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Mental Health Care Access in Puskesmas as Primary Health Care in Indonesia Farida Aisyah1, Anis Sofia Harjanti1,Az Zachra Sanati Khodijah1 1

Medical Study Program, Faculty of Medicine, Sebelas Maret University, Surakarta Abstract Mental Health based on World Health Organization (WHO) is defined as a state of

well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community. Therefore, we can not underestimate mental disorder, around 450 people in the world suffer from mental illness and around 85% people with mental illness in developing country do not get treatment and medication. Indonesia, a country with 261.9 million people living in it only has 9,825 Puskesmas. About 30% of all patients that are served by doctors in primary health care are those who experience mental health problems. Around 3,602 Puskesmas already have mental health services but only 250 meet the standards to treat mental disorders. This poses another challenge that is mental health care access in Puskesmas as primary health care. Health access should fulfill four aspect namely accessibility, availability, affordability, and acceptability [11]. With small amount of Puskesmas that meet the standard to treat mental disorders and high prevalence of mental disorders in Indonesia, mental health care access in Puskesmas as primary health care meet those four aspect as barrier. This initiates a question about how is mental health care access in Puskesmas and is written in the form of a systematic review. Systematic review on the mental health care access in Puskesmas as primary health care in Indonesia aims to raise awareness of society related to its importance of mental health access in primary health care and give solution about this health-related issue through the point of view of community, patient, medical professionals, government and medical student. Methodology used in this paper is PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) method and using online engine searching with keyword “Mental Health”, “Mental Health Access”, “Mental Health Access in Primary Health Care”, “Mental Health Access in Primary Health Care in Indonesia”. This studies used 3 journals that fulfil the criteria and for calculate quality of the paper, we used AMSTAR.

Keywords : Mental Health, Mental Health Access, Primary Health Care, Puskesmas

Keywords:

Mental Health Care Access in Puskesmas as Primary Health Care in Indonesia

Arranged by Farida Aisyah

G0018071

Anis Sofia H

G0018023

Az Zachra Sanati K

G0018039

FACULTY OF MEDICINE SEBELAS MARET UNIVERSITY 2019

Introduction Mental Health based on World Health Organization (WHO) is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community[1]. Therefore, we can not underestimate mental disorder, around 450 people in the world suffer from mental illness and around 85% people with mental illness in developing country do not get treatment and medication[2]. In Indonesia, with various psychological, biological, and social factors with diversity of population, hence the number of cases of mental disorders continue to increase which has an impact on increasing the countryâ&#x20AC;&#x2122;s burden and decreasing human productivity for the long term, based on Ministry of Health of the Republic of Indonesia data shows the prevalence of mental emotional disorders as indicated by symptoms of depression and anxiety for ages 15 years and over reaching around 14 million people or 6% of the total population of Indonesia, while the prevalence of severe mental disorders such as schizophrenia, reaches around 400,000 people or as many as 1.7 per 1,000 residents [3]. With high prevalence mental disorder in Indonesia, Indonesia needs mental health care. In Indonesia if individuals want to seek treatment using health insurance which cover their medical expenses, they will use Badan Penyelenggara Jaminan Sosial (Social Security Administrator), or people know as BPJS. BPJS services start from primary health care, primary health care is about providing essential health care, which is universally accessible to individuals and families in the community and provided as close as possible to where people live and work[4]. Primary health care consist of Pusat Kesehatan Masyarakat well known as Puskemas (Public Health Center) and other equivalent health care as Puskesmas[5]. Puskesmas is a primary health facility that organizes public health efforts and first-rate individual health efforts, prioritizing promotive and preventive efforts, to achieve the highest degree of public health in its working area [6]. Indonesia, a country with 261.9 million people living in it only has 9,825 Puskesmas[7,8]. About 30% of all patients that are served by doctors in primary health care are those who experience mental health problems[9]. Around 3,602 Puskesmas already have mental health services but only 250 meet the standards to treat mental disorders [10]. This poses another challenge that is mental health care access in Puskesmas as primary health care. Health access should fulfill four aspect namely accessibility, availability, affordability, and acceptability[11]. With small amount of Puskesmas that meet the standard

to treat mental disorders and high prevalence of mental disorders in Indonesia, mental health care access in Puskesmas as primary health care meet those four aspect as barrier. This initiates a question about how is mental health care access in Puskesmas and is written in the form of a systematic review. Systematic review on the mental health care access in Puskesmas as primary health care in Indonesia aims to raise awareness of society related to its importance of mental health access in primary health care and give solution about this health-related issue through the point of view of community, patient, medical professionals, government and medical student. Materials and Methods A systematic review of Mental Health Access in Puskesmas as Primary Health Care in Indonesia was carried out using the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) method. In order to find relevant journals and articles for this systematic review, studies search were conducted comprehensively and completely using search engine such as PubMed, ScienceDirect, Google Scholar, Research Gate, and International Journal of Mental Health Systems database with keyword “Mental Health”, “Mental Health Access”, “Mental Health Access in Primary Health Care”, “Mental Health Access in Primary Health Care in Indonesia”. The criteria of inclusion are: 1) Paper published between 2014 – 2019, within 5 years; 2) Paper published in Bahasa Indonesia or English; 3) Paper discuss about mental health care access especially in primary health care; 4) Quality of paper from moderate to high. To assess the quality of the paper used critical appraisal tool for systematic review as Assessing the Methodological Quality of Systematic Review (AMSTAR). Rating for overall confidence in the result of the paper divided into 4 category: 1) High – zero or one non-critical weakness: The systematic review provides an accurate and comprehensive summary of the result of the available studies that address the question of interest; 2) Moderate – More than one non-critical weakness (multiple non-critical weakness may diminish confidence in the review and it may be appropriate to move the overall appraisal down from moderate to low moderate); 3) Low – One critical flaw with or without non-critical weaknesses: The review has a critical flaw and may not provide an accurate and comprehensive summary of the available studies that address the question of interest; 4) Critically low – More than one critical flaw with or without non-critical weakness: The review has more than one critical flaw and should not be relied on to provide an accurate and comprehensive summary of the available studies. From the initial search 3,052 studies were identified and 2,866 studies were excluded based

on title and abstract, leaf it only 186 studies remain but then 60 studies were excluded because duplication and other 123 studies were excluded too. Eventually, we acquire 3 studies in total to fulfil criteria for this systematic review.

Figure 1. Journal Selection Chart Result The journals and article were collected between March and April 2019. In total, 3 articles used in these systematic review. The finding of this systematic review describe the content of Health Care Access in primary health care. The findings of studies show in the table below Table 1. Table of Studies Result Author

Findings

Quality of Paper

Setiyawati et Enhancing primary health care to incorporate High al.

mental health services is a key strategy for closing the treatment gap for people with mental

disorder.

The

integration

psychological care into primary health care is critical step in addressing poor access to mental health specialist. Integrating mental health care into existing primary health-care

Ref. [12]

services is considered as one promising solution to expanding access to mental health service. Primary health care is a more affordable option than specialist care and thus is another way that treatment can be made more widely available. In Indonesia, the integration of psychologist into primary health care commenced in 2004, it was initiated by the Sleman District Health Office in

collaboration

with

the

Faculty

Psychology, University of Gadjah Mada. Mawarpury

Evaluation in Aceh, Indonesia previously had High

et al.

tsunami, armed conflict, and socio-economic problems.

This

incident

result

in the

emergence of severe psychological disorders and psychosocial crises in the community. In such large number of disasters and vastness of Acehâ&#x20AC;&#x2122;s territory, the number of health worker were not comparable and result in unachieved the goal of mental health care service due to lack of mental health care access. Based on previous explanation, there is a need for mental health care service in primary health care in order to be able accessed by everybody and primary health care is community-based, so it is expected to be minimize the stigma of society against mental disorders. Research conducted for this paper and result in lack of skill from the health workers, there are no ongoing services, recording of cases is not optimal and no yet integrated. Other result explain countries with a middle low income budget for mental health allocations are less

[13]

than 1% from the national health budget. Puskesmas,

primary care

must

optimized because 71% of low income people go to primary health care, because primary health care easily accessible. Primary health care, puskesmas, also has mental health service such as: 1) Mental health service; 2) Counseling; 3) Integrated services in the community; 4) Home visit; 5) Outreach; 6) Family empowerment and referrals. Setiyawati et Non professional community health workers al.

(CHWs) have been widely reported as possibly having a role in mental health. In Indonesia, their role is currently being introduced in the national health system. Participant in this research include four stakeholder group in primary health care, that is: 1) Program managers from the district health office and primary health care services in village; 2) Health workers; 3) Mental health specialist; 4) Service user. CHWs are trained to contribute to a range of tasks such as prevention of mental disorders. CHWs must have

competencies,

this

competencies

include: 1) Knowledge, understanding and judgment; 2) Cognitive, technical, and interpersonal skills; 3) A range of personal attributes and attitudes. Another competencies also include effective communication. This competencies effective communication skills as a general principle of essential care, along with respect and dignity. This competencies

Moderate

[14]

must be fulfilled by community health workers because of international guideline.

Discussion The main finding of this systematic review is that mental health does not get attention as much as it should be. In Indonesia, mental health access still difficult especially in primary care. Mental health access in primary care in Indonesia does not meet 4 aspects, that is: 1) Accessibility, lack of mental health care provider in Indonesia, lack of mental health care service, difficult insurance bureaucracy, and communityâ&#x20AC;&#x2122;s stigma and misconception about mental health caused problem about mental health access much more complicated; 2) Affordability, when it comes as mental illness people will think about going to psychiatrist, which will cost much more expenses without health insurance; 3) Acceptability, majority of people do not take mental illness as a serious issue even if they have been diagnose with mental health disease, they do not take further medication because their belief that mental disorder can be treat with religious ritual; 4) Availability, mental health service do not distribute evenly, even if they have puskesmas, as primary health care some of them do not include mental health care service. The result of incomplete of those 4 aspect most people with mental problems have improper or no treatment and some end up being restrained (â&#x20AC;&#x153;pasungâ&#x20AC;?) or wander around and get lost in the community [15]. Solution about mental health access in puskesmas as primary health care in Indonesia can be seen for different point of view: 1) For patient point of view, patient should realize if they have been diagnosed with mental health they must seek treatment from an expert; 2) For Medical Professor, they must be ready to be worked in any area included rural place; 3) For Government, they must make BPJS bureaucracy easier and more socialized, they should make new regulation about positioning psychologist in primary health care service, so people could easily access mental health care; 4) For Medical Student, they should increase interprofessional education with student psychologist, in form of discussion about mental health access; 5) For Community, they should not judge easily on people with mental illness. Limitation of this systematic review is the lack of studies which is related to this topic, mental health access in primary health care and Indonesian government more focus on physical health, such as diabetes, cardiac disease.

Conclusion Overall, this systematic review conclude that mental health care access in puskesmas as primary health care needs further research, especially in some rural areas of Indonesia. Reference 1. World Health Organization. (2014). Mental Health: a state of well-being. Retrieve from https://www.who.int/features/factfiles/mental_health/en/ ,accessed on March 2019. 2. Dumilah, A., Misnaniarti, & Marisa, R. (2018). Analisis Situasi Kesehatan Mental pada Masyarakat di Indonesia dan Strategi Penanggulangannya. Jurnal Ilmu Kesehatan Masyarakat, 9(1), 1-10. doi: 10.26553/ikm.2018.9.1.1-10. 3. Kementerian Kesehatan Republik Indonesia. (2016). Peran Keluarga Dukung Kesehatan Jiwa

Masyarakat.

Retrieve

from

http://www.depkes.go.id/article/print/16100700005/peran-keluarga-dukungkesehatan-jiwa-masyarakat.html ,accessed on March 2019. 4. World Health Organization. (2008). What is primary care mental health. Mental Health in Family Medicine, 5, 9-13. 5. Badan Penyelenggara Jaminan Sosial. (2018). Panduan Layanan Bagi Peserta Jaminan Kesehatan Nasional Kartu Indonesia Sehat (JKN-KIS). Indonesia: Badan Penyelenggara Jaminan Sosial. 6. Menteri Kesehatan Republik Indonesia. (2014). Peraturan Menteri Kesehatan Republik Indonesia Nomor 75 Tahun 2014 tentang Pusat Kesehatan Masyarakat. Berita Negara Republik Indonesia Tahun 2014. Jakarta. 7. Tim Riset BPS. (2018). Statistik Indonesia 2018. Jakarta: Badan Pusat Statistik Indonesia. 8. Kementrian Kesehatan Republik Indonesia. Retrieve from http://www.depkes.go.id/resources/download/info terkini/Jumlah%20PKM%20per%20Desember%202017.pdf ,accessed on March 2019.

9. Kementerian Kesehatan Republik Indonesia. (2011). Deteksi Kesehatan Jiwa Dilakukan di

Puskesmas.

Retrieve

from

http://www.depkes.go.id/development/site/jkn/index.php?cid=1480&id=deteksikesehatan-jiwa-dilakukan-di-puskesmas.html ,accessed on March 2019. 10. Kementrian Kesehatan Republik Indonesia. (2017). Butuh Konsultasi Masalah Kejiwaan, Jangn Ragu ke Fasyankes dengan Layanan Jiwa. Retrieve from http://www.depkes.go.id/article/view/17072400001/butuh-konsultasi-masalahkejiwaan-jangan-ragu-ke-fasyankes-dengan-layanan-jiwa.html ,accessed on April 2019. 11. World Health Organization. Access to HIV/AIDS-Related Essential Medicines: A Framework

for

Measurement.

Retrieve

from

https://www.who.int/hiv/amds/countries/ken_AccessHIVEssentialMedicines.pdf? ua=1 ,accessed on April 2019. 12. Endang R S., Anthony F J., Harry M., & Ritsuko K. (2018). Personal Attributes and Competencies Required by Community Health Worker for A Role in Integrated Mental Health Care for Perinatal Depression: Voices of Primary Health Care Stakeholders from Surabaya Indonesia. International Journal of Mental Health Systems, 12(46). doi: 10.1186/s13033-018-0224-0. 13. Marty M., Kartika S., & Lely S. (2017). Layanan Kesehatan Mental di Puskesmas: Apakah

Dibutuhkan?.

Jurnal

Insight

Fakultas

Psikologi

Universitas

Muhammadiyah Jember, 13(1). 14. Diana S., Erminia C., Grant B., Ruth W., & Harry M. (2014). International expertsâ&#x20AC;&#x2122; perspectives on a curriculum for psychologists working in primary health care: implication for Indonesia. Health Psychology & Behavioural Medicine, 2(1), 770784. doi: 10.1080/21642850.2014.929005. 15. ASEAN. (2016). ASEAN Mental Health System. Jakarta: The ASEAN Secretariat.

“KITA SEHAT” : AN INNOVATION OF ONLINE APPLICATION TO IMPROVE ACCESS TO HEALTHCARE IN INDONESIA

PROPOSED BY

Monicha Zalzabilla A.

(20180410086)

Nabilah Ayuriestha W.

(20180410091)

Karmenita Christina

(20180410094)

Zahratul Noreisza R.

(20180410114)

FAKULTAS KEDOKTERAN UNIVERSITAS HANG TUAH SURABAYA 2019

ABSTRACT Aim We propose an online health consultation applications, called “KITA SEHAT”, that can be used to consult about health complaints, at least in cases of emergency that do not require medical action. Introduction Currently, half of the world’s population lacks access to essential health services, and universal health coverage remains a challenge for many countries worldwide. Indonesia’s health coverage program, the National Health Insurance (JKN) program, is administered by the Healthcare and Social Security Agency (BPJS Kesehatan) - an authorized body that was established in 2014 to provide medical coverage program for the Indonesian people. BPJS is an acronym for Social Security designed to provide social security programs to the public. Many people who use BPS-provided health care don't know what BPJS is like. Unfortunately, BPJS is only known by the people who live in big cities, but the majority of people in rurals area did not have any knowledge about this program. The study was carried out in 48 respondents in three locations: Alang-alang village in Bangkalan Regency and Kenjeran village, Surabaya that represented rural area, and downtown Surabaya that represented urban area. We should be able to answer community needs to meet their demands without the hassle of stepping out of their house for going to hospitals, health centers, clinics, etc. and waiting in line. With current technological developments, health consultations can be done online through mobile phone applications. Digital health ecosystems have become a necessity, and not only a trend. Nowadays people are used to looking for health information on the internet, but the source is often invalid (Chande-Mallya, Msonde, Mtega, & Lwoga, 2016). It is better to find sources with competent doctors and paramedics. This application allows people to consult their health problem by typing, voicing, even with videos. This application is safe, since it is anonymous. Of course the application for venturing will be guaranteed confidentiality, but people can also ask openly (Masanja et al., 2012). There will be a doctor consultation application that can be downloaded for free on the Google Play Store for Android or the App Store for iPhone.

Brief Research Methodology This study was an observational research with cross-sectional design (Roy Rabindra, Saha, & Roy, 2015). The study was carried out in 48 respondents in three locations: Alang-alang village in Bangkalan Regency, and Kenjeran village, Surabaya that represented rural area, and downtown Surabaya that represented urban area. This study used mixed methods (Caldas, 2009). We used anonymous questionnaire to obtained information related to BPJS ownership, usage, and knowledge. We used indepth interview to obtained opinions regarding complains and suggestions to improve access to healthcare.

Key Findings •

BPJS Kesehatan (Health Social Security Organizing Agency) is a Public Legal Entity that is directly responsible to the President and has the task of organizing National Health Insurance for all Indonesian people, especially for Civil Servants, PNS and TNI / POLRI, Veterans, Independence Pioneer Pension Recipients along with his family and other Business Entities or ordinary people.

•

“KITA SEHAT” is an application to consult with a doctor for free. Consisting of doctors who are competent and provide medical and health services to the community easily and practically. There are various advantages and features available in this application.

“KITA SEHAT” : AN INNOVATION OF ONLINE APPLICATION TO IMPROVE ACCESS TO HEALTHCARE IN INDONESIA

PROPOSED BY

Monicha Zalzabilla A.

(20180410086)

Nabilah Ayuriestha W.

(20180410091)

Karmenita Christina

(20180410094)

Zahratul Noreisza R.

(20180410114)

FAKULTAS KEDOKTERAN UNIVERSITAS HANG TUAH SURABAYA 2019

Introduction Currently, half of the worldâ&#x20AC;&#x2122;s population lacks access to essential health services, and universal health coverage remains a challenge for many countries worldwide (Evans, Hsu, & Boerma, 2013). Indonesiaâ&#x20AC;&#x2122;s health coverage program, the National Health Insurance (JKN) program, is administered by the Healthcare and Social Security Agency (BPJS Kesehatan) - an authorized body that was established in 2014 to provide medical coverage program for the Indonesian people (Agustina et al., 2019). With regards to participants of BPJS Kesehatan, they can be classified into two categories, namely recipients of contribution assistance (PBI Jaminan Kesehatan) and Non-PBI Jaminan Kesehatan. The first category is entitled for those who are less fortunate (from low social class) and those with total disabilities (BPJS Kesehatan, 2017). Access to health is the rights of all citizen of Indonesia, guaranteed by the 1945 Constitution, which is intended to be achieved by the health system of Indonesia. According to the goals of the nation's health system, health care cannot be the same as commerce, which is piling up in an effort to pursue more financial interests. The government has targeted that all Indonesians will have BPJS membership by 2019. One target of the Medium Term Development Plan (RPJM) 2015-2019 is to make sure 107.2 millions of society become the PBI participants. However, as of April 2018, the PBI participants reached 92.2 millions (Kemenkes RI, 2013). Accordingly, there are many less fortunate people who are at risk of not getting their rights, especially those lived in remote and rural area of Indonesia (Agustina et al., 2019). Most of them were unaware of their health rights including access to health care by using BPJS health insurance card. The government has already provided community healthcare ( Puskesmas ) as primary healthcare in all subdistrict in Indonesia and hospital in all regencies and cities and Indonesia. However there are lack of doctors, paramedics and healthcare facility in remote areas of Indonesia In the destroyal revolution for 4.0 era there should be innovation to overcome lack of healthcare access, based on the information technology application (Tjandrawinata, 2017).

MATERIALS AND METHODOLOGY RESEARCH DESIGN This study was an observational research with cross-sectional design (Roy Rabindra, Saha, & Roy, 2015). The study was carried out in 48 respondents in three locations: Alang-alang village in Bangkalan Regency, and Kenjeran village, Surabaya that represented rural area, and downtown Surabaya that represented urban area. The sample size calculation was based on cross-sectional formula for proportion (Charan & Biswas, 2013). The inclusion criteria were residents of the free locations, aged 18 years or older, and voluntarily participated in the study. The exclusion criteria were having mental disability, and seasonal residents. This study used Mixed methods. This research has been approved by the Human Research Ethics Committee of the Faculty of Medicine, Hang Tuah University, number KEPFKUHT/EC/M/1/IV/2019. METHODS This study used mixed methods (Caldas, 2009). We used anonymous questionnaire to obtained information related to BPJS ownership, usage, and knowledge. We used indepth interview to obtained opinions regarding complains and suggestions to improve access to healthcare. This questionnaire contained 21 questions on: 1. Respondentsâ&#x20AC;&#x2122; preference in seeking healthcare ( hospital, private doctor, public health care facility, others ) 2. Community awareness about Healthcare facility in their area 3. Knowledge about government Authorized Health Care system (BPJS) 4. Personal ownership of BPJS 5. Awareness about BPJS Coverage 6. Awareness about Aplication of BPJS 7. Personal usage of BPJS 8. Community Awareness about BPJS

STATISTICAL ANALYSIS We used descriptive statistic: central tendency, and dispersion both in numeric and categorical data. We used bivariate statistics: chi-square test as a non-parametric test and two independent sample t-test as parametric test. All statistical analyses were carried out using SPSS v. 23 software (IBM, 2015).

Results This study has taken place in Alang-alang village in Madura; Kenjeran village, Surabaya, and downtown Surabaya. The results of that were obtained concluded that majority of rural area residents prefer private mid-wives and public health center because of its easy access, meanwhile hospitals were located too far away. A lot of respondents in alang-alang village in Madura, kenjeran village and downtown Surabaya had been awared about Healthcare facility and their servuces. Community knowledge about BPJS in Kenjeran and downtown Surabaya is adequate. Whereas community knowledge in rural areas such as madura are very minimum. What is BPJS ? The local communities in Surabaya and Kenjeran already have BPJS, while most respondents in Madura have not owned bpjs yet Community knowledge regarded of Healthcare services that BPJS provided in Kenjeran and downtown Surabaya is also adequate. Meanwhile Maduraâ&#x20AC;&#x2122;s residents did not have enough awareness about its services. The majority of Kenjeran residents already used BPJS for curative treatments, this happened because the head of Kenjeran village recommended it. The respondent in Madura rarely used BPJS because lots of them have not owned BPJS yet. And the resident of downtown surabay also used BPJS most of the times, because they have been paying for it monthly. And it can be concluded that the Madura region chose a health center for treatment when they were sick while the city of Surabaya and Kenjeran chose a hospital for treatment. The Kenjeran area and downtown Surabaya have used BPJS for treatment, but this was not the case in Madura.

The following are the results of our analyses. 1. Respondents’ preferences in seeking healthcare Table 1. Respondents’ preferences in seeking healthcare

Picture 1. Respondents’ preferences in seeking healthcare There was a significant different behaviour between respondents in coastal and downtown areas (Lambda p = 0.001). Majority of respondents in coastal areas go to primary healthcare (PHC) when they are sick, whereas majority of respondents in downtown area choose hospital when they are sick.

2. Respondent’s knowledge of healthcare facility Table 2. Respondent’s knowledge of healthcare facility

Picture 2. Respondent’s knowledge of healthcare facility There was not any significant difference of knowledge related to healthcare facility among respondents in coastal and downtown areas (Lambda p = 0.312).

3. Respondent’s knowledge about BPJS Table 3. Respondent’s knowledge about BPJS

Picture 3. Respondent’s knowledge about BPJS There was not any significant difference of knowledge related to BPJS health insurance among respondents in coastal and downtown areas (Lambda p = 0.250). Most respondents in three areas have already known about BPJS health insurance.

4. Respondent’s BPJS card ownership Table 4. Respondent’s BPJS card ownership

Picture 4. Respondent’s BPJS card ownership Majority of respondents in Madura did not have BPJS health insurance card. In contast, majority of respondents in Kenjeran and downtown areas owned the card. However, the difference was not significant (Lambda p = 0.093).

5. Respondent’s BPJS coverage Table 5. Respondent’s BPJS coverage

Picture 5. Respondent’s BPJS coverage There was not any significant difference of knowledge related to BPJS health insurance coverage among respondents in coastal and downtown areas (Lambda p = 0.362).

6. Respondent’s knowledge about how to apply BPJS Table 6. Respondent’s knowledge about how to apply BPJS

Picture 6. Respondent’s knowledge about how to apply BPJS There was not any significant difference of knowledge related to how to apply for BPJS health insurance among respondents in coastal and downtown areas (Lambda p = 0.093).

7. Respondent’s usage of BPJS. Table 7. Respondent’s usage of BPJS.

Picture 7. Respondent’s usage of BPJS. There was a significant difference related to BPJS usage among respondents in coastal and downtown areas (Lambda p < 0.001). Majority of respondents in Kenjeran and downtown Surabaya have ever used their BPJS health insurance card. However, majority of Maduranese have never used BPJS health insurance card, since majority of them did not have the card, yet.

8. Respondent’s neighbourhood knowledge about BPJS. Table 8. Respondent’s neighbourhood knowledge about BPJS.

Picture 8. Respondent’s neighbourhood knowledge about BPJS. There was a significant different knowledge related to BPJS health insurance among respondent’s neighbourhood in coastal and downtown areas (Lambda p < 0.001). Majority of respondents in Kenjeran and downtown areas stated that their neighbours knew about BPJS health insurance and have ever used it.

Discussion The government of Indonesia tried to provide BPJS healthcare insurance that can be used in primary healthcare services in all areas of Indonesia and secondary healthcare services in many regencies and cities (Agustina et al., 2019). However, this research indicated that majority of respondents in rural areas did not have BPJS health insurance and lacked knowledge of BPJS coverage. Some of them had BPJS health insurance card, but they did not want to use it. Majority of respondents in rural areas preferred to visit community healthcare (puskesmas) or private midwives when they were sick using out of pocket. They stated that they did not want to be in a queue and they did not want to be uncomfortable from impolite or unfriendly attitudes of healthcare workers. “I have waited for a long time since morning to be treated, but I have to be in a long queue” (Mrs. A, 4o years, Alang-alang Village). “Every time I go to Puskesmas, I always get the same medicine of yellow and red pills, and it is only for three days. When I ask the healthcare worker to get the injection, the workers said that they could not do it” (Mrs. B, 42 years, Kenjeran Village). Other respondent stated, “I prefer to go to private midwife because it is closer to my house and I do not have to spend money for transportation” (Mrs. C, 50 years, Alang-alang Village). Almost all respondents in Kenjeran had BPJS card and they had used the card for treatment in primary and secondary healthcare services. The chief of Kenjeran village actively encouraged his residents and help them to apply for BPJS card. Further, the health cadres of Kenjeran Village were very active in educating people about BPJS health insurance. Majority of respondents in downtown Surabaya had BPJS card and have used the card for treatment in primary and secondary healthcare services. “I use BPJS card to get help in a hospital because my salary is cut every month to pay BPJS monthly payment” (Mrs. D, 46 years, downtown Surabaya). However, some of them preferred to spend out of pocket to be treated by specialists in hospital when they were sick. “I always go directly to the outpatient clinic in a hospital to get cured without using BPJS card” (Mr. N, 20 years, downtown Surabaya). Even though some respondents had BPJS card and they have used it, however, most of them did not know that BPJS also covered promotive and preventive healthcare services. Compared to Singapore, which had Medisave healthcare insurance, the coverage of Medisave was very comprehensive and large. A key principle of Singapore's national health scheme is that medical services are provided free of charge, regardless of the level of subsidies, even in the public health system. According to the World Health Organization, Singapore has "one of the most successful health systems in the world, both in terms of efficiency in financing and the results achieved in public health outcomes," according to an analysis by global consulting firm Watson Wyatt. Medisave is a Singapore program that functions as a national medical savings account and covers around 85% of all Singapore. Through the Medisave system, citizens and permanent residents contribute 6.5% -9% of their monthly salary to their personal accounts to cover their immediate personal

or family health needs, including operations and some outpatient costs. In the Medisave account, funds can earn interest and cannot be taxed. Funds in accounts are intended to be used to pay for hospital bills for account holders or close family members. Close family members include parents, children, grandparents and partners (Bai, Shi, Li, & Liu, 2012). BPJS Kesehatan (Health Social Security Organizing Agency) is a Public Legal Entity that is directly responsible to the President and has the task of organizing National Health Insurance for all Indonesian people, especially for Civil Servants, PNS and TNI / POLRI, Veterans, Independence Pioneer Pension Recipients along with his family and other Business Entities or ordinary people. Payment of BPJS contributions depends on the participants. Some of them: 1. Contributions for Wage Recipient Workers who work in Government Institutions consist of Civil Servants, members of the TNI, members of the National Police, state officials, and government employees of non-civil servants at 5% (five percent) of Salaries or Wages per month provided that: 3% (three percent) is paid by the employer and 2% (two percent) is paid by the participant. 2. Contributions for Wage Recipient Workers who work in BUMN, BUMD and Private amounts to 5% (five percent) of Salary or Wages per month provided that: 4% (four percent) is paid by the Employer and 1% (one percent) is paid by Participants. For most ordinary people, they are seeking healthcare when they are sick. They are not aware that they should maintain their health by applying healthy lifestyle behaviors. They also did not realize that BPJS healthcare insurance can be used for screening and preventive services. Lack of access to healthcare services are emerged in the community. In the industrial revolution 4.0, we should think of innovation through information technology application to overcome the problem. We should be able to answer community needs to meet their demands without the hassle of stepping out of their house for going to hospitals, health centers, clinics, etc. and waiting in line. With current technological developments, health consultations can be done online through mobile phone applications. Digital health ecosystems have become a necessity, and not only a trend. Nowadays people are used to looking for health information on the internet, but the source is often invalid (ChandeMallya, Msonde, Mtega, & Lwoga, 2016). It is better to find sources with competent doctors and paramedics. We propose an online health consultation applications, called â&#x20AC;&#x153;KITA SEHATâ&#x20AC;?, that can be used to consult about health complaints, at least in cases of emergency that do not require medical action. Some features do not charge fees, but some are paid. Even though there are free ones, the online consultants also share information about health with full competency. This application allows people to consult their health problem by typing, voicing, even with videos. This application is safe, since it is anonymous. Of course the application for venturing will be guaranteed confidentiality, but people can also ask openly (Masanja et al., 2012). There will be a doctor consultation application that can be downloaded for free on the Google Play Store for Android or the App Store for iPhone.

“KITA SEHAT” (WE ARE HEALTHY) “KITA SEHAT” is an application to consult with a doctor for free. Consisting of doctors who are competent and provide medical and health services to the community easily and practically. There are various advantages and features available in this application. The appearance of “KITA SEHAT” application is very simple with neatly arranged categories. For example, about the features available in the “KITA SEHAT” application, users can easily search for articles about features through the search column or search by letter, and will be given further information about the advantages and features. In the “KITA SEHAT” application allows users to see a row of names of doctors who are online and immediately consult. In this application, there are many doctors with their respective medical expertise. Every doctor who is joined already has a registration letter and also a practice permit so that this application is very safe and reliable. Moreover, there is a membership number IDI (Indonesian Doctors Association) also pinned on each doctor's profile. “KITA SEHAT Profile” provides further information about the doctor you wish to visit. Here, people can see the long experience, qualifications, affiliations and speciﬁcations of the doctors. People can even find photos of the clinic in question and get GPS coordinates for easy navigation to the location, directly inside “KITA SEHAT” application. Based on the technological sophistication, “KITA SEHAT” is safe for patients when sending photos related to the medical conditions. The patient's photos can be used by the doctor as a basis for diagnosing medical problems more accurately and precisely, and people can send video content, upload photos of disease history or prescription through our “KITA SEHAT” account, then share with other doctors to get a second opinion. These are the features available in the “KITA SEHAT” application: The “Ask Doctor” is a feature where users can consult directly with their doctors for free through live chat and video calls about health and complaints. Users can search for a doctor or clinic that suits their needs such as the type of disease to the user's location. To chat with a doctor, people just have to choose a doctor and then pay the rates listed on each profile, then the private chat will appear and can be accessed for 24 hours. This feature will keep their clients confidentiality. Users can also upload a health track record. The “Health Today" feature will display health news and articles, such as articles about healthy diets, pregnancy, babies and children, beauty, lifestyle, medicines, fertility, menstrual cycles, etc. written directly by the doctors. The “Go-Health” feature will makes it easy for users who want to order appealing health packages, such as clinic packages, laboratories, and hospitals that have collaborated with “KITA SEHAT”, providing drug delivery services from pharmacies that have collaborated with “KITA

SEHAT”, allows users to access information about the nearest clinic and health laboratory, and more practically, for blood sampling or urine samples, will be delivered directly to the peoples home. The “Health Schedule” feature makes it easier for users to make a doctor's appointment at a hospital or clinic to make an appointment online. People simply choose the nearest area or city, choose a doctor, and arrange time to visit. Of course, visiting time will be adjusted to the doctor's practice schedule at the hospital. Not only arranging a face-to-face schedule with a doctor, users can also order online services such as grab or gojek as a means of delivery to their destination. “Health Reminder” feature to remind people of taking medication schedules or exercise routines. This application can be a reminder for such things, both manually and automatically. Set reminders are based on day, time, and frequency. The “Health Info” feature also lists the diseases and drug lists. For those who want to add knowledge, there are indices of A-Z various types of diseases. The “Health Discuss” feature to send questions in general, so all users can see questions and replies from doctors who have joined “KITA SEHAT”. The trick is very easy, press the ‘Ask’ button on the top right after that, write the title and content of the question with a writing language that can be easily understood, writing can be long because there are no character restrictions, if people want to ask in private, use the “Ask Doctor” Feature. To use existing features, people will be charged a fee for example, such as consulting a doctor, the costs that must be incurred are doctor is prerogative and not determined by “KITA SEHAT”. The rate can be seen directly on the doctor's profile. To get credit in order to use the desired feature, the user is given several options. Payment options provided are via ATM Transfer, credit card, mobile banking.

CONCLUSION This study found majority of respondents in rural areas of Alang-alang village did not have BPJS health insurance. Many respondents prefer to spend out of pocket rather than using BPJS health insurance due to many reasons related to healthworker’s attitude, sort duration of medical treatment, and long waiting period. In the industrial revolution 4.0 era, a health application based on information technology advances, such as “KITA SEHAT” is an innovative solution that can cut the lack of access to healthcare, inexpensive, and feasible to be applied.

REFERENCES Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7 BPJS Kesehatan. (2017). Panduan praktis pelayanan kesehatan. In BPJS Kesehatan. https://doi.org/10.1016/j.clp.2007.10.002 Evans, D. B., Hsu, J., & Boerma, T. (2013). Universal health coverage and universal access. Bulletin of the World Health Organization, 91, 546–546A. https://doi.org/10.2471/BLT.13.125450 Kemenkes RI. (2013). Buku Pegangan Sosialisasi Jaminan Kesehatan Nasional dalam Sistem Jaminan Sosial Nasional. In Departemen Kesehatan RI. https://doi.org/10.1017/CBO9781107415324.004

Wikjayanti, Mutiara. ( 2013, January 10 ) Developing English Learning Module for Hotel Drivers. Retrieved from http://eprints.uny.ac.id/9380/5/lampiran-07202244139.pdf Ken, Wong S. ( 2019, March 29 ) How to Write an Appendix. Retrieved from .https://www.wikihow.com/Write-an-Appendix Dosen, Pak. ( 2017 ) Cara Membuat Kesimpulan Skripsi / Makalah / Karya Tulis / Laporan. Retrieved from https://enjiner.com/cara-membuat-kesimpulan/ Firdaus, Oktri ( 2011, September 24 ) MODEL KONSEPTUAL E-HEALTH PADA DEPARTEMEN ILMU KESEHA TAN ANAK DI INDONESIA. Retrieved from https://repository.widyatama.ac.id/xmlui/bitstream/handle/123456789/2066/KIN.HC.070.pdf

APPENDIX 1 Needs Analysis Questionnaire KUISIONER PENELITIAN MAHASISWA FAKULTAS KEDOKTERAN UNIVERSITAS HANG TUAH SURABAYA 1. Ketika anda sakit, anda lebih memilih untuk berobat ke a. Rumah Sakit b. Puskesmas c. Dokter praktek swasta d. Lainnya *lingkari salah satu 2. Apa alasan anda?

3. Apakah fasilitas pelayanan kesehatan yang tersedia saat ini (rumah sakit, klinik, puskesmas, tempat praktek dokter) cukup mudah diakses?

4. Apakah orang orang disekitar anda mengetahui tentang fasilitas pelayanan kesehatan yang tersedia? Ya / Tidak *coret salah satu 5. Apakah fasilitas pelayanan kesehatan yang tersedia sudah cukup?

6. Apa kekurangan dari pelayanan kesehatan yang ada?

7. Apa harapan anda terhadap pelayanan kesehatan yang ada dimasa yang akan datang?

8. Apakah anda mengetahui apa itu BPJS? Ya / Tidak *coret salah satu Jika ya, jelaskan!

9. Apakah anda telah memiliki BPJS? Ya / Tidak *coret salah satu 10. Apakah anda mengetahui pelayanan kesehatan apa saja yang ditanggung BPJS? Ya / Tidak *coret salah satu 11. Apakah anda mengetahui cara pendaftaran BPJS? Ya / Tidak *coret salah satu 12. Jika anda sudah memiliki BPJS, apakah anda sudah pernah menggunakannya? Sudah / Belum *coret salah satu Jika ya, untuk apa?

*jika belum lanjut ke nomor : 19 13. Fasilitas apa saja yang telah anda gunakan melalui BPJS:

14. Menurut anda, apakah layanan BPJS sudah dapat diakses dengan mudah:

15. Apakah orang-orang disekitar anda telah mengetahui dan memiliki BPJS Ya / Tidak *coret salah satu

16. Apa keluhan anda terhadap layanan BPJS ?

17. Bagaimana kesan anda terhadap layanan BPJS:

18. Apakah saran anda terhadap layanan BPJS?

*** Jika belum, 19. Apakah anda mengetahui cara pendaftaran BPJS? Ya / Tidak *coret salah satu 20. Mengapa anda belum menggunakan layanan BPJS:

21. Apakah menurut anda pelayanan BPJS dapat dengan mudah diakses? Ya / Tidak *coret salah satu Apa alasan anda?

APPENDIX 2 Sample of Research

Effectiveness of Various Health Insurances in Tackling Health Problems of the 21st Century: A Systematic Review Nico Gamalliel1, Reynardi Larope Sutanto1, Mochammad Izzatullah1, Gita Fajri Gustya1 1. Medical student, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia

Objective: To investigate the relationship between health insurance and health quality using systematic method. Background: Health insurance can be said has strong relation in achieving Goal 3 of Sustainable Development Goals (SDGs), “Ensure healthy lives and promote well-being for all at all ages”. One of the key factor in reaching ‘healthy lives’ is the access to medical care. Health insurance has been implemented across many countries in order to facilitate access for good quality medical care. Some studies indicated that health insurance have positive effect to improve health quality of patient. Another study indicated there is inverted effect between ownership of health insurance and health quality. The link between health insurance and its ability to tackle health problems therefore should be thoroughly investigated. Methods: Systematic review was conducted using keywords “Insurance, Health”[Mesh] AND “Health Care Quality, Access, and Evaluation”[Mesh] on Pubmed. Afterwards, titles are screened for relevancy and duplication. Contents then were then screened for inclusion criteria, which include studies with publication age less than five years, observational studies, and studies which look upon effects of health insurance on its users’ health, and exclusion criteria, which include inaccessible articles, articles written in foreign languages, and irrelevant articles. A total of 6 suitable studies were included in the final review and were subjected to STROBE analysis. Key Findings:

Increased usage of proper health insurance is related to an increase in overall health outcomes of various diseases, including type 1 Diabetes Mellitus (7% decrease of hyperglycemia on patients with more expensive insurance), acuity of thoracic aortic operations (underinsured patients were at greatest risk of getting acute nonelective operation; OR: 2.67), gastritis (insurance coverage reduce prevalence of H. pylori), cardiac arrest (102/100.000 to 85/100.000 incidence after insurance expansion), albuminuria (higher mortality for individuals without private insurance), and peritonitis (better prognosis for individuals with better insurance). These conditions could be explained by increase in health awareness and accessibility of medication by patients with quality health insurance. This finding could become a basis for governments to highly consider quality insurances as means to improve the health of the nation. Keywords: Health insurance, Healthcare, Quality Healthcare, Health outcome, Prognosis

Effectiveness of Health Insurance in Tackling Health Problems of the 21st Century: A Systematic Review Scientific Paper

Author(s) Nico Gamalliel Reynardi Larope Sutanto Mochammad Izzatullah Gita Fajri Gustya

Faculty of Medicine Universitas Indonesia 2019

Effectiveness of Various Health Insurances in Tackling Health Problems of the 21st Century: A Systematic Review Nico Gamalliel, Reynardi Sutanto, Mochammad Izzatullah, Gita Fajri Gustya University of Indonesia INTRODUCTION Health insurance can be said has strong relation in achieving Goal 3 of Sustainable Development Goals (SDGs), “Ensure healthy lives and promote well-being for all at all ages”. (United Nations, 2015) One of the key factor in reaching ‘healthy lives’ is the access to medical care. Health insurance has been implemented across many countries in order to facilitate access for good quality medical care. Risk-sharing mechanism such as social insurance is said to provide resources to access healthcare and to promote health. On the other hand, social insurance protects individuals and households against while the potentially devastating direct financial costs of illness.(Stone et al., 2015) The ultimate aim of health insurance is to improve the quality of health. (Schoeps et al., 2015) The impact of health insurance on health care utilization is said to be closely associated with the characteristics of the system, such as premiums, benefits, location of healthcare services, and for whom the services are intended.(Wang, Temsah, & Mallick, 2017) Some health insurance program, for example, the one in Indonesia, raise debate about its effectiveness in increasing the utilisation of health services, especially among the poor.(Vidyattama, Miranti, & Resosudarmo, 2014) Some studies indicated that health insurance have positive effect to improve health quality of patient. A study showed women managed under national health insurance scheme of Nigeria had better maternal and perinatal indices.(Lawani et al., 2016) Insurance coverage also associated with decreased in-hospital mortality.(Stone et al., 2015) Another study indicated there is inverted effect between ownership of health insurance and health quality, where enrollees of Ohio Appalachian Medicaid were more likely to have health problems such as hypertension, cardiovascular disease, and overall poorer health than non-Medicaid enrollees.(Kariisa & Seiber, 2015) The link between health insurance and this ultimate goal therefore should be thoroughly investigated. Studies these time mostly investigated the relation between participation in health insurance and mortality or survival in certain diseases. Advanced investigation and research about the link between health insurance and health problems in general, not only based on certain disease, is needed in order to find out and improve efficacy of health insurance. Here explained systematic review of literatures showing link of health insurance and health problems.

METHODS The systematic review was conducted using keywords "Insurance, Health"[Mesh]) AND "Health Care Quality, Access, and Evaluation"[Mesh] on the database of Pubmed. From there, we proceed to look for studies which are related to our topic by using our inclusion criteria. The inclusion criteria include: studies which were published less than five years ago, observational studies, and studies which look upon the effects of health insurance on the health of the users. On the other hand, exclusion criteria were also used. These include: inaccessible articles, articles written in languages other than English or Indonesian, and irrelevant articles. Afterwards, we begin to collect important data from each study, including: author(s) name, year of publication, STROBE score, type of insurance used, research design, location, sample size, type of disease assessed, method of analysis, result, and limitations of the study. The review was done qualitatively by three assessors and conclusions were then drafted after consensus had been achieved. All of this process could be viewed on Figure 1.

Identifika si

Initial search from database of Pubmed based on inclusion criteria (n = 449)

(n = 5)

Screening

Title screening of relevancy and duplication (n = 444)

Irrelevant, doubled titles excluded (n = 396)

Abstract screened (n = 43) Full-text articles excluded (n = 12): Full articles assessed for eligibility (n = 18)

Included

Inaccesible articles and articles written in foreign languages

Articles included in review and assessed with STROBEâ&#x20AC;&#x2122;s criteria (n = 6)

Insurance data is only used as control variable

Effectiveness of insurance is not measured by health outcome

Figure 1. Flow chart of the systematic review

RESULT The search was conductud via database of Pubmed. Titles were screened for relevancy and duplication. Contents were screened for inclusion and exclusion criteria. Articles went over criteria were fully assessed for eligibility and study design. Lastly, six suitable observational studies were reviewed and included in this systematic review. Articles were assessed with STROBE’s criteria to ensure its quality. STROBE result of all articles could be seen in Table 2, located on the appendix, while the entire process can be seen in Figure 1. Included study design and the respective characteristics of each study are further shown in Table 1. DISCUSSION Based on the study conducted by Xie, et.al in 2017, the usage of insurance has a very high correlation with a better condition of patients. In this study showed that people who use the high-cost share group has a lower risk of hyperglycemia rather than the low-cost share group. This means that people who pay for the insurance more will have a better condition and receive more health service than people who pay only a little amount of money for insurance. (Xie, 2017) Other study conducted by Andersen ND, et.al. reveals that people who suffer cardiac arrest and underinsured will have a higher risk for a thoracic aortic operations. This condition could be happened due to the fact that underinsured people will receive less medication and less screening. Less medication and less screening in this study mean that people will have a higher rates of hypercholesterolemia and hypertension. These two events will lead to an acute cardiac arrest. A severe acute cardiac arrest result in the demand of a thoracic aortic operation. (Andersen, 2014) The same result is also explained through a study by Hiroi, et.al. In this study the researcher discovers the correlation of H.pylori infection gastritis with the coverage of insurance. The result is positive which means that the usage of insurance will decrease the event of H.pylori infection gastritis. (Hiroi, 2017). There are other studies that showed significant improvement of healthcare outcome when using health insurance. Those studies include the study conducted by Stecker et al in 2017 that showed the significant reduction in out-of-hospital cardiac arrest in patient with health insurance. (Stecker, 2017) Another study is conducted by Saunders et al, in which the samples used are 934 individuals with urine albumin-to-creatinine ratio ≥ 30 mg/g, which is a diagnostic value of albuminuria. The study also discusses about cardiovascular mortality as one of the complication of kidney disease. The aim of the study is to compare rate of mortality between uninsured, individuals with public insurance, and individuals with private insurance. Individuals with public insurance and those who are uninsured showed higher rates of all-cause mortality compared with individuals with private insurance. Also, simi-

Author and Year of Publication (STROBE scores) Xie Y, et al; 2017 (19,33/22)

Type of Insuran ce

Resear ch Design

Locati on

Sample size Disease

Method of Analysis

Results

Limitation of Study

Private

Obser vation al Retros pectiv e

Nether lands

Type I Diabetes Mellitus

SAS 9.4: t-test, Pearsonâ&#x20AC;&#x2122;s chi-square, modified Poisson model

Higher rate of continued testing strip fills in low-cost share group than high-cost share group (89% vs 82%, P<0.001)

Pharmacy fills do not necessarily confirm actual use of dispensed testing strips, all patients were from a single large commercial insurer

Andersen MD, et al; 2017 (STROBE 16,16/22)

Private and govern mental (Medica re, USA)

Retros pectiv e

United states

7,155 patients (3,575 lowcost share group, 3,580 highcost share group) 826 patients; 736 had insurance; 90 were underinsure d

Acuity of Thoracic Aortic Operation s

Mann-Whitney rank sum test, chi-square test; logistic regression, Cox proportional-hazards regression; STATA 11.1

Underinsured patients were at greatest risk of requiring nonelective thoracic aortic operations (OR: 2.67; P<0.0001)

Hiroi S, et al; 2017 (19,1/22)

Japanes e health insuranc e

Retros pectiv e observ ational

Japan

81,119 and 170,993 patients in two databases;

Helicobac ter pylori gastritis

SAS 9.4

Insurance coverage may reduce the prevalence of H. pylori infection.

