Leprosy (also called as Hansen's disease) is one of the most dreadful diseases prevalent all over the world. It has tortured the human race all through history and has had a huge impact on various aspects of human life.

It's been over three decades since multiple drug therapy (MDT) was first used to treat leprosy, yet millions of victims still live a crippled, poor quality of life due to leprosy infection. As per the 2011 statistics, India rank's number one by contributing about 58.1 per cent of new leprosy cases detected worldwide. Read what the Indian health minister has to say about eradication of leprosy in India.

Today, on 26 January—recognised as the World Leprosy Day, we discuss why the world is still not free from the disease and what are the recent advancements in leprosy treatment so far. Read more about the stigma associated with leprosy.

Challenges to be met:

• Leprosy, till date, remains an ignored problem that gets detected at later stages because of lack of awareness of its early symptoms. Hence, there is a need for speedy and accurate diagnostic tests which can detect the disease in early stages, especially in remote areas.
• Multiple drug therapy (MDT) has been the mainstay of leprosy treatment right since it was first used in 1980s. In fact, the significant decrease in incidence of leprosy was possible only because the drugs clofazimine, rifampicin and dapsone, used for treating leprosy, were made freely available to everyone by the World Health Organization (WHO). But, with prolonged use of drugs, resistance is a huge concern and threat to control leprosy. Finding newer drugs is therefore critical.
• The mode of transmission of the disease is still unknown. For complete eradication of the disease, interrupting its transmission is also very important.

Advances in treatment of leprosy

Focusing mainly on the three aspects mentioned above, remarkable advances in management of leprosy have emerged from research point of view. Read about the efforts of India to fight leprosy.

• Last year in Brazil, the lab OrangeLife introduced a new test for diagnosing leprosy. The test is rapid and similar to a pregnancy test. A drop of blood from the patient is taken on a reactive strip to detect the presence of antibodies against leprosy causing bacteria. The test provides 90% accurate results and looks promising as a diagnostic tool in remote areas, where a large number of people are silent carriers of the disease.
• Leprosy is a disease that affects the nerves causing loss of sensation. Because initial symptoms of the disease are often misleading, detection of thickened and enlarged nerves can help in its early diagnosis. Earlier, confirmation of nerve damage was extremely difficult. But, recent advances in imaging techniques including the use of ultrasonography (USG) have made assessment of structural changes in nerves possible.
• Extensive research is carried out in various parts of the world to develop newer drugs for effectively treating leprosy, especially in people who become drug resistant over a period of time. Of all the drugs in the initial stages of testing, the drug moxifloxacin has been found to be the most active agent against leprosy causing bacteria. Other drugs including rifapentin, clarithromycin and minocycline are also proposed to be included in the new drug therapy for treatment of leprosy.
• The best approach to eliminate the disease is vaccination, and a lot of research in vaccine development is also going on. As a part of their strategy to fight leprosy, American Leprosy Missions initiated vaccine research in 2011. After completion of their toxicology studies this year, they will begin with safety trials in 2015.

With concerted efforts of WHO, all health care providers, local governments and researchers, the barriers to eradication of leprosy will surely be eliminated and the world will see an unprecedented improvement in leprosy eradication, just as it witnessed in case of polio. Read more about the views of WHO at international leprosy summit in 2013.

References:

• P Narasimha Rao, Suman Jain. Newer management options in leprosy.
• Sunil Dogra, Tarun Narang & Bhushan Kumar. Leprosy – evolution of the path to eradication
• World health Organisation: Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy. (2011-2015)
• Rapid diagnostic test promises end to leprosy torment (http://www.bbc.co.uk/)
• American leprosy Missions (http://www.leprosy.org/)
• Leprosy 2013 – The Problem and the Solutions

source: health.india.com

Global leaders -- from politicians and CEOs to academics and Nobel laureates -- will gather next week in Davos, Switzerland for the 44th World Economic Forum Annual Meeting. At this year's forum, which runs from January 22-25 and will focus on the theme The Reshaping of the World: Consequences for Society, Politics and Business, health and wellness will be a bigger focus of the conversation than ever before.

