women, including Amadi, gradually got better. Eighteen weeks after starting therapy, Amadi had no more symptoms of depression. She was once again, to use her husband's words, the fierce, loving, strong woman she had been.

Amadi's story was described by Helena Verdeli, an assistant professor of clinical psychology and director of the Global Mental Health Lab at Columbia University's Teachers College. (Amadi is not her real name.) Verdeli was one of the organizers of a study designed to test whether interpersonal therapy, which has proved as effective as medicine at curing major depression in Western settings, can work in a rural village.

By accident, the study did something else just as significant. The researchers were working with the Christian humanitarian organization World Vision, and had intended for the groups to be led by World Vision's trained health workers — nurses and health counselors. "But they couldn't spare any," Verdeli said. "They said, 'don't worry, we're going to hire their younger brothers and sisters.'" Some were in college. Some, including C.N., had only a high school degree. Yet the treatment was overwhelmingly successful: six months after beginning therapy, only 6 percent of the people treated still had major depression. This study, which took place in 15 villages, was proof that effective therapy for depression could be delivered in the poorest of settings, by lay people.

There have been other studies confirming that when done correctly, community members with minimal education can effectively treat depression. One of them took place in Goa, India. Nearly 3,000 people with symptoms of depression or anxiety were randomly assigned to receive normal services in their usual public or private clinics, or to be treated by young local women who had taken an 8-week course in interpersonal psychotherapy. Six months later, 66 percent of the patients in the public clinic who had gotten that therapy had improved. Of those who didn't get the therapy, only 42 percent had improved. (At the private clinics, where patients normally had their own doctors and better care, the doctors and the lay workers did equally well.)

Another study in Pakistan gave community health workers — women who had completed secondary school — a two-day course in listening and basic cognitive behavioral therapy. They were shown how to integrate these things into their regular visits to pregnant women and new mothers. Even that brief training made a huge difference: a year later, only a quarter of their depressed patients were still depressed, compared to 59 percent of the control group.

Interest in global mental health care was awakened by a World Bank-commissioned study in the early 1990s looking at the global burden of disease. While most research had concentrated on what causes death, this one examined disability — and found the shocking burden of depression.

The World Health Organization got involved, devoting its world health report to mental health in 2001. Four years ago, the W.H.O. started the Mental Health Gap Action Program.It pushes for greater attention to mental health in poor countries and provides technical support and guidance, mainly about how to include mental health care in primary care clinics, and train community health workers.

The tremendous prevalence of depression also caught the attention of organizations making big investments in child health and treating AIDS, tuberculosis and other diseases. It was clear that depression was keeping these programs from working as well as they could. "People on the ground realized that adherence to treatment is important," said Mark Van Ommeren, the director of mental health in emergencies at W.H.O. "But people with mental health problems are less likely to adhere."

"The question was how do you close treatment gaps where there are hardly any professionals," said Vikram Patel, a psychiatrist at the London School of Hygiene and Tropical Medicine, who also works in Goa with the nongovernmental mental health group Sangath and was the lead researcher on the Goa study. "It got people thinking: how have other people closed treatment gaps in maternal and child health for the last 15 years?" They used taskshifting — Patel prefers to call it tasksharing. "So we can do it for mental health," he said. He has been extremely influential in shaping India's plan, which includes a new cadre of community mental health workers.

Task shifting is happening even in wealthy countries to close treatment gaps; hence the rise of the nurse practitioner as physician substitute. But it's very widespread in poor countries. Across Africa, nurses and clinical officers do the work of doctors in treating AIDS. In Africa and Asia, a few days or weeks of training enable barely literate women to improve the health of their villages. When doctors are present — if they are present — their role has changed; they now supervise the others and see only the really hard cases. "It became very clear it was possible to train lay members of the community to do fairly specific things and do them well," said Harry Minas, a psychiatrist who directs the Center for International Mental Health at the University of Melbourne.

But new programs required new money, and this was present only in a few countries — usually as a result of crisis. Sri Lanka and Indonesia's province of Aceh both had long-running civil conflicts that traumatized much of the population. But they started getting access to treatment for that trauma only after the tsunami of 2005. "The number of people affected by the tsunami pales in comparison to the people who had trauma from the conflicts," said Greg Miller, who reported on mental health care in Aceh for Science magazine. "But in both places mental health care didn't exist — nothing there. With the tsunami, there was a huge outpouring of support specifically geared towards improving the mental health of survivors."

