Friday, December 23, 2011

Ide untuk Indonesia

Punya ide untuk Indonesia?

Ikutan '+' Project aja dari Philips!

Ide saya untuk Indonesia adalah untuk meningkatkan akses layanan kesehatan,
judulnya 'Tabungan Ibu'.

Kenapa Ibu?

Wanita dan khususnya seorang Ibu, sangat menarik perhatian dan juga kepedulian saya sebagai praktisi di bidang kesehatan.

Angka kematian Ibu di Indonesia (sebagai salahsatu indikator kesehatan) merupakan yang tertinggi di Asia Tenggara.
Sayangnya, angka kematian Ibu yang tinggi ini bukan gara-gara kita (Indonesia) gak punya tenaga dokter/bidan yang handal.
Dokter/tenaga kesehatan kita tidak kalah pintar dan handal dibanding tenaga kesehatan di negara maju, dalam hal menangani pasien. Tapi teteup aja angka kematian Ibu kita tinggi walaupun makin banyak orang masuk sekolah dokter/bidan.

Rasio tenaga kesehatan yang tidak berimbang dibanding jumlah pasien yang harus dilayani dan distribusi sebagian besar tenaga kesehatan yang tidak merata (perkotaan > pedesaan) menyebabkan beratnya beban kerja para tenaga kesehatan di Indonesia.

Salahsatu penyebab lainnya, menurut pengamatan saya adalah karena sistem pembiayaan di Indonesia.
Saat ini sistem pembiayaan di Indonesia sebagian besar (60-80%) masih dibebankan pada pasien (user fees/ out-of pocket payment).
Ini berbeda dengan sistem pembiayaan di negara-negara yang lebih maju dimana hampir semua orang dicover oleh asuransi kesehatan (universal coverage).

Dampaknya tentu saja sangat jauh berbeda.
Pengalaman saya sewaktu sekolah di Belanda/Denmark (yang menerapkan sistem universal coverage) ketika jatuh sakit, saya gak usah mikir-mikir dapet duit dari mana kalau mau berobat ke dokter.
Karena toh dengan adanya asuransi kesehatan, bisa dibilang saat berobat ke dokter jadi gratis.
Obat masi harus dibeli sih, tapi kan lumayan kalau layanan kesehatan sudah ditanggung negara.

Berbeda dengan pengalaman sewaktu di Indonesia, ketika saya sakit mata dan harus dilakukan operasi kecil- saya harus keluar duit dari kantung sendiri karena asuransi dari kantor sudah habis masa berlakunya.
Masih mending saya punya uang untuk biaya berobat, dan juga kalau diobati sama kolega suka dapet harga 'diskon'.

Tapi gimana dengan mereka-mereka yang gak mampu?

Orang dari kalangan ekonomi lemah umumnya menghindari ke praktek dokter, bukan karena mereka gak percaya dokter, tapi karena ke dokter identik dengan mahal!
Makanya bisa dibilang pengobatan alternatif (contohnya dukun) sangat 'menjamur' dan diterima di Indonesia, karena itulah solusi layanan kesehatan buat mereka yang gak mampu pergi berobat ke dokter.

Solusi yang saya tawarkan disebut Tabungan Ibu, karena memang khusus untuk wanita atau Ibu yang telah mempunyai anak.

Kalau seorang Ayah, punya uang lebih, biasanya akan dia habiskan untuk beli rokok, atau sesuatu yang sifatnya menyenangkan kepentingan pribadi.
Kalau seorang Ibu, punya uang lebih, biasanya akan dia habiskan untuk kepentingan keluarga/ anak-anaknya. Seorang Ibu secara alamiah memang punya sifat/ jiwa yang rela berkorban.

Oleh karena itu, dengan adanya tabungan Ibu, saya harapkan akan lebih banyak kaum ibu dan anak-anak yang bisa mendapat akses layanan kesehatan.
Ini bukan sesuatu yang mustahil, di Indonesia yang jumlahnya 236 juta penduduk ini, kita punya potensi yang besar untuk sebuah perubahan.

Silakan baca tentang ide saya, dan vote untuk mendukung perbaikan akses kesehatan bagi mereka yang tidak mampu ^^

Tabungan Ibu: Solusi alternatif untuk pembiayaan kesehatan

Saturday, November 19, 2011

Public speaking :: Learning experience

Just yesterday I made an oral presentation in local symposium in my hometown (BIDEAS).

The presentation was basically from my thesis research and most of the audiences were people that I already knew through med school or my health research unit.

But still, every time I have to made a presentation, I got a feeling of nervous - despite I have prepared it very well. I know the contents and very informed about what I was doing throughout my research. And of course, I made my own presentation and rehearsed it couple of times days before.

I have talked to myself that: 'There's nothing to worry about, these people won't harm you' and blah blah to motivate myself.