The forum's first-ever health summit will feature 25 sessions on topics including mental health, personalized medicine, health systems in emerging economies, and other pressing public health issues. More than 2,000 participants representing over 100 nations will take part in the discussions, many of which will focus on the intersection between health and broader economic and social issues.

"The time is right to elevate the conversation on health," said Robert Greenhill, managing director and chief business officer at the Forum, in a press release. "For the past few years, the critical state of the financial system absorbed much of Davos participants' attention. This year, there is a sense that the global economy is out of intensive care and embarking on rehabilitation. As we ask how metaphorically to improve the economy's health, literally improving the population's health is a good place to start."

Mental health issues will be a particular focus of the conversations. The global costs of poor mental health and its repercussions are estimated at $16 trillion over the next 20 years, according to the World Economic Forum. The World Health Organization has estimated that at least 350 million people worldwide suffer from depression, and that it is the leading cause of disability worldwide.

But the participants at Davos won't just be talking about health -- they'll be actively encouraged to make healthy decisions of their own. As part of the Davos health challenge, participants will be encouraged to make healthy choices when it comes to food, sleep and physical activity, and to track their activity for the week using Jawbone fitness trackers.

Some of the week's notable speakers on technology and health-related panels include Yahoo! CEO Marissa Mayer; Aetna CEO Mark Bertolini; Arianna Huffington, president and editor-in-chief of The Huffington Post Media Group; actor Matt Damon; and Peter Salovey, president of Yale University.

Arianna Huffington and Mika Brzezinski are taking The Third Metric on a 3-city tour: NY, DC & LA. Tickets are on sale now at thirdmetric.com.

source: www.huffingtonpost.com

Humans face the very real risk of a future without antibiotics, a world of plummeting life expectancy where people die from diseases easily treatable today, scientists say.

Experts tracking the rise of drug resistance say years of health gains could be rolled back by mutating microbes that make illnesses more difficult and expensive to cure and carry a higher risk of death.

Some say the threat to wellbeing is on the scale of global warming or terrorism -- yet resistance is being allowed to spread through an entirely preventable means

-- improper use of antibiotics.

"It is a major public health problem," Patrice Courvalin, who heads the Antibacterial Agents Unit of France's Pasteur Institute, told AFP.

"It is about more than not being able to treat a disease. It will erase much progress made in the last 20-30 years."

Without antibiotics to tackle opportunistic bacteria that pose a particular risk for people who are very ill, major surgery, organ transplants or cancer and leukaemia treatment may become impossible, he explained.

"In some parts of the world, already we have run out of antibiotics," said Timothy Walsh, a professor of medical microbiology at Cardiff University.

"In places in India, Pakistan, Bangladesh, possibly Russia, Southeast Asia, central South America, we are at the end game. There's nothing left. And unfortunately there is nothing in the pipeline either."

Resistance to drugs emerges through changes in the bacterium's genetic code -- altering the target on its surface to which antibiotics would normally bind, making the germ impenetrable or allowing it to destroy or "spit out" the antibiotic.

These super-germs triumph through Darwinian pressure, helped by humans.

The wrong antibiotics, taken for too short a period, in too low a dose or stopped to early, will fail to kill the altered microbes.

Instead, the drugs will indiscriminately damage other bacteria and give the resistant strain a competitive advantage -- allowing it to dominate and spread.

At the base of the problem is doctors prescribing antibiotics wrongly or unnecessarily, and the ease with which medicines can be obtained without a script in some parts of the world, including Asia and Africa.

As much as 70 percent of antibiotics are given for viral infections, against which they are wholly ineffective, the experts say.

Then there is the problem of farmers in countries like the United States adding antibiotics to animal feed to help herds grow faster.

Compounding all of this is the rise in global travel -- a boon for bacterial spread, and a sharp drop in antibiotics development blamed on a lack of financial incentives for the pharmaceutical industry.

A return to the pre-antibiotic era?

The World Health Organisation (WHO) says drug resistance "threatens a return to the pre-antibiotic era".