Stecker EC, et al; 2017

Govern mental (Afford

Retros pectiv e

Multn omah Count

Adult residents of Multnomah

Out-ofHospital

PASS 13, SAS 9.4

Health insurance expansion was associated with significant reduction in OHCA incidence. (middle-aged

Study only includes patient who underwent operation; does not account for unmeasured confounders, such as social variables; single-institution analysis Success rate of eradication was obtained from previous studies, potential bias of health insurance claims database Single urban geographic area as location,

(18,94/22)

able Care Act)

observ ational study

y, Orego n, United States

County (636,000)

Cardiac Arrest

population: 102 per 100,000 to 85 per 100,000 with P = 0.01; elderly population: 275 per 100,000 to 269 per 100,000 with P = 0.70)

Saunders MR, et al.; 2016 (16,4/22)

Govern Cohort ment observ and ational private insuranc e

United States

934 individuals with UACR ≥ 30 mg/g;

Albuminu ria

Cox model, Schoenfeld residuals

Higher crude rates of all-cause mortality in the uninsured and individuals with public insurance compared with those with private insurance (17.8 and 24.1 vs 10.4, respectively); similar pattern can be seen in cardiovascular mortality rates.

Wang Z, et al; 2015 (17,43/22)

New Cohort Coopera prospe tive ctive Medical Scheme (NCMS ) and the Urban Employ ees’ Medical Insuran ce (UEMI)

PD Center , Wuha n no. 1 Hospit al, China

564 patients(41 5 (77.0%) with UEMI and 149 (23.0%) with NCMS); has received continuous ambulatory PD for >3 months

Peritonitis

SPSS 17.0; chi-square test, unpaired t-test, Kaplan-Meier method, Cox regression model.

Biomedical parameters for diseases were inferior in patients with NCMS compared with patients with UEMI. (P<0.05)

Table 1. Included study designs and characteristic

underpowered regression-based techniques, assumption that OHCA can be a surrogate of SCA The study only had access to a single UACR and eGFR determination, rather than using multiple measures; limited time, data can be biased since uninsured individuals may have subsequently lost their insurance. Data were from a single center and the sample was small.

lar pattern can be seen in cardiovascular mortality rates. However, the cardiovascular mortality rate between those individuals are not significant. (Saunders, 2016) There is one study that also compare two medical insurances in China, those are New Cooperative Medical Scheme (NCMS) and the Urban Employeesâ&#x20AC;&#x2122; Medical Insurance (UEMI). NCMS is mainly for rural residents. The study is conducted by Wang et al. The result of this study is that individuals with NCMS are more inferior to those with UEMI in biomedical parameters, which include hemoglobin levels, phosphorus in blood, nutrition, and residual renal function. For example, individuals with NCMS have lower hemoglobin levels that can be due to low-income-related-malnutrition. Hypophosphatemia does exist in individuals with NCMS which also correlates with economic status in rural residents. In conclusion, individuals with NCMS does have higher rate of mortality associated with peritoneal dialysis compared with individuals with UEMI due to different economic status. (Wang, 2015) The study conducted by Wang et al also correlates with other studies that compare uninsured and insured individuals like the study conducted by Stecker et al and Saunders et al. Those three studies showed significant differences in patients with insurance or those with private insurance when compared to public insurance. Higher economic status (those with private insurance) associated with more compliance in check-ups and drug intake compared to those with lower economic status. However, compared to those who were uninsured, individuals with insurance (public or private) do have higher survival rate almost in all studies. Even though a profound connection between quality health insurance and health outcomes of its users could be seen, this systematic review has several limitations. Firstly, the studies included were quite heterogenous in location, sample size, as well as in type of insurances and diseases. This heterogenicity could become a potential source of bias. However, this should be understandable given the small amount of current literature on the effects of health insurance. Secondly, as a systematic review, it could suffer from bias of its assesors. This could also be understandable given the nature of systematic review as a qualitative literature. CONCLUSION This review using systematic method shows that ownership of health insurance may indicate better prognosis of the patient, regardless of the disease. Furthermore, government of countries may try to consider to administer a social insurance system, or at least government may try to improve level of participation of health insurance. Community also may consider to enroll health insurance in order to improve their health quality by facilitate better access to health care services, etc. These attempts may be one of many way to achieve better health level of the community. Further research should be

conducted with more homogeneous data, especially related to location the research conducted. Research also may be conducted in developing country, seeing that most of the studies related to the linking between health insurance and health quality conducted in developed country. More database also may be used in order to get more studies related to the relation between health insurance and health quality.

REFERENCES Andersen ND, et.al. (2014). Insurance status predicts acuity of thoracic aortic operations. The American Association of Thoracic Surgery, 148(5), 2082-2086. Hiroi S, Sugano K, Tanaka S, Kawakami K. (2017). Impact of health insurance coverage for Helicobacter pylori gastritis on the trends in Japan: retrospective observational study and simulation study based on real-world data. British Medical Journal Open, 7(7). Kariisa, M., & Seiber, E. (2015). Distribution of cardiovascular disease and associated risk factors by county type and health insurance status: results from the 2008 Ohio family health survey. Public Health Reports, 130(1), 87–95. Lawani, L. O., Iyoke, C. A., Onoh, R. C., Nkwo, P. O., Ibrahim, I. A., & Ekwedigwe, K. C. (2016). Obstetric benefits of health insurance: A comparative analysis of obstetric indices and outcome of enrollees and non-enrollees in southeast Nigeria. Journal of Obstetrics and Gynaecology, 36(7), 946– 949. Saunders MR, Ricardo AC, Chen J, Chin MH, Lash JP. (2016) Association between insurance status and mortality in individuals with albuminuria: an observational cohort study. BMC Nephrology, 17, 27. Schoeps, A., Lietz, H., Sie, A., Savadogo, G., De Allegri, M., Muller, O., & Sauerborn, R. (2015). Health insurance and child mortality in rural Burkina Faso. 8, 27327. Stecker EC, Reinier K, Rusinaru C, Uy-Evanado A, Jui J, Chugh SS. (2017).Health insurance expansion and incidence of out-of-hospital cardiac arrest: a pilot study in a US metropolitan community. Journal American Heart Association, 6(7), e005667. Stone, G. S., Tarus, T., Shikanga, M., Biwott, B., Ngetich, T., & Andale, T. (2015). The association between insurance status and in-hospital mortality on the public medical wards of a Kenyan referral hospital. Global Health Action, 7(1), 23137. United Nations. (2015). Goal 3: Ensure healthy lives and promote well-being for all at all ages. Retrieved

from

Sustainable

Development

Goals

website:

https://www.un.org/sustainabledevelopment/health/ Vidyattama, Y., Miranti, R., & Resosudarmo, B. (2014). The role of health insurance membership in health service utilisation in Indonesia. Bulletin of Indonesian Economic Studies, 50(3), 393–413. Wang, W., Temsah, G., & Mallick, L. (2017). The impact of health insurance on maternal health care utilization: evidence from Ghana, Indonesia and Rwanda. Health Policy and Planning, 32, 366–375.

Wang Z, Zhang Y, Xiong F, Li H, Ding Y, Gao Y, Zhao L, Wan S. (2015) Association between medical insurance type and survival in patients undergoing peritoneal dialysis. BMC Nephrology, 16, 33. Yiqiong X, Agiy A, Bowman K, DeVries A. (2017). Lowering cost share may improve rates of home glucose monitoring among patients with diabetes using insulin. Journal of Managed Care & Specialty Pharmacy, 23(8), 884-891

APPENDIX Table 2. STROBE Score Table

N o

Title and abstract

Anderse

Xie,

Wang,

Stecker

Saunders

Hiroi S,

et.al.

EC, et.al

, et.al

et.al

(2017)

(2015)

(2017)

(2016)

(2017)

n ND et al. (2014)

Introduction Background/rationale

Objectives

Study design

Setting

Participants

0,5

Variables

Bias

Study size

Quantitative variables

Statistical methods

0,8

0,6

0,4

0,6

Methods

Data sources/measurement

Results Participants

0,33

0,67

0,33

Descriptive data

0,67

Outcome data

Main results

0,33

Other analyses

Key results

Limitations

Interpretation

Generalisability

19,3

17,43

18,94

16,4

19,1

16,16

Discussion

Other Information Funding Total

INACCESSIBLE HEALTHCARE SYSTEM: THE ROLE OF TELEMEDICINE AND ITS COMPARISON TO DIRECT CONSULTATION Arief Abdurrazaq Dharma, Diva Fauziah Faqih, Anastasia Elisabeth Sarira, Aqilla Putri Milleni Udinsiah

ABSTRACT Introduction Health is a basic human needs to be fulfilled. Everyone should have access to the health services. However, there are some barriers in accessing healthcare such as the lack of healthcare providers, geographical problem and financial problem which can subsequently worsen the health problems. The rise of telemedicine nowadays becoming a brilliant issue to be talked about. Eventhough telemedicine and direct consultation already been impelemented in various countries, yet there is still lack of evidences showing the comparison between those two methods particulary in Indonesia.

Aim This study was aimed to compare the effectiveness and satisfaction level of telemedicine and direct consultation.

Material and Method This was a cross-sectional study using simple random sampling method to a number of participants with 13-34 range of age. From slovin formula with 90% of confidence interval, 96 samples were accounted in this study.The data collected by using an online questionnaire which contain 20 questions to compare the effectiveness as well as satisfactory level between telemedicine and direct consultation, the result then using wilcoxon in SPSS. Further analysis regarding cost and benefits were also done by using online questionnaire.

Result

This study used Wilcoxon nonparametry test to see the difference of effectiveness as well as level of satisfaction between telemedicine and direct consultation. Table 3 showed the comparison between telemedicine and direct consultation where the p value for effectiveness is considered as significant (p=0.007) therefore it is concluded that there was significant difference between telemedicine and direct consultation. Moreover comparative analysis on the parameter of satisfaction showed no significant difference (p=0.286) which concluded that the level of satisfaction among consumers were not significantly different between the use of telemedicine as well as direct consultation.

Conclusion There was significant differerence between the level of satisfaction of telemedicine and direct consultation, yet the effectiveness of those parameters were somehow the same. The data showed that telemedicine can become a brilliant alternative with the same level of efectiveness with direct consultation.

Keyword Telemedicine, effectiveness, satisfaction.

INACCESSIBLE HEALTHCARE SYSTEM : THE ROLE OF TELEMEDICINE AND ITS COMPARISON TO DIRECT CONSULTATION Asian Medical Students’ Association Universitas Hasanuddin

Written By: Arief Abdurrazaq Dharma Diva Fauziah Faqih Anastasia Elisabeth Sarira Aqilla Putri Milleni Udinsiah

ASIAN MEDICAL STUDENTS’ ASSOCIATION UNIVERSITAS HASANUDDIN MAKASSAR 2019

INTRODUCTION Health is a basic human needs to be fulfilled. Everyone should have access to the health services. However, there are some barriers in accessing healthcare such as the lack of healthcare providers, geographical problem and financial problem which can subsequently worsen the health problems. It is indicated that there will be around 42,600 to 121,300 physicians will enter their retirement age by 2030.(Association of American Medical Colleges,2018) There are still many areas who dont have enough access to health care providers, which either be caused by the inexistence of health care insurance or the tendency of health care professionals to locate themselves in relatively urban and suburban areas. People who live in rural or inaccessible areas might have problems when they want to go to the nearest health care provider (Newkirk & Damico, 2014). Moreover people without health care insurance might think twice to go to a doctor cosidering that they have to pay for only a consultation. These barriers sadly also exist in Indonesia and should be considered as a national health problem. Moreover the distribution of medical practitioners in Indonesia is not equal. For example the ratio of number of doctors and the population of Papua is reported to be around 4.9% compared to Jakarta with 77,6% (RI Ministry of Health, 2017). The imbalance of medical practitioners distribution subsequently made those who live in rural areas is difficult to access the health care facilities. They have to go to another town only to get medical consultation and treatment. We need to find a way to make sure that every people can get access to medical practitioners despite all those problems that exist. Not every people is able to spend their time to directly go to a doctor even if there are no barriers for them to go to see a doctor. The rise of telemedicine nowadays becoming a brilliant issue to be talked about. The existence of telemedicine can solve all the barriers that limit access to health care system. Telemedicines provide more efficient, practical, cost-effective, and, importantly, high-quality methods for patients to have medical consultation whenever they need it. Telemedicine has being growing globally especially in developed countries, and the use of telemedicine is also adopted and implemented rapidly in Indonesia.(Wan Ahmad, et al, 2016). The healthcare practitioner used the telemedicine application to evaluate patient in healthcare services by making a medical decision, remote sensing and monitoring in the

real time and store and forward management of patient by a distance (Jaber et al, 2014). Telemedicines are supported by the availability of internet networks, and of course itâ&#x20AC;&#x2122;s relevant to the number of internet users. The data showed that 53.7% of Indonesian peoples already used the internet and it keeps going up each year. In Indonesia itself, According to the survey from APJII(Asosiasi Penyedia Jasa Internet Indonesia) the recent survey in 2017 showed the precentage of internet users is 54,68% out of 262 million people in Indonesia. According to age, the most number of internet user is 13-18 years old(75,50%), followed by 19-34 years old are 74,23%, then 3554 years old are 44,06%, and for >54 years old are just 15,72%. The number of user in urban area was reported to reach 72,41% , 49,9% in rural-urban, and even 48,25% in rural area. The data somehow showed that Indonesia is ready enough to apply Telemedicine for the availability of internet is great. Eventhough telemedicine and direct consultation already been impelemented in various countries, yet there is still lack of evidences showing the comparison between those two methods particulary in Indonesia. Moreover the data on cost & benefit of Telemedicine is also lack, therefore this study was made in order to give further details on both direct consultation and Telemedicine as well.

MATERIAL AND METHOD Internet is currently claimed as one of basic human needs. The number of internet user is increased each year, not only for entertainment but also for self improvement including health. The number of those who use internet to seek for health information in the form of telemedicine even reaching 51,06% in 2017, yet there has been no data which can show the beneficial and possible flaw of telemedicine. This was a cross-sectional study using simple random sampling method to a number of participants with 13-34 range of age. After passing through the inclusion and exclusion criteria, finally there were 96 samples suited the result of Slovin formula with 90% of confidence interval. Those participants were asked to fill up 20 questions in the form of online questionnaire which aimed to compare the effectiveness as well as satisfactory level between telemedicine and direct consultation. The result of questionnaire then analyzed using paired t test in SPSS 23.0. Further analysis regarding cost and benefits were also done on Telemedicine by using online questionnaire. Finally, the results of this study were shown in the form of Table and Chart.

RESULT This study was done in Makassar, South Sulawesi, Indonesia by involving 96 samples which had passed the inclusion and exclusion criterias. The results of study were shown in the form of Table and Chart. Table 1 showed the age categories of all samples involved in this study. There were 12 (12.5%), 36 (37.5%), 25 (26.0%), 17 (17.7%), and 6 (6.3%) participants in the range of 13-17, 18-22, 23-27, 28-32, and 33-34 year of age, respectively. Moreover, there were 42 (6.3%) participants were male, and 54 (56.3%) were female (Table 2). Table 1. Age Category Age (year)

Frequency

Percent (%)

13-17

12.5

18-22

37.5

23-27

26.0

28-32

17.7

33-34

6.3

Total

100.0

Table 2. Gender Frequency

Percent

Laki-laki

43.8

Perempuan

56.3

Total

100.0

Picture 1 showed the level of satisfaction for telemedicine according to 8 aspects; time, registration, interaction, expression, explanation, question, information, cost. There were 15 participants found to be very satisfied, 66 were quite satisfied, 14 were less satisfied, and 1 participant was unsatisfied for the duration of consultation in telemedicine. As for the registration of telemedicine, there were 26, 56, 12, and 2 participants reported to be very satisfied, quite satisfied, less satisfied, and unsatisfied, respectively. Moreover, there were 20, 53, 21, and 1

participants reported to be very satisfied, quite satisfied, less satisfied, and unsatisfied, respectively, for the intercation of telemedicine. In the parameter of chances given to express their problems, there were 23, 56, 16, and 1 participants reported to be very satisfied, quite satisfied, less satisfied, and unsatisfied at all, respectively. Other than that, there were 14 participants reported to be less satisfied with the explanation given by the physician through telemedicine, while 2 participants were reported to be satisfied enough. As for the quality of questions given by the physician, 21 participants were very satisfied, 55 were quite satisfied, and 20 were less satisfied. There were 21, 62, 12, and 1 participants who were very satisfied, quite satisfied, less satisfied and unsatisfied, respectively, for the explanation given by the physician about the disease and its treatment. Lastly, there were 39 participants reported to be very satisfied of the cost spent and 2 participants were unsatisfied.

66 56

55 48

30 20 10 0

2021

1514

Very satisfied

23 16

21 14

2120

21 12 1

Quite satisfied 7 2

Less satisfied Unsatisfied

Picture 1. Level of satisfaction for the use of telemedicine

Picture 2 showed the level of satisfaction on direct consultation between patient and physician based on 8 parameters. Based on time spent for consultation,

23 participants were very satisfied, and only 1 participant were reported to be unsatisfied. On the parameter of registration, 26 participants were very satisfied, 53 were quite satisfied, and only 3 were reported to be unsatisfied. As for the interaction to talk on direct consultation, 22 respondents were very satisfied, and only 3 participants who were unsatisfied. There were 24 participants who were very satisfied for the chances given to express their problems on direct consultation, and only 2 participants who were unsatisfied. There were 27, 48, and 19 participants who were very statisfied, quite satisfied, and less satisfied on the explanation given by the physician. According to the questions asked during direct consultation, 29 participants were very satisfied and only 1 who was unsatisfied. As for the information given regarding the disease and its treatment, 26 respondents were very satisfied, 54 were quite satisfied, and only 3 participants who were unsatisfied. Finally, there were 41 participants who were satisfied for the cost spent and only 2 participants who were unsatisfied.

45 41

40 30 20

Very satisfied

23 14

10 1 0

2221

15 2

24 15

Quite satisfied

Less satisfied 13

7 2

Unsatisfied Very much unsatisfied

Picture 2. Level of satisfaction on direct consultation

100 77

50 40 30 20 10

88 80

56 40

58 38 26

19 9

16 6

Yes

Picture 3. Effectiveness of Telemedicine

Picture 3 showed the effectiveness of telemedicine according to 12 aspects. There were 40 participants who got late responses from their physicians and 56 participants were the opposites. There were 77 participants got enough care from their physicians, and only 19 participants were the opposites. As for the information about the disease given by the patient, 87 of participants already got enough information and 9 of participants didnâ&#x20AC;&#x2122;t get enough information about the disease. There are about 34 respondents who agreed that doctors answered to the given questions, meanwhile the other 60 respondents felt the opposite. About 58 respondents claimed that they were given the opportunity to discuss the further plans for their treatment, however the other 38 were given the opposite. 88 respondents were given suggestions on their symptoms, the other 8 were not given any suggestions on their symptoms. There are 70 respondents who claimed that they were not interrupted during their consultation and 26 others were interrupted during their consultation. About 87 respondents agreed that the information was told in an understandable language and manner while the other 9 felt that the language spoken by the doctors were not understandable. There are 90 respondents

who claimed that they were treated in justice and 6 others felt that they were not. About 88 respondents agree that the access to the health facilities were easier, and the other 8 disagree. As for the registration system, 80 respondents agree that it was in fact more difficult to access, while the other 16 agree that it was more accessible. For the cost itself, 88 respondents agree that the consultation cost were cheaper and the other 8 agree for the opposite.

100

50 40

50 46

54 42

30 20

70 60

Picture 4. Efectivity on direct consultation Yes

We use Wilcoxon nonparametry test to see the difference of effectiveness as well as level of satisfaction between telemedicine and direct consultation. Table 3 showed the comparison between telemedicine and direct consultation where the p value for effectiveness is considered as significant (p=0.007) therefore it is concluded that there was significant difference between telemedicine and direct consultation. Moreover comparative analysis on the parameter of satisfaction showed no significant difference (p=0.286) which concluded that the level of satisfaction among consumers were not significantly different between the use of telemedicine as well as direct consultation.

Table 3. Statistical analysisa Effectiveness between

Level of Satisfaction

Telemedicine and Direct

between Telemedicine and

Consultation

Direct Consultation

-2.711b

-1.067c

.007

.286

Z Asymp. Sig. (2-tailed) a. Wilcoxon Signed Ranks Test b. Based on positive ranks. c. Based on negative ranks.

80 70

60 50 40 28

30 20 10 0 Agree

Disagree

Picture 5. Participant's opinion on the use of telemedicine

Picture 5 showed number of participants who agreed on the use of telemedicine (70.8%) and number of participants who disagreed on that (29.1%). Moreover, picture 6 showed the reasons why participants agreed on the use of telemedicine. 63 of them stated it was quite easy to be accesed, 56 of them stated about the cheaper cost they spent on telemedicine, 53 of them stated telemedicine is good for the information can be saved and even reopened once they need that.

Moreover there were 51 participants who agreed on the use of telemedicine for its easier registration, 28 stated the communication was much more enjoyable since they donâ&#x20AC;&#x2122;t need to directly meet the doctor, and finally 18 participants chose telemedicine since the information they got in telemedicine was more complete compared to what they got on direct consultation.

50 40 30

20 10 0

Picture 6. Reasons why perople agree on the use of telemedicine

25 21

20 15 10 5

0 The doctor is untrusted

Inability to do examination

The network is not good

Possibility for misperception

Picture 7. Reasons why people disagree on the use of telemedicine

Picture 7 showed why participants didnâ&#x20AC;&#x2122;t agree on the use of telemedicine. Among 28 participants who disagreed, all of them stated that the use of telemedicine is not good since it is impossible to have an examination by the doctor. Moreover 21 of them stated that the doctor on telemedicine is untrusted and the network is somehow not good enough. Finally 3 participants made the possibility of misperception as their reason to not prefering the use of telemedicine.

DISCUSSION This study focused on effectiveness, satisfaction rate, agreement rate and costbenefit analysis in Telemedicine consultation and its comparison with direct consultation. Our data shows that there are similiarities satisfication level between online consultation and direct consultation by comparing the duration, registration, interaction, patientâ&#x20AC;&#x2122;s chances to speak, explanation, question, information, and the cost. There are no significant differences of satisfaction level of telemedicine compared to direct consultation.

The patient still can ask questions and have a good interaction even if they don’t physically meet their doctor. It shows to us that it is possible to implementing telemedicine to have online medical consultation. In terms of the comparison of the effectiveness, there are some differences between Telemedicine and direct consultation. Our survey shows that Telemedicine is more effective than direct consultation. In general Telemedicine is way much better than direct consultation, except on future treatment aspect. We assess 12 criterias, which are doctor’s responses, careness, information, answer, action, advice, interuption, language, unprofessional, access, registration, and cost. Our data shows that there are 3 aspect of Telemedicine that different compared to direct consultation which are the cost, registration system, and access. From the access and cost aspect, Telemedicine is way much better compared to direct consultation. The patient does not have to spend much money to use telemedicine because it only takes internet access to use telemedicine. The patient does not have to pay transportation to have medical consultation. The use of telemedicine can cut the cost that patient should pay to reach primary health care(Hasibian, et al, 2016). A research in Bangladesh shows that the use of telemedicine can cut 94% of the cost compared to direct consultation, also the telemedicine is more easy to access compared to direct consultation(G. Sorwar, et al, 2016). From the registration aspect, Telemedicine is better compared to direct consultation. In direct consultation, the patient must come to nearest primary health care to register their name while in using telemedicine they don;t have to do any mobilization activity. They can regist from anywhere and anytime they need medical consultation by using Telemedicine. On effectiveness doctor-patient consultation, additional examination is needed to make the diagnosis. The result of our research shows significant differences on medical consultation via telemedicine compared to direct consultation. Direct consultation is more effective than online consultation because doctor and patient can directly interacting and have a discussion about the future plan of treatment based on patient’s disease. 68 of 96 respondents agree to use telemedicine.

Most of them agree with

telemedicine because of accessible location, the low cost, the reaccessible information, and the easy registration system. Accessible location got chosen the most because with the use of telemedicine people don’t have to come directly to a Public Health Centre especially if the Public Health Centre is far enough from the patients’ location. Next, the low cost got the second most voted reason. The low cost become one of the reason why people agree

with telemedicine because they only have to pay for the cost of being telemedicine users and they dont’t have to spend more cost for transportation to the Public Health Centre. The third reason is the reaccessible information, because telemedicine only use chat rooms as the media to consult, so the previous chats and the treatment recommendations that has been given by the doctor can be stored and it can be an anticipation if the complaint is to happen again. The last one is about the easy registration system, the registration system of telemedicine can be done anytime and anywhere compared with the registration system of direct meeting that require us to come directly to Public Health Centre. For those who disagree to use telemedicine, they mostly chose on the absence of additional physical examination and other modalities. The solution for this issue is in the future, media of telemedicine must be developed again, such as the upgrade of the media from chat rooms to video calls and the upgrade of telemedicine technology, for example telemedicine can assess patients’ vital signs. The next reason is the lack of trust to the doctors and the minimum network range support. These reasons can be solved by looking for doctors that can build trust to the patients and to widen the network range to the rural area with decent connection. Compared to the research that has been done by The British Journal of General Practice, the research suggested that — at least for GPS and administrators — the assumed potential of Tele-Doc (Telemedicine) for increased efficiency is difficult to achieve. But, with the solution that has been given and the further support by the technology that keeps on developing continuously as well as the improvement of network range that continues to be widespread we believe this problem can be tackled down. This study has limitation, which only focused on sole persprection from the patients, not from the doctors and application developers.

CONCLUSION There was significant differerence between the level of satisfaction of telemedicine and direct consultation, yet the effectiveness of those parameters were somehow the same. The data showed that telemedicine can become a brilliant alternative with the same level of efectiveness with direct consultation.

REFERENCES 1. Newkirk, V., & Damico, A. (2014). The Affordable Care Act and insurance coverage in rural areas. Retrieved from http://kff. org/uninsured/issue-brief/theaffordable-care-act-and-insurancecoverage-in-rural-areas/ 2. RI Ministry Of Health(2017). Retrivied March, 17th, 2019 http://depkes.go.id/resources/download/bahan_rakerkesnas_2017/Badan%20PPS DM%20Kesehatan.pdf 3. Association Of American Medical Colleges. (2018). 2018 Update: The Complexities of Physician Supply and Demand: Projections from 2016 TO 2030: Final

report.

Retrivied

17th,

March

2019.

https://aamc-

black.global.ssl.fastly.net/production/media/filer_public/85/d7/85d7b689-f4174ef0-97fbecc129836829/aamc_2018_workforce_projections_update_april_11_2018.pdf 4. Jaber, M. M., Ghani, M. K. A., & Herman, N. S. (2014). A review of adoption of telemedicine in Middle East countries: Toward building Iraqi telemedicine framework. Science International, 26(5), pp. 1795-1800. 5. World March,

Internet 2019

Usage New

Update.

And Retrivied

Population March

Statistics 17th,

2019.

https://www.internetworldstats.com/stats.htm 6. APJII(Asosiasi Penyelenggara Jasa Internet Indonesia). (2017). Hasil Survei Penetrasi dan Perilaku Pengguna Internet Indonesia 2017. Retrivied March 17th, 2019. https://apjii.or.id/survei2017 7. G. Sorwar, et al.(2016). Cost and Time Effectiveness Analysis of a Telemedicine Service in Bangladesh. Stud Health Technol Inform. 231, pp. 132-133 8. Hasibian, et al. (2016). Telemedicine Acceptance and Implementation in Developing Countries: Benefits, Categories, and Barriers. Razavi Int J Med. 4(3), p.2 9. Chasey, Michael et al. (2017). Experiences with online consultation systems in primary care: case study of one early adopter site. British Journal of General Practice .67(664). P.e740

The Efficacy of Type 2 Diabetes Mellitus Self-Management via Mobile Phone Apps and TextMessaging: A Systematic Review of Randomized Controlled Trials Christina Wunardi1*, Herdifitrianne Saintissa Yanuaristi1, Karunia Widhi Agatin Putri1, Gabriella Eva Victoria Agustina Pangaribuan1 1

Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia *

christinawunardi@gmail.com; +6281513895541

Introduction: Good self-management plays a crucial role in increasing life expectancy and preventing serious complications in diabetes mellitus (DM) patients. However, access to medical consultation can be high for many patients due to distance and time constraints. The increase of technology uses in health care, including mobile health (mHealth) intervention based on mobile phone applications and text message, as the most standard features in all types of phone, may become a promising way to overcome this challenge. Therefore, evaluating the efficacy of using mHealth and apps and text messaging is important to resolve the issue. This systematic review is aimed to evaluate whether mobile phone app and text messaging are effective tools to increase self-management knowledge in type 2 diabetes mellitus (T2DM) on current published randomized controlled trials (RCTs) assessing the behavioral changes and clinical outcomes of people with T2DM who downloaded mobile phone applications and subscribed to text messaging provider that promote self-management in T2DM compared to usual care alone on the management of adult patients with T2DM. Methods: The systematic review was conducted using PRISMA principles to improve the quality of reporting. Two independent reviewers searched six online databases (PubMed, Cochrane Library, Scopus, Clinical Key, Science Direct, and MEDLINE) and other sources (manual search and bibliography from another study) to identify relevant studies from the year 2014-1019. A total of 235 articles were retrieved, screened and critically appraised to finally shortlisted to thirteen RCT studies included to review phase. To ascertain the validity of eligible trials, a pair of reviewers worked independently and appraised the relevant studies using the standardized critical appraisal instruments, Jadad Scale or Oxford quality scoring system. Key Findings: From thirteen studies reviewed in this paper, nine studies used text message as the intervention, three studies used the mobile application, and one study used both. Results show that text message and mobile phone application as the intervention tools gave significant impacts on both clinical outcomes (HbA1c) and behavioral changes in T2DM patients. Text messaging and mobile application were indicated as potential platforms for self-management in T2DM patients. Conclusions: The usage of mobile apps and text messaging offered benefits for T2DM selfmanagement. Nevertheless, more research with larger samples and longer duration of applied interventions and follow-up are still needed to evaluate the clinical effects and confirm the efficacy of mobile apps and text messaging in the self-management of T2DM patients.

The Efficacy of Type 2 Diabetes Mellitus SelfManagement via Mobile Phone Apps and TextMessaging: A Systematic Review of Randomized Controlled Trials Christina Wunardi1*, Herdifitrianne Saintissa Yanuaristi1, Karunia Widhi Agatin Putri1, Gabriella Eva Victoria Agustina Pangaribuan1 1

Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia

*christinawunardi@gmail.com; +6281513895541 Asian Medical Studentsâ&#x20AC;&#x2122; Association-Indonesia Word count: 4366

I. INTRODUCTION

(Kaylango, Owino & Nambuya, 2008). Failure

Diabetes Mellitus (DM) is one of the most

to remember treatment, sociodemographic

prominent

worldwide.

factors, and cost to access the healthcare

Globally, its prevalence is reported to have

system also restrain patients in sticking to the

surged from 4.7% in 1980 to 8.5% among

treatment needed (Kassahun, Gashe, Mulisa &

adults over 18 in 2014 (Moneta, 2011). In

Rike, 2016; García-Pérez, Alvarez, Dilla, Gil-

2017, one in eleven adults worldwide is said to

Guillé, & Orozco-Beltrán, 2103). A handy tool

have DM, 90% of whom have type 2 diabetes

that becomes a reminder system will help the

mellitus (T2DM) (Zheng, Ley & Hu, 2017).

patients in adhering to the treatments without

DM is also reported to be expanding more

having to face the restraint in the distance,

rapidly in middle- and low-income countries,

time, and cost.

chronic

diseases

where Asia is a major area for the rapidly emerging T2DM global epidemic (“Diabetes”, 2018; Zheng, et al., 2017). In addition, DM often comes with serious complication, as it is a major cause of blindness, kidney failure, stroke and heart attacks, and lower limb amputation (Moneta, 2011). Amongst them, cardiovascular complications are the leading cause of morbidity and mortality in patients. The key to reducing the complications are T2DM

management

strategies

including

lifestyle modifications, social support and ensuring medication adherence (Zheng, et al., 2017).

In the other hand, self-management tools have fast been developed. Data recording of blood glucose, patients’ adherence, and lifestyle changes have progressed now to using smartphone apps besides using traditional mobile phone services such as text messaging. Previous studies have proven that mobile health tools are effective in self-management, be it in the disease-management or lifestyle changes (Nour, Chen & Allman-Farinelli, 2016; Hall, Cole-Lewis & Bernhardt, 2015; Devi, et al., 2015). In Indonesia alone, in 2017, 52.59% of the population has at least one active cellular phone. This value was

As there is no cure for diabetes, self-

considerably increased compared to 2010,

management contributes a great role in the

which was only 38.05% (Lestari, et al., 2017).

lifetime of T2DM patients (Cui, Wu, Mao,

With its rising of usage, the efficacy of mobile

Wang

phone apps and other mobile phone services in

includes

Nie,

2016).

maintaining

Self-management diabetes

diet,

exercising, and taking medication regularly. Thus, factors contributing to the patients’ nonadherence to treatment must be minimized. Longer time since the last visit to a health worker is one of the factors independently associated with non-adherence to the treatment

promoting self-management of T2DM needs to be assessed. This systematic review is the first to assess the use of both mobile apps and text messaging usage in self-management simultaneously, compared to previous studies that assess the

use of mobile application or text messaging

and perceived support or benefit for diabetes

alone.

management.

With the aim to examine whether mobile phone app and text messaging are effective

1. Search Strategy

tools to increase self-management knowledge

The authors searched the electronic literature

of RCTs using six databases: PubMed,

T2DM,

the

researchers

reviewed

randomized controlled trials that assessed the

MEDLINE,

behavioral changes and clinical outcomes of

Science Direct, and Clinical Key. Keywords

people with T2DM who downloaded mobile

used in the search were:("T2DM" OR (("Type

phone applications and subscribed to text

2" OR "Type II") AND ("DM" OR "Diabetes

messaging

self-

Mellitus" OR "Diabetes"))) AND ("Self-

management in T2DM compared to usual care

Management") AND ("Smartphone app*" OR

alone on the management of adult patients

"Mobile app*" OR "text message*" OR "text

with T2DM.

messaging" OR "short message service") AND

provider

that

promote

Scopus,

Cochrane

Library,

("randomized controlled trial*"). The wildII. METHODS

card term (*) was applied to increase the

Authors conducted a systematic review of

sensitivity of the search strategy. The included

randomized

studies were original research published in

PRISMA Statementsâ&#x20AC;&#x2122; flow diagram and

peer-reviewed journals that evaluated self-

checklist to improve the quality of reporting.

management for their effect on T2DM clinical

The PRISMA Statement consists of a 27-item

outcomes

and behavioral

checklist and a four-phase flow diagram (The

reviewers

evaluated

PRISMA Group, 2009). The checklist includes

independently.

items

assigned when disagreements occurred.

controlled

deemed

trials

essential

for

based

transparent

The

third

changes. each reviewer

Two article was

reporting of a systematic review, including title, abstract, introduction, methods, results,

2. Study Selection

discussion, and funding. This systematic

Original studies were included if they were

review

(population,

randomized controlled trials (RCTs), studied

intervention, control, outcome) framework,

the self-management interventions for patients

with T2DM patients as population, the usage

with T2DM, and published within the last five

of mobile apps and text messaging as

years, that is, studies published between

intervention,

with usual

January 2014 and March 2019. The authors

diabetic care or no intervention as the control

excluded paper if they reported on primary

group, and the outcomes expected are clinical

prevention with target population among

outcomes, behavioral changes, and others,

healthy/susceptible/at-risk

including quality of life, patient satisfaction,

published in a non-English language, and

applied

the

T2DM

PICO

patients

groups,

are

inaccessible full articles. In addition, study

protocols, editorials, proposals for future

report includes only general comments with no

study,

studies,

detailed description of randomization and

qualitative studies, pilot studies, and review

blinding, one point in each category is given.

papers were also excluded. Two authors

An additional point is added when there is a

screened

the

detailed description of the appropriate method.

inclusion criteria based on the abstract and full

However, when the description method is

paper.

inappropriate, one point is deducted. When the

with

specified number and reasons for dropouts by

conference

posts,

publications Any

consensus

which

disparity

between

cohort

was

the

meet resolved

reviewers

reference to the full paper.

each subject group are provided, one point is given. Even if there are no dropouts, this

3. Data Extraction and Analysis

should be described in the statement. When

Eligible studies were reviewed and the

the total is ≥ 3 points, it is assessed as high

following data were extracted: author’s name,

quality but when it is ≤ 2 points, it is assessed

year of publication, country where the study

as low quality. However, if it was not possible

was performed, study design, number of

for the design of the study to be double-

participants in the intervention and control

blinded, it is assessed as high quality when the

groups, type of intervention (used channel,

total score is ≥ 2 points.

received information, timing, interactivity, and personalization), planned follow-up duration,

III. RESULTS

mean age of study participants, and measured

1. Study Search Results

outcomes. The researchers performed analyses

The literature search and selection process are

using descriptive statistics of the data and

illustrated in figure 1. A total of 235 articles

summarized the findings from these studies,

were retrieved from six databases and other

with emphasis on statistical results reported in

sources (manual search and bibliography from

RCTs.

another study). Full-text of 13 articles were assessed for eligibility after the exclusion of

4. Risk of Bias Assessment

duplicated twenty studies. 194 studies were

To ascertain the validity of eligible trials, a

excluded because they did not use RCT as the

pair of reviewers worked independently and

study design (n = 116), were published before

appraised the relevant studies using the

2014 (n = 42), were not correlated to the topic

standardized critical appraisal instruments,

(n = 27), or were not fully accessible (n = 9).

Jadad Scale or Oxford quality scoring system.

After the assessment of the full-text articles,

It is composed of five points in total; two in

eight of them were excluded. Finally, 13

relation to randomization, two in relation to

studies were included and analyzed in this

blinding, and one in relation to the withdrawal

paper, which met all inclusion criteria.

or dropout rate (Jadad et al., 1996). When the

FIGURE 1. Study search and selection process based on PRISMA flow diagram

2. Risk of Bias Within Studies A systematic assessment of bias in the included studies was performed using the Jadad Scale or Oxford quality scoring system to assure their validity. A number of eleven studies got three total points and two studies got

two total points

double-blinded

indicators were not applicable

to all studies.

Thus, all the studies were included as high quality. Table 1 displays the Jadad Scale scoring of the thirteen identified trials. 3. Characteristics of Included Studies The study design characteristics are shown in Appendix 1. Out of thirteen studies assessed, ten was conducted in high-income countries, two in upper-middle-income countries, and one

lower-middle-

and

low-income

countries. The condition reviewed by all the thirteen studies is Type 2 Diabetes, one study with the addition of Type 1 Diabetes, and one study with the addition of heart disease. The inclusion criteria are adult patients (>16 years old) with T2DM that already obtain care from medical professionals, have a recorded HbA1c â&#x2030;Ľ8% (Agboola et al. refers to â&#x2030;Ľ7%), use an active email account or have internet access or computer or cell phone, and understand English (or Spanish referring to Agboola et al., Capozza et al., and Horner et al.). A total of 2795 participants were included in all thirteen studies, of whom 1552 were included in the intervention group and 1243 were included in the control group. Trial size varied from 66 participants (Zamanzadeh et al., 2016) to 781 participants (Van Olmen et Table 1. Quality assessment

al., 2016) The mean age from all 2795

participants was 56.07 years, with the mean

4. Intervention Characteristics

age in the intervention group was 56.4 years

A total of

and in the control group 55.67 years.

Messaging Service (SMS) or text messaging

All interventions are also followed by a planned follow-up varied from three months â&#x20AC;&#x201C; two years. The measured outcomes are clinical outcomes (changes in HbA1c and other biomarkers in DM-correlated-diseases such as cholesterol,

blood

pressure,

albumin-to-creatinine

and

ratio),

micro-

behavioral

changes (physical activity, weight changes, oral hygiene, adherence to medications, and healthy diet), and other changes (patientsâ&#x20AC;&#x2122; satisfaction and interaction, self-management, experience

care,

self-reported

health

utilization, and diabetes-specific knowledge), which were classified for the purposes of our review into clinical outcomes, behavioral changes, and other outcome.

training participants in the use of the equipment. Agarwal et al. facilitate the participants with a phone call with a study research assistant and an appointment with the site coordinator to receive the training. Capozza et al. conducted an enrollment visit with the research assistants in semi-private rooms,

similar

Zamanzadeh

Homer

al.

who

al.

conducted

and an

applied Short

as a means of intervention media. The way that the interventions are delivered varies from sending motivational texts, sending activity feedback to evaluate behavior, sending a reminder

medication

adherence

and

physical activity, sending diabetes-related education, to giving questions and trivia related to the disease. These messages are sent on a scheduled basis, varies from twice a day to every three months. All control groups are people with T2DM receiving usual care only. The intervention using this type is considered interactive. Six out of nine studies using SMS based intervention are considered personalized to each patient. Three

Seven of the included studies described

nine studies

studies

utilized

mobile

phone

applications as intervention tools. One delivers self-management education in the form of games

and

questions,

one

sends

questionnaire regarding personal experience, and one sends a message to impact motivation, behavioral changes, and education. The mobile app that uses a game to deliver the intervention is considered non-personalized, while the other two are personalized. All mobile apps are stated to be interactive.

orientation session. Karhula et al. trained their

One study adopted both SMS and mobile

health coaching for six weeks. TorbjĂ¸rnsen et

application interventions. These interventions

al. trained their participants by team researches

provided interactive and personalized health

in meetings and a technical support telephone

coaching

service. In one study, Dobson et al. mention

parameters with a remote patient monitoring

that participants could refer to self-study.

system that includes a health record app and

and

self-monitoring

health

measurement device. The summary of all

intervention characteristics are provided in

Aside from HbA1c, three studies reported the

Appendix 2.

outcome in weight change. Two of them showed

A total of nine studies reported outcomes in clinical conditions, which are changes in HbA1c level or glycemic control, weight, blood pressure, waist circumference, triglyceride, cholesterol,

low-density

lipoprotein

(LDL), high-density lipoprotein (HDL), and urine micro-albumin-to-creatinine ratio. Eight out of nine studies reporting HbA1c outcomes showed HbA1c reduction in both intervention and control groups. Three of the nine studies only utilized a mobile application, five studies used SMS intervention, while one study applied both interventions. Most of these interventions provided personalized messages automated

self-management

support,

which implied diabetic-specific knowledge, including perception about diabetes, healthy diet,

and

the

difference between groups. One study reported

Impact on Clinical Outcomes

and

regression

intervention group, but there is no significant

5. Outcomes

total

significant

medication.

Three

studies

no effects of the intervention on weight change. Waist circumference was examined in two studies, but the result showed a contrary; one study showed a significant reduction in intervention

group

without

significant

difference between groups, while the other showed an increase in both groups. Blood pressure was examined in two studies and both of them showed regression in intervention groups. One study reported urine reduction in micro-albumin-to-creatinine

ratio,

without

significant difference between groups. Other clinical outcomes, triglyceride, LDL, HDL, and total cholesterol were only reported in one study. It outlined a greater LDL increase in the control group, HDL increase in both groups, and significant total cholesterol decrease in the intervention group.

demonstrated significantly greater reductions in statistics on HbA1c in the intervention groups rather than control groups. Four studies outlined significant improvements in glycemic control but there was no meaningful difference between the intervention and the control groups. In one of the study, Agarwal et al. was using mobile apps intervention and showed a minimal positive effect on glycemic control. As the last study reporting glycemic control, Karhula et al. used both SMS and mobile apps interventions and showed a negative impact as the HbA1c increased at the end of the study in both groups.

Impact on Behavioral Changes There are a total of eleven studies that discussed health-related behavior changes. Positive impacts can be seen in ten of the studies. Eight among eleven applied SMS as the intervention, and the other three studies used a mobile application. In detail, nine studies reported major improvements and proved to be statistically significant. One of the nine studies, Dobson et al. reported two types of behavioral changes: (1) self-efficacy (diet, exercise, blood glucose testing, and smoking behavior) and (2) DM self-care

behavior and perception/beliefs towards DM.

management, and the barrier to intervention

At the end of the study, both improved with

efficacy

self-efficacy

statistically

satisfaction was reported in three studies, but a

significant with the p-value of 0.003. In

study reported moderate satisfaction ratings.

another study, Van Olmen et al. utilized SMS

Low patient interaction in forms of app

as the mean of intervention. They also

utilization was reported in one study, while

reported two types of changes: (1) decrease in

another study reported high engagement

a negative attitude towards DM, that showed

frequency of the app. Diabetes-related quality

no statistically significant improvement, and

of life was reported significantly increasing in

(2)

self-monitoring that conversely showed

four studies, but only one study reported a

negative impact. In the eleventh study,

significant difference between groups. The

Agarwal et al. used mobile application

population of intervention groups in two

intervention and showed no contribution to the

studies reported significant improvements in

outcomes. Nine out of eleven studies showed

both groups in how supported the participants

significant improvement in behavioral changes

felt in relation to their diabetes management

including

exercise,

motivation

doing

overall, but no significant group differences on

physical

activities,

healthy

diet,

self-

appraisal, emotional, and information support.

monitoring, foot care, medication adherence,

In addition, there is only one study measured

and patient empowerment. Only one study

barrier to intervention efficacy or technical

sought to explore diabetes distress and there

issues, including malfunction software, trouble

were no significant group differences, but

in using phone keypad,

significantly improved in the intervention

messaging, and lack of personalization.

changes

are

was

measured.

High

patient

repetitive text

group. Two studies reported about how the participant perceived and sense support from

IV. DISCUSSION

diabetes management or the health care team.

At the present time, mobile phones have

Three studies reported the adherence to oral

achieved wide reach, and mobile phone apps

antidiabetic medication, which significantly

have become increasingly prevalent among

improved from baseline. It showed a higher

users (Zhao, Freeman & Li, 2016). Mobile

result in the intervention group than the

health is likely to be pervasive and the

control group, but there was no significant

research indicating their effectiveness has been

difference between groups.

growing rapidly. However, evidence for the efficacy of mobile apps and text messaging has been uncertain, and much remains

Other Outcomes Beside clinical outcomes and behavioral changes, other outcomes including patient satisfaction,

interaction,

quality

life,

perceived support or benefit for diabetes

unknown in terms of clinical results and health-related behavior changes (Han & Lee, 2018).

Thirteen

RCTs

were

included

this

management

long-term

conditions,

systematic review to evaluate the efficacy of

including diabetes. Mobile health intervention

mobile apps and text messaging in increasing

significantly

users' self-management. Self-management had

outcomes (Whitehead & Seaton, 2016).

been acknowledged as a potential intervention

Ten of the eleven studies that discussed health-

for patients with chronic disease, such as

related behavior changes portrayed positive

T2DM. Self-management is one of the

improvements.

essential elements in the Chronic Care Model,

improvement demonstrated in nine of the

which seeks to improve quality and lead to

studies. One study showed no statistically

positive health outcomes in chronic disease

significant

(Grady, et al., 2014).

outcomes and negative impact on the other

Eight studies among nine that measured

outcome.

clinical

contribution to the

outcomes

showed

positive

improved

diabetes

Statistically

improvement Only

one

significant

in one

study

showed

outcomes

measured.