In the past, perhaps, international aid might have paid for stand-alone treatment centers that would last only a few months, the therapy delivered by outsiders, with little local training or participation. Now, instead, most of the money was employed to build mental health care into the government's health system, using task shifting. The visiting psychologists and psychiatrists were there to train locals.

Lay people in Aceh learned how to identify symptoms of depression, and how to work with patients' families and support their treatment in the community. Nurses were trained in psychotherapy. Doctors learned how to treat patients with a limited number of psychiatric drugs.

Now 85 percent of health centers in Aceh have some staff with mental health training, Miller wrote. Sri Lanka, which has a similar system, is now expanding it beyond zones hit by the tsunami.

Kosovo, building a health infrastructure after the end of Slobodan Milosevic's war, found a different and very creative solution. Serbia had barred Albanians in Kosovo from getting formal medical education, and after the war Kosovo had only five clinical psychologists and 19 psychiatrists for its two million people.

"Our needs were very high, and the human resources to respond were very low," said Ferid Agani, a psychiatrist who led the construction of the new mental health system, and today is Kosovo's health minister. "The natural answer was to rely on family structure. Families are very strong here, very connected. Before, our model was centered on medication. We wanted to train teams in providing complete services based on family resilience. What could be better than having this resource?"

With advice and training from a group of doctors from the American Family Therapy Academy, Kosovo set up workshops for patients and their families, where they learned about the patient's disease and how to help. Several families were trained together, creating support groups. Meanwhile, the medical schools graduated professionals — now there are 60 psychiatrists and 600 clinical psychologists. Agani said that hospitalization is down by 60 percent and results are better.

Why did it take so long for health experts to see what now seems obvious: just as all people need access to health care, we all need access to mental health care. If depression can paralyze people who have everything, how could we ever have thought that it didn't affect people who have nothing? "There's an assumption that after you bury five of your kids you get used to it, and it doesn't hurt as much," said Verdeli. "People don't realize you don't get used to it. You just give up

WHO gives Chinese health minister award for battling smoking in country addicted to tobacco

BEIJING — The World Health Organization is giving China's health minister an award for battling smoking in a country whose people and government remain prodigiously addicted to tobacco.

China has stepped up efforts to curb tobacco use in recent years. The Health Ministry released the country's first official report on the harms of smoking in May, banned smoking in its office building and hospitals, and is lobbying for airports and other indoor public facilities to do the same.

WHO said Health Minister Chen Zhu will be presented a certificate of recognition at a ceremony on Wednesday attended by WHO chief Margaret Chan.

Tobacco control is a difficult task in a nation where huge revenues from the state-owned tobacco monopoly hinder anti-smoking measures. Nearly 30 percent of adults in China smoke — about 300 million people, roughly equal to the entire U.S. population — a percentage that has not changed significantly.

The tobacco monopoly's influence is pervasive, with cigarette companies sponsoring schools, sports events and fostering close ties with the academic community.

In December, a tobacco scientist who specializes in adding traditional Chinese herbs to cigarettes in an attempt to reduce their harmful effects was appointed to the prestigious Chinese Academy of Engineering in a move that was criticized by other academics, several of whom sent letters to the academy in protest.

Despite the many challenges that remain in stamping out tobacco use, anti-smoking activists welcomed the WHO award.

"Among the government departments, the Health Ministry is the one that has made the biggest efforts in promoting tobacco control," said Xu Guihua, vice president of the government-affiliated Chinese Association on Tobacco Control. "On many occasions, Minister Chen Zhu has told the public that tobacco is harmful and asked people to give up smoking. He also called on the government to step up tobacco control legislation."

Xu said China still needs to issue a national tobacco control plan, raise prices of cigarettes and better educate the public on the health risks of smoking.

She criticized the apparent conflict of interest in the dual role that China's State Tobacco Monopoly Administration plays as both tobacco policymaker and overseer of the China National Tobacco Corp. — the world's largest cigarette maker.

Health officials have warned that smoking-related deaths could hit 3 million per year by 2030 without greater efforts.

Last year's certificate for anti-smoking efforts was awarded to Australian Attorney General Nicola Roxon, who as health minister led a campaign to make Australia the first country in the world to require cigarettes to be sold in plain packages with large, graphic warnings.

Free generic drug policy to redefine health insurance

business-standard.com - Insurers may be burning their fingers in urban health portfolios for some time now, but the government's rural healthcare initiatives, including its decision to provide free generic drugs to public hospitals, are set to offer fresh avenues of growth for them.