Generally speaking, I would say it's a pity that we're Indonesian are always unprepared for public speaking since we were young.

Just before I left Netherlands, me and my friend (we both Indonesians who experienced master program abroad), who also acknowledged that we're tend to be unprepared for public speaking.

Also in the preparation for material. For example in scientific program, either the speaker always put too much information that it's just too difficult to digest or s/he would present it without enthusiasm - which makes it perfect for audiences to take a nap after lunchtime.

My first learning experience in public speaking, well not really public, it was in a class contained of 20 people actually- was in Amsterdam. I was taking a sexual reproductive health course in Royal Tropical Institute, and they gave us a group assignment. We had to made a small literature review and made a presentation out of it.
At that moment, I was pretty nervous, not that I didn't grasp the material. I was one of the most experienced student in the class really, with enough work experiences to share.
But I had to made a presentation (shared with others students) in English, which is not my first language. And I was not really prepare for public speaking, during my whole life. So lame.

So all I did was encouraging myself, that it couldn't be so bad- and even though it would be bad, it's just a class contained of 20 people that would remembered me as jittery young doctor from Indonesia, forever, anyway...

It turned out well, it's normal to have a high-pitched nervous voice in the beginning but then, as I familiarized with the situation- I could see myself took control.

Back to the conversation that I made with my friend, we both agreed that in Netherlands (or mostly west Europe) students were used to make a oral presentation/ public speaking since they were young. And we could see that is really an advantage if you want to be internationally (or nationally) recognized as professionals, either as a lecturer, researcher/scientist, or whatever it is. Because the presentation/ public speaking is how you 'sell yourselves' and how you also sell your content of presentation, as one package.

If I could made a change in my med school, I will definitely propose that med students should engage more in scientific events and practice for oral presentation/ public speakings.

During the International conference last month in Barcelona, I realized that Indonesians are not lack of experts nor the quality of experts themselves are highly competitive for international standard. But mostly we're Indonesians are (1) not confident enough, to present something in English (even though some of us are good enough if we have to present it in Indonesians), and/or (2) for the same reason, not confident to present it in the front of international scope.
Which is very unfortunate for scientific world, because we have so much to share in terms of knowledge or experiences.

Again, I will mention Helen Rees- my favorite speaker throughout the International conference in Bcn. Just checked out in the website and they put her presentation (in .pdf file) so we can download it and take a look how neat she has made it. Also, the most stunning presentation that I've seen in my whole life (besides Elizabeth Pisani when she's giving lecture in our class in Copenhagen).

Hope you enjoy it too :)

Saturday, October 29, 2011

What makes Indonesian (not) healthy ? [part one]

Do you know if you were born in Japan you will probably live 40 years longer than somebody who were born in Afghanistan?*
*Life expectancy for Countries

And the fact that Indonesian people have life expectancy 12 years shorter compared to their neighboring country, Singapore !
This intriguing fact is something that I learned during my core course in Amsterdam about health determinant**.
**What determines health?

It has haunted my mind and spirit as medical doctor and public health practitioner.

Epidemiology and statistics, branch of study that talked about important numbers/indicators on population, used to be unpopular class when I was a student in medical school.

I remember how bored it was and demotivated most of us to really learn something from it, or put it into practice.

Few years after I finished my medical school, I realized how important it could be.

It does tell whether we're moving from one point to another (or not), make any good or bad progress as nation in terms of managing health.

Maternal mortality rate (MMR) in Indonesia is one of the highest in Southeast Asia, but if you stratified by region- some more developed region (West Java) has lower MMR (lower than Southeast Asia rate in average) while another region, Papua has MMR 3 times higher than national average!

Back to my main question, as a title: ' What makes Indonesian (not) healthy ?'

I would use the framework borrowed from Canadians :: Population Health.

This is actually looks like my assignment as master student in International Health program-
but in the name of knowledge, science, humanity and nationalism- I write this for you all who interested in this subject (as much as I do).

1. Income and social status

Pretty much makes sense for all of us, people who are poor would more likely have worse health status than those who are richer.

Specifically in countries like Indonesia whereas most of the health expenditure come from out-of pocket (user fees) expenses.

Those who are poor assumed would spend less money on health care (they would prioritize on something that are considered basic needs e.g. foods).

And this group would likely to come late (if they happen to be sick) to the doctors, they would collect money first, seek out alternative treatment etc- in this out-of-pocket systems.

Because here doctors/health care institutions are considered as something 'expensive' or luxurious need for the poor.

It's likely this could be the case: they (the poor) couldn't afford money to go to the doctors, they become even sicker. When they go to the doctor, their worsened conditions would make them pay ever more (more treatment, more medication) compare if they seek treatment earlier.

next on health determinants . . . .