Besides

control. Evidence shows that the main

behavior, these interventions also provided

therapeutic goal for all diabetes patients is

reminders and challenges, aiming to motivate

maintaining good glycemic control so as to

the patients. The impact of SMS intervention

prevent organ damage and microvascular and

on behavioral changes reported in other

macrovascular

systematic review showed a mixed result

Desse, 2017). Through glycemic control, the

(Arambepola, et al., 2016). Health behaviors

risk of diabetes complications might be

are associated with a multitude of health and

reduced as it played an important role in the

well-being outcomes and could improve health

presence

diabetes

outcomes and quality of life in people living

retinopathy (Chatziralli, 2017). Three studies

with such chronic illnesses. Health behavior

demonstrated

greater

change interventions with impact for patients

enhancement in glycemic control in the

aims to optimize the reach, effectiveness,

intervention groups rather than control groups.

adoption, implementation, and maintenance of

Significant reduction in HbA1c also noted in

interventions and rigorous

the other four studies, but there was no

outcomes and processes of behavior change

substantial difference between the intervention

(Short, et al., 2015). Hence, mobile apps and

and the control groups. Another study implied

text messaging intervention could be an

a positive effect on HbA1c level, but it was not

effective strategy to improve outcomes of

meaningful. Only one study outlined a

users along with the high notoriety of

negative impact on glycemic control. These

smartphone use in the daily lives of users.

findings were concordant with the previous

Despite the reported high patient satisfaction

study which examined the effectiveness of

and frequent engagement of the app or SMS,

mobile phone and tablet apps in self-

two studies still outlined low mobile app

and

progression significantly

(Yigazu

regarding

the

contribution to the enhancement of glycemic

complications

knowledge

clinical

healthy

evaluation of

utilization and technical issues, consecutively.

help

Technical issues may lead to difficulties in the

management, with the result of moderate

interaction between patients and mobile app

effect on glycemic control, and no effects were

providers

Some technical

found on blood pressure, serum lipids, or

barriers including patient inability in operating

weight. In 2017, Dobson, et al. conducted a

the app or mobile phone could be prevented by

systematic review of seven RCTs investigating

providing training for the patients, which had

the

been conducted by seven out of thirteen

management interventions on hemoglobin A1c

studies in this review. Level of technology

for patients with poorly controlled diabetes.

adoption was important for both quality and

Earlier in 2019, Sahin, et al. conducted a

experience of care (Kaphle, Chaturvedi,

systematic review with meta-analysis of 24

Chaudhuri,

2015).

studies mobile text messaging interventions.

Frequency of using the mobile app was one of

The systematic review concerned on message

the strongest association with the perceived

design and delivery features, and tailoring

benefit. The higher the frequency of using the

strategies, while the meta-analysis assessed the

mobile app, the higher self-management and

moderators of the effectiveness of tailored text

positive experience gained by the participants

messaging interventions. The result shows that

(TorbjĂ¸rnsen, et al., 2018). Therefore, all

the

factors that contribute to decreasing the mobile

interventions can improve glycemic control in

app utilization, should be reduced.

type 2 diabetes patients. The findings from this

caregivers.

Krishnan

Lesh,

improve

use

usage

diabetes

text

care

and

messaging-based

mobile

text

self-

messaging

review demonstrated that the evidence for Comparison with Related Studies

improvements of SMS and mobile apps on

There are three other systematic reviews of

glycemic control is mixed. Until this study

RCTs that have assessed the efficacy of text

was conducted, we could not find any other

message intervention in patients with T2DM

relevant studies published.

and only one other systematic review of RCTs

Analogous to previous reviews reporting

that assessed the efficacy of mobile apps in

positive impacts on glycemic control for both

T2DM patients. In 2016, Arambepola, et al.

mobile apps and SMS interventions in patients

reviewed thirteen controlled trials examining

with T2DM, the evidence in this study also

the effectiveness of interventions delivered via

portrays significant improvements in the

automated brief messaging sent to mobile

intervention

devices. This study showed that automated

characteristics. Aside from glycemic control,

brief

this study also pays attention to behavioral

messaging

produced

clinically

important and statistically significant effect on glycemic control. In the late 2016, Cui, et al. reviewed thirteen RCTs examining mobile health intervention based on mobile apps to

groups

from

changes and other outcomes.

the

baseline

Strengths and Limitations of the Study This study emphasizes the use in both mobile apps and text messages as a means of the intervention, compared to previously available studies that have a major focus in mobile

potential publications might not be included in this review. Language restriction can also be accounted for as non-English publications might provide helpful pieces of information from all over the globe.

applications rather than text messages. To our

Another limitation of this study is almost all of

knowledge, this study is the first systematic

the studies considered in this review were

review of RCTs that assessed both mobile

conducted in the upper-middle- to high-

apps and text messages to explore their

income countries. Hence, it is difficult to

relationship

generalize our results to low- to lower-middle-

self-management

among

patients with T2DM.

income countries. The researchers also did not

Compared to several systematic reviews, our study also provides a comprehensive bias assessment, indicating that our study only involves high-quality RCTs for reference and have a minimal probability of bias in the making of the paper. Relevant studies were identified using an extensive search strategy

conduct a meta-analysis because included RCTs in this study did not provide sufficient and suitable data as the heterogeneity of the reported outcome is high. With the results of a meta-analysis, the effectiveness of mobile apps and text messaging can be verified more clearly.

and a large number of bibliographic sources. We also opted for excluding non-randomized trial designs as this type of studies carries a greater risk of being flawed as a result of multiple biases.

Conclusion and Recommendation According to the evidence showed in the studies reviewed, SMS and mobile apps should be considered as a potential platform

Conversely, it is also an important limitation

for self-management in type 2 Diabetes

as we excluded all studies that did not report

Mellitus patients. This systematic review has

the results of randomized controlled trials.

shown that these interventions may help to

Observational studies, review articles, and

manage T2DM and have a moderate beneficial

non-randomized trials might provide valuable

effect on glycemic control. In addition,

information for determining the effectiveness

significant behavioral improvements can be

seen in almost all of the studies.

mobile

apps

and

text

messaging

intervention. The researchers concerned about the possible bias of the typical publications. Publication bias might also account for some of the effects we observed.

The clinical implication of the favorable impact of mobile apps and SMS interventions on

improvement

behavioral

changes

including patientsâ&#x20AC;&#x2122; adherence to medication is

In addition, the researchers did not possess full

critically important and could be considered as

access to several paid articles. Thus, some

an adjuvant intervention to the standard self-

management for patients with T2DM. Given the

reported

outcomes,

access,

Agboola, S., Jethwani, K., Lopez, L., Searl,

and

M., O’Keefe, S., & Kvedar, J. (2016). Text

characteristics of this technology, it is likely to

to Move: A Randomized Controlled Trial

be effective on the community level. The

of a Text-Messaging Program to Improve

standardized design and policy are needed to

Physical Activity Behaviors in Patients

increase the functionality and the applicability

With Type 2 Diabetes Mellitus. Journal Of

of this technology.

Medical Internet Research, 18(11), e307.

The effect of this outcome should be further explored in future trials. Trials with longer

doi: 10.2196/jmir.6439 Arambepola,

C.,

Ricci-Cabello,

I.,

duration of follow-up using standardized app

Manikavasagam, P., Roberts, N., French,

technology may well demonstrate beneficial

D. P., & Farmer, A. (2016). The Impact of

clinical effects in T2DM patients. Thus, more

Automated Brief Messages

rigorous studies with larger samples and

Lifestyle Changes Delivered Via Mobile

longer applied interventions and follow-up are

Devices to People with Type 2 Diabetes: A

still needed to confirm the effectiveness of

Systematic Literature Review and Meta-

mobile apps and text messaging and explore

Analysis of Controlled Trials. Journal of

aspects of diabetes self-management.

medical Internet research, 18(4), e86.

Promoting

doi:10.2196/jmir.5425 Arora, S., Peters, A., Burner, E., Lam, C., &

V. FUNDING This review is not funded by any institution,

Menchine, M. (2014). Trial to Examine

organization, cooperation, or other third-

Text

parties.

Emergency

The

researchers

utilized

online

Message–Based Department

mHealth Patients

in With

searching platform provided by the Faculty of

Diabetes (TExT-MED): A Randomized

Medicine,

Controlled Trial. Annals Of Emergency

Public

Health,

and

Nursing,

Universitas Gadjah Mada, Indonesia for

Medicine,

literature

10.1016/j.annemergmed.2013.10.012

searching

through

electronic

databases.

63(6),

745-754.e6.

doi:

Capozza, K., Woolsey, S., Georgsson, M., Black, J., Bello, N., & Lence, C. et al.

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APPENDIX 1. Study design characteristics of included RCTs

APPENDIX 2. Summary of Intervention Characteristic

Abstract This study discusses Analysis of Health Problems and Level of Knowledge about BPJS Medical Student Diponegoro University (BPJS-K; Social Security Agency for Health) Program and its Participation on medical student of Diponegoro University batch 2017 and 2018. The purpose of this study is to describe and analyze the Medical Students Perception and Knowledge of the BPJS Program (Organizing Agency for Social Security) on medical students of Diponegoro University batch 2017 and 2018. The hypothesis proposed is "There is a Relationship between the Medical Students Perception and Knowledge of BPJS program (BPJS-K; Social Security Agency for Health)." The research method used in this research was conducted using a questionnaire with a google form filled in by 2017 and 2018 Diponegoro University medical faculty students. Data obtained were initially collected then will be presented in the form of bar charts and or circles for each question asked, analyzed and interpreted to test the truth of the hypothesis proposed. The filling in the license is closed after getting a minimum number of 100, and for the questionnaire this time we close the filling when it is already charging 103. For the sample criteria, the 2017 and 2018 medical students Diponegoro University.

Analysis of Health Problems and Level of Knowledge about BPJS Medical Student Diponegoro University Diponegoro University 1. Bella Renata 2. Iskandar Hermanto 3. Fatimah Al Atsariyah 4. Vania Verina Himawan Introduction World Health Organization (WHO), through Sustainable Development Goals (SDG) present an ambitious agenda for building a better world, which is specifically addressed through SDG3 which calls effort to ensure healthy lives and promote well-being for all at all ages by 2030 (1). Achieving the SDG3 targets, while leaving none of SDGs behind, can only be done by objectifying Universal Health Coverage (UHC) among all citizens of a country (2). UHC means that all individuals and communities receive health services they need without suffering from financial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care (3). In addition, supporting the goal of universal health coverage is also an express concern for equity and for honoring everyoneâ&#x20AC;&#x2122;s right to health (8). 193 member states of United Nations (UN) have agreed to achieve a safer, fairer, and healthier world by 2030 (1). Related to this commitment, the Government of Indonesia has introduced various social insurance programs for health, such as the Social Safety Net for Health-care, Askeskin, Jamkesmas, and the most recent national health insurance scheme, the Jaminan Kesehatan Nasional (JKN; National Health Insurance Program) (4). This program, which commenced in January 2014, pools contributions from members and the government under a single health insurance implementing agency, Badan Pelaksana Jaminan Sosial Kesehatan (BPJS-K; Social Security Agency for Health). Population coverage is planned to expand progressively and the aim is to reach universal coverage by 2019, which includes at least 95% of all citizens of Indonesia, while addressing regional disparities in service quality and accessibility, managing resources effectively, containing costs and minimizing frauds, engaging private sectors, and maintaining investment in health promotion and prevention programs. Apparently, participants of JKN had reached 187,982,949 in early 2018, which means 72.9% of Indonesian population had been legally registered as JKN participants, or in contrary, 27.1% had not been registered as JKN participants (5). Therefore, the government has conducted strategies and effort to overcome this problem. One of them is by empowerment of regional governments, specifically by expanding participation coverage to ensure all population of a regional province have been registered as JKN participants. This condition indicates achievement of universal coverage of health services and insurance (3). In 2017, 95% or 489 districts/cities out of 514 districts/cities in Indonesia had affiliated

in JKN program. Likewise, three provinces (Aceh, DKI Jakarta, and Gorontalo), 67 districts, and 24 cities have reached UHC in 2018 (5). However, implementation of UHC, in this case is JKN, includes wide range of aspects. It needs contribution from the government, health providers, primary health care, and last but not least, the main goal for UHC itself, the communities. Moreover, there are several domains which have been performed well across the countries to ensure all mechanisms which link the community environment to health; income and poverty, knowledge and education, housing and infrastructure, travel, community and infrastructure, social protection and employment, early child development, gender norms, participation, registration, accountability, and discrimination (6). These domains were divided into indicators, then these indicators are sorted into core and non-core indicators. One of the most influential core indicators are in participation domain, which includes involvement (involvement in decision-making in the health system) and health literacy (percentage of people confident about using the health system). Nevertheless, many cases which are reported in local newspapers indicate that the public has no clear sense of benefits to which they are entitled and how to get them. The BPJS-K has made efforts to avoid miscommunication and disinformation by providing information about JKN and BPJS-K on their website (www.bpjs-kesehatan.go.id) as well as putting up posters regarding the necessary procedures to access JKN in health facility providers. Instead, people still have little information and low interest regarding the health services which are available to them (4). JKN program should be disseminated widely to all societies. Health providers, which include doctors and nurses, should carry out their role to promote advantages of being JKN participants, build teamwork with public figures in order to encourage people to participate in JKN program, and spread information about JKN to educate people, so they could grow interests in joining JKN afterwards (7). Through these efforts, it is expected to increase contribution from the society in performing JKN program so universal health coverage could be achieved by 2030. Based on above information, health providers possess a vital role in achieving universal health coverage in its implementation to the society. But, this cannot be done if health providers themselves do not know necessary information and sense of participation towards JKN, or UHC in general. So, we conducted a study in order to know how much medical students know about JKN, and how important it is in enforcing equality of health. In this study, we expect to evaluate awareness of medical students in dealing with equality in healthcare access to improve community health in achieving Sustainable Developmental Goals of WHO, in order to prepare medical students in tackling healthcare problems in the future. METHODS

The research was conducted using a questionnaire with a google form filled in by 2017 and 2018 Diponegoro University medical faculty students on March 24 th 2019 until March 30th 2019 Questionnaire was created using Google Form and shared with the batch group of medical faculty students batch 2017 and 2018. The filling in the license is closed after getting a minimum number of 100, and for the questionnaire this time we close the filling when it is already charging 103. For the sample criteria, the 2017 and 2018 medical students Diponegoro University The data obtained will be presented in the form of bar charts and or circles for each question asked.

RESULT 1. The data below shows the number of medical students of diponegoro university who have BPJS. There are 93.2% medical medical students of diponegoro university who have BPJS.

2. The data below shows how often medical students of diponegoro university use BPJS when they go to hospital. There are 47.6%% medical students of diponegoro university use BPJS when they go to hospital.

3. The data below shows knowledge of medical students of diponegoro university of the registration procedure for BPJS (There are 59.2% medical students of diponegoro university know about registration procedure for BPJS)

4. The data below shows how important we should know about BPJS according to medical studentsof Diponegoro University (The graph shows percentage how important we should know about BPJS on a scale of 1-5).

5. The data below shows whether the medical students of Diponegoro University have obstacles in paying the BPJS contribution (There are 13,3% medical students of Diponegoro University who have a problem while paying the bpjs contribution).

6. The data below shows whether the medical students of Diponegoro University feel burdened with the cost of going to the doctor (There are 22.3% of medical students of Diponegoro University who feels burdened with the cost of going to the doctor).

7. The data below shows what health access which often prevents medical students of Diponegoro University from going to the nearest health care facility (from the graph showing that the most contributing health access that prevents them from going to the doctor is a time)

8. The data below shows whether when the medical students of Diponegoro University was ill, are they immediately go to the nearest health care facility (from the data shows that 19.4% of medical students of Diponegoro University staff will go to the nearest health facility, 36.9% of medical students of Diponegoro University will not go directly to the nearest health care facility but first treated, 36.9% of medical students of Diponegoro University will not go directly to the nearest health care facility, but they are treated first, and if they do not recover they go to the nearest health care facility).

9. The data below shows whether the medical students of Diponegoro University knows that when they are sick and not taken to the doctor it will cause complications (there are 91.3% of medical students of Diponegoro University who actually know that when they are sick and not taken to the nearest health care facility it will cause complications).

10. The data below shows medical students of Diponegoro University of how important it was to see a doctor when ill, on a scale of 1 - 5 (from the data obtained 1% medical students of Diponegoro University did not really matter to see a doctor when sick, 0% considered unimportant, 15.5% considered normal, 51.5% consider it important when getting sick directly to the doctor, and 32% consider it very important when they go directly to the doctor).

DISCUSSION Based on our survey to 103 people of the first year and second year medical students in Faculty of Medicine Diponegoro University, it is indicated that: 1. 93.2% of them are the member of BPJS 2. Half of them, around 52.4% do not use BPJS when examined by doctors 3. 59.2% know how to administered to be a member of BPJS 4. Around 50.5% consider BPJS is an important health care access in community 5. Luckily, 86.7% do not feel burdened to pay the fee for BPJS monthly. 6. 43.7% of them will definitely go to doctor if they have been trying to cure their disease but there is not any improvement

7. While almost all of the responders (91.3%) know that a disease will be complicated if not treated by the expert 8. The biggest problem for them to go to doctor is time just than cost, transportation, and distance. From the survey, it is known that the knowledge of BPJS among the first and second year medical student in Faculty of Medicine Diponegoro University is good. But, many of them is still not using the BPJS. Moreover, they do not immediately go to the expert when the disease is just emerging. They prefer to seek for expert’s help after some self-medication and there is not any improvement. It happens because most of them are busy with the medical student life. They do not have enough time to go to doctor and to wait long enough – just for around minutes of examination. Whereas, being healthy is an important aspect of this life. In this case, the crucial thing is to enhance the awareness of being health rather than the knowledge itself. Most of them already know the procedure of BPJS and registered as BPJS member, but they rarely use it. It is related to the busy life as medical student so that they do not use BPJS even when they are administered as one of the member. In BPJS system, patient must have many time to queue up for a long time to get examination. Then, they preferred to get some medication not using their BPJS, which will save a lot of time. Indonesian people is still categorized as a mid-low economic status while medical students are mostly come from mid-high level. It is also a contributed factor why they prefer not to use their BPJS when go to doctor. Related to things that have been explained above, we take an action to do an elucidation to improve their awareness of healthy life, not to ignore a disease even though it has mild symptoms, and to tell them the importance to spare some time to take some examination. We believe that is inappropriate to blame a busy life as an excuse to be ignorance for a healthy life. Time is manageable and no matter how busy someone is, a priority scale is the solution. In this opportunity, we also mentioned many consequences if someone is sick and not immediately seek for an expert’s help. As a fellow medical student, we share some tips on how to manage our busy life yet still prioritize a healthy life. Without a healthy body and mind, automatically we cannot undergo a busy life. And not to forget, we also explained more about BPJS in spite of the fact that many of them already know about it. In prospect to equalize medical students’ level of knowledge about BPJS. CONCLUSION

Based on the data found and data analysis can be concluded that the perception and role of the medical students of Diponegoro University on procurement BPJS Health program in detail can be explained as follows: 1. Medical students knowledge in procurement BPJS Health program Balongpanggang has enough perception well. Good perceptions are elaborated specifically that is good in procuring programs Health BPJS meet community service needs, optimal service, good, location the right and fast service get a good appreciation of medical students of Diponegoro University. In accordance with the the results of the interviews with the community stated that it was very happy and felt helped by the BPJS program This health, people feel served well. 2. Actively in the form of utilizing public service facilities seem obvious become a moral commitment, because in medical students involvement from the research results shows a significant enough. This matter society sees from the point of need which must be fulfilled. 3. Implementation of BPJS program activities Health can be concluded already quite good and meets the principle effectiveness, which is highly preferred is achievement of what is the main goal and the target of a program for the community. Simple, can be interpreted by the BPJS program Health is very easy to administer or its application so that it can be done people of various ages, easy to understand, and easily implemented by the community request health services.

REFERENCES 1. https://www.uhc2030.org/our-mission/ 3. http://origin.who.int/mediacentre/factsheets/fs395/en/ 5. https://bpjs-kesehatan.go.id/bpjs/index.php/post/read/2018/639/Jaminan-Kesehatan-

ABSTRACT Approaches to Improve Health Coverage by Increasing the Enrollment Rate and Willingness to Pay for Health Insurance: A Systematic Review Silvia Husodo, Vanessa Carolina Gunawan, Serri Rivally Faculty of Medicine, Universitas Brawijaya

Aim To assess the different approaches for increasing the willingness to enroll and pay for the health insurance in order to improve universal health coverage. Background The Government of Indonesia aims to reach universal health care coverage for all citizens by 2019. To achieve this goal, they launched a national health insurance scheme, National Health Insurance System (NHIS; or Jaminan Kesehatan Nasional), in 2014. However, it faces some serious problem, one of which is a fund deficit of Rp7.95 trillion rupiahs as of September 2018. This deficit also causes other problems that is disrupting the implementation of a good universal health coverage. There are some factors contributing to this, including the low premium rate, low coverage, and low willingness to pay the monthly premium for those who are eligible. Materials and Methods We searched the following database or websites without language restriction in 10 years period: CENTRAL (searched 16 March 2019), PubMed (searched 16 March 2019), and Science Direct (searched 16 March 2019). We included RCTs and quasi-experimental studies to assess the different approaches to increase the enrolment rate and willingness to pay for health insurance. Studies were then further assessed for risk of bias with Cochrane risk of bias tool. Results Four RCTs and two quasi experimental are included in this review. There are variable and innovative interventions that could improve peopleâ&#x20AC;&#x2122;s participation for health insurance. The interventions to increase enrolment rate are subsidy voucher, information leaflet, parent mentoring, personal telephone calls, and

automated telephone messages. The interventions to improve the willingness to pay includes free preventive medical checkup and educational intervention. Conclusion All trials have different combined interventions which makes it harder to find the single best intervention to increase the enrolment rate and willingnes to pay for health insurance. We noticed that some included trials show that interventions that include personal assistance or guidance resulted in better outcomes. It is also important to combine more than one approaches for the right population to create a more effective way.

Keyword: universal health coverage; insurance coverage; willingness to pay insurance, insurance enrollment

APPROACHES TO IMPROVE HEALTH COVERAGE BY INCREASING THE ENROLLMENT RATE AND WILLINGNESS TO PAY FOR HEALTH INSURANCE: A SYSTEMATIC REVIEW

By : Silvia Husodo, Vanessa Carolina Gunawan, Serri Rivally 2nd year medical student, 2nd year medical student, 2nd year medical student ASIAN MEDICAL STUDENTSâ&#x20AC;&#x2122; ASSOCIATION- UNIVERSITY OF BRAWIJAYA

Approaches to improve health coverage by increasing the enrollment rate and willingness to pay for health insurance: a systematic review Silvia Husodo, Vanessa Carolina Gunawan, Serri Rivally 2nd year medical student, 2nd year medical student, 2nd year medical student Asian Medical Students’ Association- University of Brawijaya 1. BACKGROUND Description of the condition Universal health coverage (UHC) is about ensuring that people have access to the health care include promotive, preventive, curative, rehabilitative, and palliative (Kieny MP & Evans DB, 2013) that they need without suffering financial hardship (World Bank, 2018). Achieving Universal Health Coverage (UHC) is one of the targets the nations of the world set when adopting the Sustainable Development Goals in 2015. Countries that progress towards UHC will make progress towards the other health-related targets, and towards the other goals. Good health allows children to learn and adults to earn, helps people escape from poverty, and provides the basis for long-term economic development (WHO, 2019). In response, by 2014, the Government of Indonesia launched a comprehensive UHC programme called the National Health Insurance System (NHIS; or Jaminan Kesehatan Nasional)—a single-payer UHC system. With 203 million members in October, 2018, the Indonesian NHIS is the largest singlepayer system in the world, and by 2017 was already managing 223·4 million consultations for both primary and advanced treatments (Agustina et al, 2018). In February 2019, approximately 82,64 % population in Indonesia have been covered. Nevertheless, BPJS Kesehatan target that 2019 achievement of 100% coverage still have not been reached. (BPJS, 2019) The NHIS faces several serious problems that contributed to the barriers to achieve the universal health coverage. Deputy Minister of Finance Mardiasmo said that the Health Care and Social Security Agency (BPJS Kesehatan), which is the administrator of NHIS itself, recorded a fund deficit of Rp7.95 trillion rupiahs as of September 2018. According to the Vice Ministry of Health, Mardiasmo, one of the root causes of this enormous deficit is the non-compliance of the informal sector workers to pay the monthly premium of JKN. Their insurance premium collectability rate is considered to be low, at 54% (tirto, 2018). The sector accounts for over 60 percent of Indonesia’s workforce, and usually provides workers with few or no employment protections. Roughly half of all informal workers earn too much to be eligible for government JKN subsidies, but still have very little

disposable income. Known as healthcare’s ‘missing middle’, these people must voluntarily enrol in and pay for cover themselves, but relatively few have (Australia Indonesia Center, 2019). As the deficit grows, the BPJS has created some controversial changes as an effort to cut the deficits. Some cancer drugs are removed from its coverage. They also cut down some medical interventions from its list. There are also some reports regarding to the mistreatment that received by some NHIS patients in hospitals. Hospitals are having difficulties to operate because the payment for claims by BPJS is delayed. Through this review, we would like to analyse the different approaches to increase the willingness to enroll and pay for the health insurance, which could save NHIS from a bigger deficit and therefore obstructing the implementation of universal health coverage. We also included the approaches that is performed on children and young adult population. They have low willingness to participate in health insurance since they believe they have very little probability of being sick and their awareness to participate in health insurance is low. Their participation is important because it could balance the larger expenses that the catastrophic patients spent. With the whole coverage so it can decreasing out of pocket personal cost for illness and increasing willingness to pay. Many strategies have been implemented and evaluated. A systematic summary and critical evaluation of the effectiveness of these interventions would help to inform government in adopting interventions for raising willingness to participate in the insurance in order to create a stable health financing system to achieve a sustainable universal health coverage in Indonesia. Objectives To assess the different approaches for increasing the willingness to enroll and pay for the health insurance in order to improve universal health coverage. 2. MATERIALS AND METHODS Criteria for considering studies for this review Type of studies The following two types of studies were included. •

Randomised controlled trials (RCTs)

•

Quasi-Experimental

Type of participants

We included variable population that are eligible for the health insurance but not enrolled or whose the willingness to pay is low. Types of Intervensions We included any outreach interventions whose aim to improve health insurance coverage and raising willingness to pay the health insurance: •

Increasing health insurance coverage: information leaflet, voucher covering 25% of the annual premium, information sheets, reminder flyers, automated telephone messages, opportunity to attend 2 school-based health insurance presentaions, parent mentoring, information kit and premium subsidy.

•

Raising willingess to pay: free preventive medical checkup and educational intervension.

Type of outcome measures Primary outcome Enrolment of uninsured population into health insurance programmes and Willingness to pay for health insurance. Secondary outcome We also extracted data on other outcomes, including measures of: •

Renewal insurance;

•

Use of healthcare services;

•

Patient satisfication; and

•

costs reduced

Search methods for identification of studies Electronic searches We searched the following database or websites wtihout language restriction in 10 years period:

•

Cochrane Central Register of Controlled Trials (CENTRAL), 2012, Issue 7, part of The Cochrane Library. www.thecochranelibrary.com (searched 16 March 2019)

•

PubMed( NCBI) (2009 to present) (searched 16 March 2019)

•

Science Direct (2009 to present) (searched 16 March 2019)

Searching other resources In addition, we also screened reference lists of all included papers and relevant reviews identiﬁed. We contacted authors of relevant papers to identify additional studies, including unpublished and ongoing studies. We also carried out a citation search for included studies to ﬁnd more potentially relevant studies. Data collection and analysis Selection of studies Two review authors scanned titles and abstracts of all articles obtained from the search and retrieved the full text of articles deemedrelevant. We then independently screened the full texts of studies. We resolved any disagreements on inclusion by discussion with a third author. Data extraction and management At least two authors independently carried out data extraction using a data extraction form. We extracted the following information: study design, type of intervention, participants, primary and secondary outcomes. We resolved any disagreements by discussion with a third author. We managed the data in Excel. Assessment of risk of bias in included studies

The risk of bias assessment was based on the Cochrane risk-of-bias tool, as shown in Table 2. Each study assessed separately for random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, Incomplete outcome data addressed, and reporting bias. For each criterion, two authors independently described what was reported in the study, commented on the description, and judged the risk of bias. We discussed unresolved disagreements with a third author.

Data synthesis We grouped study results according to the outcome measured. 3. RESULTS Table 1. Characteristic of included studies Authors

Study Design Participant

Intervention

Outcome

Results Households invited

1. Willingness to the checkup are to

pay

renew

to willing

2016

162 RCT

insurance free

policyholders

US$0.87 more for

preventive insurance

medical checkup

pay

the approximately

health Delavallade

the

scheme

insurance

premium. Respondents are 34 percentage

points

likely

Hypothetical

hypothetically

renewal

renew their policy. Checkup attendance increases

the

likelihood that a household member consulting health

any service

provider within the 3.

Wagstaff 2016

Use

healthcare

the

services

survey.

3000 households in Group 1: control voluntary RCT

Vietnam

group

of 2 months preceding follow-up

Information

enrollment in campaigns

and

Group

2: the

information leaflet government

subsidies may have limited effects on

Group 3: voucher SHI's scheme enrollment. combined covering 25% of the

The

information-

annual

subsidy

premium

intervention raised enrollment by less

quasi-

Korean

experimental

children

Group 4: both the

than

leaflet and voucher

percentage point.

Moderate

CHAMP

intervention:

41% of the parents

information sheets,

reminder

children

flyers,

fifth grade

helped uninsured in

the

automated

intensive

telephone

intervention group

messages, and the

opportunity

apply

American to attend 2 schoolin based

for

health

insurance,

health

compared

nonequivalent kindegarten through insurance Chen 2009 comparison

one

with

13%

presentations.

the control group

Intensive

intervention: all of

However,

the above services

only

uninsured children

well

=0:002). 23%

personal telephone

call

intervention group,

Them

inform of

the

availability

childrenâ&#x20AC;&#x2122;s insurance

the

compared

intensive with

10% of the control

health

group, Enrollment

programs and to rate

obtained insurance

actually health

invite

them

=0:047).

attend a school-

moderate

based

intervention

health

insurance

showed

presentation.

significant

The

no effect

on application rate or

enrollment

compared with the control group. The

WTP

for

health insurance is higher

(33.8%)

among

workers

who Informal

Khan 2013 experimental

educational

working or living in

intervention

Willingness to comparison

with

areas

any

around insurance Educational

provider

pay

intervention Kidsâ&#x20AC;&#x2122;

health those who did not

insurance Health Enrollment

Insurance

by rate

Educating Lots of Parents community

with

high proportions of (1)

(control group). PMs

were

documented to be superior

Parental

traditional

satisfaction

Medicaid/CHIP methods

uninsured children, communities with Coverage

insuring

children

low-income

identify

(95% vs. 68%; p <

the

highest renewal

families,

Latinos/ proportions

Hispanic,

African- low-income

American/Blacks in minority Dallas flores 2017 RCT

the

workers,

the quasi-

joined

Texas

County, with children,

families uninsured

.001), Cost Reduced Faster

coverage

(median of 62 days vs. 140 days; p <

(2) hire minority research

.001)

staff

responsible

for

High

community

satisfaction

engagement data

parental

and

(84%

vs. 62%; p < .001)

collection,

(3)

develop,

implement,

and

evaluate

(85% vs. 60%; p <

intervention on

Coverage renewal .001)

built

community

partnerships

PMs

cost

and

average of $636.60

which creates jobs,

per child per year,

and

but

(4)

successfully

execute

the

research

saved

$6,045.22 per child insured per year

engaging appropriate community partners Main experiment:

Intervention I raise

Intervention

enrolment by three

information

kit

percentage

and 50% premium subsidy 2950

households

distributed in 590 Sub â&#x20AC;&#x2DC;barangayâ&#x20AC;&#x2122; municipality)

2015

RCT

but

the

impact

on effect was not quite

enrolment

in significant at the

experiment: the voluntary 10% level (p =

(sub- Intervention II: re- governmentmailing

clusters distributed forms, Capuno

(37%),

points

0.11)

the run

Intervention

an Individually

recorded

across most of the extension of the Paying

enrollment rate of

Philippines

just

voucher

validity Program

3%.

and

SMS

produces

reminders Intervention

Combining III:

intervention II and

Combining home

III

assistance

enrollment rate of

with

produces

form-completion

31% among those

and the delivery of

who previously had

the

been

completed

form

the

given

intervention I.

PhilHealth office

Table 2. Risk of Bias Delavallade

Wagstaff

Chen

Khan

Flores

Capuno

2016

2009

2013

2017

2016

low

unclear unclear

low

unclear unclear

low

unclear unclear

low

(attrition bias)

low

high

low

Reporting bias (Selective reporting)

low

Entry Random

sequence

generation

(selection bias) Selection

bias

(Allocation

concealment) Blinding of participants and personnel (performance bias) Blinding (detection

outcome

bias)

assessment

(patient-reported

outcomes) Incomplete outcome data addressed

Results of the search We retrieved 17 potentially relevant papers on health insurance coverage and willingness to pay the health insurance after screening 35 titles and abstracts (after checking duplicates between databases). We examined the full text of these 17 articles. We then excluded 11 articles because they did not meet the study design inclusion criteria.The whole screening process is presented in Figure 1. Science Direct

CENTRAL

PubMed

(n=23381)

(n=1078)

(n=26341)

2.213) Total records after duplicates removed (n=50800)

Records screened by title and abstracts (n=35) Excluded due to inrelevancy (n=18) Full-text articles assessed for eligibility (n=17)

Studies included (n=6)

Figure 1. Screening Flow Diagram

Excluded due to dismatch the criteria (n=11)

4. DISCUSSION Included studies The Included RCT (Delavallade 2016) took place in India and evaluated a free preventive checkup with a qualified doctor to increase willingness to pay, hypothetical renewal, and use of the healthcare services in insurance policyholders. Heath insurance policyholders were randomly split into two equally sized group. The 80 household were the intervension group. This intervention group in the treatment group received acceess and were encouraged to use the wellness clinic for a free checkup for any or all members of the insured family under the policy. The other 82 household in the control group were not offered the preventive checkup. Visits were allowed for about 2 months after the coupon was handed out. The other included RCT (Wagstaff, 2016) took place in Vietnam and evaluated a strategy for increasing voluntarry enrollment un the government social health insurance scheme. 3000 households in 20 communes in Vietnam were randomly assigned at the baseline to a control group or one of three treatments: an information leaflet about Vietnam’s government-run scheme and the benefit of health insurance, a vouchere entitling eligible household member to 25 % off their annual premium, and both. The other study which included are a Quasi-experimental study (Khan 2013) that took place in urban Bangladesh. This study evaluate educational intervention to increase willingness to pay health insurance in informal workers, working or living in the areas around any insurance provider. The educational session take place once a week (3-4 hours) during three subsequent weeks for each occupational group. For assessing the impact of the educational intervention, WTP for joining health insurance using occupational solidarity between workers in “pre- and post-treatment” periods as well as between “control and treatment” groups were compared. The other Quasi-experimental study included (Chen, 2009) evaluate Moderate intervention such as information sheets, reminder flyers, automated telephone message, and the opportunity to attend 2 school-based health insurance presentation in Korean American children in kindergarten through fifth grade. These interventions took place for 7 months in Los Angeles, California. The authors used bivariate and multivariable analysis to assess effectiveness. Cost-effectiveness was performed using a 3-stage model and Monte Carlo simulation. Another included RCT (flores, 2017) took place in Dallas County, Texas. This study evaluate parent mentoring named “Kid’s HELP” in order to increase enrollment rate, parental satisfaction,

coverage renewal and reduce cost. The first step of the interfention is dentify target communities for intervention implementation. Criteria for community selection included those with high proportions of uninsured children, low-income families, and Latinos/Hispanics (henceforth referred to as “Latinos”) and African-Americans/Blacks (henceforth referred to as “AfricanAmericans”). For efficient data collection and to maximize community engagement, minority research team members (one AfricanAmerican female and three bilingual Latino males) were hired. Parent Mentorss, who are African-American or Latino parents with at least one child covered by Medicaid or CHIP and who reside in one of the target Dallas County communities. The study occurred from June 2011 to April 2015. Kids’ HELP created jobs because each PM was hired as a part-time employee and paid a monthly stipend for each family whom the PM mentored. Another included RCT (Capuno, 2015) took place in Phillipines. 2950 households distributed in 590 sub-municipality) clusters distributed. 1037 unenrolled IPP-eligible families in 179 randomly selected intervention municipalities were given an information kit and offered a 50% premium subsidy valid until the end of 2011. 383 IPP-eligible families in 64 control municipalities were not. Excluded studies The exclusion of 11 studies that were very close to being included but do not meet the study design requirements. Most of the excluded studies are observational studies and evaluation of a government policy. Effects of intervention 1. Increase enrolment The RCT (Wagstaff 2016) a cluster randomized experiment assessed the effectiveness of information leaflet and voucher covering 25% of the annual premium with aim to encourage enrolment of health insurance for the informal sector. The outcome measures in this study include voluntary enrolment in the government SHI’s scheme. In this trial, 3000 households participants in Vietnam were randomly assigned to interventions divided into four groups. Group 1 (control group), group 2 (information leaflet explaining how to enroll and listing the benefits of insurance), group 3 (voucher covering 25% of the annual premium for every eligible household member), group 4 (both the leaflet and voucher covering 25% of the annual premium). The voucher was valid for a period of 6 months but insurance cover

obtained using the voucher lasted 1 year from the data enrolment. In this study to matching and converting variables using coarsened exact matching (CEM). Information campaigns and subsidies may have limited effects on enrolment. The combined information-subsidy intervention raised enrolment by less than one percentage point. The quasi-experimental

non-equivalent

comparison (Judy 2016) evaluate the

effectiveness and cost-effectiveness of different school based health insurance strategies to provide coverage to uninsured Korean American children. In this trials, the participants were Korean American children in 3 groups/schools (n=1181). There are two interventions, first moderate intervention their parents received a variation of outreach methods (i.e., information sheets, reminder fyers school site presentations, automated telephone messages) and application assistance (i.e., telephone helpline, on-site assistance). Second, their parents received personal telephone call to inform them of the availability of childrenâ&#x20AC;&#x2122;s health insurance programs and to invite them to attende a school-based health insurance presentation. The outcome the uninsured in the intensive intervention group, 41% applied for insurance compared with 13% of the control group (P=0.002). In the intervention group, 23% enrolled in insurance compared with 10% of the control group (P=0.048).The parents reason for nonenrolment from the intervention group despite assistance was failure to mail in the application. The RCT (Flores 2017) community-based methodology evaluated a new methodological approach to the screening, indentification, and intervention study enrollment of uninsured minority children. There are 4 components methodological that this study used: a. Identify communities with the highest proportions of low-income minority families with uninsured children b. Hire minority research staff responsible for community engagement and data collection c. Implement and evaluate a parent mentor (PM) intervention built on community partnerships and which creates jobs d. Successfully execute the research by engaging appropriate community partners The participants in this study are community with high proportions of uninsured children, low-income families, Latinos/ Hispanic, African-American/Blacks in Dallas County, Texas with 90% of the countyâ&#x20AC;&#x2122;s 184,196 uninsured were Latino of African-American, county

uninsurance tares were 45.1% for Latino children and 19.5% for African-American children compared with 10.7% for White children, and between 69% and 71% of households have combined annual family incomes at or belos 200% of the federal poverty threshold. PM recruitment 15 mother and trained for 2 days. PM overall test score (0-100) significantly increased from a mean 62 (range, 39-82) before training and 88 (range, 6,7-100; p<.01) after training. Furthermore, PM were documented to be superior to tradiotional Medicaid/ CHIP methods in insuring children for kidsâ&#x20AC;&#x2122; health insurance

(95% vs. 68%; p<.001). First,

enrollment rate faster coverage (median of 62 days vs. 140 days; p<.001). Second, parental satisfaction (84% vs. 62%; p<.001). Third, coverage renewal (85% vs. ^)%; p<.001). The last, cost reduced with saved $6,045.22 per childe insured per year. The RCT (Capuno 2015) a cluster randomized experiment tested 2 interventions encouraging enrollment in the Individually Paying Program (IPP). The participants in this study are 2950 households distributed in 590 â&#x20AC;&#x2DC;barangayâ&#x20AC;&#x2122; (sub-municipality) clusters distributed across most of the Philippines. The interventions are main experiment (intervention l: information kit and 50% premium subsidy) and sub experiment (Intervention II: re-mailing of the forms, an extension of the voucher validity and SMS reminders, and Intervention III: Combining home assistance with form-completion and the delivery of the completed form to the PhilHealth office). The outcome of intervention I raise enrolment by three percentage points (37%), but the effect was not quite significant at the 10% level (p = 0.11). Intervention II recorded an enrollment rate of just 3%, and the combining intervention II and III produces an enrollment rate of 31% among those who previously had been given intervention I. A 50% premium subsidy, bundled with general information and personalized SMS reminders, had an impact on enrollment of 3 percentage points (37%) among those who had chosen initially not to enroll. 2. Willingness to pay The RCT (Delavallade, 2016) assess the effect of exposure to preventive care may improve the demand for quality health care as well as whether health insurance policyholders receiving this additional benefit may be more likely to renew their policy. In this study, the participants are 162 insurance policyholders. Free preventive medical check up is the intervention. The outcome are willingness to pay to renew the health insurance scheme, hypothetical renewal, use of health care services, which is households invited to the checkup are willing to pay approximately US$0.87 more for the insurance premium, hypothetical renewal the respondents are 34 percentage points more likely to hypothetically renew their

policy, and use of health care services Checkup attendance increases the likelihood that a household member consulting any health service provider within the 2 months preceding the follow-up survey. Most of this impact is driven by the poorest households and is at the extensive margin; the free preventive checkup induced more policyholders to be willing to spend a positive amount to renew their health insurance scheme. The quasi-experimental (Khan, 2013) assess the impact of an educational intervention on the willingness-to-pay (WTP) for joining health insurance. An educational intervention on occupational solidarity and health insurance is offered to groups of informal workers. Educational sessions take place once a week (3–4 hours) during three subsequent weeks for each occupational group. For assessing the impact of the educational intervention, WTP for joining health insurance using occupational solidarity between workers in “pre- and posttreatment” periods as well as between “control and treatment” groups were compared. Multiple-regression analysis is applied for predicting WTP by educational intervention, while controlling for demographic and socioeconomic characteristics. The coefficient of variation (CoV) of the WTP is estimated in control and treatment groups and expected to be lower in the latter. The WTP for health insurance is higher (33.8%) among workers who joined the educational intervention in comparison with those who did not (control group). CoV of WTP is found to be generally lower in post-treatment period and in treatment group compared to pre-treatment period and control group respectively. Future Application and Research Based on the evidence included in this review, the suggestion we offer for the future research should use well-designed randomised control trials or quasi experimental methods to help evaluate specific strategies. The weakness in this study, there are variation in quantity, range of age, geographic, and social and cultural backgrounds of the participants which can make difference outcome because of this personal and environment factors. 5. CONCLUSIONS There are variable and innovative interventions that could improve people’s participation for health insurance. All trials have different combined interventions which makes it harder to find the single best intervention to increase the enrolment rate and willingnes to pay for health insurance. We noticed that some included trials show that interventions that include personal

assistance or guidance resulted in better outcomes. It is also important to combine more than one approaches for the right population to create a more effective way. Our systematic review provides evidence of how some interventions work in certain population and area. We hope that this result could be applied further to help health insurance administrator in creating innovations to increase the coverage and make a sustainable health insurance.

REFERENCES 1. Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Achadi, E. L., Taher, A., ... & Thabrany, H. (2018). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet. 2. Australia Indonesia Center. 2019. More incentive needed for ‘missing middle’ of Indonesia’s national health Insurance. Retrieved from https://australiaindonesiacentre.org/more-incentiveneeded-for-missing-middle-of-indonesias-national-health-insurance/ 3. BPJS. (2019). Bersih

dan Transparan, Prinsip

BPJS Kesehatan Selenggarakan JKN-KIS.

Retrieved from https://bpjs-kesehatan.go.id/bpjs//unduh/index/1204 4. Capuno, J. J., Kraft, A. D., Quimbo, S., Tan Jr, C. R., & Wagstaff, A. (2016). Effects of price, information, and transactions cost interventions to raise voluntary enrollment in a social health insurance scheme: A randomized experiment in the Philippines. Health economics, 25(6), 650662. 5. Chen, J. Y., Swonger, S., Kominski, G., Liu, H., Lee, J. E., & Diamant, A. (2009). Costeffectiveness of insuring the uninsured: The case of Korean American children. Medical Decision Making, 29(1), 51-60. 6. Delavallade, C. (2017). Quality health care and willingness to pay for health insurance retention: a randomized experiment in Kolkata slums. Health economics, 26(5), 619-638. 7. Flores, G., Walker, C., Lin, H., Lee, M., Fierro, M., Henry, M., ... & Massey, K. (2017). An innovative methodological approach to building successful community partnerships for improving insurance coverage, health, and health care in high-risk communities. Progress in community health partnerships: research, education, and action, 11(2), 203-213. 8. Khan, J. A., & Ahmed, S. (2013). Impact of educational intervention on willingness-to-pay for health insurance: A study of informal sector workers in urban Bangladesh. Health economics review, 3(1), 12. 9. Kieny MP, Evans DB. (2013).Universal health coverage. Eastern Mediterranean Health Journal. Apr 1;19(4):305 10. Wagstaff, A., Nguyen, H. T. H., Dao, H., & Bales, S. (2016). Encouraging health insurance for the informal sector: a cluster randomized experiment in Vietnam. Health economics, 25(6), 663674. 11. WHO. 2019. Universal Health Coverage (UHC). Retrieved from https://www.who.int/newsroom/fact-sheets/detail/universal-health-coverage-(uhc)

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https://www.worldbank.org/en/topic/universalhealthcoverage

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from

“COMPREHENSIVE ASSESSMENT OF MOBILE HEALTH (mHealth) INTERVENTION TO OVERCOME MATERNAL HEALTH PROBLEM IN LOWMIDDLE INCOME COUNTRIES : A SYSTEMATIC REVIEW” 1

Alexander Fernando, 1Dennis Ievan Hakim, 1 Aleyda Zahratunany I 1

Faculty of Medicine, University of Brawijaya

ABSTRACT Introduction: Despite increasing effort and attention to achieve better health status holistically, maternal health problem still become the major problem that cannot be solved in low-middle income countries. Many solutions has been conducted in order to prevent and manage maternal health issues, but implementation of these solutions is constrained as overall access to quality care is lacking. Nowadays, the global proliferation of mobile technology has shift the paradigm of healthcare access, one of them is mHealth. The wide availability of mobile phones make them become a promising instrument to deliver a variety of maternal health-related interventions. Material and Methods: Systematic review about interventions of mHealth in low-middle income countries for maternal health was carried out using PRISMA statement. Studies search were conducted using search engine ScienceDirect, ProQuest, and PUBMED database using keyword “maternal health”, “mobile phone”, “mHealth in maternal”, “low-income country maternal problem” with criterion papers published in english between 2014 to 2019 and related about interventions of mHealth in maternal health. Quality assesment of included papers was conducted using CONSORT statement checklist for clinical trials study and STROBE statement checklist for observational studies. Result and Discussion : From the search, 1492 studies were identified and finally obtained 12 studies that fulfill the criterion of this systematic review. The studies are organized according to common functions of mHealth as the following data collection, emergency medical support, point-of-care support, and health promotion. Studies show that mHealth interventions give significant improvement in many aspect stated above. The strength of this studies are using only moderate-high quality studies and give a picture of the best mHealth model. Limitation is that this review lack of concerning bias aspect thus need more consideration on its internal validity. Also some studies still lack of participants thus needs more moderate-high quality studies with more participants. Conclusion : mHealth interventions gave good improvement in maternal health service and access either for the patients and care provider. Future research should explore new areas of application the mHealth interventions.