"Many infectious diseases risk becoming untreatable or uncontrollable," it states in a factsheet on antimicrobial resistance.

A case in point: some 450 000 people developed multi-drug resistant (MDR) TB in 2012 and 170,000 died from it. MDR TB does not respond to the most potent TB drugs -- isoniazid and rifampin.

Nearly 10 percent of MDR cases are thought to be of the even deadlier XDR (extensively drug resistant) variety which does not respond to a yet wider range of drugs.

Like other drug-resistant microbes, MDR and XDR TB can be transferred directly between people -- you can get it even if you have never taken antibiotics in your life.

"Antibiotic resistance is an emerging disease and a societal problem. The use you can make of an antibiotic depends on the use made by others," said Courvalin.

Another worry for health planners today is the spread of a multi-drug resistant strain of the bacterium Klebsiella pneumoniae -- a common cause of infections of the urinary tract, respiratory tract and bloodstream, and a frequent source of hospital outbreaks.

In some parts of the world, only the carbapenem antibiotics class remains effective, but now signs are emerging of resistance even to this last line of defence.

Antibiotics are thought to have saved hundreds of millions of lives since Alexander Fleming first discovered penicillin in 1928.

But even Fleming's own warnings of impending drug resistance went unheeded, and now scientists say peop

le may start dying from infections like meningitis and septicaemia that are eminently curable today.

"If we keep going like this, the vast majority of human bacterial pathogens will be multi-resistant to antibiotics," said Courvalin.

The answer? Prudent drug use -- better and faster diagnosis to determine whether an infection is viral or bacterial and whether it is even susceptible to treatment.

Farmers must stop feeding antibiotics to their livestock, and hospital and individuals improve their hygiene to prevent bacterial spread.

Yet few experts believe the damage can be undone.

"The bugs have become very sophisticated, they've become very complex," said Walsh.

"You can decrease resistance or reduce it, but never completely reverse it."

source: www.nst.com.my

And the U.S. didn't even make the top 20. The Netherlands came out on top because of low diabetes rates, low food prices and nutritional diversity. Chad landed last on the list for its costly, unhealthy food options.

Thanks in part to a diet that places the emphasis on vegetables and dairy products, the Netherlands has been named the healthiest country in the world to eat.

Though the country is better known for its liberal drug laws than its cuisine, the Dutch diet ranked the healthiest out of 125 countries in a wide sweeping report out of Oxfam that looked at factors like food availability, affordability, food quality and obesity rates.

According to the index "Good Enough to Eat," the Netherlands emerged the leader thanks to relatively low food prices, low prevalence of diabetes, and better nutritional diversity than its European rivals.

Overall, the list is dominated by European countries, with France and Switzerland tying for second place, followed by Austria, Belgium, Denmark and Sweden tying for third.

Notable absentees include the UK, Canada and the U.S.

Asian giants South Korea and Japan, meanwhile, performed the best when it comes to healthy eating habits and food availability, given their lower rates of diabetes and obesity and equally low rates of malnutrition in children.

At the other end of the spectrum, Chad landed dead last on the list, due to high food prices, poor nutritional value as well as limited sanitary conditions that includes access to clean water.

Second from the bottom are Angola and Ethiopia.

Interestingly, when it comes to unhealthy eating habits, Saudi Arabia was the lowest scoring country, ranking the worst for its high prevalence of diabetes -- a whopping 18% of the population is diabetic. A third of the population is also considered obese.

The fattest country on the list is Kuwait, where 42% of the population is obese.

To compile their ranking, researchers looked at figures from eight studies published out of international groups like the World Health Organization, the Food and Agriculture Organization and the International Labor Organization.

Meanwhile, a 2006 study published in the American Journal of Clinical Nutrition concluded that a healthy traditional Dutch diet -- defined as a high intake of vegetables, fruit, dairy products and potatoes -- was more feasible and healthier for the longevity of older Dutch women, compared to a Mediterranean diet.

