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Essential health services for all in pandemic: A mission impossible?

The COVID-19 pandemic has overburdened the healthcare system in Indonesia and many other countries. The national COVID-19 task force has warned that unless there is greater awareness about and adherence to health protocols, the health system will collapse.

Thousands have lost their lives. In these challenging times, it is critical that even as we take steps to end this pandemic, we also continue our efforts to deliver essential health services to every individual without discrimination, i.e. ensure universal health coverage (UHC). Not only will this prepare our systems for future emergencies but also guarantee that people will not suffer due to health costs.

Indonesia has been on the pathway to quality health services for all since it introduced social security reform through two policies - the national social security system in 2004 and the Health Care and Social Security Agency (BPJS) in 2011. Next came the implementation of the national health insurance (JKN) program in 2014, which was the most significant step for us toward ensuring UHC.

The JKN program aims to provide comprehensive health care for the entire population through government support and improved access to quality services. During the first six years of its implementation, the government prepared several strategies to strengthen the program’s sustainability, primarily by improving the BPJS’ management. Since then, the scheme has gradually increased its membership, reaching 220 million people or 84 percent of the population in 2019.

Prior to the JKN, Indonesia’s healthcare systems featured fragmented programs and private insurance schemes for those who could afford them, along with basic state provisions for the poorest and non-profit organizations that supported the rest. It is the JKN that sought to support people who cannot afford insurance but are not eligible for government support either. It has succeeded, in its short years, in increasing healthcare utilization and reducing catastrophic expenditure.

Indonesia’s path toward UHC has not been free of barriers. Indonesia remains riddled with inherent challenges, which have made it difficult to implement a singular insurance plan. Our unique geography makes it challenging for populations in remote areas to access quality healthcare facilities, which has led to inequities.

The JKN has also incurred severe deficits due to low participation, too low premiums and high utilization of paying members. Moreover local governments have no responsibility for financing the deficit. This has created pressure for the central government, which has a limited budget to finance the deficit. As a result, preventive and promotive services are underprioritized and the situation becomes a risk for the JKN to sustain.

Studies have indicated that there is potential for the plan to take on more financing, specifically for preventive and promotive services such as immunization programs, which can strengthen health systems and prepare better for emergencies – an important lesson to take away from 2020.

The theme of UHC Day 2020 is “Health for All: Protect Everyone”. The UHC Day campaign will mark one year since the first cases of COVID-19 were reported in Wuhan, China.

In recent times, the BPJS has taken on another critical role. It has been tasked by the coordinating human development and culture minister to use its expansive database on hospitals, aid recipients and health workers to verify hospital claims for COVID-19 treatment. It is also preparing to support with COVID-19 vaccination drives for target beneficiaries.

Further, the JKN-Healthy Indonesia card has helped many Indonesians obtain health services free of cost and get medicine delivered in the pandemic.

To cope with the outbreak, the central and local governments have taken several concrete steps, including reallocating their budget to prioritize the response to COVID-19 involving measures such as contact tracing, surveillance, in-patient care and the provision of medical supplies and health care as additional support to the JKN.

With increasing demand for health care, the JKN plays a vital role in providing essential healthcare services to COVID-19 patients and controlling the price of pharmaceuticals and healthcare services.

However, as in other countries, here too, the pandemic has affected the economy adversely. Tax collection has declined, while the need for government spending has increased. This uncertain future should be analyzed carefully for JKN sustainability.

In this difficult situation, increased investment in preventive programs has to be prioritized. In fact, it is one of the four specific objectives of the JKN program to prioritize preventive measures, which can reduce the prevalence of diseases and lower the number of sick people. As Indonesia prepares for vaccination drives against COVID-19, this will be especially important.

Indonesia and other countries have invested their resources and energy to overcome the pandemic. This crisis has reminded us that the foundation of our health care systems needs to be strengthened and only if everyone, everywhere has access to quality healthcare services, including preventive programs and tools, can we truly take steps toward a healthier future for all.

We have seen that Indonesia needs huge investment to achieve equity in accessing quality health care services. Under the current circumstances, is this a mission impossible or possible?