2. Social support networks

3. Education and literacy

4. Employment / Working condition

5. Social environment

Friday, October 28, 2011

Public transport :: Never ending problems

I love public transport.

Here or moreover abroad.

I am people person, and even though I know I could take my own car, joined with others who have their own personal car and make traffic jam in the street altogether- there were times that I kept telling myself I should stay to my idealism and take public transport.

For me, taking a public transport means a more environmental-friendly approach than personal vehicle (of course). And being in a public transport with people, it's like sharing not just a car but also a life, their stories. Sometimes, it could be very VERY annoying when you're stuck with thoughtless people, who smokes regardless the car was already suffocated enough with 10 persons.
But also there were times it could be a rewarding moment, seeing interaction of people who help each other. Being a witness of such behaviour, I know it was not such a bad idea to stay on public transport.

I admit, though, public transport system in Indonesia is not the safest place in the earth.
In fact, it's one of the dangerous experience that you could have in your whole life.

Just recently, a minivan crashed at the place close to my hometown and few people died.
When I was a young doctor in a hospital, I saw too many cars/motorbikes accidents, some of them due to irrational behavior of the drivers.
It is a crazy and tough life on the streets here.

Back again during my study (or traveling) year in Europe (or elsewhere in Asia), I analyzed what make these developed countries build a success public transport system.
Is it a good system who drive users to oblige or start from capable users who drive the good public transport system?

I've come to the conclusion of: both.
It has to be driven simultaneously by systems (also environmental) and users.

For example, any Indonesian people who have been to Singapore, they know that they have to adhere to such strict regulation (not just transport, but also not to spit in public etc. Gosh).
Or any Germans (mostly they follow the rules) who have been to Indonesia they would find their way out from tricky traffic jams by doing exactly (or almost the same) like any Indonesian.
It's just their adaptation behavior to the systems, either it's good or bad.

Even in Europe, there's a huge difference between public systems in Denmark and in Italy.
My analysis: It's just because Danes have less emotional feelings on the street and stick to the regulation easily than Italians (and oh, I'm on the Italiano side :-)
Biking rules in Netherlands is very laid-back compare to Denmark.
So this is also applied to their personalities, I'd say.

What about in Indonesia?

Here, taking a public transport it's like the option of poor people.
For those who can't afford their own personal motorbikes or cars.
It's very unreliable, chaotic, unsafe, dangerous (remember few weeks or months ago, about raping in public transport. It scares me and a lot of women too, I bet) and it's like risk taking every day when you don't have other choice.

And people, like me, who knows this experience, made a vow to themselves- as soon as I get more money I would buy my own bike/car so I won't stuck in this crazy situation everyday!

too many cars!now we have too many cars in the street!

But that's not a long term solution!

People are getting rich these days.
There will be more people who could afford their own personal vehicles.
There will be more motorbikes and cars in the street (it's already happened actually)
surely, there'll be more traffic jams here and there. We know it already!

At some point, every places in Indonesia, will be like Jakarta.
People are physically and mentally test every day in the streets due to its chaotic conditions.

The solution: We need more public transport, which is secure, reliable and cost-effective (we're not saying cheap, I'm sure a lot of people would rather to pay reasonable price as long it's worth).

We should shout it out loud to our government!
Or basically those who care, if the government burns out with too many task.
It could be public-private-shared organisation, I won't go into detail and it's not my expertise either. But we surely need this, now or later.

Tuesday, October 25, 2011

Conference addict :: Upcoming event on 2012

After my last scientific conference in Barcelona in the beginning of this month, I realized that I got addicted.

my poster presentation in Barcelona!my poster in International Health Conference, Barcelona
with Prisca, my co-supervisor from KIT, Ams

Being in the international conference was very inspiring for me. I was there for a poster presentation basically, but I could also learned so many things e.g. how to make better poster for presentation, attending seminars with experts, building networks with people all around the world.

One of the speakers that I found very inspiring for me was
Helen Rees. She brought a session about pre-exposure prophylaxis for HIV prevention, in a very practical manner. Also a stunning presentation!
One of the most impressive presentation (slides, also how she came up with the talks) that I've ever seen in my whole life as researcher (yeah I'm stil young researcher btw).

Then I googled her name and it turned out that she's indeed a very professional and dedicated person in her area (and she's part of WHO Advisory Committee).
Uh huh, no wonder why.

Now that I feel like I've learned so much from international conference, I got addicted to have some more !

Here's some of upcoming events (international scientific, clinical/ social conference) about HIV-AIDS in 2012 :

April 12-13, New South Wales (AU)
Silence & Articulation

May 23-25, Marseille (FR)
"Searching for Cure" - ISHED

July 22-27, Washington DC (US)
Turning the Tide Together

So for those who are interested, don't forget to submit your abstract and hopefully I'll see you there !