Here are the top countries for healthy eating, according Oxfam's "Good Enough to Eat," index:

1. Netherlands
2. France, Switzerland
3. Austria, Belgium, Denmark, Sweden
4. Australia, Ireland, Italy, Luxembourg, Portugal

Source: www.nydailynews.com

Lack of health care providers or lack of money to pay for medicine results in 100 million people being reduced to poverty every year, the head of the World Bank said Tuesday.

In remarks to the Center for Strategic and International Studies in Washington, DC, World Bank Group President Jim Yong Kim said economic growth is not possible without universal health care.

"All countries must harness investments in other sectors beyond health that provide the essential foundations for a healthy society," he added.

"Achieving universal health coverage requires solutions beyond the health sector, including investments in people, like education and social protection, but also things like roads, water and sanitation, and information technology. For example, policy interventions to curb tobacco use or improve air quality, diet and road safety can all play a critical role in addressing the alarming increase in chronic conditions and injuries in so many emerging economies."

Devising programs to help people requires tremendous political will, Kim said, but efforts in many parts of the world are succeeding.

"What is the lesson for us here today, as we hear the same negative arguments about universal health care?" Kim asked. "We saw with AIDS that concrete action often only happens when there is a powerful political and social movement behind it.

"And just as the AIDS activists drove the movement for treatment — and brought along the scientists, policymakers, the donors and businesses — today around the world we are seeing a large, and growing, movement to achieve universal health coverage."

Good health and related improvements are an investment, Kim stressed.

"The new report of the Lancet Commission on Investing in Health estimates that about 24 percent of growth in 'full income' in developing countries from 2000-2011 resulted from health improvements," he said. "Full income is defined as the sum of the income growth measured in the national income accounts, plus the value of the change in mortality (or life expectancy), in that period.

"Projecting forward to 2035, the commission report says that better investments in health could yield a 9-to-20-fold return in full income."

How health care improvements come about will vary from country to country, he said.

"When Ethiopia launched its free universal primary care program in 2003, at its center was a network of health extension workers," Kim said. "These 35,000 women — 10th-grade high school graduates recruited from their communities —were trained for one year and redeployed back into their communities.

"The latest survey data show that child mortality fell by over one quarter, as did child stunting. For women, anemia rates fell and contraceptive use nearly doubled, helping to reduce the total fertility rate."

source: www.allvoices.com

It is three years since India last reported a case of polio. Patralekha Chatterjee reports on how the country appears to have finally managed to beat the disease.

Despite a healthcare system beset by severe problems, India has ushered in the new year with an achievement to be proud of.

In 2009, India reported 741 polio cases, more than any other country in the world, according to the Global Polio Eradication Initiative. The last case was reported from the eastern state of West Bengal in 2011, when an 18-month-old girl was found to have contracted the disease.

The country faced unique challenges in eradicating polio.

Among them was the high population density and birth rate, poor sanitation, widespread diarrhoea, inaccessible terrain and reluctance of a section of the population, notably members of the Muslim community in certain pockets, to accept the polio vaccine.

Nicole Deutsch, head of polio operations in India for UN children's charity Unicef, said: "Despite these obstacles, India proved to the world how to conquer this disease: through the strong commitment of the government, seamless partnership comprising the government, Rotary clubs, WHO and Unicef, and above all the tireless hard work of millions of front-line workers - vaccinators, social mobilisers and community and health workers - who continue to implement innovative strategies to rid India of polio,"

The introduction of bivalent oral polio vaccine in 2010 also helped India to battle the disease. Previously, India had been using a monovalent vaccine that protected only against type 1 poliovirus transmission, not type 3. which was causing repeated disease outbreaks.

But it was organisation that was key in enabling India to cover the last mile in its battle against polio.

In a vast country of more than a billion people who are culturally, economically, linguistically and socially diverse, "micro-plans" helped because they tossed up precious data about the specifics of a particular place - areas to be covered by each vaccination team on each day of the immunisation campaign, names and designations of the vaccinators, supervisors and community workers assigned to the area along with the vaccine, logistics distribution plan and so on.

But data alone did not deliver results. Unicef set up the Social Mobilisation Network for polio in 2001 in northern Uttar Pradesh state.

The initiative was a response to resistance against the polio vaccine. Families were refusing to immunise their children in some districts in Uttar Pradesh.