The writer is a professor at the health policy and management department, School of Medicine, Gadjah Mada University, Yogyakarta.

source: https://www.thejakartapost.com/academia/2020/12/11/essential-health-services-for-all-in-pandemic-a-mission-impossible.html




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Indonesia's AI-Powered Covid-19 Test GeNose Cleared for Public Use

GeNose C19, an instant Covid-19 detection tool developed by Gadjah Mada University in Yogyakarta, has secured a distribution license from the Health Ministry, paving its way for public use, the university's development team said in a statement on Saturday.

Unlike the existing tests, which use blood, saliva, or nasal fluid for detecting the novel coronavirus's genetic marker, GeNose analyzes one's breath using artificial intelligence technology, offering a much faster and cheaper process with comparable accuracy to the existing tests.

"Thank God, GeNose C19 has officially obtained a distribution permit from the Health Ministry and started to get recognition from the regulators for use in the handling of Covid-19," Kuwat Triyana, the head of GeNose development team, said in a statement on Saturday.

Kuwat said the ministry issued the license on Thursday after reviewing the team's application.

He said the project had been backed by the Research and Technology Ministry and the State Intelligence Agency (BIN), which would also be responsible for distributing GeNose's first batch throughout the archipelago.

"With 100 units of the first batch to be released, we expect to carry out 120 tests per device or a total of 12,000 people a day," Kuwat said.

A GeNose device analyzes one's breath to detect volatile organic compounds that signify the novel coronavirus infection. The team claimed earlier that the test was up to 95 accurate, similar to the antigen rapid test.

Kuwat said the whole testing process would only take 3 minutes per person, making it ideal for screening many people in hospitals, train stations, or airports.

"Also, GeNose C19 is quite cheap, only around Rp. 15,000 to Rp 25,000 [$1-$1.8] per test. The result is swift, out in about 2 minutes [after taking sample], and do not require reagents or other chemicals," Kuwat said.

Kuwat said he hoped GeNose production capacity would increase soon. Mechanical part maker Yogya Presisi Tehnikatama Industri, electronics and sensors company Hikari Solusindo Sukses, pneumatic system maker Stechoq Robotika Indonesia, artificial intelligence developer Nanosense Instrument Indonesia, and a manufacturer Swayasa Prakarsa has formed a consortium for producing 1,000 GeNose units soon, he said.

That would bump up the county's testing capacity by 120,000 people per day, Kuwat said. "With the capacity to test that many people, it is expected we can find people infected with Covid-19 fast and allow them to isolate or seek treatment so that the chain of Covid-19 spread can be broken," he said.

source: https://jakartaglobe.id/tech/indonesias-aipowered-covid19-test-genose-cleared-for-public-use


Systemic failures in public health system led to deaths in elderly patients

The deaths of 17 elderly people earlier this summer were the result of systemic failures in the public health system in England, according to a leading public health expert.

Writing in the Journal of the Royal Society of Medicine, Professor John Ashton describes a confused picture of what was happening when cases of listeria were first reported in June, with Public Health England apparently reluctant to divulge the full story. Five patients died with others affected across the country. Only a few weeks later it was reported that 12 people in Essex receiving community treatment for wounds had died from the spread of group 'A' streptococcus.

Professor Ashton draws comparisons with two major incidents that caused 41 deaths in the mid-1980s involving outbreaks of salmonella food poisoning and legionella. According to a 1988 enquiry, a lack of effective local environmental and communicable disease control was deemed to be central to both events.

"It is now time to digest these latest failings of a public health system that was only put in place six years ago as part of Andrew Lansley's structural changes to the NHS and for public health," he writes.

"The return of the public health function to local government in 2013 meant many directors of public health were placed in structures in which they are line managed by directors of adult social care, with restrictions placed on their scope for action and freedom of expression.

"There is a schism in which the clinical perspective in local government has been disappearing and the links between local authorities and the NHS have become ever more dysfunctional."

The lesson from history, he suggests, is that we should not embark on another re-organisational folly but rather find ways to strengthen what we now have and support its evolution into something fit for purpose.