“COMPREHENSIVE ASSESSMENT OF MOBILE HEALTH (mHealth) INTERVENTION TO OVERCOME MATERNAL HEALTH PROBLEM IN LOW-MIDDLE INCOME COUNTRIES : A SYSTEMATIC REVIEW” Dennis Ievan Hakim1, Aleyda Zahratunany I1, Alexander Fernando1 1

Faculty of Medicine, University of Brawijaya AMSA Indonesia

ASIAN MEDICAL STUDENTS’ ASSOCIATION INDONESIA 2019

INTRODUCTION In Worldwide, it is estimated that 140 million women giving birth every year. However, about 720 mother passed away everyday because of condition related to pregnancy and childbirth[1]. Maternal Health thus still become an aspect to be concerned nowadays. WHO defined maternal health as the health of women during pregnancy, childbirth, and the postpartum period[1]. Despite increasing effort and attention in order to achieve better health status holistically, the maternal health issue still become the major problem that can not be solved because of unacceptable tremendous mortality rate[1]. Moreover, the mortality rate keeps increasing every year especially in low-middle income countries[2]. Recent systematic analysis conducted by World Health Organization (WHO) unfold some facts that most of maternal deaths between 2003 and 2009 were due to obstetric complications (73%) [3]. Ironically, almost all (99%) of maternal deaths that occured in low-middle income countries existed due to inadequate access to health care services[2,3]. Based on these facts, the key obstacle related to this astonishing maternal health problem is the lack of access to quality care before, during, and after delivery. There is a huge disparity related to maternal health between low-middle income and high income countries. The lifetime risk of maternal death in high income countries is one in 3700, compared with one in 160 live births in low-middle income countries [4]. Another barrier related in achieving better maternal health care acess is the dominant use of traditional birth attendants (TBAs). Many people in low income country still believe that following traditional beliefs will lead to a healthy pregnancy and safe delivery. The reality is that many TBAs are still using groundless conventional methods which increase risk of infection and sepsis that lead to maternal death[4]. This condition in fact often worsened by the inequalities of health care services due to inadequate health care facilities in local area, obstacle in cutting time and distance to the health care service, and also the imbalance in official health workers distributions. Another aspect is that there are still many problems in implementing policy to overcome maternal health problem, especially in Africa and in our continent, namely Asia. In another word, improving access to health care services is critical to achieve better maternal health status in the community, yet rural area in low-middle income countries area face a variety of barriers. Sustainable Development Goals (SDGs) was set by United Nations in order to achieve a better and more sustainable future holistically[5]. SDG 9 stated the needs to create innovation of novel technologies available, especially those related to information and communication. It is widely accepted that one of the preferable and potent technology instrument is mobile phone. GSMA Intelligence stated that two thirds of global population owned mobile phone[6]. The number of phone holder also increase tremendously in low-middle-income countries, and keep increasing for the following years. The global advancement of mobile phone users and technology have shifted the paradigm of health care access that lead to initiation of innovation namely mobile health (mHealth)[6]. Prior systematic review in 2016 shows that mobile health or mHealth provide health care system which has potential to reduce 1

inequalities in care through facilitating communication between patients and providers, promoting maternal and women’s behavioral change, assisting in data collection, and helping care provider to resolve maternal complication problems, especially in rural areas with comprehensive purpose to solve problem in access thus maximize health care service quality[7,8]. However, this systematic review needs a higher evidence with better studies quality and obvious mHealth application design. To examine whether implementation of mHealth for either patients (pregnant women or mother of neonatus) and health care provider really useful in resolving issues of maternal health problems, we reviewed experimental studies that assesed the effectivity of mHealth intervention to solve maternal health problems in low-middle income countries with a better evidence and obvious mHealth model. MATERIAL AND METHODS Protocol and registration This systematic review of large clinical trials concerning mHealth interventions in low-middle income countries for maternal health was carried out using the PRISMA Statement rules. The registration number is still unavailable. Eligibility criteria This review focusing on the domain of maternal health in low-middle income countries. The criterion of inclusion are full text paper with criterion 1) quantitative or mixed-methods paper published in english between 2014 to 2019, 2) papers evaluating mobile phone interventions addressing maternal health outcomes and improving health care provider’s skills related to maternal health care or data collection, 3) researches that were conducted in low-middle income countries, 4) Participants of any age for the care provider and pre menopausal age (<45) for pregnant and mother of neonatus patients with an inform consent. Outcomes were not pre-specified in eligibility criteria given the interest in any outcomes related to our domain. Studies were excluded when the research discussing another topics beside the outcomes of study in antenatal, delivery, and postnatal period up to 28 days postpartum in low-middle income countries. Information sources and search The systematic literature search was conducted during December 1st, 2018 and March 31st, 2019. Studies search were conducted using search engine ScienceDirect, ProQuest, and PUBMED database with keyword “maternal health”, “mobile phone”, “mHealth in maternal”, “low-middle income country maternal problem”. Study selection All duplicate articles were removed manually by main author. Screening based on tittle and abstract was done independently by three reviewers. When access to full-text articles was not available, the study was excluded.

Data collection process and data items Data extraction from database articles was done by one reviewer. Other authors cross-checked the data extraction in order to achieve accuracy. Informations were extracted on : mHealth function, location, target population and size, research methods, form of mHealth, findings of mHealth implementation, and study quality assessed using Consolidated Standards of Reporting Trials (CONSORT) statement checklist. RESULTS From the search, 1402 articles were identified. 572 studies then excluded because there were duplications. Another 721 studies were later excluded because of uncorresponding topics. Finally, we obtained 12 total studies that fulfill the criterion of this systematic review.

Figure 1. Journal Selection Systematics. In total, 12 articles satisfied the inclusion criteria. The articles revealed specific evidence of the impact of mHealth on maternal health (Table 1) or highlighted the best practices and impediments for sustaining such mHealth activities. Accordingly, the findings of this review describe the outcomes of mHealth maternal programs implemented across the globe. The studies are organized according to common functions of mHealth as the following: Data collection Emergency medical support Point-of-care support Health promotion 3

Table I. Impelmentation Overview of mHealth interventions focusing on maternal health mHealth

Location

Target Population

Intervention

Findings

Function

Ref.

Quality of

(CI = 95%, P < 0.05)

Follow Up, Rural Upper

Eligible

Patients

Health

West Region,

and

Promotion

Ghana

care provider

local

health

Study [9]

Health workers were trained to send real-time Primary outcome SMS and make a call for an appointment and

Significant

improvement

follow up to 498 respondents (290 pregnant

knowledge

about

women and 199 neonatus mother)

(23.3%), postnatal (46.6%), and

Information

about

antenatal,

delivery,

and

delivery

care

antenatal

(10.5%)

thus

postnatal care also informed to respondents

increasing the awareness of rural

Response of respondents were assesed using

participants to check their health

mixed-design

status periodically on certified

approach

qualitative

and

Moderate

quantitative method with questionarries, focus

local health care provider

group discussion, and interviews to improve the

Astonishing

validity

participant trust because of very

increase

high satisfaction level (98%) of the intervention. This is due to participants that feel cared of rural health care worker. Secondary outcome There were decline on interest of delivering in traditional birth attendants

due

increasing

awareness.

Health

Iran

Promotion

Pregnant women at

A randomized controlled trial study comparing Primary outcome

[10]

gestational age 14-

two group. Experimental group received 12-weeks

Increase in experimental group

16 weeks

SMS reminder about antenatal care of taking iron

behaivor

supplements

compliance better than control

Moderate

in iron supplement

group (96% vs 66%) Secondary outcome Decrease

anemia

experimental group Decision/

Amhara

Eligible

patients

Point-of-

region,

(1037 women)

care

Ethiopia

support

[11]

An application that sends reminders for scheduled Primary outcomes visits and educational messages on dangers sign

Women were more likely to have

and common complaints during pregnancy

at least 4 antenatal visits (27.0%

Assisted the health worker in deciding who was

versus 23.4%)

more eligible to receive ‘Routine ANC/Basic care’

Women were

than ‘Specialized Care’

deliver their baby in the health

Reported the total number, round, and type of visit

center (43.1% versus 28.4%)

for each pregnant woman for any given period

more likely to

Secondary ouctomes A significantly higher percentage of women in the intervention group had PNC in the health centers (41.2% versus 21.1%)

Appointme

Zanzibar,

Intervention : 12

An automated SMS (short message service) that antenatal care attendance

[12-

Tanzania

Health

Facilities

contain information about contact to health ourcomes

14]

(1311

Eligible

reminders

provider, health education, and appointment

High

Primary outcomes 5

and health

population),

Promotion

with

reminder was send to the patients in experimental

44% of women in the

control 12 Health

group

intervention group received â&#x2030;Ľ4

facilities

(1239

Frequencies of the message : 2x per month before

ANC visits vs. 31% in the

Eligible population)

36 week gestation and 2x per week from week 36

control group

until deliver

30% of women in the intervention group called their health providers 59% of the women in the intervention group said text message influenced their decision to attend the antenatal visit Secondary outcomes 71% felt that the educational messages helped them learn about danger signs in pregnancy and to feel that the health system cared for them Skilled birth attendance outcomes Primary outcomes Increased skilled birth attendance in the intervention

group (60%) compared with the control group (47%) Significant increase in skilled delivery attendance in urban areas; did not affect women from rural areas Secondary outcomes Higher levels of skilled delivery attendance among women who attended secondary school vs. those who had not and who were primigravida vs. those who had multiple pregnancies Perinatal outcomes Primary outcomes 2482 children were born alive, 54 were stillborn, and 36 died within first 42 d of life Overall perinatal mortality rate was 27/1000 total births; 19/1000 births in intervention clusters vs. 36/1000 births in control clusters

Intervention associated with a reduction in perinatal mortality Secondary outcomes Significant changes in stillbirths and deaths within the first 42 d of life Appointme

Kenya

HIV-Positive

Up to 14 SMS sent to HIV-positive pregnant

pregnant

women

women; SMS sent every 2 wk starting on week

19.6% of intervention women

Reminder

(intervention group

28 of pregnancy (max 8 depending on gestation);

attended a maternal postpartum

and

additional messages sent weekly during first 6

clinic vs. 11.8% women in

control group (n=

wk postpartum. Control group received standard

control

193) )

care

195)

Primary outcomes

[15]

High

[16]

High

Secondary outcomes

Study was conducted using Randomized Control

92% of intervention group

Trial (RCT)

infants received HIV testing compared with 85% of control group

Follow-up

Vietnam

1433 seeking

women early

433 women seeking early medical abortion at 4 Primary outcomes hospitals in Vietnam were randomized to clinic

No significant differences in

medical abortion at

or phone follow-up

rate of ongoing pregnancies

4 hospitals

Clinic follow-up: returned to the hospital for

Secondary outcomes

confirmation of abortion outcome 2 wk after

85% of women in the phone

mifepristone administration

group did not need an additional clinic visit 8

Phone follow-up: completed a semiquantitative

Phone follow-up and home

pregnancy test at initial visit to determine

pregnancy test were effective in

baseline HCG and again at home 2 wk later. On

screening for ongoing

the initial visit they received drugs to perform a

pregnancy; sensitivity 92.8%

medical abortion Clinic staff called women to

and specificity 90.6%

review the pregnancy test results and symptom checklist Decision support

Guatemala

Traditional

Birth

Pragmatic, randomized controlled trial assesing Primary outcomes

Attendants (TBAs)

the effectiveness of mHealth decision support to

The rate of monthly emergency

(n = 44)

improve maternal health status and referral rates

referrals is increasing either in

TBAs were individually randomized in an

early-access group (median 31

unblinded fashion and grouped into early-access

referrals per 100 births) or late-

(n=23) and later-access (n=21) group to he

access group (median 34

mHealth system

referrals per 100 births)

[17]

Moderate

The TBAs were introduced with mHealth Secondary outcomes platform that allowed collection of simple

The early detection of

demographics, maternal and perinatal symptoms

complications is significantly

and clinical signs, maternal vital signs, and fetal

increasing, specially for

health rate which can be illustrated in pictograph

hypertension (because of

list

platform feature) after

common

maternal

and

perinatal

complications. The platform also provided

intervention with platform

integrated use of peripheral sensor devies such as pulse oximeter.

Complications

vital sign abnormalities

checking by TBAs also trigerred alert text messages to the on-call team. Data

Liberia

Collection

Traditional

Birth

Attendants (TBAs)

The aims of the study are to train non-or-low Primary outcomes literate TBAs and mobile phone data collection

Mean increase in cell phone

(n=99)

knowledge score was 3.67

TBAs trained to send real-time SMS for data

between pre- and post-test

collection on the total number of pregnant

TBAs were satisfied of getting

to local server with personal information and

information from the real-time

information of identified pregnant woman using

SMS.

10-digit

Moderate

[19]

High

Secondary outcomes

women in the community; asked to send an SMS

[18]

code

â&#x20AC;˘ TBAs provided with mobile phones, call credit, and solar charger Health

Kampong

Mothers

Promotion

Chhnang,

newborns

recorded messages to mothers of newborns

About 71% respondents

Cambodia

(n=1029)

promoting about infant health

reported that the interventions

Voices messages with duration 60 to 90 s were

are useful to promote

delivered in seven periodic to the mobile phones

knowledge about newborns

of 1029 newborn mother and after the

health

An interactive voice response system send pre-

Primary outcomes

interventions, 455 registered mothers were Secondary outcomes interviewed using quantitative questionnare

About 83% of respondents reported that they would be 10

willing to pay for the services indicating that the services are useful Health

India

120

pregnant

Local health care provider were trained to send Primary outcomes

Promotion,

mother

(eligible

SMS about information and follow up in

Significant increase in

Follow up

population)

importance taking iron and folic acid

respondentâ&#x20AC;&#x2122;s knowledge.

(experimental n =

The babies of experimental group will be

Number of folic acid and iron

59) (Control n= 61)

assessed.

that administrated were

[20]

Moderate

increased to experimental group Secondary outcomes There were only two unsuccessive pregnancy during this intervention on experimental group

DISCUSSION Based on this systematic review, we found that intervention of mHealth in context of maternal health has been evaluated over a range of service applications, such as emergency medical support, data collection, point-of-care support (decision support, follow up), and health promotion (education and appointment reminders). Studies show that mHealth interventions gave significant improvement in antenatal, delivery, and postnatal attendance to certified local health care service, rather than on TBA[9,10, 12-14,15]. By the increase in demand of skills in using novel technology, using mHealth for “selftraining” of the healthworker shows an enhancement in rural’s and traditional healthworker skills and knowledge of using mobile phone[18]. This finding means that there will be an increase in rate of monthly pregnancy complication referrals to better health care service due to awareness and trust of TBAs and pregnant womens to “modern health care”[9,13]. Not only in refferal, but there were significant screening attendance in health care facilities to overcome complications. Moreover, using mHealth as a follow up device could cut distance and time to admission due to a link between patients and health care worker in communication thus patients could request a transportation as soon as possible[9,16.20]. And also, based on our findings, it can be suggested that mHealth that sends patients a voice and text messages will be a best model to be realized as a novel mHealth application strategy due to their effectivity in changing behavior in achieving better health access on maternal. Limitation of this review is the bias aspect that were not fully considered in this studies. However, No absolute consistent effects of mHealth interventions on maternal and neonatal health outcomes based on our findings. Three reports described data collections, decision support, and health promotion interventions with high quality but the sample size were small (some unknown) and the information effect of the interventions were not stritchly quantified[17,18, 20]. Moreover, since many the method of data collection of the studies in this review using quantitative methods, it increases in bias of information collection. And also, there are still lacks of evidence and research about using mHealth in low-middle income countries with a moderate-high quality studies that located in South East Asia, which becomes one of our focus in this review. Overall, These findings suggest that implementation of mHealth is useful for increasing the attendance rate and promoting behavioral change for the maternal and care provider in term follow up meanwhile need more evidence of its effectivity in other low-middle income countries such as Asia. Another issues related to implementation of mHealth is the cost. Some of intervention studies were to provide mobile phones to health providers found the additional challenge of mobile phone costs, maintenance, and lack of electricity[10,18-19]. Another problem is limited information whether the information given by SMS and voice were delivered to the subject of research or the behavioral changes were caused by the interventions or in another word there is a need to look for the confounding factor. In other word, our findings are in agreement and consistent with previous systematic review about mHealth interventions on maternal health in low-income countries that conducted in 2016[8]. This systematic review suggest that mHealth interventions offer probably best solutions in order to overcome 13

maternal health problems by improving access to quality of prenatal and obstetric care, both from provider and patients. These improvement include reducing maternal mortality, emphasizing the technologies to enhance provider performance and skills and other aspects of quality, provider motivation, and patients satisfaction. This studies cover the limitation of previous systematic review by using a better quality of studies and giving a picture of the best mHealth model, namely an application or system that focuses using voice and text media. By implementing mHealth interventions, we are one step closer to achieve holistic approach in equality of health service, in line with Sustainable Development Goals (SDGs) and create advantages of new technologies available to improve access to and quality of health, specially in maternal health. Based on this systematic review, the effectiveness of previous implementations could bridge the access to quality care thus giving maternal health care and service holistically and actualize better world health. CONCLUSION In general, this review conclude that mHealth interventions gave good improvement in maternal health service and access either for the patients and care provider and thus again underlined the needs and importance for further studies that consider the bias factor better and focusing on mHealth that using voice-text base application in other low-middle income countries. Future research should explore new areas of application the mHealth interventions and concern about the confounding factors. CONFLICT OF INTEREST The authors report no relationships that could be construed as a conflict of interest. REFERENCE

1. World Health Organization. (2016). World health statistics 2016: monitoring health for the SDGs sustainable development goals. World Health Organization.

2. Kementrian Kesehatan, R. I. (2014). Pusat data dan informasi. Jakarta Selatan: Kementrian Kesehatan RI.

3. Say, L., Chou, D., Gemmill, A., Tunçalp, Ö., Moller, A. B., Daniels, J., ... & Alkema, L. (2014). Global causes of maternal death: a WHO systematic analysis. The Lancet Global Health, 2(6), e323-e333.

4. World Health Organization. (2016). World health statistics 2016: monitoring health for the SDGs sustainable development goals. World Health Organization.

5. Griggs, D., Stafford-Smith, M., Gaffney, O., Rockström, J., Öhman, M. C., Shyamsundar, P., ... & Noble, I. (2013). Policy: Sustainable development goals for people and planet. Nature, 495(7441), 305.

6. International Telecommunications Union. (2016). ICT facts and ﬁgures: The world in 2010. Geneva: International Telecommunications Union.

7. Lee, S. H., Nurmatov, U. B., Nwaru, B. I., Mukherjee, M., Grant, L., & Pagliari, C. (2016). Effectiveness of mHealth interventions for maternal, newborn and child health in low–and middle–income countries: Systematic review and meta–analysis. Journal of global health, 6(1).

8. Colaci, D., Chaudhri, S., & Vasan, A. (2016). mHealth interventions in low-income countries to address maternal health: a systematic review. Annals of global health, 82(5), 922-935.

9. Laar, A. S., Bekyieriya, E., Isang, S., & Baguune, B. (2019). Assessment of mobile health technology for maternal and child health services in rural Upper West Region of Ghana. Public health, 168, 1-8.

10. Khorshid, M. R., Afshari, P., & Abedi, P. (2014). The effect of SMS messaging on the compliance with iron supplementation among pregnant women in Iran: a randomized controlled trial. Journal of telemedicine and telecare, 20(4), 201-206.

11. Shiferaw, S., Spigt, M., Tekie, M., Abdullah, M., Fantahun, M., & Dinant, G. J. (2016). The effects of a locally developed mHealth intervention on delivery and postnatal care utilization; a prospective controlled evaluation among health Centres in Ethiopia. PLoS One, 11(7), e0158600.

12. Lund, S., Nielsen, B. B., Hemed, M., Boas, I. M., Said, A., Said, K., ... & Rasch, V. (2014). Mobile phones improve antenatal care attendance in Zanzibar: a cluster randomized controlled trial. BMC pregnancy and childbirth, 14(1), 29.

13. Lund, S., Hemed, M., Nielsen, B. B., Said, A., Said, K., Makungu, M. H., & Rasch, V. (2012). Mobile phones as a health communication tool to improve skilled attendance at delivery in Zanzibar: a cluster‐randomised controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology, 119(10), 1256-1264.

14. Lund, S., Rasch, V., Hemed, M., Boas, I. M., Said, A., Said, K., ... & Nielsen, B. B. (2014). Mobile phone intervention reduces perinatal mortality in zanzibar: secondary outcomes of a cluster randomized controlled trial. JMIR mHealth and uHealth, 2(1), e15.

15. Odeny, T. A., Bukusi, E. A., Cohen, C. R., Yuhas, K., Camlin, C. S., & McClelland, R. S. (2014). Texting improves testing: a randomized trial of two-way SMS to increase postpartum prevention of mother-to-child transmission retention and infant HIV testing. AIDS (London, England), 28(15), 2307.

16. Ngoc, N. T. N., Bracken, H., Blum, J., Nga, N. T. B., Minh, N. H., Van Nhang, N., ... & Blumenthal, P. D. (2014). Acceptability and feasibility of phone follow-up after early medical abortion in Vietnam: a randomized controlled trial. Obstetrics & Gynecology, 123(1), 88-95.

17. Martinez, B., Ixen, E. C., Hall-Clifford, R., Juarez, M., Miller, A. C., Francis, A., ... & Rohloff, P. (2018). mHealth intervention to improve the continuum of maternal and perinatal care in rural Guatemala: a pragmatic, randomized controlled feasibility trial. Reproductive health, 15(1), 120.

18. Lori, J. R., Munro, M. L., Boyd, C. J., & Andreatta, P. (2012). Cell phones to collect pregnancy data from remote areas in Liberia. Journal of Nursing Scholarship, 44(3), 294-301.

19. Huang, S., & Li, M. (2017). Piloting a mHealth intervention to improve newborn care awareness among rural Cambodian mothers: a feasibility study. BMC pregnancy and childbirth, 17(1), 356.

20. Datta, S. S., Ranganathan, P., & Sivakumar, K. S. (2014). A study to assess the feasibility of Text Messaging Service in delivering maternal and child healthcare messages in a rural area of Tamil Nadu, India. The Australasian medical journal, 7(4), 175.

APPENDIX Prisma Checklist of this systematic review Section/topic

# Checklist item

Reported on page #

TITLE 1

Identify the report as a systematic review, meta-analysis, or both.

Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number.

Rationale

Describe the rationale for the review in the context of what is already known.

Objectives

Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).

Protocol and registration

Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.

Eligibility criteria

Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.

Information sources

Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.

Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.

Study selection

State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis).

Data collection process

Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.

Data items

List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.

Risk of bias in individual studies

Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.

N/A

Summary measures

State the principal summary measures (e.g., risk ratio, difference in means).

N/A

Title

ABSTRACT Structured summary

INTRODUCTION

METHODS

Synthesis of results

Section/topic

Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I2) for each meta-analysis.

# Checklist item

N/A

Reported on page #

Risk of bias across studies

Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).

N/A

Additional analyses

Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified.

N/A

Study selection

Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.

Study characteristics

For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.

Risk of bias within studies

Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12).

N/A

Results of individual studies

For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.

N/A

Synthesis of results

Present results of each meta-analysis done, including confidence intervals and measures of consistency.

Risk of bias across studies

Present results of any assessment of risk of bias across studies (see Item 15).

N/A

Additional analysis

Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]).

N/A

Summary of evidence

Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).

Limitations

Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).

Conclusions

Provide a general interpretation of the results in the context of other evidence, and implications for future research.

Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review.

N/A

RESULTS

DISCUSSION

FUNDING Funding

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097

For more information, visit: www.prisma-statement.org.

ABSTRACT Assessment of medical tourism effectiveness in treating patient in Asia: A systematic review Ave Maria, Shantidewi, Dita Widirahmayanti, Fatimah Az Zahra AMSA-Universitas Brawijaya Introduction: Due to globalization, many people can access to international transport and have greater awareness about health. The reasons are based on their expectation and ability to get certain medical service. Medical tourism is the movement of prosumers (to other countries) in order to acquire health services of high (repetitive) quality, an adequate level of safety and competitive prices. Although the primary motive of such travel is seeking medical care that is not easily accessible or available in the home country, patients have been found to incorporate leisure, fun, and relaxation activities as part of their decision (Zolfagharian, 2018). These factors can affect the effectiveness of medical tourism in treating patient. Material and Methods: Systematic review about assessment of medical tourism effectiveness in treating patient in Asia was carried out using PRISMA statement. Studies search were conducted using search engine Science Direct, PubMed, and SpringerLink database with keyword “medical tourism”, “effective”, “Asia” with criterion: papers published in English between 2015 until 2019; observational studies; and related about medical tourism effectiveness in treating patient. Quality assessment of included papers was conducted using STROBE statement checklist for observational studies. Result and Discussion: From the search, 552 studies were identified and finally obtained 13 studies that fulfill criterion of this systematic review. We assessed each specific area of The Dimensions of Access (Pechansky and Thomas, 1981) in association to the medical tourism in each article that we reviewed. We found that the execution of medical tourism went well in order to giving foreign patients the best treatment but several flaws are still there. Medical tourism provides treatment that not available in foreign patients’ home country and give them satisfaction. Policy development has done also to attract foreign patients. But there are issues in medical tourism including language and culture difference, cost, etc. Conclusion: Medical tourism in Asia is effective enough to fulfill health treatment demand, yet there are some aspects that requires improvement. Medical tourism in Asia has achieved most of the dimensions of access in order to fulfill the demand domestically and also from foreign countries, although there are requirements to improve the dimension of accessibility, acceptability, and especially affordability. Keywords: medical tourism; effective; concept of access; Asia

Assessment of medical tourism effectiveness in treating patient in Asia: A systematic review Pre-Conference Competition Asian Medical Studentsâ&#x20AC;&#x2122; Conference 2019

By: Ave Maria Shantidewi Dita Widirahmayanti Fatimah Az Zahra

Faculty of Medicine Universitas Brawijaya 2019

INTRODUCTION Medical tourism is a particular form of patient mobility, where patients travel across borders or to overseas destination in order to receive treatments, acquire health services of high (repetitive) quality, an adequate level of safety and competitive prices (Zolfagharian,2018; Lunt, 2016). With the increasing of globalization, many people can access international transport provider and have greater awareness about health. There are some reasons supporting this statement such as long waiting lists in many industrial countries, high rate failure of medical procedures in some countries, the high cost of medical services in developed countries, the developing countries’ considerable progress in medicine, facilitated traveling, and more or less uniform medical procedures standards (Rezaee, 2016). But mostly, medical travel was done by patient from less developed countries to major medical centers in developed country for treatment that was not available in their home country. Indonesia, one of developing country, spent approximately Rp 100 trillion per year for medical treatment overseas. In 2015, there were reportedly 600,000 patients from Indonesia seeking medical treatment overseas, up from 350,000 in 2006. Among the top destinations are neighboring island-state of Singapore (Tjahjono, 2018). It means that most people in Indonesia are hesitant the quality of health service in their country. Eventually, they would prefer to go to another country to fulfill satisfaction about adequate health and/or good medical infrastructure. One of the reasons that cause Indonesians to go overseas is the easier access to get information about medical tourism. The internet, as a significant source of health and healthcare information, plays an important role in the development of the medical tourism industry. Patients use the Internet not only to gather general health information but also to identify the specific types of medical services available in hospitals at home and abroad (Moghavvemi, 2017). Moreover, medical facilities can influence development of medical tourism’s interest. An excellent service (professional, wholeheartedly and oriented to the patient) will be able to attract new patients and maintain their loyalty (Narottama, 2017). We measure the effectiveness by using The Dimensions of Access defined by Pechansky and Thomas (1981), which includes the specific areas of availability, accessibility, accommodation, affordability, and acceptability. Overall, this systematic review aims to assess the effectiveness of medical tourism that can be an inspiration for health care provider to enhance medical tourism’s system. MATERIAL AND METHODS a. Study Search Strategy We conducted a systematic review of observational studies using PRISMA statement. Three search engines were used, which are ScienceDirect, PubMed, and Springer Link, by the following keywords: “medical tourism”, “effective”, “Asia”. We set inclusion criteria to filter the results including, 1) papers published in English within 2015-2019, 2) research conducted in Asia, 3) observational

studies. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement was used to evaluate observational studies that we got to enhance the quality of reporting. b. Data extraction Afterward, we set necessary data to be extracted from articles including: dimension of access, author and year of publication, study design, location, and conclusion. The study selection process is shown in Figure 1.

Records identified through database searching from Science Direct, PubMed, and Springer Link (n=552) Records excluded Duplicates excluded (n=1) Irrelevant topics (n= 506) Records screened (n=45)

Full text eligible observational studies included in review (n=13)

Full text excluded: Study not conducted in Asia (n=16) Not observational study (n=14) Full text not available (n=2)

Figure 1. PRISMA flow chart of study selection RESULT The literature search was conducted through ScienceDirect, PubMed, and Springer Link. In total, 13 articles fulfilled the inclusion criteria. The data characteristics of included studies are shown in Table 1. The findings of this review describe how the medical tourism conducted in several countries across Asia. The studies are organized to The Dimensions of Access defined by Pechansky and Thomas (1981) as the following: Availability Accessibility Accommodation Affordability Acceptability

Table 1. Characteristics of included studies Dimension of

Reference

access

Study

Location

Conclusion

design

Accessibility,

Khalil Momeni

acceptability

et al. (2018)

Survey

East

Main barriers to medical tourism in

Azerbaijan,

East

Iran

Language and communication, cultural,

Azerbaijan

hospitals

and

province,

clinics,

management,

policies

structural,

transfer,

are:

marketing, and

rules, brokers,

international. Availability

S. Ganguli, A.H. Case Ebrahim (2017)

Singapore

study

Seven

interrelated

pillars

that

effectively synthesize what is meant by Singaporeâ&#x20AC;&#x2122;s medical tourism model competitiveness,

are:

tourism

strategic

sector,

Public-Private

enabling planning,

Partnerships

(PPPs),

marketing and branding strategies, technology

and

innovation,

accreditation and governance, human capital development. Accomodation,

S. Moghavvemi,

Cross-

India,

Hospital websites are not sole source of

acceptability

et al. (2017)

sectional

Malaysia,

information or contact points for

and

(prospective)

Thailand

Some websites particularly provide

international

patients.

more individualized customer-centered and culturally-sensitive guidance and support concerns.

regarding Medical

non-medical advertising

restrictions and consumer protection legislation in each country play an important role here. The hospital

websites in our sample appear to target people from upper- and middle-income countries and elite from lower-income countries who are competent internet users. Availability

H.K. Lee, Y.

Survey

Malaysia

Fernando (2015)

Medical tourism as a business and a key

sub-sector

the

Malaysian

tourism industry has to further improve the supply chain management in its operations

gain

advantage,

and

competitive

outperform

rival

countries. The result of this study has shown

that

collaboration

trust have

and a

MTSC

significant

relationship. Affordability,

M. Jaapar et al.

Cross-

acceptability

(2017)

sectional

Malaysia

Two travel motivation dimensions i.e. dental care quality and dental care information access positively influenced overall satisfaction. There

negative

relationship

between cultural similarity and overall satisfaction. Cost-savings is an important factor especially among upper and lower middle-aged groups compared to the younger or senior, while the lower middle-aged group was the more satisfied group. Affordability

Mariyam

Cross-

The

Catastrophic

Suzana et al.

sectional

Maldives

unavoidable to many medical travelers

(2015)

health

spending

was

in the Maldives, despite government

subsidy, and MTO (Medical Treatment Overseas) places a heavy financial burden on the economy of the country. Many studies have so far established that

transport

costs

have

serious

implications for the accessibility of health care for the people in need. Geographical inequality in access to public funds for MTO and the disproportionate burden of travel cost in the home country borne by MTO travelers from rural areas need to be addressed in order to minimize the burden of MTO. Availability,

M. Said Yildiz

Case

acceptability,

and M. Mahmud

study

affordability

Khan (2016)

Turkey

Specializing

specific

types

medical treatments should improve efficiency of the health system and help attract foreign patients to the country. Competitive

advantage

global

medical tourism market requires not only the presence of high-quality hospitals and medical professionals in the country, but also the development of hospitals and medical facilities that provide services mainly to patients from other countries. If the medical facilities providing services to medical tourists

can

advantage

maintain

without

their

sacrificing

costthe

quality of care, demand for medical services by patients from outside the country is likely to expand and fertility

treatment may be used by policymakers as the catalyst for future development of the sector. Affordability,

Mariyam

Cross

The

Affordability:

Despite

universal

availability,

Suzana et al.

sectional

Maldives

health care, a substantial proportion

accessibility

(2018)

of travelers have declined the government subsidy, and findings also point towards the fact that the poor have not accessed medical travel. In addition, a third of participants reported not having sufficient funds for the treatment episode abroad. There is existing evidence of differential use of health services by the poor, due to stigma, transportation costs, while higher levels of ill health is existent among the poor. Continuity of care: More than a third

the

patients

had

experienced complications arising from the treatment overseas and two thirds had faced problems with communication. Availability: the medical travelers from the Maldives were driven to seek care abroad due to the unavailability of health services in the home country and for quality healthcare. Acceptability,

Rokni, L., Avci,

availability

T., and Park, S.

Survey

South

South Korea as the top destination in

Korea

medical

tourism

high

quality

H (2017)

infrastructure based on new emerged technologies.

Korean

government

reconfigure the policy and planning, especially in promotion to increase number of foreign patients. Korea also appear

solve

the

barriers

communication skill and training by recent training support and encouraging plan. Government as key factor among the barriers. Accommodation,

Abubakar

Survey

Turkey

Online WOM (world-of-mouth) has a

accessibility

Mohammed &

significant impact on destination trust

Mustafa Ilkan

and intention to travel. Structural

(2016)

modeling

revealed

that

income

strengthens the relationship between online WOM and intention to travel by increasing the likelihood of travel. Destination marketers should organize and create point-of-service activities in the form of service trials to form medtourist

impression

about

their

experience. Availability

Seow Ai Na et al (2015)

Survey

Malaysia

Marketing

practitioners

play

important role in promoting medical tourism in Malaysia. The Malaysia Government

consider

collaborating

with private hospitals to develop more foreign tourists in seeking medical tourism in Malaysia and also capitalize Kuala Lumpur as Asiaâ&#x20AC;&#x2122;s premier multiracial

cosmopolitan city with

unique lifestyle. The concept of safe

environment also plays an important role in attracting foreign tourists to Malaysia. Accommodation

Prajitmutita et al

Survey

Thailand

(2016)

Service quality and perceived value are cognitive components that precede satisfaction as affective response in the integrative model. Service quality, perceived value and satisfaction have different influence on medical tourist behaviors. Service quality influences perceived value, which has a significant direct influence on medical tourist behavioral intentions that mediate by perceived value and satisfaction.

Accomodation

Heesup Han et

Cross-

al (2015)

sectional

Korea

Four major factors of possible outcome from staying in medical hotel: financial saving, convenience, medical service, hospitality products. These outcomes moderate the linkage from attitude and desire to intention so customers will stay in medical hotel. Medical tourist desire is important to stimulate their compliance to visit medical hotel. Cognitive and affective variable are efficiently induce desires, for instance well designed advertising can increase international travelerâ&#x20AC;&#x2122;s desires to stay in a medical hotel.

DISCUSSION a. Analysis of studies Based on the systematic review, we assessed each specific areas of The Dimensions of Access (Pechansky and Thomas, 1981) in association to the medical tourism in each article that we reviewed.

Availability: Some people are willing to travel to other countries seeking for medical treatment due to some reasons, one of the main reasons is to find better and higher quality of healthcare in another country (Rokni et al., 2017). For example, Turkey has devoted to improve and specialize its technology and service quality in IVF, therefore it can have its demand increased in IVF care from other countries (Yildiz & Khan, 2016). Many other healthcare providers are continuously increasing the quantity and quality of the healthcare services in their countries, not only to compete with other countries, but also most importantly to be able to fulfil the healthcare demand in their own countries, and at the same time to welcome the tourists that are willing to utilize the medical services in the country. Therefore, in order to optimize the medical tourism sector in the country, it is essential for healthcare providers to master in certain specialities so that they can provide relatively better healthcare services. This also correlates with the increasing of affordability of the access of medical tourism; the more demand to certain health services, the cheaper the service cost might be, and therefore the more affordable the service is. Other than improving specialities, another aspect that need to be considered in competing in medical tourism sector is the management of the service itself, an example applied in Malaysia is developing Tourist Supply Chain Manager and also involving the marketing itself (Lee & Fernando, 2015 ; Na et al., 2015). The same as in Singapore that have seven pillars as the foundation of the medical tourism model, also including partnerships, human development, also accreditation and governance (Ganguli & Ebrahim, 2017). Besides seeking better health services in other countries, medical tourism happens also due to the unavailability of certain health services in the home country, one of which can be caused of geographical problem. For example, in The Maldives, people have to go to other neighbor countries to find neoplastic subspeciality healthcare. The access to that country is still difficult and so the availability of all healthcare speciality or subspeciality is not complete yet (Suzana et al., 2018). Accessibility: Based on the study, we know that access is one of the most important parts of medical tourism. The main concern for foreign patients after improving their health and receiving treatment was method of transfer to the destination country. There was no integrated management system in place to transfer foreign patients (Momeni,2018). Therefore, patients need look for information about destination

countries as much as possible. The improvement of hypermedia has led to an increase in the number of people using the Internet to access information about a product and/or service and also do consulting online reviews (Mohammed, 2016). As the patients had travelled for a wide variety of medical treatments, establishing cost effective measures of prevention and follow up care at the home country may help to reduce medical travel (Suzana, 2018). For the amenities, patients are recommended to ensure access is used when taking a medical trip : suitable, affordable, and have a universal quality. Accommodation: Medical Tourism comprises both medicine and tourism, this offering requires excellent coordination of the health-care and tourism industries. So, many industries develop medical hotel to combine medical treatment, restaurants, and rooms on one property that will offers convenience to customers. There are four major factors of possible outcome from staying in medical hotel : financial saving, convenience, medical service, hospitality products (Han et al., 2015). In the other study reinforce that service quality can influences perceived value, which has a significant direct influence on medical tourist behavioral intentions. Perceived value is a key factor to achieving medical tourist loyalty (Perenyi et al, 2016). Moreover, in this era, people can access information easily, especially about health. Websites of hospitals promoting medical tourism can provide more reliable, credible and indepth medical and nonmedical information that will satisfy the needs and concerns of medical tourists of diverse socio-economic, cultural and linguistic backgrounds. Website interactivity is an important factor in influencing these consumers' perceptions of trust, positive attitudes towards site content and intention to purchase products and services (Moghavvemi et al, 2017). Online WOM (Word of Mouth) communication also provide patient to share their own impressions and experiences via online, so millions of potential medical tourists can know peopleâ&#x20AC;&#x2122;s testimony and enable them to make the best decision (Mohammed, 2016). Affordability: We found in the articles that we reviewed that there is economic burden to undergo medical treatment overseas. The foreign patients should spend more on travel cost to go to the destination country (Suzana et al, 2015). In the study that conducted in Iran, the economic burden also brought about by dominance of brokerage since they can charge extra money to the foreign patients. Moreover, the foreign patients get in trouble to exchange their currency (Momeni et al, 2018). However, cost-savings was another important motivational dimension for medical tourists in influencing overall satisfaction. Some of the items within this dimension measured more in terms of general holiday motivation (e.g. attractive travel/tourism package, opportunity to visit other tourist attractions and reasonable cost for

quality accommodation) and only two items measured specifically dental related motivations (convenient location of dental clinic and affordable dental care) (Jaapar et al, 2017). Acceptability: In the articles that we reviewed, the foreign patients received different handling regarding how the healthcare providers undergo the treatment in foreign countries. Momeni et al. (2018) found that moral abuse of patients and their relatives was another issue. There is negative relationship between cultural similarity and overall satisfaction. (Jaapar et al, 2017). However, there are two studies that we reviewed that the destination country put effort to attract foreign patients. shows that Korean government reconfigure the policy and planning, especially in promotion to increase number of foreign patients (Rokni et al, 2017). This shows that they want to make Korean medical treatment good enough to be given to foreign patients. In Tukey, competitive advantage in global medical tourism market requires not only the presence of high-quality hospitals and medical professionals in the country, but also the development of hospitals and medical facilities that provide services mainly to patients from other countries (Yildiz & Khan, 2016). Therefore, not all countries have put their maximum effort to make the foreign patients acceptable by the healthcare providers. b. Limitation of The Study This systematic review has limitation. The articles that we reviewed conducted in just certain country in Asia. Not all country in Asia involved in the articles. Hence, the result of our review may not portray the real condition of medical tourism in Asia. The sample amount is small in several studies, also there is bias in studies that may also affect the results.

c. Future Application and Research Although plenty of studies have shown the condition of medical tourism in some country in Asia, we recommend further studies to every country in Asia regarding this matter. Not just in the destination country, but in patientsâ&#x20AC;&#x2122; origin country. We recommend that studies should be conducted on this topic further in order to make health access easier, as it should be knows no border.

CONCLUSION Medical tourism in Asia is effective enough to fulfill health treatment demand, yet there are some aspects that requires improvement. Medical tourism in Asia is developing time by time, especially in increasing the quantity and improving the quality of the health services conducted in each country. Therefore, many countries have been able to achieve the availability of the healthcare service, so they can fulfill the demand domestically and also foreign patients. Seen from the aspect of accessibility, the transfer of foreign patients needs to be simplified in order to increase the accessibility, although the access of information about the medical tourism in most countries is already easily accessible from the internet. Collaboration between healthcare sector and tourism industries is essential to develop good medical tourism system and to provide enough accommodation to the foreign patients; it has already been achieved in some countries that entitled most visited destinations for medical tourism. Economic burden is still the most considerable burden to the people from developing countries that want to access medical tourism to other countries. Not all countries yet have put their maximum effort to make the foreign patients acceptable by the healthcare providers because only a few countries so far that are seen to be concerned to foreign tourism. Language and culture difference is one of considerable burden in the acceptability of multinational medical tourism. The running of medical tourism is synergistic with other government agencies such as academics, tourism, society and the media as a global link. The government has an important role in the implementation and development of medical tourism through policies issued. Policies that are made will affect the quality of services provided to patients, such as increased infrastructure, experts, and regulations issued. In conclusion, medical tourism in Asia has achieved most of the dimensions of access in order to fulfill the demand domestically and also from foreign countries, although there are requirements to improve the dimension of accessibility, acceptability, and especially affordability.

REFERENCES Abubakar, A., & Ilkan, M. (2016). Impact of online WOM on destination trust and intention to travel: A medical tourism perspective. Journal Of Destination Marketing & Management, 5(3), 192-201. Ganguli, S., & Ebrahim, A. (2017). A qualitative analysis of Singapore's medical tourism competitiveness. Tourism Management Perspectives, 21, 74-84. Han, H., Kim, Y., Kim, C., & Ham, S. (2015). Medical hotels in the growing healthcare business industry: Impact of international travelers' perceived outcomes. Journal Of Business Research, 68(9), 1869-1877. Jaapar, M., Musa, G., Moghavvemi, S., & Saub, R. (2017). Dental tourism: Examining tourist profiles, motivation and satisfaction. Tourism Management, 61, 538-552. Lee, H., & Fernando, Y. (2015). The antecedents and outcomes of the medical tourism supply chain. Tourism Management, 46, 148-157. Lunt, Neil, et al. 2016. Medical Tourism: a snapshot of evidence on treatment abroad. Maturitas volume 88 pages: 37-44. Moghavvemi, S., Ormond, M., Musa, G., Mohamed Isa, C., Thirumoorthi, T., Bin Mustapha, M., Kanapathy, K. and Chiremel Chandy, J. (2017). Connecting with prospective medical tourists online: A cross-sectional analysis of private hospital websites promoting medical tourism in India, Malaysia and Thailand. Tourism Management, 58, pp.154-163. Momeni, K., Janati, A., Imani, A. and Khodayari-Zarnaq, R. (2018). Barriers to the development of medical tourism in East Azerbaijan province, Iran: A qualitative study. Tourism Management, 69, pp.307-316. Na, S., Onn, C., & Meng, C. (2016). Travel Intentions among Foreign Tourists for Medical Treatment in Malaysia: An Empirical Study. Procedia - Social And Behavioral Sciences, 224, 546553Narottama, N. and Susiyanthi, A. (2017). HEALTH TOURISM IN ASIA: THE READINESS OF BALI'S HEALTH TOURISM. Journal of Business on Hospitality and Tourism, 2(1), p.16. Penchansky, R., & Thomas, J. (1981). The Concept of Access. Medical Care, 19(2), 127-140. Prajitmutita, L., Perényi, Á., & Prentice, C. (2016). Quality, Value? – Insights into Medical Tourists’ Attitudes and Behaviors. Journal Of Retailing And Consumer Services, 31, 207-216Rezaee R, Mohammadzadeh M. Effective factors in expansion of medical tourism in Iran. Med J Islam Repub Iran 2016 (5 September). Vol. 30:409. Rokni, L., Avci, T., & Park, S. H. (2017). Barriers of Developing Medical Tourism in a Destination: A Case of South Korea. Iranian journal of public health, 46(7), 930–937

Suzana, M., Mills, A., Tangcharoensathien, V., & Chongsuvivatwong, V. (2015). The economic burden of overseas medical treatment: a cross sectional study of Maldivian medical travelers. BMC Health Services Research, 15(1). Suzana, M., Walls, H., Smith, R., & Hanefeld, J. (2018). Understanding medical travel from a source country perspective: a cross sectional study of the experiences of medical travelers from the Maldives. Globalization And Health, 14(1). Tjahjono, T., Honoris, H., Jegho, L., (2018). Why Singapore Hospitals are Attractive for Indonesian Patients?.