Monday, October 24, 2011

NG :: 7 Billion Population in 2011

THis is an example of nice public health message from National Geographic.

It's about demographic, the world will reach 7 billion population by 31 Oct 2011.

Enjoy !

Sunday, October 23, 2011

Health Promotion :: The Power of Information

When I was abroad, I talked to several friends that I know how did they get source of information about sexual reproductive health.

It was quite common in Europe, that young people know about their sexual and reproductive rights since very early age. Either they get the source information from school or mass media.

I asked a friend of mine, she's Indonesians but has been living in one of the state in Europe for years. She said that she never heard anything before this kinda information when she stayed in Indonesia. Then when she lived abroad, it's clearly such information were commonly spread in public.

Also information about HIV.
HIV in Indonesia is actually not involving a big number.
In general population the prevalence (only) 0.2 % but among at risk population it ranges from less than 5% (among sex workers) to more than 50% (among people who inject drugs).

While it's pretty common in developed countries, where they put every one (especially young people, who presumably sexually active groups) at risk - public health professionals put the message that 'preventive is important'.
Its implication: (Hopefully) Every young people know that they should use condom with a new sexual partner (to protect from STI) or use another form of contraceptive, if they long term partner (as birth control).

These days, information plays a major role in our life.
And it's really fast in our globalization era. Just hours ago Simoncelli had an accident in Sepang, Malaysia and it was spreading whole around the globes in one click away (if you have internet connection).
We all connected through invisible bonding, thanks to internet and mass media.

And we all may received also wrong or invalid information from media.

That's why leaders (community leaders, religious leaders) used to be and still nowadays, play essential role-- because they may be the source of information, like it or not.
Especially for uneducated people, when they can't be critical (for they concern about only their primary needs).

Unfortunately we can see in our mass media (yes I am talking about Indonesian TV channels) we have limited room for public health messages that can educated people.

I didn't watch TV (in Indonesia) that much because sometimes it could make me sick.
But I also noticed some channels consistently put nice public messages to inform viewers.

I know that every one has their own agenda, whether it's profit (and I believe cheesy movie/ infotainment could bring a lot of profit) or better motives.

Just few weeks ago I came back from Europe, then I started to notice few commercials break in TV. There's this nice public commercial talked about food substitute for rice (because in Indonesia we have so many food staples beside rice, yet they less popular).

I wish for more public health message like this. If I have people who work in media, I would like to contribute my idea to develop public health message.

We are in great need of this message e.g. how to overcome traffic jam (driving behavior), also safety in the street (also for pedestrians), or talking about healthy eating habit.

And it should be regulated in the Ministerial level!

I think for every junk food advertisement (McDonalds, KFC, etc) should be certain percentage aside for health eating habit advertisement !

It's a pity, too many young people with unhealthy eating habit were considered as 'normal' because it represent the sign of 'success' or 'wealthy'.

Then again, smoking prohibition in public space.

Ah yeah, I should have mentioned first, that tobaccos are a big deal in Indonesia.
And it's so cheap ... even kids underage could afford it.

Compare with Europe, for example, you only could buy cigarettes if you're over 18 years old.
I've noticed in some countries e.g. French, Italy, Spain I saw people from younger age also smoke cigarettes. But they have concern that if they smoke, that doesn't mean other people have to smoke too (at least better than here).

And because it's so cheap (cigarettes in Europe also very expensive because they put higher taxes) there are so many poor people that could not afford buy food, they will buy cigarette instead. That's tragic !

I think only rich people that should buy cigarettes, because when they got sick (due to respiratory problems) at least they could afford their medical care.

Maybe it sounds too cynical. But to be very practical, I would put higher tax on cigarettes -- then relocate the budget for health care --
And this works to stop people from smoking too, I believe.
I know many Indonesian friends who stop smoking when they lived in Europe for some while (because it's too expensive to buy cigarettes there).

We've seen so many innovative and impressive advertisement from this tobacco companies in Indonesia. We should also asked them to be balance by provide the information of how harmful cigarettes could be for our health.
Then again, it will be conflict of interest for them!

So, who should provide such information then?
I would say, us, community, public health professional, clinicians, if not government in general (only if they interest in the health state of their citizens).

Friday, October 14, 2011

Sexual Reproductive Health :: It's not your own business

My mother always told me to mind my own business.

Everytime I'm babbling around about this world could be a better if only people would do their task responsibly, she stopped me to talk further. For her, we could only done our part and let the rest do their own business.

But I can't !

I am a medical doctor, and what I always do is actually taking care others business.
I do care about other people's health, also about their financial insecurity, sometimes about their sex life's too.

It is so ridiculous everytime I heard people being so individualized and not really care about other people business.
Cause we know that we actually care!
And that's why we LOVE gossips so much.
Just look at the television where they talked about nonsense, these celebrities doing this and that (And oh how public adore them, for their shallow attitudes).