Notes to editors

Hospital and community deaths from listeria and streptococcus reveal weaknesses in public health - here we go again! (DOI: 10.1177/0141076819866087) by John Ashton, will be published by the Journal of the Royal Society of Medicine at 00:05 hrs (UK time) on Friday 23 August 2019.

The link for the full text version of the paper when published will be:


source: https://www.eurekalert.org/pub_releases/2019-08/s-sfi082119.php


Community Health Systems CEO says chain nearing end of hospital selling spree

Hospital chain Community Health Systems announced a net loss of $167 million in the second quarter of 2019 as they continue to sell off hospitals to stem losses.

The company said in a release that net revenue for the first half of 2019 was $6.67 billion, a nearly 8% decrease compared with the same period last year. Overall the company lost $285 million over the first six months of the year compared with a $135 million loss over the same period in 2018.

Community Health executives also signaled to investors that it is going to wind down its hospital selling spree in the near future.

The health system based in Franklin, Tenn., has struggled with low admissions throughout 2019. In the first quarter of the year, the health system had a 13.4% decrease in total admissions and a 12.8% decrease in total adjusted admissions compared with the first quarter of 2018.

Community Health reported on Monday that the total and adjusted admissions for the first half of the year declined 12.5% compared to the first half of 2018.

However, there are some bright spots for Community Health. Admissions increased 2.3% on a same-store basis in the second quarter compared to 2018's second quarter. Adjusted same-store admissions this quarter also increased by 1.3% compared to 2018.

Part of Community Health’s strategy to turn around the system is to divest facilities not in valuable markets. The company operates more than 100 acute care hospitals across 18 states.

Community Health said that it sold two hospitals on Aug. 1, bringing the total number of hospitals divested in the first six months of 2019 to seven. It sold off 11 facilities in 2018.

But CEO Wayne Smith told investors during a call on Tuesday that Community health is nearing the end of its divesture effort. He added that overall the company is expected to generate $2 billion in net revenue from the full divesture program.

"We have done really well," he said. "We will announce the end of [the program] in the relatively near future."

The company is also looking forward to getting higher payments for some hospitals via a change in the wage index payment system proposed by the Trump administration last week. The change would boost payments for certain low-wage hospitals, especially those in rural areas.

"We have approximately 40 hospitals that benefited" from the change, said Community Health President Tim Hingtgen on the call.

source: https://www.fiercehealthcare.com/hospitals-health-systems/community-health-systems-loses-167-million-q2-sells-off-more-hospitals


Improving our health care will come from greater public investments, not private alternatives

I'm an emergency room physician in Ottawa. I may have even been working when CBC Opinion columnist Neil Macdonald presented for care, which he wrote about back in June. The scene he described of long wait times, fatigued staff, and bed shortages is, unfortunately, all too familiar to me.

I have great empathy for what he experienced. It is a terrifying thing to be in a hospital, in pain, and unsure of what is wrong. However, I question his conclusion that the answer to this problem is lies in privatization of Canadian health care services.

Universal health care is a defining trait of Canada, and one that we cannot take for granted. I take great pride in working in a system where everyone can get the care that they need, rather than only those who can afford it getting the care that they want.

Those "Code Blue, Code White, Code whatevers" that Macdonald so casually referenced in his column are all critical patient emergencies, which require emergency staff to drop everything and run to the patient's side.

In those situations, every possible measure will be taken to provide every patient with the highest quality of care, regardless of income status. Whether you are a member of parliament or a single parent who is out of work, you will leave the hospital with your cardiac stent, or your emergency surgery, or whatever other treatment is required to get you back to your life and your loved ones. And you will do so without ever opening your wallet.

Health care spending

Universal health care also allows us access to primary care and preventative medicine to keep our population healthier and prevent those emergencies from developing in the first place. Much of the available evidence suggests that the failings in our health care system are due to a lack of sufficient public spending, not because there is not a private alternative.