The recent government decision to provide free generic drugs to government hospitals at an expense of $5.4 billion (Rs 29, 820 crore) could be a game-changer for the health insurance business in India. While insurers suffer a high claim ratio in urban centres, in excess of 100 per cent, the cost of health insurance in rural centres is expected to come down with the new regulation.

The cost of a generic drug is 80 to 85 per cent lower than the branded product, according to data from the US Food and Drug Administration. In case of health insurance, medicines account for 15-20 per cent of healthcare costs. This component is higher in rural areas, which generally have poor hospitalisation facilities. Also, in the case of several critical diseases, the cost of medicines is much higher than the hospitalisation cost.

"If the government decides to provide free generic drugs to hospitals, the impact will be huge, and the cost of health insurance would come down by a few times. The cost of branded medicines in health insurance is huge," said Kuldip Singh, director and general manager, National Insurance Co Ltd.

Notably, a number of government-sponsored micro-insurance schemes have quietly changed the landscape of health insurance.

A Planning Commission document, dated January 31, 2011, states three major schemes (Rashtriya Swasthya Bima Yojana (RSBY), Rajiv Aarogyasri and Kalaignar) have in as many years covered roughly 247 million, a fifth of India's population.

"Comparatively, the breadth of the coverage is by any global standards quite breathtaking and has occurred at a rapid rate in a span of three years, and this feat could be achieved even among the vulnerable population and informal workers, where the penetration has been difficult till recently," the document said.

This is in contrast to urban health insurance schemes, where insurers are being forced to raise premium due to high claim ratio.

Recently, the finance ministry had asked four general insurance companies—New India Assurance Co Ltd, United India Insurance Co Ltd, National Insurance and Oriental Insurance Co Ltd—to reduce losses in the group health insurance segment by increasing premium.

The net combined losses of the four insurance companies on group health insurance were estimated at Rs 1,500 crore in 2011-12. Group health insurance schemes constitute more than 50 per cent of the health insurance business of most public sector companies.

While in group insurance schemes the claim ratio is often as high as 150 per cent, in government-sponsored schemes it ranges from 95 to 100 per cent, said an executive of an insurance company, requesting anonymity.

"The way forward for health insurance could be to tap the rural segment, as the penetration is low and profit margins are better," the executive said.

It is the mix and variation of rural micro-insurance policy that gives insurers a profit margin. For example in RSBY, the variation in burnout ratio (evolved specifically for the schemes) is reported to be in the range of 27 -136 per cent in a large number of districts.

"This is given the fact that in several districts the utilisation rate of hospitals is extremely low. Commercial insurers are obviously making usurious profits," said the Planning Commission document.

At present, 80 per cent of all health expenditure in the country is spent through personal resources. This is despite an increase in premium from Rs 519 crore in 2000-01 to Rs 9,944 crore (19 times) in 2010-11.

"The health insurance segment is expected to grow at 30-35 per cent. If the government decides to provide generic, instead of branded, drugs, it will help in reducing the claim ratio. However, it has to be clubbed with other supply chain initiatives," said Samir Bali of Accenture.

Added P V S Lakshmi Prasad, deputy general manager, United India Insurance: "In rural centres, the move to provide free generic drug will definitely bring down the cost of insurance, but most claims in health insurance still come from private hospitals."

Drugs arsenal could help end AIDS: WHO

geo.tv - Thirty years into the AIDS epidemic, a cure remains elusive but a growing arsenal of drugs could someday help end new infections, the World Health Organization's HIV/AIDS chief says.

The key is figuring out how to best manage the latest advances, Gottfried Hirnschall said in an interview with AFP during a visit to Washington this week ahead of the International AIDS Conference that begins here July 22.

Antiretroviral drugs may reduce the risk of infected people passing on the virus, and may prevent healthy people from becoming infected through sex with HIV-positive partners, but the new possibilities have also stirred controversy.

Still, these medications saved about 700,000 lives worldwide in 2010 alone, which experts have described as an extraordinary accomplishment.

Research breakthroughs and progress in some countries "demonstrate that it is possible to really advance significantly in scaling up the response and even start to think about eliminating new infections," Hirnschall said.

The world now has 26 antiretroviral (ARV) drugs on the market and more in the pipeline for treating people with human immunodeficiency virus, which has infected 60 million people and killed 25 million since the epidemic first emerged.

"We have a fairly large arsenal of drugs available," Hirnschall said, noting that the drugs are better now than they used to be -- less toxic, more robust, less likely to trigger resistance and more tolerable -- but are still not perfect.

Side effects remain a concern, and officials are carefully monitoring the emergence of resistance, with the WHO set to release its first global report on drug resistance in low and middle income countries on July 17.