They (the celebrities) don't even care if you're injured and couldn't afford your hospital bills, but still it's so commercialized (and uneducated) that we're people thought it's normal for daily consumption.

I really think, if Indonesia people really like to mind other people business, they should do it in the right way.

There are so many rooms for help people, and yet we know that we're Indonesian good about it.

Remember Prita case?

Her case was so famous because it moved hundred thousands people to actually help her by donating small moneys.

It is in our blood. We're moved by social injustice. We could not see others people suffer.

So why we could not do it in a better way?

Talking about sex life. Hmmm... Yeah, it's always an interesting topic.

But why am I bring up this topic is because Indonesia, with 237 million of population, we're facing a problem of overpopulated country.

It's not as bad as India or China. But I'm sure we're getting there.
It's just a matter of time.

So why not propose something to stop this exploding number of citizens?

I would propose 3 things:
(a lesson learned from my scientific writing, only 3 points max.)

1. Family planning access for all reproductive ages people (women or men, married or not)
2. Sexual reproductive health information for all (esp teenagers, youth, adolescents, even kids).
3. Female education
[ Not necessarily in order, but those things are very essential ]

I was actually about to mention 'access to safe abortion' (if needed).
But I recognize this topic could be highly sensitive and leading to many discussions/debates, also touching religion/ belief perspective.
So I will set aside this topic after top 3 priorities that I've mentioned.

The first 2 priorities seem obvious and make sense to point out.
Therefore, I would start with my last point : Female education.

Why is it so important in sexual reproductive health program.

Because I believe the core of the problem in my developing countries (with overpopulated problem) is somehow interrelated with the (inequality) woman's position in society.

I will show this correlation with simple manner:

Uneducated female -> early marriage, lower wages in employment sector, low bargain power in intimate relationship, lower position in society -> (limited?) access to health service -> worse health outcome (for herself and her children).

Maybe not as simple as that.
In above calculation, there's always assumptions (and theories) applied e.g.
uneducated female less to have access to health service because she doesn't know how to find it (not informed) or doesn't know that she actually need the service (health seek behavior).

Anyway, I'm not the expert of such theories as well.
May the social scientists explain such behaviour.

What I'm concern is, how serious the government (yes they should) and also other sector (including religious sector) put effort to female education, if not gender equality in this country.

Why female?

Because I am woman and I know how care we (women) toward our family (esp children).
I believe if a woman well-raised, she could also able to raise a healthy child (or children) and taking care her family well. And hopefully the final outcome is a healthy nation.

Women are more likely to sacrifice for the sake of their kids and family.
We all know the story about women who struggle of her financial crises so that her children could have better life. And women would invest more on her child's need (men, even if he has kid, would spend more on gadget or his own pleasure!).

It is so common sense, right?

Another example is street kids. I've seen many of them without their parents in the street.
Some are altogether with the mother asking small money in the street.

Mothers are always to blame in this case. We're gonna say (in our heart, or loudly), 'How come the mother dare to do this to their children?'

Maybe they do dare for the money (it is a strong motivation though, as strong as many corruptors steal money from the government),
maybe it's the only way they know how to get money.

Female education though is not a simple remedy for gender inequality.

There's another aspect e.g. male education (likewise we educate female, our society indeed need smarter men, too. Just look at our public figures these days and we're realized they could be as ignorant as uneducated people as well).

In my area of intervention, if we educate the women about HIV and contraceptives- we should not forget to inform the couple (likely men) as well. Otherwise, the men would think it's ONLY WOMEN responsibility to take charge of family planning program, while it should be BOTH.

Also religious sector, could influence the acceptance of contraceptive options (or basically many aspect besides contraceptive).
It is a country with biggest number of moslem population anyway ...

And oh, also talking about abortion.

Yes, I do believe God and I do worship Him, and I believe there is heaven and hell.

But it doesn't make me against abortion, because I believe safe abortion could be an option sometimes.
I could not imagine the woman who got raped and have no access to safe abortion had to carrying fetus for 9 months unwillingly in her womb!

pregnant belly
And if we're pretty good at access to family planning to those who need it, we're actually don't have to face abortion issue at all.

Now, remember Ariel case ?
Ariel is a famous lead vocalist from famous (cheesy) boyband from my hometown.

And he got prosecuted for having sex in his own place, because somebody publicized his videotape (?!???)

It is really confusing case. It's his own (sex) business, he's not even stealing government money like corruptors !

I'm not on his side at all. (I'm not taking side in this case).
I'm just upset how people could care wrongly about this sexual case, while they should more care rightly about other issue.

So my conclusion is, if we're so care about other people's business especially sex life, why not doing it in a right way?
Why not transparently educated our people about sexual and reproductive health facts-
instead of tell them what to do.