In fact, the Scandinavian health care system that Macdonald touts in his column actually devotes a greater percentage of its annual health care spending toward its public systems than we do. According to the Canadian Institute for Health Information, Sweden devoted 84 per cent of its total health expenditure to its public sector in 2017, compared to only 70 per cent in Canada, while achieving higher average life expectancies and lower rates of mortality and morbidity in a population that is older than ours.

That's not to say that our system doesn't have problems. Wait times for non-emergency procedures, such as joint replacements, are too long. Hospitals are overcrowded. Family doctors are hard to find. I don't deny any of this. But no Canadian will be denied time-sensitive or life-saving care because they can't afford it. Nor will they wake up to a lifetime of crippling medical debt in exchange for the privilege of being alive.

Macdonald noted in his article that he received excellent care at an American public hospital that treats patients with private insurance, Medicare, and Medicaid. But more than one in 10 Americans don't fall into any of those categories. These are the "working poor," who are not poor enough to qualify for Medicare or Medicaid, but still too poor to afford private insurance. Almost 40 million of these Americans may not be able to access the care they need because they can't afford it. That's not a system that I'm willing to idolize.

In countries where mixed models of private and public health care exist, such as the two-tiered systems in the UK and Australia, higher wages and greater resources can incentivize specialists into private practice, resulting in a deterioration in the quality of care and resources available to the public sector. These systems have also demonstrated that as private health care spending increases, wait times in the parallel public sectors can also also increase, leaving those who can't afford private care even further behind.

Yes, the Canadian health care system is flawed, and there is much room for improvement. So let's work within the system we have to advocate for better access to primary care, better coordination of services, and more long-term care beds. Let's be vocal against governments that want to make further cuts to an already overburdened health care system.

And to those who look at privately paid health care south of the border with rose-coloured glasses, I ask you to think about those who can't afford to do so, and reassess your position. I'm glad Macdonald came forward with his experience. He sheds light on some critical gaps in our current system, which make being a patient an even harder experience than it already is. But we must have equal compassion for every patient's journey, regardless of their ability to pay, and take a stand for universal health care.

Then we can take steps toward improving on the foundation of universal access, rather than talk about dismantling it.

source: https://www.cbc.ca/news/opinion/health-care-investment-1.5212828


The Trouble With Cambodia’s Health System

This month, the Cambodian government made clear that “fake news” about Prime Minister Hun Sen’s death on Facebook would be treated as a criminal matter, following yet another trip by him to Singapore for medical treatment. Seeking care overseas is common for some of the country’s wealthy elite. But for regular Cambodians, the country’s own healthcare system is the only choice they have to address their issues.

Amid the focus on many other headline developments, including Cambodia’s alignments with China and the United States, the state of the country’s healthcare system is often not explored in depth, particularly among international outlets. But periodic crises tend to point to the issues therein, and the most recent one is the ongoing dengue epidemic hitting Cambodia.

The director of Kantha Bopha Children’s Hospitals, a network of charitable hospitals, has said that as of July 1 his hospitals in Phnom Penh and Siem Reap have seen 30 children, out of more than 16,000 dengue fever patients, die from the virus this year. In more rural areas, hospitals are showing signs that they cannot handle the influx of patients. The Cambodian Red Cross had to set up tents around one referral hospital in Stung Treng province because of a shortage of beds. To the news of hospitals being unable to cope with the dengue crisis, Ou Virak, president of the Future Forum think-tank, tweeted: “Very alarming and a national emergency. Our health care system is broken and the poor are paying the heaviest price.”

“Broken” might be too strong, but the problems facing Cambodian healthcare are sure to become more daunting unless the government stumps up more money. The statistics make this clear. Cambodians still live, on average, some six years less than their neighbors in Thailand, and seven years less than the Vietnamese. On average, they only live 0.1 years longer than the people of Timor-Leste, the poorest nation in Southeast Asia, with an economy a tenth the size of Cambodia’s.

Cambodia has made clear strides in healthcare. In 1990 the average life expectancy from birth was just 53.6 years. But between 1997 and 2019 the average life expectancy from birth rose by 13 years, from 56.2 years to 69.3 years, according to United Nations Development Program’s data. Almost all other indicators point to similar progress over the last three decades. For instance, between 1990 and 2015 the maternal mortality ratio went from 1,020 deaths per 100,000 live births to 161, while the percentage of the population using improved sanitation facilities rose from 12.3 percent to 48.8 percent. Between 1990 and 2016 the mortality rate of infants (per 1,000 live births) decreased by 68.9 percent.