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The Characteristics Of Radiological Examination Of MDR TB Patients In Southeast Sulawesi Halu Oleo University Sandradevi, I Dewa Ayu Meyta Putri1, Alfiyyah Hastari Syaf2, Muhammad Syarif Hidayat Ruslan3

Drug-resistant TB is a TB disease caused by Mycobacterium tuberculosis germs that have experienced immunity to OAT. MDR TB (Multi Drugs Resistent) is one type of tuberculosis bacterial resistance to at least two first-line anti TB drugs, namely Isoniazid and Rifampicin which are the two most effective TB drugs for TB treatment applied to the Directly Observed Therapy Short-Course (DOTS) strategy . Globally in 2013, an estimated 3.5% of new cases and 20.5% of cases of tuberculosis re-treatment, contracted MDR TB. Thus around 480,000 people are estimated to be infected with MDR TB. In Indonesia it is estimated that 2% of new tuberculosis cases and 12% of tuberculosis cases with repeat treatment are cases of tuberculosis caused by MDR TB. In addition, it is suspected that there are still more than 55% of MDR TB patients not yet detected and getting the right treatment. The incidence of MDR TB in Southeast Sulawesi is spread across various districts, namely the city of Kendari reaching 3.03%, Kabupaten Muna reaching 0.77%, Kabupaten Konawe reaching 2.04%, Bau-Bau reaching 1.57%, Kabupaten Konawe Selatan reaching 1, 5%, North Konawe Regency reaches 2.7% and Wakatobi reaches 6.54% of MDR TB incidence. The absence of research on the characteristics of the results of radiological examination and BTA sputum in MDR TB patients in Southeast Sulawesi, this study aims to increase the knowledge of many people that the treatment of TB disease should be a special concern in the community. This research is a descriptive study with a cross sectional design. The population in this study were all patients diagnosed with MDR-TB in Southeast Sulawesi Province in 2014-2017 as many as 40 MDR TB patients consisting of 28 men, 12 women aged 15-55 years, 34 people and age> 56 years as many as 6 people. In this study secondary data were obtained from the Southeast Sulawesi Provincial Health Office and medical record data at Bahteramas General Hospital in Southeast Sulawesi Province. The data dipole will be processed using a computer program. Based on investigations of TB (chest X-ray), there were 14 chest X-ray images of infiltrates and cavities (35%) while the results of sputum examination in patients with multidrug resistant tuberculosis ) most found in BTA (+1) totaling 21 people (52.5%). Keywords : Radiology Examination, Sputum BTA, MDR TB

The Characteristics Of Radiological Examination Of MDR TB Patients In Southeast Sulawesi

Authors : I Dewa Ayu Meyta Putri Sandradevi Alfiyyah Hastari Syaff Muhammad Syarif Hidayat Ruslan

Medical Faculty Halu Oleo University Kendari 2019

Introduction Tuberculosis Resistant is a disease that caused by Mycobacterium tuberculosis bacterial that already resistant to anti-TB drug. One of the drug-resistant TB that is currently of concern is TBMDR (Multidrug Resistance Tuberculosis). MDR-TB is one type of tuberculosis bacterial resistance to at least two first line of anti-TB drug, such as Isoniazid and Rifampicin that actually is two types of anti-TB drug that the most efficient to the patient who had Tuberculosis and these two types of drugs is already applied in Directly Observed Therapy Short-Course (DOTS) strategy. Tuberculosis especially Multidrug Resistance Tuberculosis (MDR-TB) is one of health concern that must be overcome, because the incidence of these disease is increased every year and that make an impact on increasing the incidence of Extensively Resistant Tuberculosis (XDR-TB) (Ministry of Health, 2014) Multidrug Resistance (MDR TB) is tuberculosis due to infection with Mycobacterium tuberculosis that has been resistant to rifampicin and isoniazid with or without resistance to other antiTB drugs. Rifampicin and isoniazid are two very important drugs in TB treatment that are applied to the DOTS strategy (WHO,2016) Generally, the types of Anti TB drug resistance is divided into : a. Primary resistance is if a patient has never received OAT treatment or has received OAT treatment for less than 1 month b. Initial resistance is if it is not known with certainty whether the patient has had a history of OAT treatment before or has not c. Secondary resistance is when the patient has a history of OAT treatment of at least 1 month (Soepandi, 2010) Globally in 2013, an estimated 3.5% of new cases and 20.5% of cases of tuberculosis retreatment, contracted MDR TB. Thus around 480,000 people are estimated to be infected with MDR TB. Tuberculosis is a serious problem in Indonesia, because Indonesia is still included in countries with

tuberculosis

pain

burden

and

high

prevalence

MDR

(WHO,

2014).

Indonesia is one of 27 other countries in the world with a large number of MDR TB cases, there are 6800 new cases of MDR TB each year. The 2013 Global TB Report data showed MDR TB rates in patients who had never received OAT treatment before, around 1.9% and around 12% for those who had previously received OAT treatment. TB is said to be drug resistant if there is resistance to OAT (Ministry of Health, 2014) In Indonesia it is estimated that 2% of new tuberculosis cases and 12% of tuberculosis cases with repeat treatment are cases of tuberculosis caused by MDR TB. In addition, it is suspected that there are still more than 55% of MDR TB patients not yet detected and getting the right treatment (Ministry of Health, 2015) WHO estimates that there are 480,000 MDR TB cases worldwide, while deaths from MDR TB are estimated at 250,000 cases in 2015. WHO in the 2015 Global Tuberculosis Report reports that

Indonesia is one of the 27 other countries in the world with a large number of MDR TB cases, namely there are 6800 new cases of MDR TB each year. An estimated 1.9% of new TB cases and 12% of TB cases are re-treated. Based on the 2017 Annual Report, Indonesia ranks second in the highest cases of MDR TB in Southeast Asia after India (WHO, 2016). The incidence of MDR TB in Indonesia increases every year. In 2012 in Indonesia there were 696 MDR TB cases, in 2013 it increased to 1,094 cases, then in 2014 to 1,752 cases and in 2015 in Indonesia there were 1,860 confirmed cases of MDR TB, 15,380 suspected cases of MDR TB and 1,566 cases treated (Ministry of Health, 2016). Based on data from the Southeast Sulawesi provincial health office MDR TB cases increased every year, namely in 2014 there were 7 MDR TB patients, in 2015 there were 8 MDR TB patients, in 2016 there were 23 MDR TB sufferers, and in 2017 there were 28 MDR TB patients. In 2016, the incidence of MDR TB in Southeast Sulawesi was spread across various districts, namely the city of Kendari reaching 3.03%, region of Muna reaching 0.77%, region of Konawe reaching 2.04%, Bau-Bau reaching 1.57%, South Konawe reaches 1.5%, North Konawe reaches 2.7% and Wakatobi reaches 6.54% incidence of MDR TB (Central Sulawesi Health Office, 2016). The absence of research on the characteristics of radiological examination of chest X-ray MDR TB patients in Southeast Sulawesi, it is necessary to conduct research on the characteristics of radiological examination of chest X-ray MDR TB patients in Southeast Sulawesi in 2014-2017, as data so that management of MDR TB can be handled appropriately. Materials and Methods This study was a descriptive study with a cross sectional design to determine the characteristics of radiological examination of MDR TB patients in Southeast Sulawesi Province in 2014-2017 through data and medical records as research data. This research was conducted in January-February 2019 at the Southeast Sulawesi Provincial Health Office and Bahteramas General Hospital in Southeast Sulawesi Province. The population in this study were all patients diagnosed with MDR-TB in Southeast Sulawesi Province in 2014-2017. The sample in this study were all MDR TB patients in Southeast Sulawesi Province in 2014-2017 who met the inclusion and exclusion criteria using the total sampling method. In the study there were inclusion and exclusion criteria from the study sample, including: a. Inclusion criteria The inclusion criteria in the study sample were 1) Patients diagnosed with MDR-TB 2) Medical record data is clear and complete b. Exclusion criteria Exclusion criteria in the study sample were 1) The patient has extra pulmonary TB

In collecting data the research tools and materials used are medical records, pens, paper and computers. Ethical aspects in research are maintaining the confidentiality of the patient's identity and the confidentiality of the information obtained. In this study secondary data were obtained from the Southeast Sulawesi Provincial Health Office and medical record data at Bahteramas General Hospital in Southeast Sulawesi Province. The data obtained will be processed using a computer program. Steps for processing data include: a. Editing, namely an attempt to re-examine the correctness of data obtained or collected. b. Coding, which is giving numeric codes (numbers) to data to facilitate data processing. c. Entry, which is entering data to be processed using a computer. d. Tabulating, namely grouping data according to the variables to be studied so that they are easily added up, arranged, and arranged to be presented and analyzed. e. The operational definition of research is: Table 1. Operational Definition Variable

Definition

Result

Additional

A medical examination is carried out

1. Radiography

Examination

on certain indications to obtain more

2. Sputum (BTA)

complete

information.

Examination

for

TB,

Supportive namely

radiological examination, laboratory examination consisting of blood and sputum (Amin, 2014)

Results The study was conducted at the Southeast Sulawesi Provincial Health Office and Bahteramas General Hospital in Southeast Sulawesi Province. The sample in this study were all patients with MDR TB in Southeast Sulawesi Province in 2014-2017 with the sampling method being total sampling. In this study secondary data were obtained from data from the Southeast Sulawesi Provincial Health Office and medical record data at Bahteramas General Hospital in Southeast Sulawesi Province to determine the characteristics of MDR TB patients in Southeast Sulawesi Province in 2014-2017 1. Characteristics of MDR TB patients in Southeast Sulawesi from 2014-2017 Distribution of samples of patients with MDR TB by age can be seen in table 2.

Table 2. Distribution of the number and percentage of characteristics of Multidrug Resistant Tuberculosis (MDR TB) patients in Southeast Sulawesi in 2014-2017 based on age. Age

Total

Percent (%)

15-55 years old

>56 years old

Total

100%

Source : Secondary data. Table 2 shows that the highest age group in Multidrug Resistant Tuberculosis (MDR TB) patients is in the productive age, namely the age group of 15-55 years, amounting to 34 people (85%) and age> 56 years totaling 6 people (15%). 2. Sex characteristics of MDR TB patients in Southeast Sulawesi in 2014-2017 Distribution of samples of MDR TB patients by sex can be seen in table 3. Table 3. Distribution of the number and percentage characteristics of Multidrug Resistant TB in Southeast Sulawesi in 2014-2017 based on Gender Gender

Total

Percent (%)

Male

Female

Total

100%

Source : Secondary data. Table 3 shows that there are more men than women in Multidrug Resistant TB (MDR TB). There are 28 men (70%) and 12 women (30%). 3. Characteristics of work for MDR TB patients in Southeast Sulawesi in 2014-2017 Distribution of samples of patients with MDR TB based on work can be seen in table 4. Table 4. Distribution of the number and percentage of characteristics of Multidrug Resistant TB in Southeast Sulawesi in 2014-2017 based on occupation Occupation

Total

Percent (%)

Civil Servant

Entrepreneur

27,5

farmer

Housewife

Student

7,5

Unemployment

100%

Total Source: Secondary data

Table 4 shows that in many Multidrug Resistant Tuberculosis (MDR TB) patients who work, they work as entrepreneurs totaling 11 people (27.5%), employees (PNS) totaling 4 people (10%), and farmers totaling 8 people (20% ) Patients who did not work consisted of housewives totaling 6 people (15%), 3 students (7.5%) and unemployment totaling 8 people (20%). 4. Characteristics of the history of treatment of pulmonary TB patients with MDR TB in Southeast Sulawesi in 2014-2017 The distribution of samples of MDR TB patients based on a history of pulmonary TB treatment can be seen in table 5. Table 5. Distribution of the number and percentage of characteristics of Multidrug Resistant Tuberculosis (MDR TB) patients in Southeast Sulawesi in 2014-2017 based on a history of pulmonary TB treatment Medical History of pulmonary TB

Total

Percent (%)

New Case

Relapse

32,5

Default

62,5

Failure

Transfer In

Other Case: Chronic case

Total

100

Source : Secondary data Table 5 shows that the most multidrug resistant tuberculosis (MDR TB) patient based on the history of pulmonary TB treatment found 25 treatment dropouts (62.5%), 13 relapse cases (32.5%), 2 new cases (5%), cases failed, transfer cases and chronic cases not found (0%).

5. Characteristics of radiological sign for MDR TB patients in Southeast Sulawesi in 2014-2017

The distribution of samples of MDR TB patients based on TB investigations (chest X-ray) can be seen in table 6. Table 6. Distribution of the number and percentage of characteristics of Multidrug Resistant (MDR TB) patients in Southeast Sulawesi in 2014-2017 based on investigations of TB (Chest X-ray) Radiological Sign

Total

Percent (%)

Infiltrates and cavities

Infiltrates and opacities

17,5

Infiltrates and fibrosis line

Opacities and cavities

Infiltrates

Cavities

12,5

Opacities

Total

100%

Source : Secondary data Table 6 shows that in patients with Multidrug Resistant Tuberculosis (MDR TB) based on TB investigations (chest X-ray), there were 14 chest X-ray images of infiltrates and cavities (35%), infiltrates and opacities of 7 people (17.5%), infiltrates and fibrosis line numbered 2 people (5%), opacity and cavity amounted to 2 people (5%), infiltrates totaling 6 people (15%), cavities totaling 5 people (12.5%), and opacity totaling 4 people (10% ) In addition to chest X-ray examination, examination of other supporting MDR TBs studied was sputum examination. The distribution of samples of patients with MDR TB based on investigations of TB (sputum examination) can be seen in table 7. Table 7. Distribution of the number and percentage of characteristics of Multidrug Resistant (MDR TB) patients in Southeast Sulawesi in 2014-2017 based on TB investigation (Sputum Examination) Sputum Examination

Total

Percent (%)

12,5

52,5

1-9

2,5

7,5

Total

100%

Source : Secondary data Table 7 shows that the highest results of sputum examination in patients with Multidrug Resistant TB

(MDR TB) were found in (+1) totaling 21 people (52.5%). Furthermore, successive (+3) totaled 10 people (25%), (+2) amounted to 5 people (12.5%), (-) totaled 3 people (7.5%) and (1- 9) totaling 1 person (2.5%).

Discussion Characteristics of radiological examination with BTA sputum in MDR TB patients in Southeast Sulawesi in 2014-2017 The results showed that in patients with Multidrug Resistant Tuberculosis (MDR TB) based on TB investigations (chest X-ray), the most chest X-ray images were obtained with infiltrates and cavities totaling 14 people (35%). The results of this study are in line with the research conducted by Asmalina (2016), which found radiological abnormalities of chest X-ray in the form of cloudy spots (infiltrates), which amounted to 28 people (90.32%) accompanied by a description of cavity and pleural effusion of 2 people (6.45%) and 1 person (3.23%). The results showed that the results of sputum examination in patients with Multidrug Resistant Tuberculosis (MDR TB) at most in (+1) amounted to 21 people (52.5%), (+3) amounted to 10 people (25%), (+ 2) amounting to 5 people (12.5%), (1-9) totaling 1 person (2.5%) and (-) totaling 3 people (7.5%). The results of this study are in line with the research conducted by Mulyadi (2011), which is obtained samples with sputum examination results (+1) Total of 15 people (44.1%), (+2) and (+3) have the same results ie -one of 7 people (20.6%) and (-) totaling 5 people (14.7%). Pulmonary tuberculosis patients who have (+) sputum are highly infective people transmitting pulmonary tuberculosis infection to others. The higher the positive degree of phlegm examination results, the higher the level of transmission to other people. The high number of cases of smear TB (+) needs to be watched out so that there is no transmission of tuberculosis because based on data from the Southeast Sulawesi Provincial Health Office in 2016, cases of smear (+) in Southeast Sulawesi are found, namely 3,105 new cases of positive in sputum examination in (Provincial Health Southeast Sulawesi, 2016) This study only explains the characteristics of the results of radiological examination with sputum examination in MDR TB patients without explaining other criteria so that further research needs to be done.

Conclussion

The results showed that in patients with Multidrug Resistant Tuberculosis (MDR TB) based on tuberculosis examination (chest X-ray), the highest chest x-ray images were obtained with infiltrates and cavities of 14 people (35%), and results of sputum examination in Multidrug Resistant

Tuberculosis MDR) at most (+1) totaling 21 people (52.5%), (+3) totaling 10 people (25%), (+2) totaling 5 people (12.5%), ( 1-9) totaling 1 person (2.5%) and (-) totaling 3 people (7.5%). Reference Amin, Z., Bahar, A., 2014. Buku Ajar Ilmu Penyakit Dalam: Tuberkulosis. Jilid I. Ed VI. Interna Publishing. Jakarta. Dinas Kesehatan Provinsi Sulawesi Tenggara. 2018. Profil Kesehatan Sulawesi Tenggara Tahun 2017. Data & Informasi Dinas Kesehatan Provinsi Sulawesi Tenggara. Kendari. Kemenkes RI. 2014. Pedoman Nasional Pengendalian Tuberkulosis. Direktorat Jenderal Pengendalian Penyakit dan Penyehatan Lingkungan. Jakarta. World Health Organization (WHO). 2017. Global Tuberculosis Report 2016. Switzerland.

Stigma as a Factor of Healthcare Accessibility Problem Jeanette Sefanya Yefta, Michelle Joshalyn Natasha, David Clinton Napitupulu, Luigi Collins Aribowo Universitas Kristen Krida Wacana Adequate healthcare is a fundamental, universal human right. Said healthcare must have adequate health service, protection from financial strain due to medical expenses and equal access to health services. Someone is healthy if they are in a state of complete physical, mental, and social well-being. This means that being mentally healthy is just as important as being physically healthy. Universal healthcare should also cover and provide mental healthcare access for those in need. However, in reality, â&#x20AC;&#x2039;people often pay more attention to their physical health than their mental health, coupled with low numbers in health professionals and the stigma about mental health. When talking about problems with accessing healthcare, not only should we think of the supply and infrastructures, but also the social factors on mental health. People in Indonesia still consider talking about mental illnesses to be taboo. What comes to mind when talking about mental health is patients in the mental asylum or homeless people with their odd behaviour. However, that is not the case. Victims suffering from mental illnesses become detached with their family and peers due to fear of being ostracized and suffer from the negative impacts arising from the stigma as they are afraid of being judged and hesitate when they seek help or treatment. Some ways are available to lessen the stigma surrounding mental health. The most basic way is to start eliminating the stigma around an individual and offer acts of compassion towards those suffering from mental health complications. Social media and streaming platforms may also help in mitigating the ever-growing stigma by raising awareness through people speaking up about the issue. In addition to that, the government should also do a much broader scale mental health promotion and to provide better and evenly access to mental healthcare across the nation.

Stigma as a Factor of Healthcare Accessibility Problem

Jeanette Sefanya Yefta Michelle Joshalyn Natasha David Clinton Napitupulu Luigi Collins Aribowo Universitas Kristen Krida Wacana

Introduction As a fundamental human right, proper healthcare is something that must be provided by a country's government. Not only does it have to be adequate to ensure the wellbeing of its people, but it is also something that every human being deserves to receive regardless of their gender, race, religion, belief, and their ability to pay or in short, their social economic status. This root concept has since given rise to the universal healthcare system in many countries in the world, including Indonesia. The main objectives of universal healthcare are equity in access to health services, adequate health service, and protection from financial strain due to medical expenses. This is all done to ensure the health and wellbeing of all the people. A healthy person is someone who is in a state of complete physical, mental, and social well-being. That means being healthy is not just about taking care of the things that are visible but also the things that are quite hidden. Being mentally healthy is just as important as being physically healthy. Mental health problems might be fairly hidden, but its adverse impacts could be extremely devastating. A healthy person should be capable of doing productive things, but for people with mental illnesses, this could prove to be difficult. It is as if there is something in the back of their minds holding them back, making them seem lazy or unmotivated and in turn lowering their quality of life in general. As it is a problem relating to health, universal healthcare should also cover and provide mental healthcare access for those in need. However, in reality, this is something that is often overlooked. â&#x20AC;&#x2039;People often pay more attention to their physical health and tend to ignore their mental health as it is definitely easy to take mental health for granted. Unlike physical illnesses, there are no visible indicators to alert you that your mental health is suffering, you actually have to pay attention. This is the reason people usually donâ&#x20AC;&#x2122;t know they have a mental health problem until physical symptoms start appearing. Despite being very common, mental health problems are still mostly overlooked by society. It is estimated that over 1.1 billion people worldwide or roughly 1 in 6 people have one or more mental disorders or substance abuse. In Indonesia, the prevalence of people suffering from depression is 3.7% of the population or about 9 million in 250 million. This contributes to 10.7% of the global burden of mental health problems. In contrast, Indonesia only has 773 psychiatrists and 451 clinical psychologists. This disparity in numbers has made mental health care services less accessible in this nation. In addition to that, mental health problems in Indonesia are often purposely hidden away from the public eye. People who suffer from it tend to keep it to themselves instead of reaching out for help to avoid attracting unwanted attention. One of the primary cause of this would undoubtedly be the lingering stigma on people with mental illness in society. Societyâ&#x20AC;&#x2122;s misconception on mental health and its problems is the most significant contributor to the problem with mental health access. As if the problem with the availability of mental healthcare professionals is not enough, our society is currently not the most supportive regarding that matter. People who are trying to seek help from a mental health

professional are often considered ‘crazy’, looked down on, or ridiculed in general. This harsh reality has made those who are in dire need of help inevitably cower in shame or even worse, guilt. This made them block themselves from getting the help they needed, making the mental health issue more complex. When talking about problems with accessing healthcare, what usually comes to mind first would be the problems with the supply and infrastructures. However, this is not entirely the case. In most situations, people are simply not utilizing the available healthcare services offered to them. In this paper, we will be trying to present our view of the problem with healthcare accessibility from a different perspective, where the problem with access is in reality much deeper than what meets the eye. Problems When one isn’t feeling well, down with a fever, for instance, what would they usually do? Of course, they would first try treating it by taking some fever reducers to lower the fever and reduce the pain. And if they still don’t feel any better after trying to treat it themselves, they would go get it checked by a professional. Being ill would make one unable to work or study properly so usually, as a result, we would inform their teachers or bosses that they may not be able to make it to school or work and would need a day off or two to recuperate. Catching a cold or fever is a very common, human experience. Every single person must have at some point in their lives experienced it so it is easy for everyone to understand and empathize to those who are excusing themselves from their daily duties because of it. It is not something to be ashamed of as it can happen to anyone, anytime and anywhere. Something that can be physically seen is usually easier to understand, but there are so much more than what meets the eye. To be completely healthy, moreover productive, not only should a person have a healthy body, but also a healthy mental state. While discussions regarding physical health are very common, discussions regarding mental health are not something that is being talked about openly, even considered taboo in some societies. In Indonesia, despite the prevalence of mental illness being quite high, its people are still relatively close-minded about it. Misconception plays the most prominent roles in this problem. When most people hear the words “people with mental disorders” the first thing that comes to mind would typically be the homeless people on the street who is shabby, unkempt, and often disrupt peace in society with their screams or even at times their act of throwing goods. People would think that every single person with mental illness is at least has the potential to become like that. Thus, people who are being suspected or admitted that they have a mental problem is usually being treated like the aforementioned people. They are being looked down on, mocked, ridiculed, or simply avoided. What most people do not understand is that to be wholly healthy, it requires both mental and physical health and not only physical alone. Due to mental health being inconspicuous and can only be sensed, mental

health is often forgotten as a part of ourselves that has to be maintained as a part of self-care. Mental health is not something visible. The problems with it can only be felt by those who are suffering from it. Even so, mental health is still a matter that cannot be overlooked. No matter how physically healthy

someone is, it is insignificant if they are mentally unwell. Physical and mental health are two inseparable objects as these two go side by side. Mental health can and will affect physical health and vice versa. The stigma lingering about those who suffer from mental health problems is actually much more detrimental than what most people could imagine. People who laugh or joke about mental health problems might have innocent intentions, but they do not realize the further repercussions. Despite the availability of treatments for mental health problems, victims of mental health illness are hesitant to access it as they are afraid of being judged, mocked, ridiculed, or even belittled. Not only do the stigma can be deeply impairing to someone, but it will also promote the already existing healthcare access problem in an indirect manner where the individuals suffering from it are not utilizing the facility offered. Mental illnesses can be cured and controlled. People who possess mental health problems can still live a long and productive life as long as it’s treated appropriately. However, untreated cases, wherein people not reaching out to get help, mostly lead to suicide. Being considered taboo to even talk about, the stigma that adheres to mental health problems will not be easy to be shifted. The lack of awareness causes people to not become aware of the negative impacts this stigma can induce as well as sufferers not accessing the help they should be getting. Anxiety about how will their family, friends, and the people around them will react once they found that they have mental health problems leads to them shutting themselves in from getting professional help. Even to those who are finally opening up about their mental health problems, things are not getting easier. They still have to suffer the negative responses they are receiving. People do not usually trust what they are telling, saying that it is their excuse to be unproductive, that they are exaggerating, or simply telling them to just deal with it. Getting such responses may lead the sufferers to lose their trust and hope, having second thoughts about reaching for help. Like any other diseases or illnesses, mental health problems require a cure to be remedied. In the worst of cases, medication is even needed to aid the sufferers. This is a serious matter that should not be overlooked and should get more attention from society in general. People are actually dying from this stigma and this should be a big concern to everyone. Solution and Recommendations Being the main cause of the problem, the stigma and negative thoughts concerning mental health problems is something that should be changed and be abolished. As part of society that has a higher degree of education than the general public, higher education students and especially, medical

students are supposed to have higher awareness regarding this subject. By starting with smaller scale movements it would definitely be possible to help change the stigma that has developed in society. This will undoubtedly create a significant impact if done earnestly. Beginning from oneself, one could help by eliminating the use of stigmas and stereotypes towards those with mental illness, offering assistance like listening, recommending and encouraging one to seek aid to certified mental health workers. Social media and streaming platforms such as TV and radio may also help in mitigating the ever-growing stigma. Raising awareness through people speaking up about how the stigma is real and people who have gone through how stressing depression is could open the minds of people who previously had never realized it. In turn, more and more people will do the same and perhaps seek treatment for their depression. In addition to that, the role of the government is also really important to do a much broader scale mental health promotion and to provide better and evenly access to mental healthcare across Indonesia so that every citizen can have equal access to the treatment they require for their illness. Changing something that has been lingering for so long might not easy, but it is never too late to make movements towards a better future. Conclusion So in conclusion, adequate healthcare is a fundamental, universal human right. To ensure the health and wellbeing of all the people, healthcare must have adequate health service, protection from financial strain due to medical expenses and equal access to health services. And to define health, we could say that someone is healthy if they are in a state of complete physical, mental, and social well-being. This means that being mentally healthy is just as important as being physically healthy. Even though mental health problems could be fairly hidden, its adverse impacts could be extremely devastating. As it is a problem relating to health, universal healthcare should also cover and provide mental healthcare access for those in need. However, in reality, this is something that is often overlooked. â&#x20AC;&#x2039;People often pay more attention to their physical health and tend to ignore their mental health. Aside from the disparity in the number of mental healthcare professionals, mental health problems in Indonesia are often purposely hidden away and very stigmatized. This has caused people to tend to keep it to themselves instead of reaching out for help in fear of being considered â&#x20AC;&#x2DC;crazyâ&#x20AC;&#x2122;, looked down on, or ridiculed in general. That, in turn, leads them to not utilizing the available healthcare services offered to them and get the help that they needed. When talking about problems with accessing healthcare, not only should we think of the supply and infrastructures, but also the social factors on mental health. In Indonesia, despite the prevalence of mental illness is quite high, its people are still relatively close-minded about it. Open discussions regarding mental health are quite uncommon and even considered taboo in some societies. Misconception also plays one of the most prominent roles in

this problem. When most people hear the words “people with mental disorders” the first thing that comes to mind would typically be the shabby, unkempt looking homeless people that often disrupt peace in society. For that reason, people who are being suspected or admitted that they have a mental problem is usually being treated like the aforementioned people. They are being looked down on, mocked, ridiculed, or simply avoided. What most people do not understand is that to be wholly healthy, it requires both mental and physical health and not only physical alone because one’s mental health can and will affect their physical health and vice versa. The stigma lingering in society about those who suffer from mental health problems is actually detrimental. Victims of mental health problems are made to be afraid of being judged, mocked, ridiculed, or even belittled for reaching out for help. This could make victims of mental health problems hesitant to access the help that they need despite its being widely available. This is a serious matter that should not be overlooked and should get more attention from society in general. People are actually dying from this stigma and this should be a big concern to everyone. Mental illnesses can be cured and controlled. People who possess mental health problems can still live a long and productive life as long as it’s treated appropriately. However, untreated cases, wherein people not reaching out to get help, mostly lead to suicide. Being considered taboo to even talk about, the stigma that adheres to mental health problems will not be easy to be shifted. The lack of awareness causes people to not become aware of the negative impacts this stigma can induce as well as sufferers not accessing the help they should be getting. Being the main cause of the problem, the stigma and negative thoughts concerning mental health problems is something that should be changed and be abolished. By starting with smaller scale movements it would definitely be possible to help change the stigma that has developed in society. Starting from oneself, one could help by eliminating the use of stigmas and stereotypes towards those with mental illness, offering assistance like listening, recommending and encouraging one to seek aid to certified mental health workers. Social media and streaming platforms may also help in mitigating the ever-growing stigma by raising awareness through people speaking up about the issue. In addition to that, the government should also do a much broader scale mental health promotion and to provide better and evenly access to mental healthcare across the nation. References 1. Mental Health. (2019). Retrieved from https://www.who.int/mental_health/en/ 2. What

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6. Knaak, S., Mantler, E., & Szeto, A. (2017). Mental illness-related stigma in healthcare. Healthcare Management Forum, 30(2), 111-116. doi: 10.1177/0840470416679413

AMSC White Paper â&#x20AC;&#x201C; Abstract Fakultas Kedokteran Kristen Krida Wacana Adjusting to the Better Healthcare System Author: Maximillian Justin Irawan, Jonathan William Goutama, Eliasyer, Gabriel Maigester Pabuang Ponglabba Indonesia, a country full of different cultures, religions, races, over 700 languages and even more than 300 ethnics, that houses a population of 264 million people.With a country this diverse from its wonderful sea and landscape. All these diversity is what makes Indonesia a great country in the eyes of the world and yet as beautiful it is of a rose, it still has its thorns. Indonesia as a developing country faces a critical health awareness problems ranging from facilities, health insurance, medical expenses and even transportation since some indonesian live in remote places. Out of all these 264 million people, the economy gap between the rich and the poor can be considered too far stretched, that mostly the poor canâ&#x20AC;&#x2122;t even do something. The solution lies where we as a society in Indonesia, should change our way of thinking about our own health and how we view the healthcare system. Indonesiaâ&#x20AC;&#x2122;s health aspect can be considered underdeveloped. The society here still have a stigma that the healthcare system and medical facilities here are inadequate, so they turn a blind eye to it, and went for a much more unsuggested alternative for cure. We, as a pioneer in medical world, especially medical students should come straight down to the field more frequently because education is for their greater good.

Adjusting to the Better Healthcare System Maximillian Justin Irawan Jonatahan William Goutama Eliasyer Gabriel Maigester Pabuang Ponglabba Universitas Kristen Krida Wacana

Introduction Indonesia’s health access problem is one of those main problems that hasn’t been completely solved in this last few years. Problems like this can be seen through a lot of aspects such as education, hospitals internal affairs and much more. The aim of this white paper is that we, as a student must do what we can to identify and give some promising results. Our concerns towards the problems is also backed up by our aspiration to build a more sustaining medical health in Indonesia.

Outlined Problems BPJS

BPJS is a public legal entity that we can briefly say they provide health services for all Indonesians. In its implementation, the insurance encountered many problems. The most serious problem is about financial deficit. In the period January to August 2018, the insurance got a financial problem in last period as insurance participants, we have to pay on time so that the program can really work well. BPJS as a large organization has value and of course the value of the organization is a pillar as a determinant that the organization has gone well and of course we will evaluate each of these values and try to find the better solution. Organization Values of Indonesian Health Insurance 1. Integrity: One of the key principle at doing task and responsibility through a harmony of the mind, how we speak and act accordingly to the situation 2. Professionalism: An act of doing a task with solemnity and in line with its competence and responsibility 3. Excellent Service: The will in providing the best service with sincerely to all member 4. Operational efficiency: A way to achieve an optimal workforce through a plan and a rational budget as needed. About these values on BPJS it is actually a really good values and they are doing a pretty good job but there is still a lot of problems towards the performance and responsibility of what must be done. Ironically, there are quite a lot of complaints which is quiet easy to deal with by the parties involved. These are some of those examples: 1. There are still many rejections from BPJS patients by the Hospital → the reason for the absence of rooms, ICU, NICU-PICU. The number of FKTPs = 20,653, FKTL = 2,314 hospitals, supporting facilities (optics and pharmacies) = 3,477. Meanwhile the number of RJTP visits = 25,546,761 visits, the number of referrals = 3,895,217 referrals, the number of RJTL visits = 7,173,051 visits and the number of RITL = 912,383 cases (data per 1/3/18). 2. BPJS patients are forced to go home in an unfit condition. 3. BPJS patients are also asked to pay for medicines and even admin fees. 4. Sometimes it took months for an action to be taken on a patient.

Financial problems is also a fatal problem because it coincides directly to the sustainability of BPJS. Causes of JKN Financing Deficit: Revenue is lower than Financing RKAT 2018: Beneficiary = Rp. 79,77 T Financing = Rp. 87.80 T

A. Acceptance (as of Feb 2018): Rp. 12.92 T consisting of: Contribution Beneficiary (PBI): 4.24 T State Administration PPU: Rp. 836 M Ex TNI / Polri: Rp. 176.25 M PPU Business Entity: Rp. 4.03 T Non Wage Recipient Workers (PBPU): Rp. 1.34 T Jamkesda: Rp. 1.04 T

B. Financing (as of Feb 2018): Rp. 14.74 T consisting of: First Level Outpatient (RJTP): Rp. 2.19 T First Level Hospitalization (RITP): Rp. 191 M Advanced Outpatient (RJTP): Rp. 4.17 T First Level Hospitalization (RITP): Rp. 8.09 T Promotive and Preventive: Rp. 27.27 M Operating Expenses: Rp. 800, 23 M Low Acceptance because: 1. Contribution has not been in accordance with the actuarial count, as PBI contributions are still Rp. 23,000 /person/month (actuarial count of Rp. 36,000 / person / month) 2. Implementation of Article 16I Perpres no. 19/2016 which mandates JKN contributions to be reviewed no later than 2 years, the government has not implemented 3. Participants are still 196 million from the total population of Indonesia of 257 million â&#x2020;&#x2019; Legal Theory of Large Numbers High Financing: 1. Cost control has not gone well as the cost of Mild Caesar Surgery is Rp. 2.76 T for 504,270 Mothers, while Mild Vaginal Delivery was Rp. 404.4 Billion made to 229,607 Mothers 2. The high number of referrals from FKTP (such as Puskesmas, clinics and family doctors) to hospitals is an average of 12.5 percent. 3. Capitation payments to FKTP (first-rate health facilities) have not been utilized to improve the quality of FKTP, but have become the object of regional government corruption 4. The existence of fraud committed by the RS such as upcoding, readmision, etc.

Healthy Lifestyle 1. Wash hands with clean water and soap. Wash hands with clean water and soap before preparing food, every time the hands are dirty. 2. Wear healthy latrines 3. Defecation behavior uses only latrines. 4. Doing physical activity every day This indicator is measured based on individuals who usually carry out heavy or moderate physical activities on seven days a week. 5. Eat fruits and vegetables every day Fruit and vegetable consumption behavior was measured based on individuals who used to consume fruits and vegetables for seven days a week. 6. Don't smoke in the house Households that do not have individuals with smoking habits at home when there are other household members and also take into account households that do not have members of the household who smoke. 7. Use of clean water The behavior of using clean water is obtained from household data that uses clean water sources in a category that is good for all household needs. Criteria for the use of good clean water are water sources from tap water / PDAMs, drill wells / protected dug wells, protected springs, and rainwater storage. 8. Eradicate mosquito larvae Households with the behavior of eradicating mosquitoes in this indicator are good households that drain baths once or more in a week or who do not use bathtubs and do not bathe in rivers.A lot of people still donâ&#x20AC;&#x2122;t have the access to have these kind of healthy lifestyles such as clean water, they need to go to the river which is sometimes dirty and use them as their main source of water, this is one of the main reason they got sick. Mindset The mindset is still a problem in the implementation of health services in Indonesia. Various community mindset in the use of health insurance in Indonesia is still not too good, for example, people feel disadvantaged if they have to pay a monthly fee if not used. Several community afraid if there are additional costs due to lack of economy in the middle to lower class. These wrong mindset can also have an impact on public awareness of health insurance.

Awareness This is one of the main reason that the access of health in Indonesia is not really good because of people are not aware of the health problem. At most area and places they still think that sickness is a small problem and they didnâ&#x20AC;&#x2122;t want to really raise the voice to the government. Solution To solve the problem that has been summarized we must see that the efforts of the BPJS are very good. Settlement of existing problems must be started from the BPJS first, the problem especially as the

problem of the community does not get complete health facilities because using BPJS must be completed first. The problem of budget deficits also needs to be considered, the causes of low revenues and high expenditure must be considered, for example by reviewing article 16I of Presidential Regulation no. 19/2016 which mandates JKN contributions that should be reviewed every 2 years, besides that there is also a need for supervision in the implementation of BPJS so that fraud does not occur that can harm BPJS as a provider of health insurance services and also people who are BPJS participants. In addition, the mindset and awareness of the public about BPJS must also be changed, the mindset regarding using BPJS is even detrimental to be overcome. Socialization to the community is important to change the community mindset and awareness of the importance of BPJS so that BPJS can reach more and more community groups in Indonesia. Healthy lifestyle that are bad enough must also be improved by educating places that are underdeveloped or inadequate in the field because if the health lifestyle is good, it means that a good environment can support the people around them to be concerned about the health around them which can be related to Awareness. To increase awareness / awareness that a bad mindset towards access to health in Indonesia can also be changed by providing education in sectors especially low and high, this education also takes many forms by means of counseling or other social actions. In the low sector students or people concerned with health in hospitals can take to the streets and directly educate people and can work together with leaders in these areas and even by teaching them to care, can change their lifestyle and their stigma towards health in Indonesia. A bad stigma for coming to the doctor is also one of the problems of the mindset that can be solved by means of education by telling them that if they care more about health, certainly the voice of the community will build up for smooth access to health.

Recommendation To increase the education level in the sectors, a cooperation is needed. Either with the government or non-government organization. For example, Australian government made a policy that all the children should be vaccinated. Similar to that but on a lower scale, maybe we could propose to the government about a policy regarding a clean and healthy lifestyle. The community should be given a proper study about healthy lifestyle through health counseling otherwise you canâ&#x20AC;&#x2122;t join in to BPJS. Or even the non-government organization we could teach them about this healthy lifestyle through a mass explanation or even in small groups, in return the organization may give some souvenir such as a free 1 month BPJS card or so on. Conclusion To change what is in the BPJS on paper seems to be an easy thing to do, but what must be emphasized is that we, as medical students can dive straight into the streets to change the stigma/mindset of people in Indonesia concerning these health issues. If both sector (community-government) and the people just block each other out, our dreams of good health access is only a mere illusion. As one saying goes, action speaks louder than words.

Bibliography BPJS. (2017). Laporan Pengelolaan Program dan Laporan Keuangan. Retrieved from bpjs-kesehatan.go.id: http://bpjs-kesehatan.go.id/bpjs/dmdocuments/1578f2022d8c51fefb20da6e7b119be3.pdf Juliana. (2015). Pertumbuhan dan Pemerataan Ekonomi Perspektif Politik Ekonomi. 120-131. Kementrian Kesehatan RI. (2011). Pedoman PHBS. Jakarta: Menteri Kesehatan RI. Siregar, T. (2018, Mei 24). Isu Faktual Pelaksanaan Jaminan Sosial. Retrieved from BPJS: http://bpjskesehatan.go.id/bpjs/dmdocuments/1578f2022d8c51fefb20da6e7b119be3.pdf

Now More Than Ever Christian University of Krida Wacana Azarya Sihite1 , Shindie2 , Alega Greacia3 Abstract To ensure public health, especially for mothers and children, the Government of Indonesia has sought it through Puskesmas as the first institution closest to the community which is the spearhead for preventive and promotive programs. Limited health costs are also not a problem because the Government has even provided a health insurance called BPJS. Key Word : Vaccinated, Primary Health Care Introduce Indonesia is the largest archipelago country in the world, and the fourth most populated country. It comprises more than 17 000 islands, the largest being Java, Sumatera, Kalimantan/Borneo, Sulawesi/Celebes, and Papua. Indonesia has 255 461

million inhabitants linked by one official

language, Bahasa Indonesia, while there are more than 700 local languages. Administratively, the country has 34 provinces, 514 districts, more than 7000 subdistricts, and more than 80 000 villages. Though it has a stable life expectancy, Indonesia is still challenged by poverty, and 11% of the population is living below the poverty line.1 Indonesia is facing a triple burden of health care problems due to (a)re-emerging diseases such as polio and diphtheria, due to challenges in the distribution and scope of child immunization. (b) the ineffective control of infectious diseases such as tuberculosis, malaria, dengue fever and other infections (c) the rise of chronic diseases into the list of top five catastrophic disorders in the country, leading to increased risk of metabolic disorders, such as diabetes mellitus, hypertension, dyslipidaemia, and cancers, in addition to cardiovascular problems, trauma and injuries. 1 Quality of life dan equal are basic of human right. In Indonesia accordance with Article 34 of the Nation Constitution of 1945 and Nation Health Act No. 36 of 2009 truly support the health movement as a human right that is in accordance with the ideals of the Indonesian nation and the state making it a priority and national development must also consider increasing the degree of public health. 1

Outline Problems In Indonesia immunization is adjusted to the age of the child. For complete basic immunization, infants under 24 hours are given Hepatitis B immunization (HB-0), age 1 month is given (BCG and Polio 1), age 2 months is given (DPT-HB-Hib 1 and Polio 2), age 3 month is given (DPT-HB-Hib 2 and Polio 3), age 4 months is given (DPT-HB-Hib 3, Polio 4 and IPV or injectable Polio), and age 9 months is given (Measles or MR).

Since vaccination decision affect not only mother and their kids, but also the community, these decisions cannot be treated as individual ones. At the point where individual decision might harm the community. Because there are two points of problem that come from internal or because of external problems. Mother can be influence by other people stories such as their children are still sick even though they have been immunized or other information that has not been proven truth, hesitant about the benefits, disbelief in the health agency or external problem such access to health. Vaccination has strongly developing into modern medicine and shows positive impact. Vaccines can be given to children and adults, depending on the health conditions needed. The function of vaccines is also to protect from the risk of disability and death where the provision of vaccines is believed to protect against the risk of disability and death. That means the more vaccinated people there are, the harder it is for a disease to spread. It means we protect individual health, but also protect the whole community against potential outbreaks. In this paper we want the obstacles to rejection of vaccines to disappear by reminding the importance of providing education and health facilities such as Puskesmas and Posyandu.

Solution Primary Health Care (PHC) was introduced by the World Health Organization (WHO) around the 1970s, with the aim of increasing public access to quality health services. In Indonesia, Primary Health Care has 3 (three) main strategies, namely multisectoral cooperation, community participation and the application of technology that is in accordance with the implementation in the community. According to the Declaration of Alma Ata (1978), "PHC is the first contact of individuals, families, or communities with a service system". This understanding is in accordance with the definition of the National Health System (SKN) in 2009 which stated that, "Primary Health Efforts are basic health efforts where the first contact of individuals or communities occurs with health services." 2 In Indonesia, the implementation of Primary Health Care (PHC) is carried out in Puskesmas and community-based networks and community participation, namely Posyandu which is in every district and subdistric. According to the national health system Puskesmas (Community Health Center) is the first fondation health care facility that is responsible for organizing individual health efforts and community health efforts. The purpose of establishing a Puskesmas is for national health development, increasing awareness, willingness and ability to live healthy for everyone who lives in the working area of Puskesmas. The function of Puskesmas is 3 (three), center for mobilizing health-minded development, the center for community empowerment, and the first fondation health service center. The first health service in the Puskesmas includes promotive, preventive, curative and rehabilitative services. 2 The Puskesmas is responsible for organizing individual health efforts and public health efforts, both of which are viewed from the national health system as a first level health service. The health efforts are grouped into 2 (two), namely compulsory health efforts and development health efforts. 2

1. Mandatory Health Efforts The mandatory health efforts of the Puskesmas are efforts that are determined based on national, regional and global commitments and that have a high leverage to improve public health. This mandatory health effort must be carried out in every Puskesmas in the territory of Indonesia. The mandatory health efforts are health promotion effort, environmental health efforts, maternal and child health efforts and family planning, efforts to improve community nutrition, efforts to prevent and eradicate infectious diseases, treatment efforts 2. Development Health Efforts Health efforts to develop Puskesmas are efforts that are determined based on health problems found in the community as well as those adapted to the capabilities of the Puskesmas. Development health efforts are selected from the list of existing primary health center efforts, namely school health efforts, sports health efforts, public health care efforts, occupational health efforts, dental and oral health efforts, mental health efforts, eye health efforts, elderly health efforts, efforts to foster traditional medicine.3 In addition to the existence of Puskesmas, there are also other health businesses called Posyandu (Integrated Service Posts). Posyandu is one form of Community based Health Efforts (UKBM) carried out by, from and with the community, to empower and provide facilities for the community to obtain health for mothers, babies and children under five. There are various types of activities carried out by Posyandu such maternal health of children, family planning, immunization, improved nutrition, overcoming diarrhea, basic sanitation, provision of essential medicines. 4 Posyandu is one form of Community Based Health Efforts (UKBM) managed and held from, by, for, and with the community in managing health development to empower the community and provide convenienceto the community in obtaining basic basic / social health services for accelerate the decline in Maternal and Infant Mortality. Thus Posyandu is a basic health activity organized by community and for communities assisted by health workers.4

Conclusion Therefore, the Government has made primary health efforts, namely Puskesmas in each district and subdistrict, community based networks and community participation, namely Posyandu that serves child immunization. As hope, there is the closest contact between individuals or communities to get health services. To solve external and internal problems that have been explained, Puskesmas have mandatory health principles, that is efforts to promote health, environmental health efforts, maternal and child health efforts, efforts to improve community nutrition, efforts to prevent and eradicate infectious diseases and treatment efforts. Because the main principle of Puskesmas is developed promotion and preventive efforts, so if the program is well implemented by the Puskesmas internal and external problems can be solved because with good education built good health. And also for the cost

problem the Government has established BPJS a health social security agency to help and guarantee that the community can access Puskesmas and other health services for free.

Recommendation Problems that Posyandu might face are lack of community and qualified cadre. Cadres are expected to bridge between health officers or experts with the community as well help the community identify and face or answer health needs themselves. In this case the Posyandu Cadre as a motor for driving public health must be a reliable communicator in disseminating information on health to the community. Through Posyandu, this cadre must communicate the maternal and child health information appropriately. Thus, community participation in managing and utilizing Posyandu programs can be seen from active community participation in Posyandu activities every month such as utilizing free immunizations, weighing toddlers, controlling health.

References 1. World Health Organization, 2017, Primary health care systems (PRIMASYS): case study from Indonesia, cited: April 5, 2019. <https://www.who.int/alliancehpsr/projects/alliancehpsr_indonesiaabridgedprimasys.pdf?ua=1 2. Departemen Kesehatan Indonesia, 2011, Implementasi Primary Healt Care di Indonesia, cited April 5, 2019 <http://www.depkes.go.id/pdf.php?id=1558 3. KEPMENKES,

2004,

cited:

April

2019.

<https://peraturan.bkpm.go.id/jdih/userfiles/batang/KEPMENKES_128_2004.pdf 4. Saepudin E, Rizal E, Rusman A, 2017, â&#x20AC;&#x2DC;Posyandu Roles as Mothers and Children Health Information Center ` , Record and Library Jurnal ,Vol 3, No. 2.

LOW PUBLIC AWARENESS ABOUT THE BENEFIT OF THE PROLANIS PROGRAM FOR IMPROVING THE QUALITY OF LIFE IN DIABETES AND HYPERTENSION PATIENT IN INDONESIA.

