The Sealed Nectar

Scenario: Physician Income and Its Impact on Quality

Scenario: Medical Doctors and Specialists Distribution in Indonesia.

There is a huge gap between the DISTRIBUTION of medical doctors and specialists in REMOTE and NON-REMOTE areas, not only in Indonesia but all over the world.

Facts:
1. There is a positive correlation between the availability of health workers and better health outcomes, as well as increased coverage of essential health interventions.

2. The World Health Report 2006 estimated that the world lacks about 4 million health workers, if a minimum level of health outcomes is to be achieved (WHO 2006).

3. Health worker shortages are currently reported by many other countries, both developed and developing. Such shortages are symptoms of a poorly managed health workforce and health care system. The causes of the crisis are complex, and have to do with insufficient production capacity, but also with an inability to keep the workers that are being produced in the places where they are most needed. (WHO: Increasing access to health workers in remote and rural areas through improved retention,2009)

4. In the majority of countries, rural and remote areas are usually lacking sufficient numbers of health workers. Approximately one half of the global population lives in rural areas, but these areas are served by only 38% of the total nursing workforce and by less than a quarter of the total physicians’ workforce. (WHO: Increasing access to health workers in remote and rural areas through improved retention,2009)

Thus, we can assume that most of health workers are more attracted to serve in urban rather than remote areas. But why?

Most physicians prefer to settle in urban areas offering opportunities for professional development, education and other amenities for their families, and attractive employment opportunities.

There are many things that had been done by Indonesia's laws and regulations in governing the health sector of Indonesia. I chose a few that have correlations to improve the gap difference, which are:
- 1974 by Presidental Instruction (Inpres) : Mandates that all new medical graduates serve in under-served rural districts for 1–3 years.
- 1991 by Presidential Regulation No. 37 : Regulates the recruitment of doctors as temporary employees.
- 2002 Ministry of Health Regulation No. 1540 : Regulates the placement of doctors during service period.
- 2004 Local Government Authority Act No. 32 : With decentralisation each local government has authority to recruit their own medical personnel as local government employees.

*notes: Not all laws and regulations remain until now. For example, after the Indonesia crisis of 1997 the policy of mandatory service was challenged as violating the rights of doctors to choose their jobs. Most doctors who finished their period of mandatory service sought to become civil servants to ensure lifetime job security. Eventually, the mandatory service program was replaced by a voluntary contract arrangement.

Problems:
Although there is an existing acts and regulations for the governance of the medical profession in Indonesia, its implementation was not consistent, with significant arbitrariness in the application of regulations by governments at all levels. The biggest constraint in devising and implementing measures to address the weaknesses discussed below is that the Government of Indonesia, in the last three decades, has allocated less than two per cent of its national budget for health care.

Solutions:
How can we persuade doctors to serve in remote areas?

Offer a fine tune incentive packages that the physician wont say no to. The types of incentives (can be cash, housing, career development etc) can be decided after a simple survey technique is done to assess doctors' reactions to potential incentive packages together with policy analysis.

Ministry of Health is developing initiatives to provide placement-related fellowships for young doctors to pursue specialist training. Under this program, a doctor can apply for a fellowship (covering educational costs and living allowances during 4-5 years of specialist training), conditional on the doctor signing a contract that commits him or her to a given number of years service in a smaller district after graduation.

The more remote and less developed the district, the shorter the period of mandatory service. Past evidence from the placement of general practitioners shows that doctors are more likely to consider remote postings when an adequate incentive system is in place, indicating that financial incentives can be an effective mechanism for achieving a more even distribution of health workers.



References:
1. Lecture note: International health and decentralization, dr. Yodi Mahendradhata M.Sc,PhD
2. Research at the World Bank: Attracting Doctors to Rural Areas (Indonesia)
3. WHO: Increasing access to health workers in remote and rural areas through improved retention,2009
4. Viewing Decentralization as an Opportunity: In Improving Availability of Health Workers in Underserved Areas, Anna Kurniati, Ferry Efendi, 2009

Salam.