I believe when people well-informed enough, s/he could weighed decision what's best for her/him. It's time to take our responsible to our body !

Thursday, October 13, 2011

Why Public Health :: Matter of Life

Why Public Health ? Why International Health ?

That question appeared in my mind. And also in minds of others people; friends, colleagues, families, who has questioned my decision. Why am I taking interest of this subject and even pursued my master on this subject.

I would say: Because it's really important (especially in developing country, where I came from).

It's a simple answer, yet defines so many things that we're (Indonesia) lack of.

We have (currently) huge problems in mass transportation, infrastructure, community health, waste managements and sanitation, human capacity, emergency/ disaster preparedness, development problems... Just name it and you could find it here, in Indonesia, the biggest archipelago with 237 millions of population.

homeless, Braga corner
It does really sound fantastic to have such big number for population. It also describe our problem to organize the system (politic, economy, health) that would fit enormous number of citizens, spreading in more than thousands islands, with different needs and characteristics.

But I would limited my theme just into Public Health.
The area that I interested the most.

Back to my question in the first sentences,
' Why Public Health ? '

When I was doing my governmental duty, post graduated from my medical school (I was so proud that I had finally graduated from a long and suffering yet impressive medical study. I was ready to save people's life and also the whole world). I was located in Sumbawa, an island next to east of Lombok. Why I was there is part of my plan, a bit of accident also coincidence.
I was there only about 9 months. But it was enough for me to decide I could not save the world just by saving people's life one at a time.
It was just TOO frustrated.

Basically what I did, I was saving this patient from one disease but then he would died by something else. He would died because he even couldn't get the money to come into the nearest health facility to get treatment in time. He would died due to lack of nutrition. He would died cause his ignorance that simple medication would actually could cure his symptoms.

Another patient that I treated, would just keep coming back for the same issue.
Malaria is highly prevalent in the area, and just medications to cure the symptoms not really actually treat the environmental cause of Malaria.

In the end, I decided that if I really want to save this people, or this nation (in terms of health issue) I have to do something bigger.
And it has nothing to do with being a clinician.

Somebody has to do something. I want to do my part. It's my calling.

So I took a master program in International Health. It took 3 years (I sent my application 3 times, in 3 consecutive years) to get what I want. My whole 1 year entire program was funded by European Union (I got Erasmus Mundus scholarships) and I studied in 2 different universities in Europe; Royal Tropical Institute, Amsterdam and University of Copenhagen, Denmark.
It was a fantastic year and I learned a lot (still a bit from what I should know) about health systems, managements, and policies.
And I am sure this is my passion, this is what I would like to do further in my career path.

Before I got enrolled in my master program, I also had a chance to work as a researcher in the field of HIV. Most of the time I was doing social studies that related to people living with HIV.

Doing this as clinician, (if it's not one's calling) it's even more frustrated.

If only we're clinicians could treat all the symptomatic people with HIV, it still will not eliminate the problem (because far more people with asymptomatic actually need intervention as well).

Most of the time, these people not even aware that they actually AT RISK.
Or those who already aware that they at risk are AFRAID of SEEK further treatment (sex workers and transgenders are highly stigmatized, they hardly seek treatment if they get sexually transmitted infections. Self treatment are pretty common for them).
Or those who already reached the health care facilities, sometimes get DISCOURAGED by the unfriendly approach of health care workers.

This is a chronic disease (and also infectious disease). And it has so many social aspect apart from merely the clinical aspect. It touches issue of gender relation, sexual behaviour, addiction, adherence, stigma and discrimination & so forth.

It's a very interesting subject (for researcher) but also complex and confusing in its intervention.

And it was not easy because it cannot be intervene by only clinical intervention.

You have to talk with religious leaders, political officers, sex workers and their pimps (also the owner of pubs/ karaoke bars), local governments (of course) to really target the cause of social problem of HIV.

As you can see, public health could be indeed a very important and essential aspect in Indonesia- by giving example of HIV epidemic (my interest).

There's also a whole aspect of public health need to target.

Just take a stroll in the streets of Bandung- my hometown- and see how many street kids on the red light asking for small money.

Does it bother you people?

I guess we all know about this fact, yet don't know what to do.
(Or don't care about it anyway).
It was so hopeless and we BLAME to the government how come they let this happen.

Of course we should blame someone when something wrong happen.
But it doesn't solve the problem.

This street kids represents (common) social issues in Indonesia: lack of social insurance, huge social inequality (riches get everything, poor left with nothing), public ignorance etc.

I was so annoyed by this fact!

And I felt it long before I got the chance to study to Europe to see how this wealthier nations managed their health systems and managements.

I would like to do the same for my country! Because this is my country (many expats or international donors would help Indonesia, but few of Indonesian themselves feel the same calling).