PCC AMSC SINGAPORE 2019

Marvin Leonardo Suwontopo Arondino Darmawan Widia Ramdani Husain Deivy Alfa Makalew AMSA-Universitas Sam Ratulangi Asian Medical Student Association-Indonesia 2019

LOW PUBLIC AWARENESS ABOUT THE BENEFIT OF THE PROLANIS PROGRAM FOR IMPROVING THE QUALITY OF LIFE IN DIABETES AND HYPERTENSION PATIENT IN INDONESIA. 1. Introduction Indonesia is the 4th largest populated country in the world with a total population of 264.935.824 people. Indonesia is a developing country that is still struggling with a lot of health related problems. In the past, there have been numerous people exposed to the danger of infectious diseases. This lead to a low awareness among the Indonesian people regarding the danger of non-communicable diseases especially those that are related to what we call the metabolic syndrome. This condition is not good because with the ever growing numbers of obese people in Indonesia, there are more and more people who will end up having hypertension or type 2 diabetes mellitus. That is why it is important for the community to understand better about the danger of non-communicable disease and the way to prevent or to change the quality of life when someone has already contacted that particular disease. 2. Problem Discussed The city of Manado is the capital of the North Sulawesi province. According to the data from the 2018 National basic Health Research (RISKESDAS 2018) North Sulawesi currently has a prevalence of 2,9% for diabetes and this number is 0,9% higher than the prevalence number of diabetes in Indonesia. This means that North Sulawesi is one of the major contributors to the high number of diabetes cases in Indonesia. Not only that, but the prevalence of hypertension is also very high with North Sulawesi ranked 1st from 34 provinces with the prevalence of 13,2% for hypertension. This number is 4,8% higher than the national prevalence of hypertension in Indonesia which is 8,4%. This data is further supported by the obesity prevalence data which North Sulawesi once again ranked 1st among the 34 provinces of Indonesia with the prevalence of 30,2% and this number is 8,4% higher than national prevalence for obesity which is 21,8%. As a medical student living, and studying medicine in Sam Ratulangi University Faculty of Medicine, the data above is very concerning and it goes to show that the people of north Sulawesi is in danger of falling to non-communicable disease. This fact is further supported by the local culture here in North Sulawesi where people usually eat a lot during a feast. Also the growing trend is that people are becoming less and less physically active nowadays especially in the city regions. This trend means that

there are more calories, more fat and more glucose going into a personâ&#x20AC;&#x2122;s body compared to the amount of output energy. This is why the numbers of obesity cases in north Sulawesi is so hard to bring down.

We need to realize that according to the data above that our people have a very high chance of developing Hypertension and diabetes and this can lead to serious complication which will increase the cost and also prolong the illness resulting in serious disruption in quality of life for the sufferer. 3. Proposed Solution

Prolanis, Program Pengelolaan Penyakit Kronis (Chronic Disease Care Management Program) is a health care program and approach that integrates its members, health care facilities and BPJS Kesehatan in its execution for achieving better health for BPJS kesehatan members that have chronic non communicable disease for optimal quality with more efficiency and efficacy of the health cost. Prolanis aims to encourage people with non-communicable disease to have optimal quality of life with the indicator of 75% registered member that goes to primary care facilities have good results in specific laboratory examination regarding their disease so that they can better understand how to prevent the complication of their diagnosis. Dr Rudi Hartoyo, one of primary care doctor who is working with BPJS Kesehatan as primary health care facility in Manado city is the object of our observation. As a family doctor, it has been dr Rudi’s responsibility to implement the Prolanis program to his patients. Hypertension and type 2 diabetes mellitus patient that is handled by dr Rudi all joined his Prolanis club which they named Trinitas. There are a lot of efforts done by dr Rudi to ensure the success of Prolanis program. This effort consists of doing cardio exercises every Saturday morning with his club, finding the right instructor, and also at the same time educating his patient to begin the healthy lifestyle. To increase the participation of his patient in the club, dr Rudi entrusted his patient with managerial position in the club. This led to the club member having a sense of belonging and also this help for the club member to know the job description of each person. After hearing testimonies from most of the club member, they admit that they all love dr. Rudi so much because they felt the impact of dr. Rudi’s attempt to educate them and this has in turn led to them believing that healthy lifestyle is a very important “need”. Dr. Rudi also received numerous awards in the regional and national level for his contribution to increase quality of health especially in primary care settings. Prolanis is indeed the answer to minimize the continuous impact of hypertension and type 2 DM patients to live a healthier life. However, despite being so well, encouraged a lot of sponsorships to support the clubs, and becoming a Prolanis management mentor to any other BPJS/primary health care

doctors in Manado, we observed that dr Rudi and his clubs still donâ&#x20AC;&#x2122;t get the publication and recognition they deserved especially that us donâ&#x20AC;&#x2122;t know that Prolanis exists in the first place. We hope that by this paper and our trailer video, the government and media will be more encouraged to promote Prolanis and any other healthy lifestyle campaign such as Germas (Gerakan Masyarakat Sehat/Healthy Community Movement), especially with social media that is proved to be an amazing tool for advertisement and promotion, so the society will have a better mindset of how to stay healthy and prevent diseases rather than how to fix and cure a disease. 4. Conclusion With the Prolanis program, we hope to change peopleâ&#x20AC;&#x2122;s perspective to not only rely on medication to control the progress of their disease but also to implement the healthy lifestyle. Aerobic exercise is one of the simple but effective method that the people can use and practice that can help to increase their quality of life and this leading to healthier and fitter body that the Trinitas Club member has testified. However, we encouraged government and media to promote more healthy lifestyle campaigns, in this case Prolanis. 5. Recommendation As medical students, we encourage us AMSA around the world to step down to the field more often, particularly to educate the society directly on how to live healthily. With this, our capabilities in health prevention and promotion will be sharper before we are ready to become future medical doctors in healthcare facilities. 6. References 1. Lauralee S. introduction to human physiology. 8th ed. China: Brooks/Cole, cengage learning; 2013. 2. K Sembulingam, Prema Sembulingam. Essentials of medical physiology. 6th ed. Bangladesh: JayPee brothers medical publishers; 2012 3. Kementerian kesehatan republic Indonesia, hasil utama RISKESDAS 2018. Indonesian ministry of health. 2018 4. BPJS kesehatan. Panduan praktis PROLANIS (program pengelolaan penyakit kronis). 2017

5. F. Ekawati, H Kusnanto, M Claramita, N A syah, O Hilman. Primary health care systems comprehensive case study from Indonesia. Geneva: World Health Organization. 2017. License: CC BY-NC-SA 3.0 IGO. 6. John E Hall, Arthur C Guyton. Textbook of medical physiology. 12th ed. USA: Elsevier Saunders; 2011 7. Walter F Boron, Emile L Boulpaep. Textbook of medical physiology. 2nd ed. Philadelphia: Elseviers Saunders; 2012. 8. Liu S. A. M. goodman.J. Nolan R. Lacombe S. Thomas S G. blood pressure responses to acute and chronic exercises are related in prehypertension. Official journal of the American college of sports medicine. 2012 9. Golbidi S. Mesdaghinia A. Laher I. exercise in the metabolic syndrome. Oxidative medicine and cellular longevity volume 2012, Article Id 349710. 2012 10. Ana R. A Yuniastuti. Effectiveness of tera gymnastics and healthy heart gymnastics on blood pressure among elderly with hypertension in sinomwidodo village, Tambakromo Subdistrict, Pati District. Public health perspective journal. 2018

Abstract Low Public Awareness About The Benefit of The Prolanis Program for Improving The Quality of Life in Diabetes and Hypertension Patient in Indonesia. Authors: Marvin S. Arondino D. Deivy M. Widia H from AMSA-Universitas Sam Ratulangi

As of today, some of the major problems of public health in Indonesia and North Sulawesi, specifically, are Hypertension, Typed 2 Diabetes Mellitus and Obesity. The data from Basic National Health Researchers (Riskesdas 2018) by the Ministry of Health in 2018, shows that hypertension and obesity prevalence in North Sulawesi is the highest in Indonesia, compared to the other 33 provinces. Not only this data only, there also have been a significant increase in typed 2 DM prevalence compared to the data in 2013. Prolanis, Program Pengelolaan Penyakit Kronis (Chronic Disease Care Management Program), is a program by BPJS Kesehatan of Indonesia for primary health care facilities to help minimize the impact of these chronic non-communicable diseases in the hope to improve the quality of life of the diagnosed patients. One of the key pillars of the program is the implementation of healthier lifestyle goals by morning aerobic exercise every saturday morning. Dr Rudy Hartoyo, one of the BPJS doctor in this field is helping us to observe his Prolanis club and taught the authors how he manage and maintain his club. Doctor Rudy is doing really well for his club and he reached the BPJS’s target. His Prolanis patients are happy and feeling the improvement after joining Prolanis. Despite doing so well and have a lot of achievements, Doctor Rudy and his two Prolanis clubs still don’t receive the publication their reserved. So that’s why we encouraged the government and media to scope more about Prolanis and more healthy lifestyle campaign like Germas, Gerakan Masyarakat Sehat (Healthy Community Movement) and many others.

Rumah Sehat: a Health Community in Jambi Michelle Gracella (1 st), Halimatussadiah, Siti Shafira Alawiyah N Jambi University, Jambi, Indonesia

Background According to World Health Organization (WHO), non-communicable diseases (NCDs) kill 41 million people each year, equivalent to 71% of all deaths globally. Tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets all increase the risk of dying from NCDs. In Indonesia, Baseline Health Research 2018 shows the prevalence NCDs has increased compared when it was 2013. Similarly in Jambi, sufferers of NCDs continue to increase each year. Even these diseases begin to spread among young people. An increased has been caused due to an unhealthy lifestyle. In accordance with the third sustainable development goals (SDGs) in Indonesia, regarding the point of good health and welfare, one thing that needs to be considered is about NCDs. Therefore, we need to reduce the mortality rate due to NCDs by change the lifestyle. Solution To overcome this problem, a community was formed to help its members to change their lifestyle to be healthier. Its name is â&#x20AC;&#x153;Rumah Sehatâ&#x20AC;?, a community with various ages, ranging from young to old, which is formed so its member can support each other. Key findings: non-communicable disease, lifestyle, community, healthy life, support group, bad habit

White Paper Full Report

Rumah Sehat: a Health Community in Jambi

Michelle Gracella (1st ) Halimatusadiah Siti Shafira Alawiyah Nasution White Paper Full Report April, 2019

BACKGROUND Non-communicable diseases (NCDs) are the major health burden in the industrialized countries, and are increasing rapidly in the developing countries owing to demographic transitions and changing lifestyles among the people. Even NCDs have become the highest cause of death in the world as a whole. Especially in developed countries, non-communicable diseases are already a more common cause of death than infectious disease. Thus, we believe that addressing the problems and issue connected with non-communicable diseases will lead to major health gains worldwide. Research has clearly shown that non-communicable diseases have their roots in unhealthy lifestyle. Risk factors like unhealthy nutrition over prolonged period, smoking, physical inactivity, excessive use of alcohol, and psychosocial stress are among the major lifestyle issues. In accordance with the third sustainable development goals (SDGs) in Indonesia, regarding the point of good health and welfare, one thing that needs to be considered is about NCDs. In 2030 it is targeted to be able to reduce up to one-third mortality, through prevention and treatment, also improve mental health and welfare. To lessen the impact of NCDs on individuals and society, a comprehensive approach is needed requiring all sectors, including health, finance, transport, education, agriculture, planning and others, to collaborate to reduce the risks associated with NCDs, and promote interventions to prevent and control them. Monitoring progress and trends of NCDs and their risk is important for guiding policy and priorities. In real life situation, planned on community programs are an important component of the strategy to help solve this problem. The huge gap between our knowledge about what needs to be done and the everyday situation of most of the people in the developing countries is due to several obstacles that prevent making healthy changes. The aim of community programs is therefore to build a bridge to help individuals and communities to overcome these obstacles.

OUTLINED PROBLEMS According to World Health Organization (WHO), non-communicable diseases (NCDs) kill 41 million people each year, equivalent to 71% of all deaths globally. NCDs disproportionately affect people in low- and middle-income countries where more than three quarters of global NCD deaths occur. Vulnerable and socially disadvantaged people get sicker and die sooner than people of higher social positions, especially because they are at greater risk of being exposed to harmful products or unhealthy dietary practices, and have limited access to health services. Children, adults and the elderly are all vulnerable to the risk factors contributing to NCDs, whether from unhealthy diets, physical inactivity, and exposure to tobacco smoke or the harmful use of alcohol. These diseases are driven by

forces that include rapid unplanned urbanization, globalization of unhealthy lifestyles and population ageing. Unhealthy diets and a lack of physical activity may show up in people as raise blood pressure, increased blood glucose, elevated blood lipids and obesity. These are called metabolic risk factors that can lead to cardiovascular disease, the leading NCD in terms of premature deaths. In Indonesia, Baseline Health Research 2018 shows the prevalence NCDs has increased compared when it was 2013. Also the number of deaths due to NCDs is very worrying for our country. That was stated by the ministry of health who explains that is increased up to 59.5%. Cardiovascular diseases account for most NCDs deaths followed by cancers, respiratory diseases, and diabetes. An unhealthy lifestyle is the main cause of non-communicable diseases. Baseline health research reported 34.7% of the population aged 15 years and more smoked every day, 93.6% consumed fewer fruits and vegetables and 48.2% less physical activity. The increase in non-communicable diseases has a negative impact on the nation’s economy and productivity. Treatment of NCDs often takes a long time and costs a lot. Some types of NCDs are chronic and/or catastrophic diseases that can disrupt the economy of sufferers and their families. In addition, one of the effects of NCDs is the occurrence of disability, including permanent disability. Similarly in Jambi, sufferers of NCDs continue to increase each year. Even these diseases begin to spread among young people. The head of health department explains that an increased has been caused due to an unhealthy lifestyle. They said that laziness among young people can trigger noncommunicable diseases to shift to young age.

SOLUTION A number of community-based health intervention projects have aimed at promoting risk-reducing lifestyle changes in different populations. These projects were usually started in the field of cardiovascular disease prevention and emphasized the fact that merely providing risk-reduction measures for clinically high-risk people in health service settings would have only a limited impact in the whole country. On the other hand, if the population as a whole were to be targeted, even a modest risk-factor and heart-healthy lifestyle change would potentially have a huge public health impact. In Jambi, a community was formed to help its members to change their lifestyle to be healthier. Its name is “Rumah Sehat”, a community with various ages, ranging from young to old, which is formed so its member can support each other. The intervention strategy of this community was based on lowcost lifestyle modifications and society participation.

The important things about support group are they have a function that can give self-confidence for other people. They can motivate each other to make a better life with healthy activities. So they can together reduce mortality and increase life expectancy in Jambi.

CONCLUSION Non-communicable disease has become a major health problem all around the world, and as we know, lifestyle has a major impact on cause it. Thus, to prevent NCD cases, a lifestyle change is a must. Community such â&#x20AC;&#x153;Rumah Sehatâ&#x20AC;? has proving a big impact of lifestyle changing of their members. People with same aim gathered and support each other to have a healthy lifestyle. The existence of such group also proves that there is an enhancement in public awareness of the importance of a healthy lifestyle. We believe that the growth of groups like this in the community can have a positive impact on reducing the number of cases of diseases that caused by lifestyle such NCDs.

RECOMMENDATION We highly recommend the establishment of such community in society. We believe that kind of communities or support group like this will really help improve healthy lifestyle in society. If the presence of this kind of community can be indicated as how people awareness of the importance of healthy lifestyle, then the growth of this kind of community is expected to be directly proportional with the increase of the society awareness of healthy lifestyle.

REFERENCES Non-communicable diseases. (2018, June 1). Retrieved from https://www.who.int/news-room/factsheets/detail/non-communicable-diseases Potret

Sehat Indonesia

dari RIKESDAS 2018.

(2018, November

2).

Retrieved from

http://www.depkes.go.id/article/view/18110200003/potret-sehat-indonesia-dari-rikesdas-2018.html Penyakit Tidak Menular (PTM) Penyebab Kematian Terbanyak di Indonesia. (2011, August 11). Retrieved

from

http://www.depkes.go.id/article/view/1637/penyakit-tidak-menular-ptm-penyebab-

kematian-terbanyak-di-indonesia.html Penyakit Tak Menular Mulai Menghantui Kaum Muda, Termasuk Jantung. (2018, August 15). Retrieved

from

https://jambi-independent.co.id/read/2018/08/15/27169/penyakit-tak-menular-mulai-

menghantui-kaum-muda-termasuk-jantung/ Said, A., Budiati, I., Reagan, H.A., Riyadi, Hastuti, A., etc. (2016). Potret Awal Tujuan Pembangunan Berkelanjutan (Sustainable Development Goals) di Indonesia. Retrieved from http://www.bps.go.id

Innovation Towards JKN Mobile Application Involving Artificial Intelligence (AI) to Optimize Health Promotion to Overcome Health Problems in Indonesia Nurul Mufliha Patahuddin, Shafira Aulia Hanifa, Raina Maharani Tasyandita, Alif Nurul Hikmat

Abstract Based on a survey from RISKESDAS (the Indonesian Health Research and Development Agency) on 2018, 4 of the 5 deadliest diseases in Indonesia are non-communicable diseases. In addition, according to WHO 7.8 juta children in Indonesia diagnosed with stunting which make Indonesia the forth highest number of stunting in the world. Most of these health problems are very influential on the health of the nation, but actually these problems stem from a lack of understanding of things as simple as a healthy lifestyle. The health promotion in Indonesia is still not optimal due to the unequal distribution of health workers across Indonesia regions. Thus, there is a need of a new innovation to make sure that the health promotion can reach out every place, for example using the technology of smartphones. Mobile JKN is an online application provided by BPJS Kesehatan that facilitate the administration of BPJS participants. Currently, Mobile JKN has already been installed more than 5 million times by smartphone users. Based on the need of health promotion about disease prevention that can reach every place as well as the fact that there is large numbers of smartphone users and Mobile JKN in Indonesia, we propose an innovation about the new upgraded version of Mobile JKN. In this version, we are going to introduce new features about educational health articles from reliable sources to prevent false information about health. This article will be supported by Artificial Intellegence system, so patients will only obtain articles that they really need based on the patient's health status and history of disease. It will also provide information about the possibility of risk factor based on the prevalence of disease in the place where the patient live. Key findings: equality, health promotion, smartphone, technology, artificial intellegence, JKN Mobile

Asian Medical Studentsâ&#x20AC;&#x2122; Competition Singapore 2019 Innovation Towards Mobile JKN Application Involving Artificial Intelligence (AI) to Optimize Health Promotion to Overcome Health Problems in Indonesia

Authors :

Nurul Mufliha Patahuddin Shafira Aulia Hanifa Raina Maharani Tasyandita Alif Nurul Hikmat

Asian Medical Studentsâ&#x20AC;&#x2122; Association 2019

INTRODUCTION Health promotion is one part of the health care that aims to improve understanding and awareness to the health problems. In Indonesia, health promotion became one of the main focuses of the Government especially in preventing non-communicable diseases that are related to the unhealthy lifestyle. Prof. Dr. Nila F. Moeloek, Minister of Health of Indonesia, underlined the urge that Indonesia should not only just focused on curative efforts but focus more on the health problem prevention efforts. Therefore, the health promotion about prevention of diseases is very important and need to be implemented. According to Usman Sumantri, Chief of Human Resources Development on Ministry of Health, health promotion is still not optimal in Indonesia especially in the localized area, like in the regency outside Java Island due to the uneven spread of health workers in Indonesia. Thus, there is a need for a new innovation to solve this problem and make sure that this health promotion can reach out of every place, for example by using technology. Technology is an important thing in our life. In Indonesia, technology evolved over time including the popularity of smartphones in Indonesia. According to Emarketer's Digital Marketing Research Institute in 2018, the number of active users of the smartphone in Indonesia is more than 100 million people. With that amount, Indonesia became the country with the fourth largest smartphone active users in the world after China, India, and America. Based on survey conducted on 2017 by APJII (Asosiasi Penyedia Jasa Internet Indonesia), the Indonesia Internet Service Provider Association, the distribution of internet user in Indonesia based on island is as follows: Java (58,08%), Sumatera (19,09%), Kalimantan (7,97%), Sulawesi (6,73%), BaliNusa (5,63%), and Maluku-Papua (2,49%). The percentage of device ownership is as follows: computer/laptop (25,72%) and smartphone (50,08%). APJII predicted that the use of the internet, especially through the media of smartphone, will increase over the years. The increase rate of smartphone use pushes the easier way for us to spread the information. Even though it contributes to increasing numbers of false information or hoax but it also facilitates communication between the communities including education, health promotion, etc. These opportunities are optimized by the Government as a step to provide optimized services, such as the launching of mobile applications, named Mobile JKN. JKN stands for Jaminan Kesehatan Nasional (National Health Insurance). It is a national insurance program administered by BPJS (Badan Penyelenggara Jaminan Sosial), the Indonesian social insurance administration organization, that managed by the government to provide medical coverage program for Indonesia citizens. BPJS is regulated by the law Undang-Undang No.24 Tahun 2011 and JKN by Undang-Undang No.40 Tahun 2004. Individual participation is mandatory for all Indonesian

resident. In addition to every Indonesian, foreigners who have been working in the country for at least six months are also eligible to join the program. Mobile JKN was officially launched on November 15th, 2017 by BPJS Kesehatan. The application is a concrete manifestation of the commitment of BPJS Kesehatan in providing optimal access and service for BPJS participants. Health administrative activities that are used to be done in a branch office or health facilities, is now transformed into a form of application which can be used by participants anywhere and anytime without time restrictions (self-service). Available main features on Mobile JKN include BPJS registration, membership, and billing. It also provides information about the location of the nearest healthcare facilities, history of userâ&#x20AC;&#x2122;s health services, and BPJS customer service. Currently, Mobile JKN itself already been installed more than 5 million times by users of Mobile Applications and this application already has more than 1 million android user and more than 2,000 iOS user in Indonesia. Mobile JKN application requirement is very easy, the BPJS participant just has to download the application via Google Play Store and the Apple Store. This application is recommended for Smartphone using the android system version 4.0 upwards and the iOS system 10. After the application is installed, the participant must register on the menu available on the Mobile JKN. The launching of this application certainly facilitates the community in accessing health facilities in a very innovative way. With this application, the users no longer need to queue up or go to the BPJS office to register the BPJS, move their Fasilitas Kesehatan Pertama (Primary Health-care Facility), nor other administration. Moreover, the socialization of this application is still one of the goals of BPJS Kesehatan, whenever someone become come to the office of BPJS to register or to do administration, the officer there will advise them to install this app and the satisfied rate of Mobile JKN's user is also high which will promise the constantly increased rate of Mobile JKNâ&#x20AC;&#x2122;s user in the future in all of the parts of Indonesia. But on the other side, the Mobile JKN application is still only used in the curative aspect of a patient which means that it just help patients who already had complaints of illness and wish to seek treatment and have not maximized performance to do disease prevention yet. Based on the need of health promotion about disease prevention fairly and evenly that can reach every place as well as the fact that there is large numbers of smartphone users and Mobile JKN in Indonesia, we propose an innovation about the new upgraded version on mobile JKN. In this version, we are going to introduce new features about educational health articles from reliable sources to prevent false information about health. This article will be supported by Artificial Intelligence (AI) system, so patients will only obtain articles that they really need based on the patient's health and history of the disease. It also will provide information about the possibility of risk factor based on the prevalence of the disease in the place where the patient lives. In addition, there will be also rewarded features added that will give missions related to a healthy lifestyle which when completed, the user will earn prizes.

We also propose an idea to add special features for pregnant and lactate woman to prevent their children from stunting. OUTLINED PROBLEM Based on the results of the National Health Work Meeting held by the Ministry of Health of Indonesia in 2018, Indonesia is currently faced with three health problems that gain government's attention, namely an increase in tuberculosis cases, a high prevalence of stunting, and the coverage and quality of immunization. In addition to these three problems, there are also several other health problems that are no less urgent and require some more attention from the government and society, such as maternal and child health problems; the increased burden of non-communicable diseases; and infectious diseases. Based on a survey from the Health Research and Development Agency, 4 of the 5 deadliest diseases in Indonesia are non-communicable diseases. Most of these health problems are very influential on the health of the nation, but actually, these problems stem from a lack of understanding of things as simple as a healthy lifestyle. From the explanation above, it can be concluded that most health problems in Indonesia can be handled by providing education about public health to the community, most importantly for prevention measures. In Indonesia, health promotion in community health centers has been regulated by the Minister of Health Decree Number 585 since 2007. Some of the health promotion programs organized by the Indonesian government are the Healthy Living Society Movement (GERMAS) and Clean and Healthy Life Behavior (PHBS). Both movements are campaigns so that people can maintain their own health. The other forms of health promotion are health promotion in the school and work environment that aims to educate the public in creating a healthy, clean and comfortable learning and working environment. However, this does not mean that the government's efforts have no obstacles. One of the biggest challenges in the efforts of health promotion in Indonesia is the access that is not yet equal. Based on a study conducted by the Directorate of Community Health and Nutrition from the National Development Planning Agency (BAPPENASS) in 2010, there were 4 priority issues in the implementation of health promotion: (1) financing, (2) regulation, (3) employment, and (4) cross-sectoral cooperation. In the matter of costs, there has been an increase in the allocation of funds from the State Revenue and Expenditure Budget (APBN), but the number of public health extension workers is still very minimal. Of the 33 provinces, only 11 provinces belong to the expert category. Many community health educators also do not receive appropriate education and training. In order to support the development of Community-Based Health Efforts (UKBM) activities, it is also necessary to support facilities and infrastructure that include print media, electronic media, and means of mobilization in the form of vehicles. Another problem is Indonesian people's trust which still refers to local myths so that their mindsets are not familiar with the health sciences of the experts.

From what can be observed, the use of technology for health promotion is still not optimal. This can be seen from the high number of smartphone users in Indonesia but the low level of prevention efforts in the community. The nation's focus on health issues should not only be on curative efforts but also considering investment in the preventive field. Because, with the prevention efforts from the beginning, it will avoid the disposal of the budget, energy, and time for treatment efforts that should not be needed. There is also a dilemma where on the one hand there are groups of people who have very little public health information but on the other hand, the rapid development of technology causes doubts in information credibility. As technology advances, society is very close to science. They can easily get various kinds of information on the internet according to their needs. Health sciences are no exception. The internet has now stored various information about the disease, the course of the disease, and especially the method of treatment. This is where the ability to sort information is needed because not all information on the internet is accurate. The example can be seen from misleading information about vaccination that causes parents to have doubts about the vaccine so they decide not to give their children vaccinations. SOLUTION Technological developments offer many solutions to various types of problems in the life of this modern era, one of them is in the medical world. As explained earlier, the problem of the lack of public knowledge about healthy lifestyles is partly due to a lack of access to reliable and well-targeted health promotion. Here we offer a solution to this problem through the use of the Mobile JKN application that has been provided by the Government as facilitating for BPJS users. Currently, Mobile JKN has only provided features related to the administration of BPJS participants. We could see that if Mobile JKN is developed further it can be an effective media to improve the health of the Indonesian people, due to the fact that more than 5 million Indonesians have this Mobile JKN and the non-stop socialization of this app by the government and the high rate of stratifying user that will make Mobile JKN user definitely continue to increase in number. We propose an idea to add health promotion features to Mobile JKN. Not just an ordinary health promotion, the features we offer are using the Artificial Intelligence system. Artificial Intelligence (AI) in healthcare is the use of algorithms and software for approximate human cognition in the analysis of complex medical data. Specifically, AI is the ability to computer algorithms to approximate conclusions without direct human input. The AI system in Mobile JKN will detect each of user's health condition data that has been inserted and adjust it to the type of health information that will be delivered to the user.

Machine learning is one of the components to make Artificial Intelligence (AI) works which means learning from experience. This enables the application to predict what is the best health information for users based on users' medical records and epidemiology of the certain disease in the local area. Here, the good performance of health workers at regulating patients' health records at their health facilities is very necessary, so that the information provided is on target. Next is a neural network or "making associations" which way it works is related to cognitive computing or "making inferences from context". These components of AI require assistance from the experts, in this case, doctors or medical professionals, to create the health database containing pathogenesis, pathophysiology, and risk factor of the disease so that the application can make a conclusion in the form of diagnosis or healthy lifestyle instructions based on user's record. This feature allows the users to find out more about their health conditions, detail information of their illnesses, possible diseases that can be suffered by users based on their disease history and prevalence of the disease in the user's area. For example, a user went to a clinic and based on his health examination, he had influenza. In addition, his BMI result stated that he was obese and when he carried out a blood test, his glucose level was high. He also lives in Papua which is a susceptible are for dengue. After the data inserted to the application, the AI system will analyze them and thus display educational articles in the user's account related to obesity, diabetes, and dengue. The advantage of this AI system is that the health information obtained by the user is informed that is truly in accordance with the needs of the user, or in other words, well-targeted. The role of health workers in the implementation of this idea is very important. To avoid false information, the health articles displayed will be made by professional doctors in Indonesia who are trustable and strictly regulated by the BPJS Kesehatan and the Government with longtime verification and editing before released. Health workers also have responsibilities to ensure the patients input their medical history with great responsibility.

Figure 1. Mechanism of Proposed Health Education Feature on Mobile JKN

Besides that, we also oppose the idea to add "My Achievement" feature. It provides a list of missions for users related to implementing a healthy lifestyle. An example is a suggestion to exercise every 3 times a week with a minimum duration of 30 minutes. If the user successfully completes the mission, the user will get points as a reward. The accumulated point can be exchanged for points such as a discount coupon for a regular checkup at the public hospital. With the existence of this feature, users are expected to be more motivated to improve the quality of their lifestyle. In addition to non-communicable disease, stunting is one health problem that is quite threatening to Indonesia. Most of the causes are a lack of maternal knowledge about the composition of nutrients needed during pregnancy and lactation. As a solution, special features will be added for pregnant and lactating women. First, it will be in the form of articles related to the nutritional adequacy of children and mothers as it is the most important aspect in preventing stunting. It will give the mothers the information about what they should consider before arranging daily menus during pregnancy and lactation. There will also be obstetric examination reminder calendars to help the mothers check when to visit the obstetrician. These features facilitate the pregnant and lactating mothers to be more aware of the condition of her and her baby. To make sure this idea can solve unevenly health promotion in Indonesia, we need to make sure that all the society, especially in the localized region, uses this application. So, the publication and socialization of this new feature need maximum efforts from every health workers. CONCLUSION Good health promotion could be an effective way to prevent most of the health problems in Indonesia. By utilizing smartphone technology, the unequal distribution of health promotion problem in Indonesia could be resolved. The modification of Mobile JKN application made by BPJS Kesehatan by adding a reliable health promotion feature using Artificial Intelligence system along with the existing administrative feature could be a new solution to help the health promotion efforts and overcome the health problems in Indonesia. To make sure this innovation work well, we need help to promote and new policy by the government. RECOMMENDATION Of course, this idea requires further research and study and support from various parties such as the Government, the community, and also parties that related in the realization of the updating the feature of Mobile JKN application: 1. The University whether in health science fields, engineering computer, information, visual design, and other related fields from students or researchers to be able helping the collection of supporting data in of advanced research to maximize this innovation.

2. The government or private institutions towards research to support this idea by helping the funding in the advanced research for the development of the Mobile JKN application and the help through serving the data of competent human resources that will be needed to develop the application. 3. The Government, especially the BPJS party and Minister of Health as the giver of the policy to allow the implementation of these innovations, helps the funding of the Mobile JKN development, disseminating the latest version of the application, as well as giving information and assistance that needed in developing the application. 4. Health workers, in this case, the doctors, nurses, and the one who regulates the medical record to the patient's medical history to make sure input their medical history with great responsibility and helping to make the reliable articles for Mobile JKN and socialize it to the societies. 5. The BPJS administration staffs to promote Mobile JKN and ensure that all the BPJS participants, either old or new participants, have installed the application. 6. The community, as the user, to use the application in accordance with proper usage and maximize features available such as screening and health promotion articles for the sake of their health.

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It Takes Time to Realize Andi Muhammad Rifky, Ahmad Taufik Fadillah Zainal, Dwi Murti Ni Widiastuti, Giordano Bandi Lolok Hasanuddin University Abstract. In 2014, the Government of Indonesia introduced a new health insurance scheme, known as Jaminan Kesehatan Nasional–Kartu Indonesia Sehat/ National Health Insurance- Healthy Indonesian card (JKN-KIS), which was managed by Indonesia’s National Healthcare Security Agency, namely Badan Penyelenggara Jaminan Sosial–Kesehatan (BPJS-Kesehatan). JKN-KIS was the result of a merger of preexisting social health insurance schemes. Furthermore, the Ministry of Health (MOH) introduced several new medicine policies for supporting the implementation of the JKN-KIS program. The coverage of BPJS participation for Bukan Penerima Upah/workers without wage (BPU) is 25,397,828 people, for active BPU participants there are 13,787,832 people while inactive there are 11,609,996 people. One of the reasons for participants being inactive (temporarily deactivated) is because they do not pay contributions (arrears) for more than 1 month from the 10th of each month. Various efforts have been made by BPJS to overcome all the problem and achieve membership targets. One of the efforts is to raise awareness of the importance of JKN is by socializing to the public through mass and audiovisual media. But it is still not large and comprehensive. Therefore, spreading the information about the importance of the JKN interestingly and easily accepted by the community is one of the solution for the problem that faced by BPJS. In the current era of digitalization, the internet is one of the basic needs of society. Through the internet we can do more persuasive socialization. It cannot be denied, nowadays people prefer something instant, so it is very difficult to attract people who want attend a socialization. So, our video entitled “It Takes Time to Realize" is a manifestation of our solution to convey messages to the community with a unique and easily accepted way. Keyword

: JKN-KIS, BPJS-Kesehatan, BPU,

IT TAKES TIME TO REALIZE WHITE PAPER

ANDI MUHAMMAD RIFKY

(C011171039/AMSA-UNHAS)

AHMAD TAUFIK FADILLAH ZAINAL

(C011171332/AMSA-UNHAS)

DWI MURTI NI WIDIASTUTI

(C011171075/AMSA-UNHAS)

GIORDANO BANDI LOLOK

(C014172120/AMSA-UNHAS)

ASIAN MEDICAL STUDENTSâ&#x20AC;&#x2122; ASSOCIATION INDONESIA 2019

Introduction Based on WHO definition, health is a state of complete physical, mental, and social wellbeing,

and not merely the absence of disease or infirmity. A person can’t be considered as a healthy person once he or she does not suffer from mental or physical illness . Indonesia is one of the developing countries that are concern about its people health problem. One of the government ways to solve it is by providing a health institution called National Social Security Agency/ Badan Penyelenggara Jaminan Sosial (BPJS).1 Many countries strive for universal health coverage (UHC), a concept recommended by the World Health Organization (WHO) to ensure that all people have access to health services they need without suffering financial hardship. One of the goals of UHC is to eliminate out-of-pocket payments (OOPs), a direct payment made by an individual to healthcare providers at the time of service use2,3. OOPs can be a great catastrophe for the family of a sick individual 4. In low middle-income countries (LMICs), the proportion of OOPs in healthcare spending for medicines is high, ranging from 50% to 90% 5. Moreover, medicine expenditure is accounted for up to 67% of total health expenditure . Appropriate policies are needed to reduce OOPs on medicines and to control medicine expenditure 6. Furthermore, in order to move towards UHC, WHO has recommended to incorporate health technology assessment (HTA) to establish policies on medicines. The WHO defines HTA as the systematic evaluation of properties, effects and/or impacts of health technologies and interventions 7. HTA is a critical component of evidence-based policy decision making 8.9. In line with the global trends, Indonesia also makes a concerted effort to achieve UHC. Prior to 2014, Indonesians were supported by several social health insurances. The three biggest social health insurances were Asuransi Kesehatan (Askes, for civil servants and the military), Jaminan Kesehatan Masyarakat (Jamkesmas, for lower income classes), and Jaminan Sosial Tenaga Kerja (Jamsostek, social security program for laborers). Notably, the fragmented health insurance schemes made health care spending and service quality difficult to control. Regarding medicines, previous studies have reported a large number of different medicine formularies existing with an unclear evidence-base 10. In addition, OOPs were still dominant, e.g. Indonesia accumulated OOPs was 49% in the year 201313. In 2014, the Government of Indonesia introduced a new health insurance scheme, known as Jaminan Kesehatan Nasional–Kartu Indonesia Sehat/ National Health Insurance-Healthy Indonesian card (JKN-KIS), which was managed by Indonesia’s National Healthcare Security Agency, namely Badan Penyelenggara Jaminan Sosial–Kesehatan (BPJS-Kesehatan). JKN-KIS was the result of a merger of pre-existing social health insurance schemes. Furthermore, the Ministry of Health (MOH) introduced several new medicine policies for supporting the implementation of the JKN-KIS program.14 KIS was integrated with the PBI (Penerima Bantuan Iuran, Premium Assistance Recipients) program of the JKN (Jaminan Kesehatan Nasional, National Health Insurance) program. This program is part

of the SJSN (Sistem Jaminan Sosial Nasional, National Social Security System), which is mandated by Law No. 40/2004 on SJSN. The law requires that the JKN premium of the poor is paid for by the government through the PBI program. In July 2013, the premium assistance is Rp19,225 per PBI recipient and the total number of recipients is 86.4 million people. In 2017, the premium assistance is Rp23,000 per recipient and the total number of participants of the KIS program is 92.4 million people.14

II.

Outlined Problems In Indonesia health insurance is "managed" by the BPJS. One form of BPJS participation is

participants who are not wage earners (BPU). They have to pay contributions every month with a certain amount in accordance with the desired class of care. But it cannot be denied that there are still many people who have difficulty making payment of contributions every month. The ability to pay health insurance is highly dependent on income level (Djahini et al, 2018) Similar to informal sector workers (motorcycle taxi drivers), their ability to pay BPJS contributions (Ability to Pay) is strongly influenced by income factors and the number of family dependents in the household. Access to health services is not easy for those who are low-income (poor) and informal sector workers (Sarkar, 2007). This research shows that informal sector workers want monthly payment of contributions to one family member who bears all family members. This is very reasonable, because informal sector workers do not have excess income. Their income is only enough for living expenses (food, house, rent, etc) (Nurbaeti et al, 2017) A lot of evidence shows that socio-economic levels such as income and education are related to health care services. The fairness of access to health services is considered a key component of achieving the Universal Health Coverage which is also a part of efforts to realize sustainable development (SDGs) (Huda et al, 2017). Poverty is also proven to be a limiting factor for access to health services (Jacobs, Ir, Bigdeli, Annear, & Damme, 2012). Research in India shows that health insurance ownership can increase access to health services (Devadasan et al., 2010). In Indonesia, ownership of the BPJS card is one of the efforts to realize fair access to health services. The only thing is, people with no insurance complains of not having enough money to afford them. While trying to reach the target number of national health insurance participation (Jaminan Kesehatan Nasional, JKN) 257.5 million in 2019. BPJS is challenged with all the problems that arise. Starting from deficit problems, arrears to service problems. In 2014, Health BPJS deficit reached IDR 3.8 trillion. In 2015, the deficit increased to IDR 5.9 trillion. In 2016, the deficit increased again to IDR 9 trillion. In 2017 the deficit reached up to IDR 9.75 trillion and finally in 2018, the Health BPJS deficit was estimated at IDR 10 trillion. Health BPJS President Director Fahmi Idris said, in the matter of the DJSN, the ideal contribution for the community

in third-class hospitals should be IDR 50,000/month. Class II hospitals are IDR 63,000/month and class I IDR 80,000/month. In its implementation, only first class contributions that match the ideal contribution are IDR 80,000 / month. For third-class participants, they only pay IDR 25,500 /month, which means they must be subsidized at Rp24,500 / month. Second-class participants pay IDR 51,000 /month and get subsidies of IDR 12,000 /month. Of course this is one of the factors that causes a significant increase in the BPJS deficit each year, on the other hand BPJS arrears to several hospitals that reach trillions, actually worsen the problem. The Ministry of Health, noted, until November 30 th 2018, BPJS-Kesehatan still had arrears to hospitals which reached IDR 1.72 trillion (BPJS, 2018). Based on data released by the Minister of Health, Nila Moeloek, the total bill came from outpatient care of IDR 471.26 billion, hospitalization of Rp1.18 trillion, medicines amounting to Rp66.97 billion, and out-of-package equipment of IDR 5.37 billion. The problem of deficits and arrears will certainly have a major impact on the community, BPJS services that are less optimal and often complained of are a result of this problem. Nowadays the coverage of BPJS participation for Bukan Penerima Upah/workers without wage (BPU) is 25,397,828 people, for active BPU participants there are 13,787,832 people while inactive there are 11,609,996 people. One of the reasons for participants being inactive (temporarily deactivated) is because they do not pay contributions (arrears) for more than 1 month from the 10th of each month. So that public awareness to participate and pay BPJS contributions on time is the key to answering these problems.

III.

Solution Public awareness is the key to all current JKN problems. When the community understands the

urgency of National Health Insurance, pays contributions every month with the right time, wisely uses the Indonesia Healthy Card, and participates in disseminating information about JKN to the public. It doesn't take long to fix all of these problems. Therefore, we made this short video, to educate the public about the importance of the National Health System not only for ourselves but also for others including the middle to lower economic groups. As a smart and caring society, it is not right for us to focus all problems on the government and BPJS. Analyzing this problem actually focuses on the community itself. Public awareness about BPJS health services is indeed very high. However, that does not mean that all processes run smoothly and without obstacles. One debate that often occurs is that BPJS Health participants are late on paying their monthly fees. As we know that a number of these contributions will become funds in the health services provided by BPJS. That is, if many participants are late in paying membership fees, then it can become an obstacle for BPJS in guaranteeing health services, thus impacting the BPJS deficit and arrears that continue to soar each year. Without realizing it, we as a society become the root of the collapse of

BPJS's current health services. Therefore, the change to be better is not something that is worth waiting for, we need to change that change together and the community is the main actor. Nowadays, various efforts have been made by BPJS to overcome all the problem and achieve membership targets. One of the efforts is to raise awareness of the importance of National Health Insurance is by socializing to the public through mass and audiovisual media. But it is still not large and comprehensive. Therefore, spreading the information about the importance of the National Health Insurance interestingly and easily accepted by the community is one of the solution for the problem that faced by BPJS. In the current era of digitalization, the internet is one of the basic needs of society. Through the internet we can do more persuasive socialization. It cannot be denied, nowadays people prefer something instant, so it is very difficult to attract people who want attend a socialization. So, our video entitled â&#x20AC;&#x153;it takes time to realize" is a manifestation of our solution to convey messages to the community with a unique and easily accepted way, that will be published on the internet and social media such as google, youtube, facebook, instagram, twitter and other social media, which are closely related to the people who live in the current millennial era.

IV.

Recommendation The rapid growth of the minimarket in the community has made minimarket one of the most

visited places by the community. This can be one recommendation for government to utilizing the minimarket as a means to educate the public regarding the importance of the National Health Insurance program.from this paper we suggest that good cooperation between the government and the minimarket by establishing an Standar Operating Procedure (SOP) that aims to remind the public to pay BPJS during the transaction process, so that the public can actively pay BPJS contributions every month, and BPJS contributions do not experience delinquency which can lead to an increase in the BPJS deficit. By achieving these objectives, it is hoped that BPJS will be able to provide the best service to the community.

Conclusion Participation problems, deficits, arrears to health services are problems faced by the

government and society today. Lack of public awareness regarding the urgency of JKN is the main factor causing these problems. The frequency of public delinquency in BPJS payments each month leads to an increase in the BPJS deficit each year, which results in less optimal health services by BPJS. Therefore, to break the problem, the role of the community and the government is needed. By disseminating information related to BPJS that is wrapped in an attractive and easily accepted society and ensuring dissemination of information through the internet and social media is one solution to this problem ... We as the authors also recommend to the government to collaborate with partners such as minimarkets to make SOPs which aims to educate and remind the public to pay BPJS monthly

contributions every time they visit a minimarket, considering that minimarkets are the most visited places every month. Through this white paper and video, it is expected to be one way to publish BPJS information that can make us aware of the importance of BPJS-Health in ensuring our health as a community. The hope is the formation of full awareness of the community regarding the importance of participating in JKN, the importance of paying monthly contributions on time, so that the BPJS deficit and delinquency problems can be resolved and BPJS health services can be optimized.

REFERENCES 1. Angelis A, Lange A, Kanavos P. (2018). Using health technology assessment to assess the value of new medicines: results of a systematic review and expert consultation across eight European countries. The European Journal of Health Economics;19(1):123–152. 10.1007/s10198-0170871-0 2. Bigdeli M, Laing R, Tomson G. (2015) Medicines and universal health coverage: challenges and opportunities. 3. BPJS. (2017). Laporan Pengelolaan Program dan Laporan Keuangan Jaminan Sosial Kesehatan Tahun 2017. 4. Cameron A, Ewen M, Ross-Degnan D, Ball D, Laing R. (2009). Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis. The lancet;373(9659):240–249. 5. Chalkidou K, et al. (2013) Health technology assessment in universal health coverage. Lancet . December 21;382(9910): e48–9. 10.1016/S0140-6736(13)62559-3 6. Devadasan, et al. (2010). Community health insurance in Gudalur, India, increases access to hospital care. Health Policy and Planning, 25, 145 - 154. 7. Diack A, Seiter A, Hawkins L, Dweik IS. (2010). Assessment of governance and corruption in the pharmaceutical sector: Lessons learned from low- and middle-income countries. 8. Djahini-Afawoubo, D. M., & Atake, E.-H. (2018). Extension of mandatory health insurance to informal sector workers in Togo. BMC Health Economic Reviews. 9. Indah Sari. (2018). BPJS Kamu Terblokir Karena Telat Bayar? Ini Solusinya. Accessed on March 26th 2019. https://blog.tunaikita.com 10. Jacobs, B., Ir, P., Bigdeli, M., Annear, P. L., & Damme, W. V. (2012). Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian coun-tries. Health Policy and Planning, 27, 288 - 300. 11. Koalisi A. (2018). Perbedaan JKN, BPJS, KIS dan Hubungannya dengan UHC. Accessed on 27 th March 2019. https://www.iac.or.id 12. Kwon Soonman, Kim Sujin, Jeon Boyoung, Jung Youn. (2014) Pharmaceutical Policy and Financing in Asia-Pacific Countries.: OECD Korea Policy Centre, Graduate School of Public Health, Seoul National University (WHO Collaborating Centre for Health System and Financing). 13. Nurbaeti, Andi Surahman Batara (2017) . AbIlity To Pay BPJS For Informal Sector Workers (Study In Ojek And Becak/Bentor Drivers). Volume 8, N0 2, Desember 2018,Page 165 -172 14. Rickwood S, Kleinrock M, Nunez-Gaviria M, Sakhrani S, Aitken M. (2017). The global use of medicines: outlook through 2017 IMS Institute for Healthcare Informatics; 2013:5. 15. Roy Franedya. (2019). BPJS Kesehatan: Dari Defisit Hingga Tunggakan Rumah Sakit. Accessed on March 26th 2019. https://www.cnbcindonesia.com 16. Sarkar, S. (2007). Health Insurance for the Poor in Informal Sector. Indus Journal of Management & Social Sciences, 1(2). 17. Suryahadi A and Izzati A. (2018) Cards for the Poor and Funds for Villages: Jokowi’s Initiatives to Reduce Poverty and Inequality.The SMERU Research Institute. 18. Wirtz VJ, et al. (2017). Essential medicines for universal health coverage. The Lancet ;389(10067):403–476. 19. World Health Organization. (2018). Global Health Expenditure Database. 20. World Health Organization. (2019) Health Technology Assessment, HTA, WHO Definition (EB 134/30). 21. World Health Organization. (2016). Monitoring health for the SDGs sustainable development goals. 22. World Health Organization. (2010). The world health report: health systems financing: the path to universal coverage: executive summary.