But look more closely at the numbers and one finds that progress is slowing. Take life expectancy, for instance. It rose by 4.8 years between 1990 and 2000, then almost double that rate (8.2 years) between 2000 and 2010, but afterwards slowed down and grew by only 2.7 years between 2010 and 2017, the latest year on record. Or take the infant mortality rate, which decreased 6.1 percent between 1990 and 2000, then more than halved between 2000 and 2010, before falling by just under a third between 2010 and 2016. For almost every indicator, the same pattern emerges: little progress in the 1990s, then a fundamental change at rapid rates during the 2000s, but much slower progress this decade.

In one sense, this is only to be expected. Cambodia began at a woefully low starting point, before a considerable injection of foreign aid and capital investment in the 2000s allowed for quick progress. But as standards rise, it becomes increasingly more difficult for the country to maintain progress without an equally audacious financial commitment from the state.

Sift through UNDP data and you find that the vast majority of countries have increased their spending on healthcare as a percentage of GDP over the last three decades. Thailand spent 3.2 percent in 2000 and 3.8 percent in 2015. China increased spending from 4.5 percent to 5.3 percent, while even Timor-Leste increased it from just 1.3 percent to 3.1 percent.

But the amount the Cambodian government spends on healthcare as a percentage of GDP is decreasing; from 6.4 percent in 2000 it rose to 7.5 percent in 2011 before dropping to just 6 percent in 2015. Government data show that government allocations to the health ministry as a percentage of the overall state budget also declined this decade, from 7.2 percent in 2013 to 6.6 percent in 2019. In fact, spending on healthcare fell in real terms by $30 million in this year’s budget compared to last year’s, down to $455 million.

Beyond those aggregate numbers, the government’s approach to healthcare is also worth noting. The government has been moving the costs onto either patients (through allowing the rapid expansion of the private healthcare sector, which is arguably larger and more competent than state clinics) or onto the private sector itself (with the National Social Security Fund, which workers and employers pay into).

What one finds, then, is that at a time when the government needs to pour increasing amounts into the healthcare system, it is putting on the brakes. And unless it is prepared to stump up more money, progress will slow down and public anger will grow, as the wealthy elite continue to travel abroad for treatment while most ordinary Cambodians struggle at underfunded local hospitals.

source: https://thediplomat.com/2019/07/the-trouble-with-cambodias-health-system/


Improving emergency healthcare services in Jordan

In partnership with the European Union (EU) and the Jordanian Ministry of Health, UNOPS will improve three public health facilities to better serve communities impacted by the Syrian crisis.

With over 663,000 registered Syrian refugees in Jordan, demand on the country's already overextended social services has increased, significantly affecting livelihoods and access to quality public services in host communities.

As part of the EU’s Regional Trust Fund in Response to the Syrian Crisis, this €10 million project will improve Jamil Tutunji Hospital in the Sahab district of Amman, Ramtha Hospital in Irbid, and Ruweished Hospital in Mafraq.

"The EU will continue to assist the Ministry of Health in improving the health services provided to local communities and Syrian refugees by meeting their health needs, promoting resilience, and strengthening the national health system and services," said the EU Ambassador to Jordan, H.E Andrea Matteo Fontana at an official launch held 17 July.

UNOPS will design and construct new emergency facilities at all three health facilities, and rehabilitate two existing emergency departments, in order to enable Jordan's health sector to meet the increased demand. UNOPS will also deliver all necessary medical equipment and provide three fully-equipped ambulances. The facilities will be fitted with solar energy, wastewater treatment systems, external solar lights, and solar water heaters, to enhance sustainability as well as safety.

UNOPS is pleased to cooperate with the EU and Jordan in two of our areas of expertise: infrastructure and procurement. The project will substantially improve the quality of health services provided to those in need.