Recent studies have shown the potential benefits of starting treatment early, before the viral load gets too high, as a way to protect an infected person's health and lower the risk of passing the disease to a partner.

Research on using ARVs as a way to prevent HIV in healthy people -- also known as pre-exposure prophylaxis or PrEP -- has shown conflicting results, with some promise seen in studies on heterosexual couples and gay men who took the pills faithfully.

However, one major study of African women failed to show any protection from ARVs compared to a placebo and had to be stopped early.

"We see this as probably being a central conversation at the conference -- the appropriate initiation for treatment and also how to best take advantage of antiretrovirals for prevention more broadly speaking," Hirnschall said.

A US advisory panel has urged the Food and Drug Administration to approve the first-ever HIV prevention pill, Truvada by Gilead Sciences, for use in some high-risk populations. A decision is expected by mid-September.

Truvada is already on the market as a treatment for people with HIV.

But some health care workers fear that the availability of a pill that could reduce the risk of getting HIV may encourage people to stop using condoms and spark a rise in risky sex behaviors.

Others are concerned about the ethics of providing HIV drugs to healthy people, when vast numbers of infected people across the world still do not have access to life-saving treatments.

And some high-risk groups remain difficult to reach, such as sex workers and injecting drug users who are often shut out from treatment due to restrictive laws.

"In many countries where they (drug users) constitute the major risk group, they have lower access to treatment," Hirnschall said.

"We also know that in many places, men who have sex with men cannot access services in general, or sex workers by the same token because they are stigmatized, they are criminalized in many countries and it is not easy for them to come forward to be tested and then to access services."

The WHO is also working up a set of guidelines for administering antiretrovirals as prevention to healthy people that should be available in time for the conference.

PrEP "is a promising approach. We believe it is one that is probably becoming a niche intervention for certain individuals where other preventions may not be accessible or may be difficult to implement," Hirnschall said.

"There are very few magic pills. But it might be one additional intervention that we could add to the arsenal of interventions that we have."

Hirnschall said he was "very optimistic about the conference," the first to be held in the United States since 1990 and made possible due to the lifting of travel restrictions on HIV positive people by Washington a few years ago.

"We will hear from countries what is happening on the ground," Hirnschall said.

"The challenge is not just to set brave policies but really to have the capacity and resources that it takes to implement those.

World Health Organization Fails In Its Effort To Defend Mercury In Vaccines Before United Nations

marketwatch - PUNTA del ESTE, Uruguay, July 12, 2012 /PRNewswire via COMTEX/ -- Bows to Pressure from CoMeD

Bowing to pressure from the Coalition for Mercury-free Drugs (CoMeD, Inc.) and other organizations, the World Health Organization (WHO) revealed its 2004 guidelines on eliminating, reducing, and replacing Thimerosal in vaccines to public health officials worldwide.

WHO made its disclosure before the United Nations Environment Programme (UNEP) where it met unprecedented resistance to its defense of the use of neurotoxic mercury in vaccines. "This is a huge development," says CoMeD's Vice President, David Geier, while speaking at UNEP's INC4 meeting.

INC4 met June 27-July 2 in Uruguay, to negotiate a global treaty on mercury. CoMeD and other nongovernmental organizations who participated strongly opposed the use of mercury in human medicines. More importantly, entire continents and many individual nations expressed their desire for mercury-free vaccines.

Moreover, CoMeD is putting intense pressure on the World Health Organization by actively assisting nations in banning Thimerosal-preserved vaccines. One of these nations, Chile, became the first developing country to stop this use of mercury in 2012.

Cristina Girardi, a member of the Chamber of Deputies of Chile, addressed the opening session of INC4 gathering. While speaking, she warned, "... to keep the mercury in vaccines is to endanger the vaccine program in a misguided effort to protect a known neurotoxin."

Rev. Lisa K. Sykes, CoMeD's President, brought the danger vaccine mercury represents to a historic level of understanding. Rev. Sykes counseled, "The de facto, economic prioritization of mercury-free vaccines ... constitutes a double standard in vaccine safety. This disparity must be corrected rapidly ... and preference ... must shift to mercury-free vaccines globally, if we hope to avoid accusations of discrimination ... in regard to global immunization policy."

Sykes also cited the support of the global United Methodist Church, representing 11.5 million, and the U.S. National Health Freedom Coalition, representing 20 million. Both these groups support a ban on the use of mercury in vaccines and uphold the right of informed consent for all persons.