THE QUINTESSENCE OF HEALTHCARE Firshan Makbul, Liani Elisabeth Enggy, Leony Octavia, Gabrielle Natasha Sutanto Hasanuddin University ABSTRACT Since health is a human right, WHO & World Bank come up with a program called Universal Health Coverage (UHC), where nobody have to suffer from the financial hardship while paying to get the healthcare they need & deserve. Indonesia is a rapidly growing middle-income country with 262 million inhabitants spread over 17.744 islands, and presents unique challenges for health systems and universal health coverage (UHC). From 1960 to 2001, the centralised health system of Indonesia made gains as medical care infrastructure grew from virtually no primary health centres to 20.900 centres. Life expectancy improved from 48 to 69 years, infant mortality decreased from 76 deaths per 1000 live births to 23 per 1000, and the total fertility rate decreased from 5Âˇ61 to 2Âˇ11. However, gains across the country were starkly uneven with major health gaps, such as the stagnant maternal mortality of around 300 deaths per 100.000 live births, and minimal change in neonatal mortality. The novel UHC system introduced in 2014 focused on accommodating adaptive implementation features and quick evidence-driven decisions based on changing needs. The UHC system grew rapidly and covers 203 million people, the largest single-payer scheme in the world, and has improved health equity and service access. While Indonesia has made steady progress, around a third of its population remains without cover and out of pocket payments for health are widespread even among JKN members. To help close these gaps, especially among the poor, the Indonesian government need to implementing a set of UHC policy reforms that include the integration of remaining government insurance schemes into the JKN, accreditation of all contracted health facilities and a range of demand side initiatives to increase insurance uptake, especially in the informal sector. Key Findings : UHC, NHIS, primary health care, global healthcare, health systems,

THE QUINTESSENCE OF UNIVERSAL HEALTHCARE

By: Firshan Makbul Liani Elisabeth Enggy Leony Octavia Gabrielle Natasha Sutanto

AMSA Universitas Hasanuddin

INTRODUCTION Financial problem has been one of the major cause of getting the healthcare people needed. According to the WHO, 400 million people lack the most basic life-saving health care, and 17% of people in low-middle-income countries (which made three-quarters of the world’s population) are pushed or further pushed into poverty (US $2/day) because of health spending. While up to one-third of households in Africa and Southeast Asia borrow money or sell assets to pay for health care. (http://healthforall.org/welcome/) United Nations’ 1948 Universal Declaration of Human Rights Article 25 stated that ”Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.” This means that access to healthcare should be available to everyone, regarding their financial status, where they are from, their race, etc. Because of this, development agencies such as World Health Organization (WHO, 2015) and the World Bank, come up with the program called ’Universal Health Coverage’ (UHC). UHC is defined by the WHO as a means to ensuring that ”all people obtain the health services they need without suffering financial hardship when paying for them”. Their goal is to give everyone a good quality health service and financial protection from healthcare costs. Indonesia is an archipelago country with more than 300 different ethnics. It used to have a centralized health system from 1960 to 2001, with some of the first primary health centers. Life expectancy improved from 48 to 69 years, infant mortality decreased from 76 deaths per 1000 live births to 23 per 1000, and the total fertility rate decreased from 5.61 to 2.11. However, gains across the country were starkly uneven with major health gaps, such as the stagnant maternal mortality of around 300 deaths per 100 000 live births, and minimal change in neonatal mortality. It turns out, the method one size fits it all cannot address the complexity and diversity in population density and dispersion across islands, diets, diseases, local living styles, health beliefs, human development, and community participation. (Bellwood, 2007) In 2014, Indonesia implement a comprehensive single-payer UHC program called National Health Insurance System (NHIS) or Badan Penyelenggara Jaminan Sosial (BPJS). It changed the approach, accommodating diversity with flexibility and adaptive implementation features and quick evidence-driven decisions based on changing needs

In 4 years, Indonesian NHIS has

become the largest single-payer system in the world with 203 million members and managing

223.4 million consultations for both primary and advanced treatments in 2017. (Social Security Agency for Health, 2017) KEY OBJECTIVES Achieving UHC requires countries to advance health services. The proportion of the population covered should extend to encompass all people in a country (universal population coverage). The range of services covered should expand as resources permit, including sufficient investment in essential public health functions. Services must be accessible and be of adequate quality to be effective. And, the proportion of the financing required to deliver services should be increasingly drawn from pooled funds raised

through compulsory prepayment mechanisms,

including general or specific taxation or public social insurance.

Figure 1 : Three dimensions to consider when moving towards universal coverage Source : adapted from www.causehealth.be ●

Objective 1 : Improve health systems equity in Indonesia

●

Objective 2 : Improve service preparedness

●

Objective 3 : Improve financial sustainability

Objective 1 : Improve health systems equity in Indonesia Outline Problem The newly launched SDGs illustrate that, for all countries in the region (and indeed, the world), health will be one priority of many in the coming years. Target 3.8, pulled out the ambition to “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services, medicines and vaccines for all”,thus making UHC a target for every

country. UHC is a target in the SDGs because it is also considered a vital component of ending poverty and promoting well-being. (Beattie, Yates & Noble, 2016) Concerns about the poor and most vulnerable not getting adequate access to quality health care are widespread in low and middle-income countries (LMICs) and have led to an intense advocacy for universal health coverage (UHC). Equity, defined by the World Health Organization as ‘the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically’ - is fundamental to UHC. (Wiseman et al, 2018) The inequities in health indicators, such as mortality rates, availability of health-care services, and people living below the poverty line are reflected in high variability across and within provinces and districts. The head count ratio as measured with the national poverty line declined from 21,6% in 1984 to 10,6% in 2017. (Statistic Indonesia, 2017). Although the national head count ratio was 10, 6% in 2017, provinces in eastern Indonesia such as Maluku, Papua, and West Papua were three times greater than the national ratio, whereas Daerah Khusus Ibukota Jakarta, Bali, North Sulawesi, and Bangka Belitung were less than half the national ratio. Disparities include provinces with high poverty and high inequality (eg, Papua, West Papua, and West Nusa Tenggara), low poverty and high inequality (eg, Jakarta and Bali), and medium poverty and inequality (eg, West Sumatra and Riau). UHC in this context must address the geographic and factors affecting care provision and use across all regions and groups. Indicators of overall health status in Indonesia have improved significantly over the last two and half decades, with life expectancy rising from 63 years in 1990 to 71 years in 2012, under-five mortality falling from 52 deaths per 1000 live births in 2000 to 31 deaths in 2012, and infant mortality falling from 41 deaths per 1000 live births in 2000, to 26 deaths in 2012. However, progress on maternal mortality and communicable diseases has been slower, with maternal mortality remaining high (210 deaths per 100 000 live births in 2010), and continuing high incidences of tuberculosis (TB) and malaria. At the same time, risk factors for NCDs, such as high blood pressure, high cholesterol, overweight and smoking, are increasing. (WHO, 2017) Proposed Solution / Policy UHC has often been launched in the aftermath of a national crisis as a means of nation-building accompanied by a narrative linking UHC to the delivery of citizens’ rights, and as an important mechanism to unite the nation through shared expectations. According to Bump et al (2016) by using its authority to ensure equitable access to health resources, the government is meeting its responsibility as a duty bearer to guarantee the rights of its people. By engage political

actors, including the head of state, parliamentarians, administrators also can give big impact to the citizen for paying their UHC system. -

the system develops and remains appropriate for the country’s circumstances, approach to decentralised administration, regulatory capacity and budget;

political leaders understand and appreciate the political benefits and costs of different policy options, in particular the merits of reaching full population coverage

those who are more likely to perceive themselves as losing out are engaged early to ensure they do not become spoilers

Objective 2: Improve service preparedness Outline Problem Puskesmas or pusat kesehatan masyarakat, as said by Ministry of Health Regulation No. 75 of 2014, is a public health facility that organize first-degree public health or individual, which prioritizes promotive and preventive efforts, in order to elevate public health as much as they can. Puskesmas should be at least one per sub-district. The problem, is that most puskesmas that is located in eastern region and rural areas (especially outside Java), don’t have the necessity and the qualities needed to support them. Most of them don’t have electricity and physicians that stay in that place. So most of them have to travel for miles to bigger health cares like hospitals, to get the medication that they needed. Also, most health professionals do not want to go work there, because, as said by Sparrow and Vothknecht, around 12.000 housing facilities for doctors and nurses were in damaged condition. Most of these puskesmas also have poor basic equipment. A research in 2012 said that, in 2011, around 5860 puskesmas (65.6%) don’t have any working incubator and around 7448 puskesmas (83.4%) without laboratory facilities. Investment funding was made by the government through JKN. It said that the budget for primary health care has increased through capitation system. However, MoH Regulation - No. 19 of 2014 on the Utilization of National Health Insurance Capitation Fund for Health Services and Primary Health Centres Operational Costs (Minister of Health, 2014a) - said that the puskesmas are not allowed to use the capitation fund to invest in capital investment or any maintenance costs. Allocation of capital is controlled by government, and they prioritized on upgrading so that puskesmas can provide inpatient care, like by increasing the number of beds. Increase of NHIS members and costs led to enhancement of the medicine and medical supplies. As said in the introduction, NHIS is trying to give everyone personal medication, no more one size fits it all. That’s why, there are so many kind of drugs made and circulating in Indonesia.

The government tried to limit it by making an e-catalogue, and to use a more low cost - effective drugs. Even though thereâ&#x20AC;&#x2122;s an e-catalogue that tends to recommend low cost - effective drugs, a 2015 survey showed that 18% of patients in hospital were still charged for medicines by the provider. Proposed Solution / Policy -

Make budget allocation for maintenance of primary health care, so medical professionals will feel comfortable while working and locals will want to come back again.

Ministry of Health should evaluate every â&#x20AC;&#x2039;puskesmas for every 3 months, so broken, disposable equipment , and drugs that run out can be replace as soon as possible. So, health workers can do their job efficiently and according to the guideline.

Objective 3: Improve financial sustainability Outline Problem Health is clearly stated as one of the important objectives in the Indonesian constitution and is also well defined in the Ministry of Health National Strategic Plan. In terms of financial protection and equity in health financing, Indonesia is still struggling. Even though JKN coverage is steadily increasing, OOP expenditure is above average. Catastrophic spending remains at a high level with many workers in the informal sector not yet insured. Implementation of the single risk pooling mechanism (JKN) poses several risks to equity in health-care financing and service utilization. As all funds and risks are collected in a single pool, provinces xxx or districts with limited health infrastructure and supply-side readiness, and lower health-care utilization, might receive less government subsidy compared to well-developed areas. Indonesia faces the challenge of increasing health expenditures. Although there has been a substantial increase in health spending at national level, health spending as a proportion of gross domestic product (GDP) remains below average among the low-to-middle-income countries (3.1% of GDP in 2012). The government share of total health expenditure also remains low, at only 39%, whereas private, primarily out-of-pocket (OOP) expenditure, is 60% which means private sectors still financed the majority of health spending. (â&#x20AC;&#x2039;Center for Financing and Health Insurance, 2016) Resources available for health come either from public mechanisms (tax funding, social insurance and external aid) or through private mechanisms such as private insurance schemes, direct out-of-pocket (OOP) payments and some limited use of personal health savings accounts. Total health expenditure (THE) calculates spending on health from all sources of financing,

including public and private sources. Figure 2 shows the total and public health spending in Asia and Pacific, expressed as a percentage of GDP. (UNICEF, 2016)

Figure 2 : Total Health Expenditure (THE)

and

Public

Health

Expenditure (PHE) in Asia and Pacific Countries 2014 Most countries spend well under 4% for public expenditure on health (or indeed 3%) with some notable exceptions. The higher the PHE as a share of THE, the more control a country will have over how it can allocate

resources

equitably

respond to its burden of disease. The so-called missing middle remains a problem wherein people who work in the informal sector and who are not living in poverty are not covered by the NHIS because of low self-enrolment. (Statistics Indonesia, 2016). The lower-middle-income group has the highest number of uninsured people, whereas the high-income group has the lowest. Moreover, even though the government is fully subsidising the premium of people who are living in poverty and those who are just above the poverty line, around 34·4 million people remain uncovered by the NHIS because of rapid changes in household welfare and eligibility according to Dartanto, Rezki,, Pramono, Siregar, Usman, Bintara (2016). The sizable missing middle poses a major obstacle to achieving UHC by 2019, as required by law.

Proposed Solution / Policy ➔ Increase Tobacco Tax Increasing the tax on alcohol and tobacco is another way of generating income for health expenditure in Indonesia. A modest proposal for the future is to raise the tobacco tax to cover the health and economic costs of smoking-related diseases. Because the impact of smoking is also expensive for the government. In 2012 the government received Rp79.9 trillion in tobacco excise but, due to smoking related diseases, the country also suffered economic losses and

health-care costs amounting to Rp240 trillion (Natahadibrata 2013). We propose some convenient way to overcome this problem : ➢ Design features to simplify the tax structure, to analyse the elasticity and optimise the revenue increase and to encourage behaviour change. ➢ Assess whether the tax needs to be allocated specifically for health care. In most countries this allocation is lighter and less of a problem from the analytic point of view. ➢ Assess the impact on tobacco farmers and other workers who manufacture ➔ Cooperating with private sector : increasing private sector insurance The first step should be to restructure the package of benefits that provides only inpatient class III rooms for all patients under BPJS. Some contribution costs could also be introduced. The special drug service for civil servants, established at the beginning of 2014, needs to be eliminated. The government should allow private insurance companies to sell additional policies for the provision of class I and II inpatient room services, special drugs and wider access to laboratory and diagnostic tests, as happens in other countries such as Singapore. At the same time, the government needs to develop complementary legislation to monitor and regulate private insurance. The kinds of regulations required to arrange private insurance include: -

standard finance and non-finance arrangements for the influx of patients and operations;

rules for reporting the arrival and departure of patients; and

consumer protection and mechanisms to enhance fairness.

CONCLUSION Health is an essential thing that is needed by everyone regardless of their status. One of the best solution there is today is Universal Health Coverage (UHC). UHC aims to give everyone the same healthcare without suffering from financial hardships. In Indonesia, there’s an UHC program called NHIS / BPJS. Although it has lowered the mortality rate, it still does not cover many diseases. Also, many primary health care is not quite ready to deal with as being the first line in NHIS. That is why, medical professionals are not spread thoroughly and many people cannot get the healthcare they deserved. Lastly, many people still pay for their own healthcare rather than from the government funding. That is why, although good, the implementation of UHC in Indonesia still needs improving, particularly from the financial department, as the main goal of UHC is to take everyone’s burden off the financial hardships.

RECOMMENDATION We hope that the government can make new policies regarding primary healthcares, so they can be accessible for everyone and can get the job done. We also hope that the government can invest some fundings for health services, either from taxation or from working together with private sectors, so NHIS can quickly become a true UHC, where people will not need to worry about financial problems when talking about health and well-being. REFERENCES Beattie, A., Yates, R., & Noble, D. J. (2016). Accelerating progress towards universal health coverage in Asia and Pacific: improving the future for women and children. BMJ global health. Bellwood P. (2007). Prehistory of the Indo-Malaysian archipelago. Canberra: Australia National University. Bump J, et al. (2016). Implementing pro-poor universal health coverage. Lancet Glob Health. Center for Financing and Health Insurance. (2016). Performance Accountability Report 2016. Jakarta: Ministry of Health Republic of Indonesia. Dartanto T, Rezki JF, Pramono W, Siregar CH, Usman, Bintara H. (2016). Participation of informal sector workers in Indonesia’s national health insurance system. JSEAE.

Health for All WWW healthforall. (n.d.). April 3, 2019. http://healthforall.org/welcome/ Ministry of Health Republic of Indonesia. (2014). MoH Regulation 2014 Republic of Indonesia. Natahadibrata N. (2013). “Calls for a Complete Ban on Cigarette Ads”. Jakarta Post. Social Security Agency for Health. (2017). Program management and financial report year 2016. 2017.https://bpjs-kesehatan.go.id/bpjs/index.php/arsip/categories/Mzg/laporan-keuangan(acc essed Apr 5, 2019). Statistics Indonesia. (2016). National socio-economic survey 2016. Jakarta: Statistics Indonesia. Statistics Indonesia. (2017). Statistical yearbook of Indonesia 2017. Jakarta: BPS. United Nations. (1948). Universal Declaration of Human Rights Article 25. Wiseman, Virginia, et al. (2018). International Journal for Equity in Health. An evaluation of health systems equity in Indonesia: study protocol.

World Health Organization. (2017). The Republic of Indonesia Health System Review. New Delhi: World Health Organization, Regional Office for South-East Asia. World Health Organization. (2015). Tracking Universal Health Coverage Report. France: WHO. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5418650/)

ERADICATING DISPARITIES OF HEALTHCARE ACCESS FOR PEOPLE WITH SEVERE MENTAL DISORDER Kevin Eliezer Ferdinandus, Sharqi Muhammad Ash Shiddiqi, Bidhari Hafizhah AMSA-Universitas Gadjah Mada ABSTRACT Background The burden of mental disorder not only affects the health of the patient, but also their productivity which in turn will also hinder the productivity of their workplace as a whole. According to Indonesiaâ&#x20AC;&#x2122;s Basic Health Research (RISKESDAS) 2018, the prevalence of mental disorders in the population reaches 7% of the total population. The exponential increase from the 1.7% rate in 2013 should be a wake-up alarm for the country about its mental health situation at the moment. People with mental disorders have a higher mortality rate and shorter life expectancy compared to the general population. They do not only struggle with their own mental condition, but also from stigmas applied by the society to them. These stigmas can be a barrier for them to access the healthcare that they need. Proposed Solutions To ensure equal access of healthcare for people with mental disorders, we are proposing a solution in the form of contact-based education to reduce the widespread stigma on mental disorder. The contact-based education that we are proposing can be divided into direct contact-based education and indirect contactbased education. Direct contact-based education is done through facilitating interaction between healthcare providers and persons with lived experience of mental health problems. Indirect contact-based education is another form of contact-based education done through the help of creative contents, such as videos, infographics, and posters. Keywords: mental disorder, stigma, contact-based education.

ERADICATING DISPARITIES OF HEALTHCARE ACCESS FOR PEOPLE WITH SEVERE MENTAL DISORDER

Kevin Eliezer Ferdinandus, Sharqi Muhammad Ash Shiddiqi, Bidhari Hafizhah

AMSA-Universitas Gadjah Mada Indonesia

ERADICATING DISPARITIES OF HEALTHCARE ACCESS FOR PEOPLE WITH SEVERE MENTAL DISORDER Kevin Eliezer Ferdinandus, Sharqi Muhammad Ash Shiddiqi, Bidhari Hafizhah AMSA-Universitas Gadjah Mada

INTRODUCTION A mental disorder is a syndrome characterized by clinically significant disturbance in an individualâ&#x20AC;&#x2122;s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning (American Psychiatric Association, 2013). Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. American Psychiatric Association further classifies mental disorders into 22 subcategories such as schizophrenia spectrum and other psychotic disorders, bipolar and related disorders, depressive disorders, etc. Each mental illness can be further classified based on its severity into mild, moderate, and severe. The etiology of mental disorders varies depending on the disease itself, but mainly it can be divided into biological factors, genetic factors, and psychosocial factors (Sadock et al., 2014). Biological factors are problems that arise from the body itself, such as neurotransmitter imbalance, hormonal alterations, structural abnormality or variation of the brain. Genetic factors are also thought to contribute to the development of mental disorders. In the case of bipolar disorder, the presence of as many as four loci on chromosome 18 has been linked to bipolar disorder. Psychosocial factors have been observed to precede the occurrence of depression, anxiety disorders, etc.; hence the inclusion into the etiological factors. The common signs and symptoms of mental disorders consist of erratic thought patterns, unexplained changes in mood, lack of interest in socializing, lack of empathy, inability to tell the difference between reality and fantasy, or a seeming lack of control. This, however, is not a complete list of symptoms. It is also highly unlikely for someone to accurately self-diagnose themselves, even with the aid of instruments such as online questionnaires that are widely available. Only a qualified healthcare professional can diagnose mental disorders with any degree of accuracy. The burden of mental disorder not only affects the health of the patient, but also their productivity which in turn will also hinder the productivity of their workplace as a whole. In the U.S., serious mental disorders cost the country $193.2 billion in lost earnings per year (Insel, T.R., 2008). The European Union, a region

with highly sophisticated healthcare system, the direct and indirect costs of handling mental disorders were estimated at €798 billion and is expected to double by 2030 (Gustavsson et al., 2016). With the information above in mind, we can say that handling mental disorders can be a challenge for the government from a public health perspective. According to Indonesia’s Basic Health Research (RISKESDAS) 2018, the prevalence of mental disorders in the population reaches 7% of the total population. The exponential increase from the 1.7% rate in 2013 should be a wake-up alarm for the country about its mental health situation at the moment. The staggering rate of mental disorder prevalence in the society is especially concerning since mental disorder attributes to almost 8 million deaths per year globally (Walker et al., 2015). In a 2016 report released by Human Rights Watch, people with psychosocial disabilities in Indonesia are often shackled or faced into institutions without their consent where they face abuse. More than 57,000 people in Indonesia with mental health conditions have been subjected to pasung – shackled or locked up in confined space – at least once in their lives, with about 18,800 currently shackled, based on latest available government figures. The government has taken some steps by starting an anti-shackling campaign. However, due to the complicated bureaucracy and decentralized model of government, implementation at the local level has been very slow. OUTLINED PROBLEMS People with mental disorders have a higher mortality rate compared to the general population. According to a meta-analysis conducted by Walker et al., 2015, the mortality rate of people with mental disorders is 2.22 times higher than the general population or people without mental disorders, with 10 years of potential life lost (YPLL). Patients with chronic mental disorder have 20 years average decline in life expectancy compared

with

the

general

population

(Goldman

al.,

2016).

The society tends to reason that the disparity between the life expectancy of people with mental disorder and the general population exists because most severe mental disorder patients die relatively more because of unnatural causes (e.g., homicide, suicide, accidents) when compared with the general population. However, in 2013 Lawrence et al. presents us with the data that shows the majority of deaths amongst people with severe mental disease (SMD), such as schizophrenia, bipolar and depression, are attributable to preventable and modifiable physical health conditions, both non-communicable and communicable. His research shows that 77.7% of deaths were attributed to physical health comorbidity such as cardiovascular disease (29.9%) and cancer (13.5%).

Another factor that contributes to the development of non-communicable disease in SMD patients is their medication, which are usually antipsychotics. The adverse reaction to this medicine includes weight gain which poses significant risk of lipid abnormalities and cardiovascular problems in this population (Muench & Hamer, 2010). People with mental disorders does not only struggle with their own mental condition, but also from stigmas applied by the society to them. Stigma is a social construction that devalues people as a result of a distinguishing character or mark (Biernat & Dovidio, 2000). Stigmas applied to mental disorder patients can generate calamitous effects for the patient. It can lead to adverse consequences such as low self-esteem, poor treatment adherence, increased symptom severity, and poorer quality of physical care. Our uttermost concern on the issue of stigma is the stigma in healthcare. In part, this occurs because primary care and other health providers sometimes make decisions contrary to typical care standards. This might occur because providers endorse mental illness stigma (Corrigan et al., 2014). Healthcare providers often feel that patients with mental illness are difficult, manipulative, and less deserving of care. This causes the patient to feel devalued, dismissed, and dehumanized. They often feel left out of decision-making during consultations, receive threats of coercive treatment, made to wait excessively long to receive healthcare, are given inadequate information on their condition, are treated in a demeaning manner, and are told they would never get well. Research has shown that this behavior from healthcare providers are not exclusive to a few insensitive providers. Rather, it occurs consistently throughout the whole healthcare system (Knaak et al. 2017). The consequence of this stigmatization against people with mental illness include delays in seeking help, discontinuation of treatment, and poorer quality of mental and physical care. People with mental illness seeking healthcare for non-mental related illness often receive poorer treatment. Biases in healthcare providers such as diagnostic overshadowing and therapeutic pessimism, are the main causes of this problem. Diagnostic overshadowing is defined as a tendency of clinicians to attribute symptoms or behavior of a person as a consequence of their present mental disorder. As an example, if a patient with a mental disorder complains about a recurrent headache, the clinician in charge is less likely to presume that the condition might foreshadows chronic conditions such as stroke or meningitis.

Therapeutic pessimism is the state where clinicians hold pessimistic views about the reality and likelihood of recovery of the patient, which is experienced as a source of stigma and a barrier to recovery for people seeking help for mental illnesses. Research also suggests that pessimism about recovery for some healthcare workers is associated with a sense of helplessness, leading them to believe that what they do for the patient doesnâ&#x20AC;&#x2122;t matter. Poor treatment of people with mental illness by healthcare providers has contributed to the decreased willingness of those patients to seek help, both for their mental and physical condition. The lack of support, both from healthcare providers and their peers, also contributes to higher rates of suicide in people with mental illness. As it is the role of the government to ensure access of quality care for vulnerable populations, in this case people with mental disorders, steps need to be taken to address and eradicate these issues. PROPOSED SOLUTION To ensure equal access of healthcare for people with mental disorders, we are proposing a solution in the form of contact-based education to reduce the widespread stigma on mental disorder. Stigma reduction in healthcare providers is one of the best ways to provide and model high quality equitable health care in persons with mental health conditions for both their physical and mental health problems. Contact-based education has been proven to be able to decrease negative attitudes directed towards people with SMD (Corrigan, 2007). A study in Chile found that the general public and healthcare workers perception towards people with SMD tends to be less authoritarian and less restrictive when they have experienced contact with people with SMD (Zarate et al., 2006). The contact-based education that we are proposing can be divided into direct contact-based education and indirect contact-based education. Direct contact-based education is done through facilitating interaction between healthcare providers and persons with lived experience of mental health problems. This has been shown effective to produce most positive changes in attitude towards people with mental health problems. It focuses on intensive social contact where healthcare providers meet at multiple time points in order to learn about that personâ&#x20AC;&#x2122;s life by hearing testimonies, experiences of illness and recovery, as well as their experiences within the healthcare system. This social contact approach is qualitatively different to any other typical provider-patient interactions because people with mental health problems are seen not as patients

but as educators. Social contact has been shown to disprove stereotypes, reduce anxiety, create personal connection, boost empathy and improve understanding of recovery. Indirect contact-based education is another form of contact-based education done through the help of creative contents, such as videos, infographics, and posters. We break it down into guided sessions and awareness-raising social media campaign. In guided sessions, participants are required to watch and analyze short videos that show different experiences of people with SMD. The videos show situations of stigma and discrimination that those affected have experienced (with health personnel present), as well as good experiences that have happened to them in the context of their health care. The goal of the session is to encourage group reflection. The session will also integrate non-stigmatizing practices through the plan and execution of behaviors that increase positive attitudes and respectful and inclusive treatment toward people who have SMD. The program format emphasizes contact conditions that favor its effectiveness, i.e., status equality between the participants, achievement of common goals, and establishment of a cooperative relationship. Furthermore, the contact strategies focus on favoring empathy, which is inversely related to prejudice. To make sure that the guided sessions are effective, we propose the sessions to be made mandatory for primary healthcare worker for at least once. We also propose the employment of facilitators and cofacilitators to lead the session. The facilitatorâ&#x20AC;&#x2122;s minimum qualification is being a healthcare worker who has been trained on the topic of SMD, characteristics and effects of stigma; he/she also needs to spend at least 20 hours of contact training process. The co-facilitators will be people who have been diagnosed with SMD who has received adequate amount of training to facilitate sessions. As for the awareness-raising social media campaign, we believe that with the help of social media, the government can start raising the awareness of the society as whole. The method that we are proposing is for the government to actively create contents for trending social media in society (e.g.: Instagram, Facebook, Twitter, etc.), be it in the form of videos, infographics, online photo frames (e.g.: Twibbon) and many more. With the relatively low cost and low barrier of entry, we believe that social media is a good platform that the government can capitalize on. In 2018, the Indonesian internet user penetration rate reaches 50% which accounts to half of the population (Hootsuite, 2018). For social media, the penetration rate comes slightly lower in the amount of 49% (Hootsuite, 2018). The data also shows that the average amount of time that an average Indonesians spend on social media on a daily basis reaches 3 hours and 23 minutes (Hootsuite, 2018), another opportunity that the government can capitalize on to raise awareness on this issue and eradicate stigmas.

CONCLUSION People with severe mental disorders (SMD) have a worse health prognosis when compared to the general society, as we can see from the staggering difference on the mortality rate, years of potential life lost, and life expectancy. Despite of that fact, it has been proven that the atrocious outcomes of mental disorder can be tackled by ensuring that people with mental disorders receive equal access and treatment to healthcare. The action that needs to be taken to ensure equal access of healthcare for people with SMD is to fight the widespread stigma on mental disorders in the world that we live in, mainly to the healthcare workers and providers. With the eradication of stigma in healthcare workers, we hope that people with SMD will receive the treatment that they need and they deserve which in turn will lead to the increased quality of life for patients with SMD that we can observe from the mortality rate and life expectancy. RECOMMENDATION We recommend the government to start adopting contact-based education approach to overcome stigma about mental disorders. The government can start by building the foundational framework to implement mandatory direct contact-based education and guided indirect contact-based education session throughout the country for the healthcare workers working on the field. We also encourage the government to capitalize the opportunity to grab the societyâ&#x20AC;&#x2122;s attention through social medias in various forms of creative contents. Collaborations with market influencer or famous public figure to grab the societyâ&#x20AC;&#x2122;s attention are encouraged to increase the exposure from their audiences and also earn credibility, provided that the government is working with the parties that are well-suited to their campaigns and target audiences. REFERENCES American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington DC. Biernat, M., & Dovidio, J. (2000). Stigma and stereotypes. Corrigan, P. W. (2007). Changing mental illness stigma as it exists in the real world. Australian Psychologist, 42(2), 90-97. Corrigan, P. W. (2014). Mental health stigma and primary health care decisions. Psychiatry Research, 218(1-2), 35-38. Goldman, L., & Schafer, A. I. (2016). Goldman-Cecil Medicine (25th ed.). Philadelphia: Elsevier.

Graber, M., Bergus, G., Dawson, J., Wood, G., Levy, B., & Levin, I. (2000). Effect of a Patient's Psychiatric History on Physicians' Estimation of Probability of Disease. Journal of General Internal Medicine, 15(3), 204-206. Grandรณn, P., Saldivia, S., Vaccari, P., Ramirez-Vielma, R., Victoriano, V., & Zambrano, C. (2019). An Integrative Program to Reduce Stigma in Primary Healthcare Workers Toward People With Diagnosis of Severe Mental Disorders: A Protocol for a Randomized Controlled Trial. Frontiers in Psychiatry. doi:10.3389/fpsyt.2019.00110 Gustavsson, A., Svensson, M., Jacobi, F., Allgulander, C., Alonso, J., Beghi, E., . . . al., e. (2011). Cost of disorders of the brain in Europe 2010. European Neuropsychopharmacology, 21(10), 718-779. Human Rights Watch. (2016). Hidup di Neraka: Kekerasan terhadap Penyandang Disabilitas Psikososial di Indonesia. Insel, T. (2015, February 24). Post by Former NIMH Director Thomas Insel: Mortality and Mental Disorders. From National Institute of Mental Health: https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2015/mortality-and-mentaldisorders.shtml Insel, T. R. (2008). Assessing the Economic Costs of Serious Mental Illness. The American Journal of Psychiatry, 165(6), 663-665. Islam, S. M. (2019). The role of social media in preventing and managing non-communicable diseases in low-and-middle income countries: Hope or hype? Health Policy and Technology, 8(1), 96-101. Kementerian Kesehatan Republik Indonesia. (2018). RISKESDAS 2018. Jakarta. Knaak, S., Mantler, E., & Szeto, A. (2017). Mental illness-related stigma in healthcare. Healthcare Management Forum, 30(2), 111-116. Lawrence, D. (2013). The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population based registers. The BMJ. doi:https://doi.org/10.1136/bmj.f2539 Muench, J., & Hamer, A. (2010). Adverse Effects of Antipsychotic Medications. American Family Physician, 81(5), 617-622. Sadock, B. J. (2014). Kaplan and Sadock's Synopsis of Psychiatry (11th ed.). New York: Wolters Kluwer. Self-stigma, stigma coping and functioning in remitted bipolar disorder. (2019). General Hospital Psychiatry, 57, 7-12. Stuart, H. (2016). Reducing the stigma of mental illness. Global Mental Health, 3(17). Venture, H. &. (n.d.). Indonesia Digital Landscape 2018. Walker, E. R. (2015). Mortality in Mental Disorders and Global Disease Burden Implications. JAMA Psychiatry, 72(4), 334-341.

World Health Organization. (n.d.). Mental Health Management Information Sheet: Premature death among people with severe mental disorders. From https://www.who.int/mental_health/management/info_sheet.pdf Zรกrate, C., Ceballos, M., Contardo, M., & Florenzano, R. (2006). Influencia de dos factores en la percepciรณn hacia los enfermos mentales; contacto cercano. Rev Chil Neuropsiquiatr.

mQueue: Your Queueing Solution Vanessa Carolina Gunawan, Silvia Husodo, Ivanna Yuhan, Daniel Setyawan P.M AMSA-Indonesia

BPJS (Social Security Organizing Agency) is a governmental public institution to achieve universal health coverage which established on January 1, 2014. Health insurance held by BPJS is based on social insurance and equity principle using the Healthy Indonesia Card. Starting January 21, 2019, BPJS has covered 81.75% of Indonesia's population. However, BPJS still has many obstacles, such as referral system where the patients have to queue for hours in primary health care. Nevertheless, these obstacles can be overcome. Nowadays, the rapid development of information and telecommunications technology, makes the use of handphone become very easy for most people. The use of social media and mobile applications reached 92 million users in Indonesia. This digital transformation can be one of the opportunities as a solution for BPJS to improve its services. In this paper, an online queue application is designed and features are provided to access the nearest health facilities along with temporary queue numbers that can be accessed via smartphone. This application makes queueing effective and efficient, so patients can manage time optimally for other activities and improving the quality of tiered referral services so that the quality of health services and health access can increase. Key findings: 1. BPJS still has many obstacles, such as referral system where the patients have to queue for hours at primary health care. 2. The use of social media and mobile applications reached 92 million users in Indonesia with a variety of ages. 3. This digital transformation can be one of the opportunities as a solution for BPJS to improve its services. 4. Online queue application makes queueing effective and efficient, so patients can manage time optimally for other activities and improving the quality of tiered referral services so that the quality of health services and health access can increase.

MQUEUE: YOUR QUEUEING SOLUTION

By : Vanessa Carolina Gunawan, Silvia Husodo, Ivanna Yuhan, Daniel Setyawan P.M 2nd year medical student, 2nd year medical student, 2nd year medical student, 2nd year medical student ASIAN MEDICAL STUDENTSâ&#x20AC;&#x2122; ASSOCIATION- INDONESIA 2019

mQueue: Your Queueing Solution Vanessa Carolina Gunawan, Silvia Husodo, Ivanna Yuhan, Daniel Setyawan P.M 2nd year medical student, 2nd year medical student, 2nd year medical student, 2nd year medical student Asian Medical Students’ Association- University of Brawijaya 1. BACKGROUND The right to health is one of a set of internationally agreed human rights standards and is inseparable or ‘indivisible’ from other rights (WHO, 2017). At least half of the world’s population still do not have full coverage of essential health services. All United Nation (UN) Countries have agreed to try to achieve universal health coverage (UHC) by 2030, as part of the Sustainable Development Goals (WHO, 2019). Universal health coverage is defined as ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user the financial hardship (WHO, 2019). Indonesia still experiencing healthcare crisis such as unequally distributed health services. Therefore, Indonesia needs an universal health coverage system to overcome those problems. Indonesia as one of the UN countries has implemented universal health coverage system called BPJS Kesehatan (Health Social Security Organizing Agency) which is established on January 1st, 2014. BPJS Kesehatan is based on social insurance and equity principle using the “Kartu Jaminan Kesehatan Nasional” (Healthy Indonesia Card). Starting January 21 st, 2019, BPJS Kesehatan has covered 81.75% of Indonesia's population. BPJS Kesehatan has a tiered referral system where new patients can obtain specialist or sub-specialist services after obtaining referrals from health facilities in the earlier strata. There are 3 levels of health services in Indonesia; the first level which provides basic health services (Puskesmas as known as community health center); second level that provides specialist health services (Type B and C hospital); and third level that provide sub-specialist health/ Type A hospital (Permenkes no. 71 Tahun 2013). This tiered referral system turned out to have consequences that make patients have to go to the first level health center to reach higher health facilities so the queue of patients in the first level health center were overcrowded.

2. OUTLINED PROBLEMS Long queue is one consequence of the BPJS’ tiered referral system where primary health care is the first level for BPJS Kesehatan member to obtain health care services. “The Puskesmas” is a district/ city official technical implementation unit responsible for organizing health development in a work area (Peraturan Menteri Kesehatan Republik Indonesia Nomor 74 Tahun 2016). In reality in the field, Puskesmas services are often unsatisfactory because of the long queues and long waiting times. This long queues will lead to prolong patient’s waiting time. Waiting time is the duration needed by patients to obtain health services starting from the registration process until entering the doctor’s examination room (Laeliyah and Subekti, 2017). Waiting times have been linked to inefficiencies in health care delivery, prolonged patient suffering, and dissatisfaction among the public. They have become important policy issues in many OECD (The Organisation for Economic Co-operation and Development) countries, where national waiting time statistics are routinely collected in various countries (Viberg et al, 2013). Waiting time standard according to Permenkes No 129/Menkes/SK/II/2008 is less than 60 minutes. The truth is in BPJS Kesehatan capitation financing system, the number of patients who need health care services much more exceeding primary health care’s capacity. It is common to find patient care being postponed because of long waiting periods, and patients often spend more time waiting than actually consulting with health care providers. For instance, a national study of Malaysian public hospitals documented that the average patient wait time, from registration to receipt of a prescription slip, was more than 2 hours, whereas the average time spent consulting the medical personnel was just 15 minutes (Xie and Or, 2017). This problem is related to the very limited human resources, limited health care room, and technical issues. So, patients have to wait for more than 60 minutes (Laeliyah and Subekti, 2017).

54 52 50 48

Patient's Prevalence

46 44 42 Fast (<60 min)

Slow (>60 min)

Graphic 1. Estimated waiting time prevalence in â&#x20AC;&#x153;Puskesmas Setiabudi, South Jakarta (Laeliyah and Subekti, 2017) (Wati, 2017) reported that waiting time expectation in Puskesmas Setiabudi, South Jakarta is 19.7 minutes. In this Puskesmas, there are two general practitioners, every doctor only examines 6 patient per hour, while the average of patient arrival for the three-day survey is 20 patients per hour. This problem will cause very long queues. This Puskesmas operating hour is about 8 hours start from 7.30 am. With all of the available services, it is estimated that the last patient of the first 20 subjects in the initial hour, will wait 90 minutes. If the performance of this service lasts for 8 hours with an average input of 20 patients per hour, then there will be 62 patients who are forced to not be served on that day. This is not in accordance with the patient's expectations (waiting 19.7 minutes) because the 3rd patient sequence in the first hour has waited 20 minutes (Wati, 2017). Waiting time have direct impacts to patientâ&#x20AC;&#x2122;s satisfaction and willingness to return. (Xie and Or, 2017) stated that patients were more likely to be satisfied if they did not have to wait long and increased waits resulted in reduced patient satisfaction and decreased willingness to return. Waiting time also contributes to a range of public health issues, including impaired access to care, interruption of hospital work patterns, and prolonged patientâ&#x20AC;&#x2122;s suffering. Queueing time is the time that the patient uses to get health services starting from the registration point until entering the doctor's examination room (Laeliyah and Subekti, 2017). As we know there are arround 80% of Indonesian people already have mobile phone so this is a great chance (Statista, 2019). In line with the queue problem in health facility we proposed mQueue to

overcome this crucial problem. mQueue is a mobile application that facilitate patient to pick up the queue number wherever they are without have to go to the health facility such as primary health care or hospital. This application aims to reduce the number of queues in primary health care facilities. This mQueue is targeted to outpatient patients who will be checked in primary healthcare from elderly and youngsters. Through this innovation we hope the refferal system of BPJS Kesehatan is getting better so there is no more overload of patients are queuing in primary health care and hospitals that can disturb the health services.

Steps how to use mQueue:

1. This is our opening display

Figure 1. mQueueâ&#x20AC;&#x2122;s opening display

2. Patient who want to use this application must input their BPJS number and birth date, so our system can detect the patientâ&#x20AC;&#x2122;s account.

Figure 2. Log In Interface

3. Next, he/ she has to turn on their location, so our server can detect the nearest health facility.

Figure 3. Location reminder

4. After that, there are some preferred health facility that can be chose.

Figure 4. Hospital options

5. Furthermore, there are queue number and current queue number showed in this application, so the people can estimate how much time to wait and also can allocate the waiting time more beneficial like have a rest. Another advantage from this application is 30 minutes reminder before the queue number is called, then patient can prepare and go to the nearest health facility that is chosen with no weary for long queue and can arrive safely and happily.

Figure 5. Hospital options Table 1. Decription of the steps in developing mQueue No. Step

Description

Planning

Identify problem and design the applicable innovation solutions.

User Research

Collect information that related to the recent problem which is the long queueing time in health facility and specific target innovation.

Development

Innovation development process based android application software (progamming and designing).

Testing

Application trials (initiating phase-completion phase-finishing phase).

Implementation

National application usage process with a training system using video tutorials. This application can be downloaded in Google play store and App store.

Reporting

Collecting data to impact evaluation and continuous improvement.

3. CONCLUSION AND RECOMMENDATION The application of the tiered referral system in the BPJS system which cause patients unable to receive specialist and sub-specialist services without going through first level health facilities, of course, has the consequence of a large number of patients queueing in these health facilities. This condition reflects the inefficiency in hospital services. Besides that, overcrowd health care facility does not only affect the patient but also can increase the severity of disease and cause socio-economic costs (Bahadori et al, 2014). To solve this problem, we would like to propose an innovation idea of online queueing application, that we called as mQueue. This application enables the patient to save and manage their time with other activity such as rest at home, better than just waiting for hours in the health facility. Beside that, this application has features such as monitoring and give information about the rest time needed before the queue will be called to get the service. This way, it will provide convenience that is very beneficial for the patient and optimization of the services provided. As a long term innovation, this application is expected to be published nationally so that it can be widely used by the public. Therefore it is necessary to have advocacy together with BPJS Kesehatan which aims to create a patent joint workflow that can later improve the quality of health services. In addition, it is expected that this application can be supported and based on the Minister of Health Regulation so that it has a clear legal basis in starting, implementing, and developing community services, so that being able to support service activities and health services provided by mQueue to the public can be judged legally. In addition, this innovation will publish in apps store and Google Play Store as an official application that is accessible to the public.

Lastly, we, as a medical student and as an agent of change wish to contribute to the health individual and especially for our future patients by creating this innovation that we hope may be able to give effective waiting time management. Here, we propose an innovation of mQueue, an

online application which we expect to be able to enhance the current policy and technology applied in our hospital in order to create better health access and achieve the Sustainable Development Goals.

REFERENCES Bahadori, M., Mohammadnejhad, S. M., Ravangard, R., & Teymourzadeh, E. (2014). Using queuing theory and simulation model to optimize hospital pharmacy performance. Iranian Red Crescent Medical Journal, 16(3). Indonesia, K. K. R. (2016). Peraturan Menteri Kesehatan Republik Indonesia Nomor 74 Tahun 2016 tentang standar Pelayanan Kefarmasian di Puskesmas. Jakarta: Kementerian Kesehatan Republik Indonesia. Laeliyah, N., & Subekti, H. (2017). Waktu Tunggu Pelayanan Rawat Jalan dengan Kepuasan Pasien Terhadap Pelayanan di Rawat Jalan RSUD Kabupaten Indramayu. Jurnal Kesehatan Vokasional, 1(2), 102-112. Nomor, P. M. K. R. I. 129/Menkes/Sk/Ii/2008. Standar Pelayanan Minimal Rumah Sakit. Permenkes, R. I. no. 71 Tahun 2013. Tentang Pelayanan Kesehatan pada Jaminan Kesehatan Nasional. Statista. (2019). Indonesia mobile phone users 2013-2019. Retrieve from https://www.statista.com/statistics/274659/forecast-of-mobile-phone-users-in-indonesia/ Viberg, N., Forsberg, B. C., Borowitz, M., & Molin, R. (2013). International comparisons of waiting times in health careâ&#x20AC;&#x201C;Limitations and prospects. Health Policy, 112(1-2), 53-61. Wati, R. (2017). Sistem Antrian Pelayanan Pasien pada Puskesmas Kelurahan Setiabudi Jakarta Selatan dengan Menggunakan Metode Waiting Line. Jurnal Techno Nusa Mandiri, 14(2), 91-96. WHO. (2017, December 29). Human rights and health. Retrieved from https://www.who.int/newsroom/fact-sheets/detail/human-rights-and-health WHO. (2019).Universal health coverage (UHC). Retrieve from https://www.who.int/news-room/factsheets/detail/universal-health-coverage-(uhc) Xie, Z., & Or, C. (2017). Associations between waiting times, service times, and patient satisfaction in an endocrinology outpatient department: A time study and questionnaire survey. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 54, 0046958017739527

SOCIETY PARTICIPATION AND SUPPORT ON UNIVERSAL HEALTHCARE COVERAGE FOR BETTER HEALTH SECURITY Hanna Melisa, Andra Danika, Ahmad Abdilla Adiwangsa, Adolf Gideon 3rd year medical student, 3rd year medical student, 2nd year medical student, 4th year medical student ASIAN MEDICAL STUDENTSâ&#x20AC;&#x2122; ASSOCIATION- UNIVERSITY OF BRAWIJAYA In 2015, Indonesian Ministry of Health introduced Medium Term Development Plan (RPJM) 20152019; there are six points which in this case, we will focus on RPJM 4 which states about universal health coverage and quality management of Social National Coverage System (SJSN Kesehatan). Universal healthcare coverage in Indonesia, also known as JKN (Jaminan Kesehatan Nasional) which is administered by BPJS Kesehatan (Badan Penyelenggara Jaminan Sosial), was introduced in late 2013 and began to operate on the 1st of January 2014. It was planned to achieve 95% participation of Indonesian citizens in 2019, but it only reaches 81% by now; Indonesia faced financial difficulties in the late 2018. This situation happened because of the low payment rate made by the society, low participation, and insufficient funding by the government. Indonesian government has already made a national law regarding BPJS and all of the operations, stated in UU/24/2011 which consists of participation, funding, and management of BPJS; Perpres/82/2018 also revises several points of the older law in UU/24/2011. Our goals in making this paper and video are to raise sense of belonging to BPJS, sign up for BPJS, feel the benefit, and most importantly to pay the insurance fee regularly to help the unfortunate. We also think that the government should centralize the BPJS funding. And of course there is an urgent need to restructure and rearrange the finance of BPJS. Last but not least, canvassing is a method where civil servant visits business ventures to explain and ask them to register their employees for BPJS insurance. Key Findings: There are several problem regarding BPJS, such as low participation, low insurance payment, financial problem and the need to re-manage.

SOCIETY PARTICIPATION AND SUPPORT ON UNIVERSAL HEALTHCARE COVERAGE FOR BETTER HEALTH SECURITY

By: Hanna Melisa, Andra Danika, Ahmad Abdilla Adiwangsa, Adolf Gideon 3rd year medical student, 3rd year medical student, 2nd year medical student, 4th year medical student ASIAN MEDICAL STUDENTSâ&#x20AC;&#x2122; ASSOCIATION- UNIVERSITY OF BRAWIJAYA

SOCIETY PARTICIPATION AND SUPPORT ON UNIVERSAL HEALTHCARE COVERAGE FOR BETTER HEALTH SECURITY Hanna Melisa, Andra Danika, Ahmad Abillah Adiwangsa, Adolf Gideon 3rd year medical student, 3rd year medical student, 2nd year medical student, 4th year medical student ASIAN MEDICAL STUDENTSâ&#x20AC;&#x2122; ASSOCIATION- UNIVERSITY OF BRAWIJAYA I.