In the name of Allah, most Gracious, most Merciful.

Without realizing how fast time flies, we are in the week 6 of 4.2: Health System and Disaster Management block! Wise man says, time flies when you are having so much fun. No, it was not due to Merapi eruption or the fact that we got two weeks holiday in the middle of our block. The survivors had suffered a lot when their house burnt down or when they lost their family members in this incident. Thus, it is no fun at all.

My biggest condolences to Yogyakarta people for the losses. May each souls rest in peace and all survivors continue to lead their life, learning and believing that all things happen for a reason. It is a lesson for all of us. They are tested with patient, while we are tested with the sense of brotherhood, kinship and responsibility towards human kind. Thus, lend a helping hand.

“Small gestures of help, means a lot to someone who is in need.”

But what impressed me most you see, the fact that they are very strong.

When we talked to one of the survivor, she said,” kita pernah merasa tidak memiliki. Kemudian yang Kuasa memberi kita kesempatan merasa ada, maka merasa tidak memiliki lagi, tidak ada apa-apanya. “

…………………………..

Just maybe, the correct sentences would be, time flies when you are having a lot of things to do! Our packed schedule and the block exam are nearing. Thus, to make it short, I’m thinking of writing the blog systematically by tutorial-based-on-week-system. It means that I will post entries based on week and the scenario from the tutorial sessions. Besides helping me to organize this blog better (the dateline is nearing!), at the same time, I can study for the block exam. May this give benefit to you as well. :)

So, here it goes…

Bismillah.

every 1st December is a World Aids Day. Each year, a theme is chosen to unite the global effort to face the challenges of the AIDS pandemic.And for 2010, the theme that had been selected by the World AIDS Campaign's Global Steering Committee for 2010 is: Universal Access and Human Rights.

This worldwide effort is designed to: encourage public support and programming to prevent the spread of HIV infection; provide awareness and education about HIV/AIDS; and demonstrate compassion for those infected or affected by HIV.

AIDS Facts
Worldwide estimates in 2008 (UNAIDS):
Over 60 million have been infected since 1981:

• 33.4 million living with HIV/AIDS
• Over 25 million have died

2.7 million infected in 2008 (7,400 per day)
2 million deaths in 2008
430,000 children infected in 2008

In Sub-Saharan Africa: about 5,200 are infected and 4,100 will die each day. 22.4 million are living with HIV in this region.

As a future medical doctors, may we have the strength and boost our efforts in drawing attention to AIDS, it’s prevention, treatment, and how it impacts all of our daily lives and how it impacts globally. Thus all of these means a crystal clear and solid education to our society about Aids and HIV. (semangat!)

a simple story that i encountered in Stadion Maguwoharjo last 27 november 2010.

Kami turun dari tingkat 3 stadion maguwoharjo ke tingkat 2 menggunakan jalan yang biasa dilalui pembawa kereta. Berpapasan dengan seorang nenek akhir 80-an, berkulit cerah dan berbadan kecil, dengan tipikal kebaya labuh lama, kain batik jawa dan anak tudung yang sering diguna mbah-mbah andai keluar beraktivitas di luar. kami tersenyum padanya. Di tangannya kelihatan baldi separuh penuh berisi air. Dia mengucapkan salam pada kami dengan muka berseri dan senyum penuh:

Imagine when just yesterday, you were sleeping safe and sound with the comfort of home, and in a matter of few minutes or hours, all of that is gone. You are now living with strangers in a big hall, where you share a place to sleep, food to eat and toilets with everyone else (non-family members). The cause of evacuation can be due to volcanic eruption that burnt down your house, flood that causes damage to your properties, or a freaky earthquake that even hunts you in your dreams (post-traumatic).