“UNOPS remains committed to continuing to support Jordan in its efforts to both deliver assistance to those most vulnerable and to help achieve the Sustainable Development Goals," Ms. Kaloti added. Bana Kaloti - Director, Middle East Region

Currently, around 22 per cent of Jordan’s population face challenges accessing services while only 40 per cent of refugees living outside camps have access to healthcare services, leaving over 300,000 people without regular access to health services.

“It is unquestionable that the support offered by the European Union over the past years is a backing for Jordanian efforts to face health sector challenges imposed by the effects of the Syrian crisis,” said H.E. Dr. Saad Jaber, Jordan's Minister of Health.

source: https://reliefweb.int/report/jordan/improving-emergency-healthcare-services-jordan


Presiden Jokowi Teken Inpres Soal Kedaruratan Nuklir

PRESIDEN Joko Widodo (Jokowi) telah meneken Intruksi Presiden tentang tentang Peningkatan Kemampuan Dalam Mencegah, Mendeteksi, dan Merespons Wabah Penyakit, Pandemi Global, dan Kedaruratan Nuklir, Biologi, dan Kimia.

Inpres yang dipublikasikan oleh Sekretaris Kabinet (Setkab) pada Selasa (9/7/2019) ditandatangani oleh Presiden Jokowi 17 Juni 2019 lalu.

Dalam Inpres yang dimuat Setkab.go.id itu Presiden menginstruksikan kepada Menteri Kesehatan untuk mengkaji dan menyempurnakan peraturan perundang-undangan dan kebijakan di bidang kesehatan.

Hal itu terkait peningkatan ketahanan kesehatan global serta dukungn pembiayaan.

“Tingkatkan kemampuan dalam mencegah, mendeteksi, dan merespon wabah penyakit, pendemi global, dan kedaruratan nuklir, biologi, dan kimia,” bunyi diktum Pertama poin No. 9 Inpres Nomor 4 Tahun 2019 itu.

Presiden juga menginstruksikan Menkes untuk meningkatan kapasitas surveilans kesehatan.

Diharapkan Kemenkes yang mampu mengindentifikasi kejadian yang berpotensi menyebabkan kedaruratan kesehatan masyarakat.

Misalnya saja situasi di pintu keluar masuk negara, resistensi antimikroba, dan keamanan pangan.

Selain itu, Presiden juga menginstruksikan Menkes untuk meningkatkan cakupan dan kualitas pelaksanaan imunisasi, serta meningkatkan kapasitas dan memperkuat jejaring laboratorium yang mendukung identifikasi permasalahan kesehatan masyarakat.

Melalui Inpres tersebut, Presiden juga menginstruksikan kepada Menteri Perindustrian untuk meningkatkan surveilans kewaspadaan, deteksi potensi risiko, dan respons cepat penanggulangan keadaan darurat bahan kimia berbahaya yang bersumber dari berbagai industri kimia.

Seperti diberitakan Setkab Inpres tersebut ditujukan antara lain kepada Menko Polhukam, Menko Bidang Pembangunan Manusia dan Kebudayaan, Menteri Dalam Negeri, Menteri Luar Negeri, Menter Pertahanan dan Menteri Hukum dan HAM.

Inpres juga ditujukan pada Menteri Keuangan, Menteri Riset, Teknologi dan Pendidikan, Menteri Kesehatan, Menteri Perindustrian, Menteri Komunikasi dan Informatikan serta Menteri Pertanian.

“Menetapkan kebijakan melalui evaluasi, kajian, dan/atau penyempurnaan peraturan perundang-undangan dan mengambil langkah-langkah secara terkoordinasi dan terintergrasi sesuai tugas, fungsi, dan kewenangan masing-masing dalam meningkatkan kemampuan mencegah, mendeteksi, dan merespon wabah penyakit, pandemi global, dan kedaruratan nuklir, biologi, dan kimia, yang dapat berampak nasional dan/atau global,” bunyi diktum PERTAMA Inpres ini kepada para pejabat di atas.

sumber: https://wartakota.tribunnews.com/2019/07/09/presiden-jokowi-teken-inpres-soal-kedaruratan-nuklir