BACKGROUND

In 2015, Indonesian Ministry of Health introduced Mid Term Development Plan (RPJM) 20152019; there are several important points (Ministry of Health, 2015): (1) increase health and nutritional status of mother and child (2) increase disease control (3) increase access and basic healthcare service quality, and referral especially in rural, undeveloped, and border areas (4) increase universal healthcare coverage by Indonesian Health Card (Kartu Indonesia Sehat) and manage quality of Social National Coverage System (SJSN Kesehatan) (5) fulfilment of healthcare workers, medicine and vaccine (6) increase healthcare system responsiveness Focusing on the Mid Term Development Plan (RPJM) RPJM 4, we will try to describe and discuss about universal healthcare. Universal healthcare coverage in Indonesia, also known as JKN (Jaminan Kesehatan Nasional) which is administered by BPJS Kesehatan (Badan Penyelenggara Jaminan Sosial), was first introduced in late 2013 and began to operate on the 1st of January 2014. It is a new universal healthcare coverage that replaces the old ASKES and also integrates with JAMSOSTEK to create a new insurance system for the society. BPJS Kesehatan was established under the law of Undang-Undang Nomor 24 Tahun 2011. It was planned to achieve 95% participation of Indonesian citizens by 2019, but in fact, it seems to be lagging behind the targets and facing financial difficulties in the late 2018. This situation happened because of the low rate of payment made by the society, low participation of society, and insufficient funding by the government. Besides, many surveys show that the society has a bad habit of only paying the insurance fee when they need to use it. It is too significant that all of these factors put BPJS in a difficult position to stand and provide appropriate treatment for the ill patients.

Based on Media Indonesia, on January 1st 2019, there are only 81% of people were covered by BPJS and that was below the expectation of 95% by that time. It is stated that some factors, such as not centralized healthcare system in some provinces and lack of residentsâ&#x20AC;&#x2122; identity number, slow down the participation of the national healthcare coverage. Basically, BPJS works just like any other government insurance which provides healthcare coverage for registered Indonesian citizens who have paid the monthly fee. BPJS was established by a very basic philosophy of mutual cooperation (gotong royong) in which the more fortunate patients help the less ones by paying the insurance fee (subsidi silang). BPJS participation is divided into three groups starting from the lowest (around 25.500 Rupiahs per month) to the highest (around 80.000 Rupiahs per month) with a middle group (around 51.000 Rupiahs per month). Until the end of December 2018, approximately 12 million of people have not paid their insurance fee which makes the financial deficit get even worse. All of these messes make BPJS experience financial loss until they cannot pay the provided services by the associated hospitals.

BPJS participants consist of two large groups, the governmentally funded (Penerima Bantuan Iuran/PBI) and non-governmentally funded (Non-Penerima Bantuan Iuran/Non-PBI). The PBI is later divided into PBI APBN (national funding) and PBI APBD (district funding). And the Non-PBI is divided into PPU-PN (insurance for government employees), PPU-BU (insurance for business entity), PBPUPekerja Mandiri (insurance for non-salary employees), and Bukan Pekerja (insurance for non-employees). Based on data from BPJS on 2019, the participation rate is shown below: Group

Participation (in million)

PBI-APBN

PBI-APBD

35.3

PPU-PN

17.2

PPU-BU

32.9

PBPU-Pekerja Mandiri

31.4

Bukan Pekerja

5.1

Total

218.1 (BPJS, 2019)

It is clearly seen that the participation rate of PBI-ABN is still far from the target of 109.9 million based on RPJM (Ministry of Health, 2015) with an estimated lack of almost 14 million participants or about 12.5 % participants. Besides, the Non-PBI group also lacks in the number of participants an estimated lack of almost 20 million participants, which is a very serious problem because this group is the one that provides BPJS with an extensive external money rather than depending on governmentâ&#x20AC;&#x2122;s funding, which was also

worsened by lack of adequate management and planning. Data from 2014 until 2018 shows significant rising in BPJS financial deficit starting from 3,3 trillion rupiahs to 16,5 trillion rupiahs. Surely, the government has to step in and do something about it, but until now the effort the government has made seems to be inadequate yet ineffective. Therefore, our goals in making this paper are to raise sense of belonging to BPJS, sign up for BPJS, feel the benefit, and most importantly to pay insurance fee regularly to help the unfortunate and people in need. Rather than having two healthcare systems, we think that it is better for the government to hurry and merge all the regional district funding (APBD) insurances with the national funding (APBN) insurance, and also ask districts to contribute in financial need of BPJS. The government also needs to think about restructuration of BPJS and change of system to make BPJS operate more efficiently. Last but not least, we need to do campaign or socialization about BPJS to everyone especially in rural or border areas to join BPJS and remind them not to forget to pay on time so that they will get the best service.

II.

PROPOSED POLICY The government of Indonesia has already made a national law regarding BPJS and all of its

operations, stated in UU/24/2011 which consists of participation, funding, and management of BPJS. In addition, there is a newer policy in Perpres/82/2018 which consists of rules about unpaid insurance fee; the government has increased the delay period of payment up to 24 months, and during the first 45 days after membership activation, participants must pay the fine which is about 2,5% times INA-CBGâ&#x20AC;&#x2122;s tariff times the period of payment delay for every healthcare service they receive. For every unpaid fee, BPJS will deactivate your service rights from the first day of the following month. In case you are wondering what will happen after 24 months of unpaid/delay, BPJS will revoke your healthcare insurance. INA-CBG which stands for Indonesian Case Base Group is the healthcare service given to the patients. We do not wish to make a change to the national laws, but we would like to encourage people to obey the laws made by joining BPJS and always pay the fee on time, specifically for the non-governmental funding groups that will help BPJS to last. Of course, this plan will require the involvement of government, society, and local institutions. Local institutions play a major role in helping to socialize the function and importance of joining BPJS, and also as a reminder to pay the fee on time so that everyone will receive a better service for a better well-being.

CONCLUSION

III.

From the facts and data above, we can conclude that BPJS is surely a breakthrough in Indonesiaâ&#x20AC;&#x2122;s national health insurance, but like others, there are always some flaws in everything including the management and funding issues. Due to its low participation and payment rate, BPJS is struggling to provide seamless healthcare service among people of the republic of Indonesia. Our main focus is to raise participation and remind others to pay the fee of BPJS by showing its benefit towards a better health security in our nation. We think that it is important to ask for the help of local primary healthcare workers to do more campaign about BPJS including its benefit and also persuade people to join. We always believe that our nation can do it. A solid work-relationship between local primary healthcare center, government, and society as well as BPJS itself will make a better healthcare in Indonesia.

IV.

RECOMENDATION As we can see from all those mentioned facts previously, we think that the government needs to

make a new movement and breakthrough which can bring a significant impact for BPJS. Firstly, the government should make effective commercials about how easy it is to pay the insurance fee and obviously doing persuasive actions for the society to pay on time by stating all the benefits of BPJS and asking them to join right away. Second, we think that the government should centralize BPJS as soon as possible, so that there wonâ&#x20AC;&#x2122;t be any double identities between nation and regions, and maybe the central government can ask local government to assist funding for their local people. Third, we think that there is an urgent need to restructure and rearrange the finance of BPJS. Canvassing is a method where civil servant visits business ventures to explain and ask them to register their employees for BPJS insurance. Actually, the government has executed canvassing method in the past years. However, we still think that there is not enough effort from the government. Lastly, as a good citizen, we need to realize that this is a big program with huge benefit. Therefore, we need to support the government and remember to pay the insurance fee on time!

References BPJS. (2019). Peserta Program JKN. BPJS Kesehatan. CNN Indonesia. (2018). Jokowi Sindir Pengelolaan Keuangan BPJS Kesehatan. Retrieved from https://www.cnnindonesia.com/ekonomi/20181017114027-78-339168/jokowi-sindirpengelolaan-keuangan-bpjs-kesehatan Gumelar, G. (2019). Pangkal 'Penyakit' Defisit BPJS Kesehatan. Retrieved from https://www.cnnindonesia.com/ekonomi/20180919164958-78-331498/pangkal-penyakitdefisit-bpjs-kesehatan Kusuma, D. (2019). Kepesertaan JKN Baru Capai 81%. Retrieved from http://mediaindonesia.com/read/detail/208356-kepesertaan-jkn-baru-capai-81 Ministry of Health of Indonesia. Rencana Strategis Kementerian Kesehatan Tahun 2015-2019. Jakarta: Ministry of Health; 2015. Ministry of Health of Indonesia. (2015). Rencana Aksi Kegiatan Pusat Pembiayaan dan Jaminan Kesehatan. Jakarta: Ministry of Health; 2015. The Government of the Republic of Indonesia. (2011). Undang-Undang Republik Indonesia No. 24 Tahun 2011 tentang Badan Penyelenggara Jaminan Sosial. Lembran Negara RI Tahun 2011, No. 116. State Secretariat. Jakarta. The Government of the Republic of Indonesia. (2018). Peraturan Presiden Republik Indonesia No. 82 Tahun 2018 tentang Jaminan Kesehatan. Lembaran Negara RI Tahun 2018, No. 165. Kabinet RI Secretariat. Jakarta.

â&#x20AC;&#x153;DEAR MOMMYâ&#x20AC;?

Farrah Ziva Putri Handri Ansyah1, Kezia Berlianti Rukmana2 , Irene Yasmina Vilado3 Brawijaya University, Malang, Indonesia It is known that Indonesiaâ&#x20AC;&#x2122;s healthcare coverage is a major problem and one of the cause is the

inequality of birth certificate. Having a birth certificate is important to acquire a lot of rights and benefits, including healthcare access which is provided by the government. Despite its importance, many children in the developing country has difficulties to obtain one, including Indonesia. Based on Central Bureau of Statistics 2016, 18.32% children of Indonesia do not have birth certificate, which equals to 45 million people with no access to healthcare. These children are not registered into the national population database, but this data is vital to monitor health policy and track progress towards the Sustainable Development Goals. The barriers may vary, from geographical, financial, and lack of information. Government already made an alternative such as online birth certificate, but this program is not successful as it is still too complicated. To overcome this, we use the advancement of technology. This 3-minute-video is aimed at the government and society to show the importance of birth certificate related to healthcare coverage and to propose our solution for an easier way to obtain birth certificate. Our solution will include mobile phone application such as text messages and Whatsapp to make it easier to make birth certificate. Key findings:

1. Having a birth certificate is important to acquire a lot of rights and benefits, including free healthcare access

2. In 2016 18.32% citizen of Indonesia do not have birth certificate, which means around 47 million people.

3. Birth certificate can be a a vital information to monitor health policy and track progress towards the Sustainable Development Goals.

4. By using technology, the making of birth certificate will be easier, and more children will get more coverage on our health database.

AMSC VIDEOGRAPHY COMPETITION

“DEAR MOMMY” Birth Certificate: A Solution to Equal Health Access

BRAWIJAYA UNIVERSITY Farrah Ziva Putri Handri Ansyah, Kezia Berlianti Rukmana, Irene Yasmina Villado

INTRODUCTION Birth certificate is a ticket to citizenship. Without one, an individual does not officially exist under a country and therefore lacks legal access to the privileges and protections offered by the said nation. It is also a vital tool by which an efficient government counts its citizen and provides data to better services, including healthcare. Birth certificate is crucial to both government and the individual. It is a fundamental human rights. Birth certificate is a physical proof of the fulfillment of what we call as the “first right”, the right to an official identity. Registration of birth is the country’s first acknowledgement of a child’s existence. It represents recognition of a child’s significance to the country and of his or her status under the law. In Indonesia, it is written under the law that a child’s identity must be given since his/her birth in the form of a birth certificate. Birth certificate is not only used as a legal acknowledgement, this ticket to citizenship is the key to access services provided by the government. These services include access to healthcare, access to immunization, access to education, and protection to many things. To emphasize on its importance in health services it must be noted that a child cannot be legally vaccinated without proof of birth in at least 20 countries and in Indonesia itself, birth certificate is needed to get health insurance such as BPJS. It has been established that a birth certificate is significant for the individual, that being said, a birth certificate is also profound for the nation. An effective government based the quantities and qualities of its services on data. With a sufficient birth registration, a country can provide services to the citizen effectively and efficiently. For example, without an efficacious registration systems, the authorities will not have the estimated number of vaccines needed, or even more fatal, a country will not have access to accurate data of its own birth rate — or death rate. These informations are vital to monitor health policy in order to track progress towards the achievement of the Sustainable Development Goals. Indonesia still has a lot of homework to do in managing birth certificate registration. According to Central Bureau of Statistics in 2016, 18.32% children aged 0-17 years old do not have birth certificate, which means around 45 million people cannot access healthcare while only 25% of children aged from 0-5 do not have birth certificate. These children are what we called the “invisible”. They are under the protection of no law and denied from many privileges. The basic required documents in order to get a birth certificate are birth notification letter from the associated hospital where the baby was born or from a licensed health practitioner, marriage certificate of the parents, family card, national ID cards of both parents, and additionally name and national ID of two birth witnesses.

Indonesiaâ&#x20AC;&#x2122;s government has come up with the solution of online birth certificate but only in some of the advanced district as it is still conducted by Dispendukcapil (Population and Civil Registration Agency) of each area. Indonesia also has a legal provision of free birth registration within the prescribed time (60 days). However, these procedures are still rendered complicated, inaccessible, corrupted, and even unknown especially to the people living in isolated rural location and people with low income. Percent of People Aged 0-17 with Birth Certificate

Source: Susenas 2016 (processed by National Strategy of Civil Registration -State Ministry for Development Planning)

Komisi Perlindungan Anak Indonesia (Indonesian Child Protection Commission) has continuously made attempts to advocate minimization on the documents required to register a childâ&#x20AC;&#x2122;s birth but the target still has not been achieved. There are still many barriers and issues regarding the accessibility that we need to overcome. OUTLINED PROBLEMS Indonesia ranks in the bottom 20 for countries with low registration of children number and the problem is worse in rural areas. The lowest rate of birth certificate registration in 2018 is recorded in Maluku, Papua, and West Papua. Mainly because of financial and geographical problems. In Indonesia, coverage of birth certificate in the country has only reached 63 percent and the population in rural that have received birth certificate are twice more less than the population in urban areas. From SUSENAS 2016, 25% of the population in Indonesia ranging from 0-5 years old do not have birth certificate and only 66% of children aged 0-17 do have birth certificate and able to show the document. Percentage of birth certificates ownership (Children 0-5 years old)

Percentage of birth certificates ownership (Children 0-17 years old)

Have and able to show

Have but are not able to show

Do not have

Do not know

Source: Birth Certificate Coverage Problem: National Strategy of Civil Registration -State Ministry for Development Planning

In Indonesia one of the main barriers of registering a newborn is cost. Indonesia has made it free of charge since 2002, however, according to UNICEF, only 300 districts have implemented this rule. Until now, all across Indonesia the implementation of this rule has remained inconsistent with several factors from lack of information, corrupt group of people and the complexity of the process itself which then resulting in parents paying hidden fees to middlemen to finish the process faster. The cost of using middlemen to finish the required documents varies across the country but overall, the cost increase much more significantly. Distance was also another barrier to obtain a birth certificate. Indonesia with its wide and spread out archipelago country has some challenges itself for the population as a lot of the districts are still very remote. Average distance to the nearest civil registration office is 26 kilometers away. For example, the furthest distance to the office at the province of West Java is about 18 kilometers and in Nusa Tenggara Barat and Nusa Tenggara Timur the distance can reach as far as 200 kilometers. Let alone the distance, other challenges such as lack of transportation that are very uncertain and irregular combined with risky journey needs to be considered. Lack of information is one of the problem since there are a lot of people that decided not to get their birth certificate, just because they do not know what is the benefit to have one. Which is a huge problem since it will affect their rights especially access to healthcare services.

Source: Indonesiaâ&#x20AC;&#x2122;s Missing Millions, AIPJ Baseline Study on Legal Identity The impact of this problem is huge as it affects how the newborns receive education, protection, and healthcare since birth certificate is used as a requirement to enroll to a school and receive immunization. As an example, it is found that in Nusa Tenggara Barat people who has birth certificate are 75% more likely to receive the healthcare they need. The government also needs data of the total population so the distribution of the vaccines can be conducted effectively. According to RISKESDAS (Research of Basic Health Indonesia) 2013, only 8 out of 34 provinces reached the national target of Universal Coverage Level because it is not evenly distributed.

PROBLEM SOLUTION Having our main concern being presented, we propose a solution for this problem: The equity of birth certificate via mobile phone. The following is the process: 1. Form a team and spread them Form a team to act as the nearest center to make birth certificate. We will collaborate with the government and hospitals to form the team. One team per district each. Each team will consist the following: -

The hotline guard The hotline guards are the one that receive text messages and send it to “the Maker”. Their task are also to sort the text messages to organize which order is currently on progress, which one is still pending or which one is finished.

The maker The maker are the one that receive details from the hotline, print and stamp the birth certificate.

The indoor courier The indoor courier are the one that send the birth certificate to the email address.

The outdoor courier The outdoor courier are the one that deliver the birth certificate to the house address.

2. Make a Hotline A hotline that can be contacted via mobile phone and application such as Whatsapp will be available. The applicant can message the specific number of the hotline to give the details for the birth certificate content. The message template will be: NAME: FATHER’s NAME/NIK*: MOTHER’s NAME/NIK*: PLACE OF BIRTH: DATE OF BIRTH: ADDRESS: EMAIL**:

(*unique code citizenship number) (**is not compulsory):

3. The making of birth certificate The team will receive the details from text messages, and process it. 4. Delivery The delivery will be done by the team in the nearest district, and the applicant will also receive the soft file via email. If the person gave birth at the hospital, the birth certificate will be made in that hospital. 5. Socialization Before and during the proceeding of this program, the team will do a socialization regarding the program and the hotline to the public so the public can contact them to make sure that everyone has thorough understanding of it. CONCLUSION Indonesia always try to fight inequality in health coverage, but sometimes we forget to look at the bottom of the problem on why health coverage has not been implemented efficiently. One of the basic and most vital factor is incomplete data recording on the national civilization database and certainly birth registration play a huge role in it. A lot of people do not have access and resources to register while some are not informed on the process of birth certificate registration. With birth certificate, an individual will be recognized by the country and its law and they will receive protection and healthcare that is provided by the government, most importantly, they will also be eligible to apply for a healthcare insurance and vaccination and immunization programs. Birth registration is also crucial for the improvement of healthcare system and policies because in order to make an accurate solution it needs accurate data. Overcoming the barriers which are distance, cost, and time is very important, that is why we think our solution will make it easier, and a lot of people will able to have it using our means of technology and maximizing our abundant human resources. RECOMMENDATION In order to make this program works efficiently, the collaboration of the government and the hospitals will be needed. This program also needs a fixed regulation, which will be discussed with the government and needs to be implemented consistently all across Indonesia. Also, since this program is free, we will need the governmentâ&#x20AC;&#x2122;s help to allocate more funding so this program could function. This kind of program are prone to accidental duplication and therefore to make a strong system for the birth certificate database, a skilled and thorough system is needed. We will collaborate with the hospital so every time when a baby is born in a hospital, they can get birth certificate immediately. With this, we expect this program will function well especially to those in remote areas and others who have barriers in distance, cost or lack of information.

REFERENCE Bappenas. (2017, 24 September). Permasalahan Cakupan Akta Kelahiran: Strategi Nasional Pencatatan Sipil dan Statistik Hayati (PS2H). Retrieved from http://kompak.or.id/userfiles/media/Maliki%20Bappenas%20Problems%20PS2H%20Block%20Chain s.pdf Duff, P., Kusumaningrum, S., & Stark, L. (2010). Barriers to Birth Registration in Indonesia. The Lancet, 4(4), PE234-E235. Retrieved from https://doi.org/10.1016/S2214-109X(15)00321-6 Down, U. (1998).Birth Registration: The first’ Right. Unicef. The Progress of Nations (pp. 4-11). Retrieved from https://www.unicef.org/pon98/06-13.pdf Kusumaningrum, S., Bennouna, C., Siagian C., Agastya, N.L.P.M.A. (2016, July). Back to What Counts: Birth and Death in Indonesia. Jakarta: The Center on Child Protection Universitas Indonesia (PUSKAPA) in collaboration with the Ministry of National Development Planning (BAPPENAS) and Kolaborasi Masyarakat dan Pelayanan untuk Kesejahteraan (KOMPAK). Setiyawan, David. (2019, 8 January). KPAI Dorong Inovasi Pemda untuk Pengurusan Akte Kelahiran. Retrieved from http://www.kpai.go.id/berita/kpai-dorong-inovasi-pemda-untukpengurusan-aktekelahiran Sumner, C., Kusumaningrum, S. (2013). AIPJ Baseline Study On Legal Identity Indonesia’s Missing Millions. Retrieved from http://www.cpcnetwork.org/wp-content/uploads/2015/02/AIPJPUSKAPABASELINE-STUDY-ON-LEGAL-IDENTITY-Indonesia-2013.p Ministry of Health Republic of Indonesia. (2013). Pokok-pokok hasil RISKESDAS Indonesia tahun 2013. Retrieved from www.depkes.go.id/resources/download/general/Hasil%20Riskesdas%202013.pdf Tim KPAI. (2013, 23 July). “Akta Kelahiran” Hak Anak yang Terabaikan. Retrieved from http://www.kpai.go.id/berita/akta-kelahiran-hak-anak-yang-terabaikan UNICEF. (2010, June). Children In Indonesia: Birth Registration. Retrieved from https://www.unicef.org/indonesia/UNICEF_Indonesia_Birth_Registration_Fact_Sheet__June_2010.pdf

Searching: New Approach to Access Health Care in Digital Era Muhammad Revi Ramadhan, Kevin Marcell, Novelina Gracea, Theresa Puspanadi AMSA-Brawijaya

One of health care access issue, assessed from the demand perspective is that there are some people who does not utilize health care services provided. With the advancement of information and communication technology, some people opt to avoid accessing health care, and instead, go online to search health information about symptoms they experience, even try to diagnose themselves using that information. Unfortunately, Unfortunately, only 41% got their diagnosis confirmed by medical professionals, while other 18% got their diagnosis wrong, and 35% did not even visit the clinicians to get professional opinion. The amount of inaccurate health information in the internet may lead to inappropriate treatments or delays in seeking necessary health services. However, if done right, online health searching can bring positive impact to the patients. To bring the best of digital health care and limit negative effects, we propose the government to create more public policies and do more actions to support digital skill improvement of all citizens, reduce misleading health information online, clarify false health information, and encourage the use of medical application, such as AloDokter and HaloDoc that provide online doctor consultation so that people can find reliable health information on internet. Following an online consultation, a face-to-face meeting can be arranged whenever necessary to form appropriate diagnosis and treatment plan. Hopefully, by integrating information and communication technology in health care like this, we can overcome the health care access barrier.

Searching: New Approach to Access Health Care in Digital Era

AMSA-Indonesia AMSA-Brawijaya Muhammad Revi Ramadhan Kevin Marcell Novelina Gracea Theresa Puspanadi

Background Health care access is a complex issue that continues to be problem around the world, especially in developing countries. Measures of supply and demand can be used to assess the health care access problem. From the supply perspective, the quality and effectiveness of health care need to be improved. While from the demand perspective, some people may not utilize health services provided. In order to solve the problem, these two perspective need to be considered. Many studies have looked into ways to improve service quality and effectiveness, but there are far less studies to address the barrier between people and health care1. Over the past years, numbers of people using internet has surged dramatically. Annual digital research conducted by We Are Social and Hootsuite reported that during January 2018 to January 2019 only, there ware approximately 1 million new internet users each day, making the total of 4.388 billion people or 57% of the world population now online2. Among all countries on earth, Indonesia ranked 4th on absolute internet growth, increasing 17.3 million from last year alone. The same research revealed that on average, Indonesians spend 8 hours and 36 minutes on the internet every day, with google.com and google.co.id being the top two most visited sites on the internet3. Survey by Pew Research Centre revealed that 8 out of 10 people search health information online. This behavior could be a good or a bad thing.

Outlined Problems One of the problem regarding health care access is that although health care facility is provided, some people still opt to avoid access health care. A national survey conducted in U.S. showed that nearly 1 out of 3 respondents avoided seeking medical care, even when they experienced symptoms and major health problems4. Some factors that causes this includes low quality of health care provided, therefore there is little demand of it. Aside from that, income, price of health care service, travel cost and foregone earnings, as well as culture, gender issue, knowledge, education, play role as barrier to access health care1. A research by National Institute of Health developed conceptual model of medical care avoidance influenced by Crisis Decision Theory (Fig. 1). Crisis Decision Theory propose that people respond to negative events by firstly: appraising the severity of threat, secondly: identifying available response options, and lastly: evaluating available response options. Based

on their study, participants who had low perceived need to seek medical care may appraise their illness as little threat or consider they can handle the “crisis” themselves. Participants who had factors limiting access may have felt that they had limited response options or felt that seeking medical care was not an option. Participants who reported unfavorable evaluations of medical care may have recognized sufficient threat to seek care and perceived it as a possible option, but considered the costs of seeking care to outweigh the gains4. Rather than visiting the doctor, apparently some people prefer to look up their symptoms online. Study on online health behavior by Pew Research Center in America reveals that 72% of internet users go online to search for health related topics5. As much as 77% of online health seekers began their search using search engine such as Google, Bing, or Yahoo. Only 13% of them began searching at a site that specializes in health information, like WebMD. While another 2% started their research from more general site like Wikipedia and the other 1% started at a social network site like Facebook6. As much as 65% of them reported to browse about specific disease or medical problem and 35% percent tried to specifically figure out what medical condition one had, or in other words, looking for online diagnosis5, 6. Unfortunately, among those online diagnosers, only 41% got their diagnosis confirmed by medical professionals, while other 18% got their diagnosis wrong, and 35% did not even visit the clinicians to get professional opinion5. This is dangerous because different diagnosis leads to different treatment and unsuitable treatment is potentially harmful for the patients. Online health seekers should be aware that there was an abundance of poor-quality Web-based health information. Concerns for the quality of online health information and the potential harm from inaccurate health information have been raised by some research. Health information from unqualified sources may lead to inappropriate treatments or delays in seeking necessary health services7. Sometimes, people experience symptoms of disease but keeping themselves away from health care. This phenomenon, described as “patient delay”, may result in late detection of disease, reduced survival, and potentially preventable human suffering4. However, when done properly, searching for health information online can help patients to be more informed about their disease thus able to share decisions and questions their health professionals7. Moreover, patients with chronic illness were more likely to find blogs posts, doctor reviews, hospital reviews, and podcasts as place to communicate with other

patients and help each other out5. Considering that solving online health information issues means reducing barrier to health care access and maximizing potential benefit from the advancement of information and communication technology, it is becoming important to open a discussion and brainstorming to find best solution for this matter.

Proposed Policy/ Solution We would like to propose the government to create more public policies and do more actions to address online health information issues, so that we can avoid delay in health care access and bring the most out of the online health information. The existing public policy in Indonesia, which is Republic of Indonesia Minister of Health Regulation No. 46 Year 2017 on National E-health Strategy, is focused more on using information and communication technology to optimize the primary, secondary, and tertiary health care performance, but much less on using information and communication technology itself to properly educate people about health8. To change this, firstly government has to change their paradigm in internet. Internet is not merely a source of information, but a sector of public health that can be developed more. Based on our research and study, the following are some of strategies that the government can use to tackle online health information issues: 1. Improve digital skill of all citizens The fast growing netizen population in Indonesia has to be supported with good digital literacy. This means we need more public education and training on the ability to use information and communication technologies to find, evaluate, create, and communicate information. More concreate examples would be educating people to find information on reliable sources. A comparative research suggested Google and Bing as good search engine to start browsing medical information9. Websites run by governmental, non-profit organization, foundations and universities that specialize in health are also considered reliable. Another good tip is to avoid websites like Wikipedia that allows multiple users to edit, as well as commercial and biased websites. This kind of skills will help to protect people from misleading information.

2. Monitor websites providing health information Other than educating people to protect them from leading information, we also have to work simultaneously to reduce misleading information online. Ministry of Health can collaborate with Ministry of Communication and Information to do surveillance and shutdown to websites that provide misleading health information, much like how they do shutdown on porn, gambling, and other negative websites. Netizens can also be involved in this surveillance, as they are able to report negative websites to Ministry of Communication and Information. 3. Creative hoax busters These days, false information can spread and go viral in a blink of an eye. Once people believed it, it is hard to change their mind. So we need creative hoax clarification that can go as viral as the hoax and at the same time triggers people to rethink about the false information they get. Creation of Miss Lambe Hoax, video series created by Ministry of Communication and Information to report and clarify hoaxes by is a brilliant start. Unfortunately, these videos have not gain enough viewers to educate. Adding more variety of presentation format, for example interesting ground investigation, exclusive interview, experiments to break the myth, or a collaboration with Indonesian content creators and influencers can help to bring audience to this well-intentioned show. 4. Innovative medical application as an alternative Some traditional barriers that prevent people from accessing medical care and opt to just online health searching include constraints of time, distance, transportation, money, and insurance. Websites and applications such as AloDokter and HaloDoc that offer free online consultations with doctors can help to eliminate those barriers. This is a safer alternative to regular online health searching because people can directly consult their problems to a reliable source via chat, voice call, or video call. Some applications even provide home care services to facilitate patients who are too ill or not have resources to go to the doctor. Face-to-face meeting with doctors is important to do whenever required following initial assessment in the consultation, because in online consultation , doctors cannot do proper physical examination which consist of inspection, palpation, percussion, and auscultation10. Therefore, face-to-face meeting is still required to form appropriate diagnosis and therapy. However, as these websites and application becoming more popular, government have to regulate it to ensure every doctor working there is registered and competent.

Conclusion In this digital era, large volume of health information can be easily accessed on the internet. Digital literacy become important to pick trustworthy health information among many misleading information. With the advancement of technology, we can now do online health consultation to get the most reliable information, and whenever necessary, online consultation should be followed by face-to-face meeting with doctors to form appropriate diagnosis and treatment plan. Hopefully, by integrating information and communication technology in healthcare like this, we can overcome the healthcare access barrier.

Recommendation Most of the sources for online health research are from America. There are still very few sources from Asia and especially from Indonesia. Thus, more research and study on online health is needed to analyze the population behavior here.

References 1. O'Donnell, Owen. (2007). Access to health care in developing countries: breaking down demand side barriers. Cadernos de Saúde Pública, 23 (12), 2820-2834. https://dx.doi.org/10.1590/S0102-311X2007001200003 2. Kemp, Simon. (2019, January). Digital 2019: Internet Use Accelerate. We are social and Hootsuite. Retrieved from: https://wearesocial.com/blog/2019/01/digital-2019global-internet-use-accelerates 3. Kemp, Simon. (2019, January). Digital 2019: Indonesia. Retrieved from: https://datareportal.com/reports/digital-2019-indonesia 4. Taber, J. M., Ph, D., Leyva, B., Persoskie, A., & Ph, D. (2014). Why do People Avoid Medical Care ? A Qualitative Study Using National Data. J GEN INTERN MED, 30(3), 18–24. https://doi.org/10.1007/s11606-014-3089-1 5. Fox, S., & Purcell, K. (2010). Chronic Disease and the Internet. Pew Internet & American Life Project. 6. Fox, S., & Duggan, Maeve. (2013). Health Online 2013. Pew Internet & American Life Project.

7. Chu, J. T. W., Wang, M. P., Shen, C., Viswanath, K., Lam, T. H., Siu, S., & Chan, C. (2017). How, When and Why People Seek Health Information Online : Qualitative Study in Hong Kong. Interactive Journal of Medical Research, 6(2). https://doi.org/10.2196/ijmr.7000 8. Peraturan Menteri Kesehatan Republik Indonesia Nomor 46 Tahun 2017. Tentang Strategi E-Kesehatan Indonesia. Jakarta: Kementerian Kesehatan Republik Indonesia. 9. Wang, L., Wang, J., Wang, M., Li, Y., Liang, Y., & Xu, D. (2012). Using Internet Search Engines to Obtain Medical Information : A Comparative Study. Journal of Medical Internet Research, 14(3), 1–19. https://doi.org/10.2196/jmir.1943 10. Greenhalgh, T., Vijayaraghavan, S., Wherton, J., Shaw, S., Byrne, E., Campbellrichards, D., … Morris, J. (2016). Virtual online consultations : advantages and limitations ( VOCAL ) study. BMJ Open, 6, 1–13. https://doi.org/10.1136/bmjopen2015-009388

Appendix

Fig 1. Conceptual model of health care avoidance

Treat or Threat: Indonesia’s Bonus Demography.

Proposed by: Reynanda Fathanza Hizrian.

130110160170

Tsabitah Amaluna Zahra

130110170125

Made Dwi Aryastana J.

130110160158

Satria Angga Widitama

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Addressed to: PCC AMSC 2019 Singapore, AMSA – Indonesia

Asian Medical Student Association – Universitas Padjadjaran 2019

Treat or Threat: Indonesia’s Bonus Demography. Reynanda Fathanza H.1, Made Dwi A.J.1, Satria Angga W..1. Tsabitah Amaluna Z .1 Asian Medical Student Association – Universitas Padjadjaran Correspondence: reynanda.hizrian@gmail.com Contact: +62 813 811 51 684 Abstract According to United Nations estimates, the current population of Indonesia is 268,857,457. The number is equivalent to 3.49% of the total world population, making the country to rank number 4 in the list of countries worldwide by population. The median age in Indonesia is 28.3 years, and according to the United Nations, Indonesia will experience demographic bonus in 2020-2030. Between 2015 and 2030, the number of older persons – those aged 60 years or over – in the world is projected to grow by 56%, from 901 million to more than 1.4 billion. As populations continue to age, it is imperative that Governments design innovative policies specifically targeted to the needs of older persons, including health care. Because if it is not managed properly, the gold standard of pension care cannot be met. Another thing that is crucial is the financial management and savings for pension days. Regarding this issue, the government already make a regulation with BPJS Ketenagakerjaan offers three different programs including old age security and pension security. There are two types of workers that could be the participants of the programs, which is formal and informal workers. Formal workers are the one that work for one company and having some type of working agreement, set pay and/or benefits, a stable location, regular hours and some type of payroll taxes and Social Security contribution. But unfortunately, the number of Informal Worker are far more greater than the formal but less than 1% that already participated in this kind of program. As youth, we are far concerned about what will happened in the next decades rather than tomorrow. Thus, by having this idea we would like to propose thing to government also raising population awareness regarding this issue by advocating things to several stakeholders such as: government, employer, worker, also youth.

Treat or Threat: Indonesia’s Bonus Demography.

Proposed by: Reynanda Fathanza Hizrian.

130110160170

Tsabitah Amaluna Zahra

130110170125

Made Dwi Aryastana J.

130110160158

Satria Angga Widitama

130110170144

Addressed to: PCC AMSC 2019 Singapore, AMSA – Indonesia

Asian Medical Student Association – Universitas Padjadjaran 2019

Treat or Threat: Indonesia’s Bonus Demography. Reynanda Fathanza H.1, Made Dwi A.J.1, Satria Angga W..1. Tsabitah Amaluna Z .1 Asian Medical Student Association – Universitas Padjadjaran Correspondence: reynanda.hizrian@gmail.com Contact: +62 813 811 51 684 Background The current population of Indonesia is 268,857,457 based on the latest United Nations estimates. The number is equivalent to 3.49% of the total world population, making the country to rank number 4 in the list of countries worldwide by population. The median age in Indonesia is 28.3 years, and according to the United Nations, Indonesia will experience demographic bonus in 2020-2030. This means the number of productive population is twice as much as the non-productive population. If handled properly, the abundant human resources can surge gross domestic product significantly and be the leap of a country to its economic growth. Nonetheless, the demographic bonus comes as a two-edged-sword where despite the possibilities of great outcomes and benefits, unless treated accordingly, could lead to catastrophe. And also the direct aftermath of this condition is the following aging population trend. Between 2015 and 2030, the number of older persons – those aged 60 years or over – in the world is projected to grow by 56%, from 901 million to more than 1.4 billion. Virtually all countries are expected to see substantial growth in the number of older persons, and that growth will be faster in the developing regions than in the developed regions. In 2050, 44% of the world’s population will live in relatively aged country where more than 30% of people are above age 60. Indonesia is experiencing an increase in the older population growth throughout the period of 1990-2020. Thus, Indonesia will enter the ageing era in 2020, marked by the elderly’s percentage reaching 10% and approximately 30% in 2050. As populations continue to age, it is imperative that Governments design innovative policies specifically targeted to the needs of older persons, including health care. Because if not managed properly, the gold standard of pension care cannot be met. Another thing that is crucial is the financial management and savings for pension days. The Global Strategy and

Action Plan on Ageing and Health (2016-2020) included strengthening long-term care as one of the global action plans. In Indonesia, developing social protection schemes for elderly and increasing the fulfillment of elderlyâ&#x20AC;&#x2122;s basic rights are some of the points stated in the Medium-Term Development Plan (2015-2019) on Policy Direction on Ageing and Social Protection. Also stated in the National Action Plan for Elderly (2016-2019) to increase the number and quality of first-rate health facilities and advanced referral health facilities that perform aged health care services, and to increase the role of the elderly in improving the health of families and communities. By definition, demographic dividend as stated by UNFPA is the structural shift of populationâ&#x20AC;&#x2122;s age that results in the growth of national economy potential. This dividend occurs when the population of working-age (15-64) is larger than the population of nonworking-age. Indonesia will undergo an era of demographic dividend in the near future. Social Security Administration Body for Employment, or BPJS Ketenagakerjaan offers three different programs including old age security and pension security. The major difference between these two are old age security only paid once when participants retire, passed away, have permanent disability or permanently leave Indonesia. Meanwhile, pension security paid each month to the participants who have reached retirement age. There are two types of workers that could be the participants of the programs, which is formal and informal workers. Formal workers are the one that work for one company and having some type of working agreement, set pay and/or benefits, a stable location, regular hours and some type of payroll taxes and Social Security contribution. In the other hand work situation means the person doing the work has little or no job securities, doesnâ&#x20AC;&#x2122;t have a contract and might not have the same employer for more than a few weeks or months. The Joseph Rowntree Foundation, a policy research organization, cites three main identifiers of informal working: low wages, few benefits and limited hours. Unfortunately based on data from Badan Pusat Statistik, 72.672.192 workers are working in the informal sector or 58,35% of the total workers in Indonesia. from this numbers, only 0.033% of informal workers participate in the programs. Most of the workers that are

participating come from the formal sectors. This will threaten the potential of demographic financial dividend in Indonesia and eventually could switch into demographic burden. Despite already having all those plans and acts, the goal of improving the quality and care for pension days of elder population cannot be met if the population itself didnâ&#x20AC;&#x2122;t do anything. The very first, important thing to achieve the goal is to increase the awareness of the public of pension days. The first peak demographic bonus will occur in 2034, with the requirements of 60 productive workers for supporting 100 residents, the figure supports a population below 50, and contributes 0.22 percentage points towards economic growth. The bonus demographic period can be extended by maintaining Total Fertility Rate (TFR) at 2,1%, reduce the Infant Mortality Rate (IMR) quickly, thus increasing the productivity. Bonus Demographics complement the competitiveness of the workforce through the implementation of healthy living movements, contested Guarantees National Health Insurance, or Jaminan Kesehatan Nasional (JKN) and the National Social Security System (SJSN), Achieve Secondary Education universal, and strengthening the relevance of vocational and industrial training and education. In addition, supported investments rose through the development of savings, deposits, investments and long-term investments, efficiency and convenience investment, development, financing, development and sustainable income systems.

Table 1. Number of Indonesiaâ&#x20AC;&#x2122;s population based on age and gender

Pension Days Care According Peraturan Pemerintah,

GR 45/2015 requires all employers other than state

ministries etc. to enroll all of their employees in the pension security program ("Pension Program"). Participants in the Pension Program can be either: (i) salary earners (i.e. employees); or (ii) non-salary earners. Participation in the pension program starts with the first contribution being paid into the pension program. The contribution to the Pension Program is 3% of the monthly salary. The monthly salary is the actual pay consisting of base salary and fixed allowances which is received for the last one month. However, practically it can be calculated before tax (i.e. based on gross income) due to any non-fixed allowances that might be received by the employee. Specifically for salary earners, the contribution is paid jointly, 2% by the employer and 1% by the employee. The contribution will be reviewed by BPJS within at least 3 years of payment of the first contribution and the employer's contribution may be gradually increased to up to 8%. The employee's contribution to the pension program is deducted by the employer from the employee's monthly salary which for 2015 is limited to a maximum salary of IDR7,000,000. This salary limit for contributions may be changed every year. The entire contribution is paid to BPJS Manpower. A delay in the payment of contributions may result in the imposition of a fine of 2% of the monthly contribution for each month of delay in payment. Employers are responsible for paying the fine. Initially, the pension benefit paid to the participant will be from IDR300,000 to IDR3,600,000 per month at the most. The benefit is payable until the employee passes away. The benefit can be obtained by a participant only after the participant has: been enrolled in the program for at least 15 years or 180 months; and reached retirement age. Currently the retirement age is 56, but starting on 1 January 2019, the retirement age will be 57 years. This retirement age will gradually increase by one more year every three years until the retirement age finally becomes 65. The type of pension benefits that will be paid could be: (i) an old age pension; (ii) a disability pension; (iii) a widow’s or widower’s pension; (iv) a child’s pension; or (v) a parent’s pension. The following Pension Program benefit may be claimed on several circumstances if:

the old age pension once the participant has reached pension age and has paid contributions for 15 years or equivalent to 180 months. Payment of this benefit ceases upon the demise of the participant. a disability pension if the participant suffers total permanent disability before reaching pension age. Payment of this benefit ceases upon the demise of the participant or if his/her disability is no longer defined as total and permanent. a widow's or widower's pension will be received by the husband or wife of the participant who passes away. Payment of this benefit ceases upon the demise or remarriage of the widow or widower. a child's pension to a child on a condition: (i) if is his/her parents who were participants both pass away; or (ii) if the widow or widower of the participant passes away or remarries. Payment of this benefit ceases when the child reaches the age of 23, finds work or marries. a parents' pension to the parents of a participant who passes away leaving no wife, husband or child. Payment of this benefit ceases upon the demise of the parents. Pension Program benefits are paid as follows: the first payment is paid when: (i) upon the Pension Program benefit entitlement being calculated and receipt of all the required supporting documents by BPJS Manpower; or (ii) within 15 (fifteen) days of the Pension Program benefits becoming payable, assuming all the required supporting documents have been received by BPJS Manpower. the next payment is paid at the latest on the first day of the following month. If an employer does not comply with GR 45/2015, the following progressive sanctions may be imposed: written warning, a fine, and the withdrawal of certain public services under the prevailing laws. GR 45/2015 does not mention anything about the previous pension fund under Law No. 11 of 1992 and, indeed, the two programs seem to overlap each other. However, the Pension Program under GR 45/2015 is mandatory and therefore employers must enroll all their employees in it as well as continuing with separate existing pension fund obligations. According to some observers, the new Pension Program is likely to cause stagnancy in the

private pension fund industry. It remains to be seen how GR45/2015 will be implemented as we note that some provisions are unclear and will be further regulated in the ministry regulation, e.g. the procedures for the payment of the pension benefit. Under GR46/2015, participants in the old age security program are salary earners (e.g. employees) and non-salary earners (e.g. independent consultants). The contribution payable to BPJS Manpower depends on the type of participation. Salary Participants contribution is 5.7% of the employee's monthly salary, of which 3.7% is paid by the employer and 2% by the employee. The monthly salary here means the basic salary plus fixed allowance(s) (if any). The contribution is based on certain figures from the participant's income listed in the Attachment to GR 46/2015. The participant may choose how much to contribute him/herself. For example, if the participant's income is from IDR9,200,000 up to IDR10,199,000, the basic salary for calculating the old age security contribution is IDR9,700,000. Therefore, the contribution payable to BPJS Manpower is IDR194,000. The amount of contribution can be seen in the Attachment to GR 46/2015. The contributions for both salary and non-salary earner participants are paid to BPJS Manpower. A delay in the payment of contributions may result in the imposition of a fine of 2% of the monthly contribution for each month of delay in payment. Specifically for salary earner participants, employers are responsible for paying the fine. Old age security benefits are payable when the participant reaches 56, passes away, suffers a permanent disability, or leaves Indonesia permanently. The benefits are payable in a lump sum. If the participant passes away, then the benefits will be given to the legitimate heirs (i.e. widow/widower or children). If the participants have no legitimate heirs, then the old age security benefits will be paid to: immediate family until the second degree; siblings; in-laws; and the appointed party under the participant's testimony.

If the employee resigns or is terminated before reaching retirement age, the old age security benefits are only payable when the employee reaches 56. The benefits are calculated from the total accumulation of contributions paid plus its growth. Participants may also claim the benefits before they satisfy any of the above requirements in order to prepare themselves for retirement before they reach retirement age. However, they must have participated in the program for at least 10 years; and the benefits can only be claimed up to a certain limit: either 10% of total benefits for preparing for retirement or 30% to buy a house. If an employer, among others, does not enroll its employees in the old age security program, BPJS Manpower may impose the following progressive sanctions: written warning, a fine, and the withdrawal of certain public services under the prevailing laws. The public's attention has been drawn to GR46/2015 because now participants must have participated for at least ten years to claim benefits before reaching retirement age, while previously, participants only needed to have participated for five years to claim the benefits. Conclusion Based on the problem Based on the problem we’ve stated above, basically we already have several countermeasures and assurance to prevent the worst happened. But looking at the population’s compliance toward the program, we are really terrified by the possibilities that it could happened for the worst. So, as part of youth’s and population that would participate to improving Indonesia’s prosperity, we would like to voice our concern and addressing to several stakeholder such as: Government: We already know that up to this paper was written, government always try to come up with the solution to this issues. But there are several things that we would like to propose to the situation that could be improve the effectiveness of the regulation itself, such as:

Raising awareness to the population regarding the regulation itself, by addressing the issue not only to the segmented community but also different community that not involved directly on the situation. Promoting the participation of the population toward the regulation for the populationâ&#x20AC;&#x2122;s benefit. Reinforcing the law enforcement regarding the issue and giving a firm sanction toward people that not being cooperative to the regulation itself. Ensuring the regulation are beneficial to the population, not only toward segmented worker class such as government-body employee, especially to the people who work with no job securities and updating the regulation with regard to the populationâ&#x20AC;&#x2122;s need. Employer Most of the employer already applied the regulation to their workers. But as we stated in the background above, not all work field could be applied directly to this regulation. Also there are several people that work only for temporary, not a permanent position and such given no securities toward the employee. Based on this problem, we would like to appeal the employer to treat the employee properly. Even if they not a permanent worker, they should have a mechanism to ensure their pension days care is assured. Youth As a future generation of this country we have to doing our best to improving ourselves thus improving the nationâ&#x20AC;&#x2122;s prosperity. But as a young people still not aware of the condition the will face in the future, we would like to raising awareness to the youth generation regarding this issue, and the essence of the pension days care for themselves. If we could aware of what we will do in the future, doing our anything our jobs do, we have to aware not only for the current moment, but also envisioning the future after we retire. By having the knowledge of such regulation, we could having a sense of security doing our jobs, thus the worst case that we are scared of could be prevented from happening.

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