I know I could do it in so many ways.

For now, I am writing it down as a promise to myself.

Saturday, September 24, 2011

my learning experience (in PH)

Taken from my other blog

” Abis master ngapain ? Bakal praktek lagi ? “

Itu dia pertanyaan orang-orang yang pengen tau gimana kelanjutannya setelah saya menyelesaikan program master selama 1 tahun.

Dengan latar belakang pendidikan dokter, tentu aja saya bisa kembali lagi ke negara asal (Indonesia) dan kembali praktek atau melanjutkan spesialisasi.

Tapi untuk saya, buat apa?
Kalau memang ingin terjun di bidang klinis, gak akan kemaren ‘ikut-ikutan’ sekolah master. Keukeuh lagi apply bidang yang paling banyak permasalahannya di Indonesia, yaitu health systems, management and policies = sistem, manajemen dan kebijakan kesehatan.

Menurut pendapat saya, sudah banyak dokter umum ataupun spesialis yang bertebaran di Indonesia. Istilah Sunda-nya mah ‘pabalatak‘.

Sayangnya proporsi tenaga kesehatan ini tidak merata, kebanyakan dokter dan tenaga kesehatan tentu aja lebih suka berdiam di kota-kota besar daripada di pedalaman atau kampung-kampung.

Kenapa? Jawabannya mudah. Karena dimana ada duit, disitu ada prakter dokter.

Mungkin itu jawaban yang terlalu vulgar.

Tapi biarlah, kan ini blog punya saya sendiri :-)

Okeh, penjelasannya adalah : Karena sistem pembiayaan kesehatan di Indonesia didominasi oleh sistem out-of-pocket.

Dalam sistem out-of-pocket (OOP) ini artinya biaya yang keluar untuk berobat kalo ke dokter, ditanggung oleh pasiennya sendiri.
Dampaknya sudah jelas, mereka yang punya duit akan cenderung bisa memilih dokter sendiri, memilih mau berobat dimana (ke Puskesmas, praktek dokter pribadi, atau langsung ke Rumah Sakit), juga bisa menentukan mau beli obat yang mahal atau menentukan mau periksa laboratorium dkk.

Pada intinya, kalo punya duit (dalam sistem OOP) artinya kita bisa mendapat pelayanan apapun.

Sebaliknya, kalau tidak punya uang?
Mereka yang tidak punya uang, atau yang penghasilannya terbatas (bahasa halusnya) harus memilih jalur alternatif. Yaitu berobat ke tempat yang lebih murah (biasanya dipilih Puskesmas), berobat ke dukun dulu (karena ke dokter mahal), atau mencoba mengobati sendiri. Inilah juga sebabnya kenapa banyak orang miskin suka telat berobat ke dokter (dan kalau sudah nyampe dokter biasanya kena marah lagi: ‘Pak, koq sakitnya nunggu parah gini baru ke dokter…’)

Itulah dia yang terjadi di banyak tempat di Indonesia.

Itulah juga sebabnya kenapa walaupun banyak dokter dan tenaga kesehatan di Indonesia tambah banyak, tapi tidak mencerminkan bahwa rakyatnya akan semakin sehat.

Karena banyak tenaga kesehatan tidak menjamin rakyatnya sehat jika,


juga MANAJEMEN kesehatannya tidak berubah,
ditunjang oleh KEBIJAKAN kesehatan yang menopang kedua perubahan tersebut.

Mungkin untuk sebagian orang ini teori yang terlalu sulit untuk dimengerti.

Tapi, teruslah membaca, akan saya coba jelaskan konsep ini pada Anda.

Pertama-tama, kita ambil sistem kesehatan di negara maju.

Siapa yang disebut negara maju? Bukan hanya negara yang pendapatan perkapitanya besar, tapi juga negara yang indikator kesehatannya bagus.

Artinya umur harapan hidupnya tinggi, juga angka kematian ibu dan anak yang rendah. Ini semua mencerminkan bahwa negara itu makmur, sehingga kelompok populasi rentan (orangtua, wanita, anak-anak) bisa menikmati pertumbuhan ekonomi negaranya.

Saya ambil contoh dua negara dimana saya pernah merasakan tinggal dan juga nyicip sistem kesehatannya, yaitu Belanda dan Denmark.

Di kedua negara ini, karena sistem politiknya cenderung ke arah sosialis maka sistem kesehatan yang digunakan juga didominasi oleh Social Health Insurance atau asuransi kesehatan sosial.

Pada sistem ini, semua orang yang sudah mempunyai penghasilan (kelompok usia produktif) diwajibkan membayar premi asuransi kesehatan. Biasanya langsung dipotong dari pendapatan. Buat mereka, haram hukumnya gak punya asuransi kesehatan. Karena, biaya ke dokter di negara maju ini sangat mahal.
Jadi, semua orang diwajibkan untuk punya asuransi kesehatan.