The objective of this treaty on mercury is to "to protect human health and the global environment from the release of mercury and its compounds by minimizing and, where feasible, ultimately eliminating global, anthropogenic mercury releases to air, water and land."

WHO to announce: Mix of pathogens caused mystery illness in Cambodia, doctors say

Phnom Penh, Cambodia (CNN) – The World Health Organization, in conjunction with the Cambodian Ministry of Health, will conclude that a combination of pathogens is to blame for the mysterious illness that has claimed the lives of more than 60 children in Cambodia, medical doctors familiar with the investigation told CNN on Wednesday.

The pathogens include enterovirus 71, streptococcus suis and dengue, the medical sources said. Additionally, the inappropriate use of steroids, which can suppress the immune system, worsened the illness in a majority of the patients, they said.

The sources did not want to be identified because the results of the health organization's investigation have not yet been made public.

Dr. Beat Richner, head of Kantha Bopha Children's Hospitals - which cared for 66 patients affected by the illness, 64 of whom died - said that no new cases had been confirmed since last Saturday.

FULL STORY

Indonesia Still Struggling With Too Many Pre-Term Births

jakartaglobe - Linda Rullis sold her motorcycle and borrowed money from relatives to cover neo-natal treatment for her daughter, who was born after only 24 weeks of pregnancy, barely weeks within the threshold of survival. The baby girl is now one year old and weighs 5.1kg.

"I insisted on taking her home after she had been treated for four months because I couldn't afford the treatment anymore," Rullis, 30, told IRIN. "When she was born she weighed only 690g, but luckily she seems to be doing just fine now."

The World Health Organization defines any birth before 37 weeks (259 days) of pregnancy as pre-term, while a full-term pregnancy is anywhere from 37 to 41 weeks.

A recent multi-agency report ranked Indonesia among 10 countries worldwide with the highest number of pre-term births, where 15.5 babies out of every 100 live births are born too early — about 676,000 babies annually.

Globally some 15 million infants — more than one in 10 births — are born too early each year, and more than one million die shortly after birth. Countless others suffer some type of lifelong physical, neurological, or educational disability, according to the report.

Indonesia's rank in the ninth position puts it above Pakistan and below Mauritania. Belarus, Ecuador, Latvia and Finland have among the lowest rates of too-early births among countries that provided the UN data.

"The dominant cause of pre-term births in Indonesia is infections, including vaginal and renal infections," said Ali Sungkar, an obstetrician-gynaecologist and lecturer at the medical school of the University of Indonesia in Jakarta, the capital.

"Most of those mothers who give birth to pre-term babies come from low socio-economic backgrounds. They have low body mass index and suffer from anaemia," he told IRIN.

Smoking, alcohol consumption and depression also contribute to pre-term births, and once a woman delivers an infant prematurely, she is more likely to do so again Sungkar said.

He estimated that such births cost the state 10 times more per child than full-term deliveries, and "the government won't have the money to cover all the costs," but added that there was little research available on this.

Indonesia has no universal health insurance, but poor people can get free medical treatment if they present the necessary documents. Patients usually cover around 73 percent of their health costs out of their own pockets, according to government data reported to WHO in 2009.

20 million vulnerable

More than 76 million of Indonesia's 240 million people are covered by Jamkesmas, a health-fee waiver for the poor, but a legislator recently told local media that an estimated 20 million poor people are not covered because their data cannot be verified.

The government has said it will increase the number of people eligible for Jamkesmas to 86.4 million in 2013, in line with updated data collected by the Central Bureau of Statistics. An amount of 7.4 trillion rupiah (US$791 million) has been allocated to health subsidies for 2012, with each qualified family entitled to up to 2.5 million rupiah ($266).

Sungkar said antenatal care played a key role in preventing pre-term births and more training should be given to midwives and clinic personnel. The Indonesia Health Profile 2010 noted that four out of 10 pregnant women do not make the recommended four antenatal visits.

Ivan Sini, an obstetrician-gynaecologist who practices in a private hospital in Jakarta, said a lack of financial resources and poor healthcare infrastructure were among the obstacles to curbing pre-term births.

"Puskesmas [government-run community health clinics] and referral health systems are not evenly available throughout the country," Sini pointed out. "Even with limited budgets, the government should be able to expand the reach of these peripheral services."

In 2007 the country had less than 23 health workers per 10,000 residents, the minimum number needed to provide life-saving care, according to WHO.

A Health Ministry expert in health financing, Triono Soendoro, recently told state media that Indonesia's health system was facing challenges in reforming health management, improving infrastructure, and reaching people living in the more remote parts of the far-flung archipelago.