There were many reasons why this happened - parents did not see polio as a risk; repeated immunisation rounds had created doubts in their minds; and some believed rumours that linked the polio vaccine to impotency.

The Indian government and its polio partners realised that a new approach was needed.

This led to strategies to make polio vaccination more acceptable among people who had been resisting it.

'Holistic'

Children who suffered from severe bouts of diarrhoea did not fully benefit from the oral polio vaccine.

So, community mobilisers started talking about the need for hand-washing, hygiene and sanitation, exclusive breastfeeding up to the age of six months, diarrhoea management with zinc and oral rehydration therapy, and routine immunisation, necessary to sustain the success of polio eradication.

This holistic approach has paid off.

India's polio campaign gathered momentum when it focused on marginalised and mobile people, and began working in earnest with religious leaders in Muslim communities to urge parents to immunise their children.

For example, in Bihar in eastern India - once a polio hotspot in the country - a key focus of the polio programme is migrants.

In recent years, continuous vaccination has been conducted at 51 transit locations at the state's international border with Nepal and 11 important railway stations. Bihar also saw special drives during popular festivals and fairs.

While India appears to have stopped indigenous transmission of wild poliovirus, the risk of importation is real and has increased since 2013 with outbreaks in the Horn of Africa region and the Middle East, in addition to the continuing poliovirus transmission in Afghanistan, Pakistan and Nigeria.

"India needs to stay extremely vigilant and continue its efforts to ensure that the children remain protected against polio, until the disease is eradicated globally," said Nicole Deutsch of Unicef.

"India plans six polio campaigns in 2014 and 2015. In each campaign, 2.3 million vaccinators will immunise nearly 172 million children."

India has also set up polio immunisation posts along the international borders with Pakistan, Nepal, Bangladesh, Burma and Bhutan to vaccinate all children up to the age of five years crossing the international borders.

India's dramatic turnaround paves the way for polio-free certification of the entire South East Asia Region of the World Health Organization. The South-East Asia Regional Certification Commission for Polio Eradication (RCCPE) is expected to meet in Delhi in the last week of March 2014.

"If the commission is convinced that there is no wild poliovirus in the region and the surveillance quality is good enough to pick up any wild poliovirus and phase 1 laboratory containment work has been completed, it will certify the South East Asia Region of WHO as polio-free," a WHO spokesperson told the BBC.

India's successful control of polio has had other benefits.

A health ministry official connected with India's National Polio Surveillance Project (NPSP), a collaboration between the government and the WHO, said strategies that worked in the case of polio were now being used to push up routine immunisation.

This is good news. Too many Indian children still die because they do not get the vital vaccines.

source: www.bbc.co.uk

The disease detectives at the Centers for Disease Control and Prevention have named the top five global health threats they expect to tackle in 2014. They are:

1. The emergence and spread of new microbes
   While it's rare, CDC scientists do come across new diseases each year. In 2013, the new Heartland virus carried by ticks was confirmed in northwest Missouri. Federal health investigators collected samples in the state after two farmers from St. Joseph were sickened by the virus that carried a novel genetic profile.
   
   Also last year, CDC helped public health officials in the Republic of Georgia identify a new virus related to smallpox that infected shepherds there. Only one in five countries worldwide has the technology to detect and fight emerging infections, said the CDC's director, Dr. Tom Frieden. The CDC is making disease detection a major priority in 2014, in the U.S. and abroad. New technologies and software have enabled faster DNA identification of infectious germs.
    
2. The globalization of travel and food supplies
   Diseases that were thought to be eradicated in the U.S. are now back because of lower vaccination rates and increased international travel. In 2013, measles cases in the U.S. doubled to 175, almost all linked to foreign travel. Measles outbreaks can only be prevented if the majority of the population is vaccinated. American scientists are training their colleagues worldwide and helping build new labs to investigate outbreaks.
   
   Disease can spread anywhere in the world within 24 hours, Frieden said. The most recent global pandemic, involving the H1N1 swine flu, spread to 23 countries within six weeks of being discovered in Mexico in 2009. Contaminants in the food supply can also spread quickly, as evidenced by the 2011 E. coli outbreak in nine states.
    