Apakah ada orang-orang yang dibebaskan dari premi? Tentu saja ada.
Kelompok veteran (pensiunan), anak-anak, orang yang gak punya kerja, orang yang tidak mampu dst, dibebaskan dari premi tapi masih dijamin oleh asuransi kesehatan.

Prinsip dari Social Health Insurance ini adalah: ‘Mereka yang mampu bayar (kelompok usia produktif), menanggung beban kesehatan mereka yang tidak mampu bayar.’

Secara logika, ini adalah sistem kesehatan yang adil. Ya kan?

Bagaimana kesan saya selagi jadi pasien di negara tersebut?
Untungnya, selama di Belanda (3 bulan lebih) saya jarang sakit. Atau paling sakit ringan yang gak perlu ke dokter.

Tapi waktu di Denmark, pernah saya lumayan sakit (sakit koq bisa lumayan) sehingga merasa perlu ke dokter.

Caranya: di Denmark semua orang punya kartu tanda pengenal (semacam KTP) yang bisa dipakai untuk kartu berobat ke dokter. Kartu ini multifungsi, juga bisa dipake untuk buka tabungan di bank, atau pinjam buku ke perpustakaan, atau buka nomor kartu SIM telefon. Jadi nomor identitas yang ada di kartu ini identik dengan nama kita sendiri. Pada saat kita nelefon dokter untuk bikin janji – nomor identitas inilah yang harus disebutkan.
Owhya, dokter yang bisa mengobati juga hanya dokter tertentu yang tinggalnya dalam wilayah tempat tinggal kita. Dan harus didaftar sebelumnya. Jadi seperti dokter keluarga ASKES lah kurang lebih.

Selanjutnya, saya tinggal datang ke tempat praktek dokter tsb (dekat rumah, jalan kaki hanya 7 menit) sesuai dengan waktu yang telah ditentukan. Lalu menyebutkan nama saya dan nomor identitas. Juga menyertakan kartu saya tentunya. Nunggu sekitar 10 menit karena masih ada 1 pasien anak. Gak berapa lama dipanggil oleh dokternya.

Asik juga karena selain tempat praktek deket dan gak usah tunggu lama, dokternya tertarik untuk ngobrol-ngobrol. Juga dia menyarankan pemeriksaan penunjang dan tes darah. Dibuat lembar referal untuk tes darah ke laboratorium.

Semua konsultasi dan pemeriksaan penunjang tersebut GRATIS, alias gak bayar.
Kenapa bisa, karena sistem kesehatan sosialis itulah. Dipotongnya tentu dari pajak.

Pajaknya juga gak tanggung-tanggung. Sistem pajak yang dianut adalah Progresif (sama seperti di Indonesia, hanya di Denmark pengelolaannya jelas dan tanpa korupsi :-)
Tapi tentu aja walaupun pajak yang dipotong bisa sebesar 40% dari pendapatan, tapi penduduk Denmark dan Belanda lebih bisa merasakan ‘hasil’ dari pajak daripada di Indonesia. Seengga-engga, saya pendatang sementara, sudah bisa merasakan hasil pajak mereka, yaitu fasilitas dan layanan publik yang nyaman termasuk layanan kesehatan.

Itulah sekilas yang saya pelajari saat menempuh program master, dalam bidang international health (yang juga termasuk bidang public health).

Dan sampai saat ini saya yakin, Indonesia sebenernya gak (cuman) butuh lebih banyak dokter atau tenaga kesehatan saja, tapi juga praktisi di bidang ilmu kesehatan masyarakat.
Lihat saja di sekeliling kita, masih banyak pekerjaan rumah yang bisa ditangani pakar bidang ilmu kesehatan masyarakat/ public health : menangani sampah/ waste management, promosi gaya hidup sehat (kampanye anti rokok, pola makan sehat, anti junk food), penyediaan trotoar di jalan (supaya orang yang jalan gak ketabrak motor/ mobil!).
Bisa dibilang itu semua bukan pekerjaan yang sepele, bahkan kalau liat kondisi Indonesia sekarang, ini adalah sebuah tantangan bagi praktisi ilmu kesehatan masyarakat.

Buat saya, pekerjaan itu menarik kalau ada tantangannya. Dan itulah sebabnya public health sebenarnya ilmu yang sangat menarik dan applicable!
Juga saya harapkan akan lebih banyak orang (baik dengan latar belakang medis atau bukan) yang lebih mendalami bidang ini.

Seengga-engganya kalau Indonesia mau semakin maju dan sehat, harus lebih banyak praktisi di bidang ini. Bukan cuman dokter doang yang dibutuhkan.
Lagian, dokter juga manusia . . .