Disaster's definition:

"A situation resulting from an environmental phenomenon or armed conflict that produced stress, personal injury, physical damage, and economic disruption of great magnitude." - US disaster relief specialist, Frederick C. Cuny (1944-1995)

"The result of a vast ecological breakdown in the relations between man and his environment, a serious and sudden (or slow, as in drought) disruption on such a scale that the stricken community needs, extraordinary efforts to cope with it, often with outside help or international aid." - World Health Organization (WHO)

How will you respond?

Feeling sad, lost and shaken are the normal responses right after disaster, starts with the critical phase of less than 1 month prior to the disaster. When not handle or manage poorly, the condition worsens to the second phase of post traumatic syndrome disorder. Next, prolonged stressor will produce negative responses to these three aspects; behavioral, physiological, emotional and cognitive. Traumatized individual leads to decrease productivity, become burdens to family, people and community and have higher risk of suicide.

What is the role of public mental health systems in disaster managements?

“People have access to social and mental health services to reduce mental health morbidity, disability, and social problems.” SPHERE Project: Humanitarian charter & minimum standards in disaster response

The minimum standards are based on two key indicators:

(1) Social intervention

- Access to an ongoing and reliable flow of credible information on the disaster and associated relief efforts. ( the survivors of the disaster should be informed clearly about what will happened to them, what they should do before, during and after the events and must always be updated thoroughly by a trusted sources and not listening to random speculations and rumors. Peace of mind is the key.)

- Maintenance of normal cultural and religious events, e.g., funeral ceremonies

- Access to schooling and normal recreational activities for children and adolescents. ( fun school and recreational activities like football had been done in many places where the survivors stay and it work wonders! The children and adolescent spend their time doing beneficial and fun things that can help them forget about the tragedy.)

- Participation of the in the community efforts for adults and adolescents

- Inclusion in the social networks for the isolated persons, e.g., orphaned children.

- Reunification of separated people and families. (every person will be worried about the conditions of their family members. Knowing that our family is safe and can be with them during this crucial time will bring great moral supports.)

- Shelter and community organization for the displaced people

- Involvement of the community in the decisions regarding religious and other community facilities.

(2) Psychological and psychiatric intervention

- Access to psychological first aids at health service facility and in the community for the people experiencing acute mental distress

- Availability of care for urgent psychiatric complaints through the primary health care system

- Continuous treatment for individuals with pre-existing psychiatric disorders. Sudden discontinuation of medications is to be avoided.

- Plans for community-based psychological interventions for the post-disaster phase.

Dealing with post disaster conditions is as crucial as facing the disaster itself. The question that we always have to ask ourselves as we lend a helping hand: what more can I do?

References:

1. Lecture Note: Panel Discussion Global and Mental Health System (Capacity Building) on Disaster and Public Mental Health by Dr. Rahmat Hidayat.

2. Lecture Note: Disaster Management in Mental Health by Dr. Bambang Hastha Yoga

3. WHO websites

4. Additional information from respected doctors during lectures.

Managing health is not an easy job. It is not something that can be done by one person, in a short period of time or without maintainance. Thus, a good system is needed to realize its goal. It is an overgoing process, handled by commited profesionals in many multidisciplinary levels.

A health system is the sum total of all the organizations, institutions and resources whose primary purpose is to improve health – WHO

It is not about physicians alone, but also includes health infrastructure, funds, health worker staffing, logistics, transport, communications, tracking progress, effective financing. health commodities (such as equipment and medicines) and even providing best services to patients.

There are few things that had been stressed out by WHO in implementing well functioning health system. It includes a balanced between population’s need and expectation with these few ways:

- improving health status of individuals, families and communties

- defending the population against what threatens its health

- protecting people against the financial consequences of ill-health

- providing equitable access to people-centered care

- making it possible for people to participate in decisions affecting their health and health system. (people don’t care how much you know, until they know how much you care! Show your professionalism by guiding their choices, and not instructing them to do this and that without giving any reasoning.)