3. The rise of antibiotic-resistant infections
   Some bacteria have become resistant to several types of antibiotics, making it harder to fight infectious diseases. Drug-resistant infections are particularly dangerous for people with a compromised immune system, including those with cancer, kidney failure or organ transplants. In some cases, doctors and nurses have had to resort to less effective and more toxic antibiotics when the first-line defenses fail. Patients with antibiotic resistant infections incur longer hospital stays, long-term side effects and death. More than 2 million Americans contract antibiotic-resistant infections each year, and 23,000 die, according to the CDC.Several drug-resistant bacteria, including forms of gonorrhea, tuberculosis, salmonella and strep are considered urgent or serious threats to public health because doctors are running out of drugs to treat these infections. The overuse of antibiotics is the main pathway for drug-resistant infections. About half of antibiotic prescriptions are considered to be unnecessary. Antibiotics given to farm animals before slaughter are another main source of resistance. The CDC is working with the FDA to reduce the use of antibiotics in the food chain.
   
   "One of my key principles in using antibiotics properly is to make sure the patient receives the correct amount of a medication that only treats the bacteria or germs involved in the infection," said infectious disease pharmacist Ryan Moenster, associate professor at St. Louis College of Pharmacy. "If the doctor diagnoses you or a family member with a viral infection, don't demand medication like amoxicillin because antibiotics do nothing for viral infection."
    
4. Inadvertent or intentional release of pathogens
   The 2009 death of a scientist who caught the plague in a University of Chicago lab alarmed many in the disease research world. An estimated three of every 1,000 lab workers are sickened each year, most commonly with hepatitis, typhoid fever or tuberculosis, according to the National Institutes of Health.
   Many labs employ safety officers to oversee work with cultures including flu, pneumonia, salmonella, E. coli and other pathogens.
    
5. Bioterrorism
   Some inhaled pathogens such as anthrax, pneumonic plague or smallpox are considered potential weapons in a bioterrorism attack. St. Louis University is studying a new plague vaccine at the behest of federal health officials for potential use in the military. The military has previously used a plague vaccine, but it caused side effects such as headaches and fever.
   
   The CDC works with health departments in every state to conduct bioterrorism drills and train public health workers on emergency preparedness. They monitor local labs to make sure they can conduct tests quickly when a lethal substance is detected. Many of the systems were also tested during the H1N1 flu pandemic, as hospitals set up tents and secured extra ventilators for the influx of patients.

source: tbo.com

The Constitution promises every citizen access to social security and emphasizes the role of the state in providing universal social security coverage. On Jan. 1, citizens started to see the fulfillment of such promise, as the long-awaited national health insurance (JKN) came into effect.

Dubbed the largest health insurance in the world, the JKN will first cover approximately 120 million people automatically entitled to primary health care and third-class coverage at partner hospitals.

Among those, some 86.4 million are underprivileged (formerly covered by Jamkesmas insurance), who are the recipients of premium payment assistance (PBI), for which the government has set aside Rp 19.3 trillion (US$1.58 billion) from the state budget.

Groups with assumed employment, who contribute through individual (entrepreneurs and informal workers) or group (employees) schemes, will also be covered.

As many have noted, the launch of the JKN sparks new hope and anxiety at the same time. The government indeed has lots of homework.

Information on the new scheme needs to be disseminated to the public, health workers and hospitals, while it also needs to ensure the readiness of hospitals and other health facilities. Data (especially on poor people) needs to sort out, as does other technical issues such as the registration process.

It must be noted though that in a country as vast as Indonesia, disparity between regions, hospitals and health workers will continue to create challenges in managing a massive health reform such as the JKN. Decentralization will remain a stumbling block in enforcing existing clinical and quality

standards.

There are at least two issues that must receive careful attention, in light of decentralization.

First is the excessive number of people to be registered as poor people and its implication to local

governments and hospitals.

This will likely take place during the transition from the regional level health insurance schemes such as Jamkesda (and other local programs like Jamkes Aceh, Jakarta Sehat, etc.) to the JKN.

According to statistics, (PPLS 2011, the most recent Social Protection Program Data Collection of the Central Statistics Agency, BPS), there a total of 96.7 million poor people, which means there is an excess of more than 10 million people that would not be covered by the JKN.

This group of people is expected to be covered by the regional health insurance. The problem is that there have been ample examples how regional governments or their local hospitals were on the verge of bankruptcy because of the number of poor people using the former local health coverage schemes had soared, compared to official data used to estimate the number of initial recipients.

Garut and Sukabumi in West Java and Boyolali in Central Java, are some of the mostly quoted regencies in such cases. The list will be longer if we include eastern Indonesia's regencies, which also suffer from a lack of local capacity in managing health services and finances.

The central government must pay attention to the regencies with lower fiscal capacity and a higher number of poor people to ensure that the data discrepancy regarding the poor does not disrupt public services or even lead to bankruptcy.

The role of the Social Security Agency (BPJS) in conducting the payment process on time so that burdens do not fall on hospitals and local governments is pivotal. Also, attention should be given to speed up the provision of medical workers in such facilities.

Meanwhile, some local governments have expressed hesitation to merge into this nationwide scheme right away because of this data discrepancy. The local government of Surakarta, for instance, refused to migrate and contribute to the JKN from its local budget (APBD) due to worries over the jump in the number of people intending to register.

Similarly, the municipal government of Manado in North Sulawesi decided to continue its local insurance because it did not want to interrupt its program and its budget this fiscal year.

The Health Ministry needs to allocate a specific period of time for a systematic transitional process to the local administrations to completely merge their schemes into the JKN, hence, their budgets can be better used to improve the quantity and quality of health workers and facilities.

Second is the risk to the poor living in poor and marginalized regions. The poor excluded from PBI living in poor regions are in fact the poorest of the poor. They are similar to those not covered in Jamkesmas and local schemes like Jamkesda.

Living in the regions with the worst off economies, their local governments do not have much budget discretion to charge the already limited budget for those beyond the number of poor people covered by the central government.

For the poor listed as PBI, the risk is the quality of services they will be receiving. They will only be able to access low-quality hospitals because many poor regions in Indonesia lack health workers and facilities.

On paper, the service types and quality should be equal, regardless of the types of hospital, because

the Indonesia Case-Based Group (INA-CBG) system, a fee-for-diagnostic reimbursement system will be applied.

However, one only needs to go to any public hospital to see the reality. In the past, those lining up in the Jamkesmas and local Jamkesda line were often more poorly served than those with Askes health

coverage and those with private health insurance.

With the JKN, the risk of discriminatory treatment of service providers to the users could be repeated, given the low premiums provided for the PBI. This poorest group is entitled to assistance of only Rp 19,225, while informal workers are covered with premiums of Rp 25,500 up to Rp 59,500, and the formal workers are covered up to 5 percent of wages.

In the long run, there must be an effort to equalize the amount of premiums for the poor, so that the JKN is not perceived as maintaining different classes of recipients.

The JKN must not be seen as just a mere continuation of Jamkesmas, which was seen as an inferior program compare to other health insurances. It must be plotted to gradually close the gap of services for people of different socio economic status. This will need commitment from the central government to allocate more for premiums for the poor, and at the same time ensure that the BPJS' investment is safe and financial condition is healthy, to contribute more for this end.

These highlight the importance of public monitoring and a reliable complaint mechanism system. Therefore, despite the presence of the BPJS Supervisory Board tasked with internal monitoring, and the BPJS Watch from the outside, it is important for the public and civil society to keep an eye on the JKN's implementation.

This is vital, especially to ensure that the poor and marginalized are no longer treated discriminatively, which defies the very purpose of having national health insurance: to ensure that the state provides social security to every citizen, especially the poor and marginalized.

The writer is a research and program manager at Perkumpulan Prakarsa (Center for Welfare Studies), Jakarta, and holds a postgraduate degree from The University of Melbourne's development studies program.

source: www.thejakartapost.com