Medical Logistic For disaster

             In conjunction to the practical session about medical logistic for disaster I am going to have tomorow, I have done some reading on logistic management in the setting of disaster.

             First, lets clarify the key word "logistic". What is logistic? The word "logistics" comes originally from the military procedures for the procurement, maintenance, and transportation of materiel, facilities, and personnel. Generally, logistic refers to "a system whose parts interact smoothly to help reach a goal promptly and effectively thanks to the optimized use of resources". According to Pan American Health Organization-WHO,2001,  "logistics are required to support the organization and implementation of response operations in order to ensure their timeliness and efficiency in emergency relief operations."

           Besides, PAHO-WHO has classified the logistic items into ten classes as below.

1. Medicines;

2. Health supplies/Kits;

3. Water and environmental health;

4. Food;

5. Shelter/Electrical/Construction;

6. Logistics/Administration;

7. Personal needs/Education;

8. Human resources;

9. Agriculture/Livestock;

10. Unclassified. ( * supplies that may have expired, can't be identified due to poor  labelling,etc.,are useless, have spoiled or were packed too dangerously  to be sorted out.)

Basically,in the health sector, the logistic items are categorized into two main groups: - medical logistic and non-medical logistic. Medical logistic comprises of medicines and health supplies/kits. The rest are put under non-medical logistic. Ok, now back to the main topic I am going to talk about here.

            When a disaster strikes, loss of life or injury are events that are unavoidable. To preserve life or health of the disaster victims, it is essential for the drugs and medical equipments to be readily available in sufficient amount . Besides, the authority must optimize the use of all the resources, by storing and distributing the medical supplies in such a way that their quality are assured and that they are used rationally. In short, medical logistic is managed through the process of  selection, procurement, storage, and distribution. In fact, the support from organizations and regulations of work, human resources, information system and financing system is neccesary to run the management in a effective manner.

             Initially, a selection committee which comprises doctors, nurses, pharmacists, and representatives of the ministry of health will work together to develop a list of basic and critical medical supplies to be provided to the affected population. The selection criterias such as health care needs, the characteristics of the patients who require treatment, the availability of supplies and the capacity of the health system are taken into account. For instance, various countries will have their own list of basic drugs and medical products to respond to those health problems happen in the disaster. If no such list present, reference could be made from WHO- standard list of essential drugs and medical supplies for use in emergency situations.



Sample of basic drugs for Emergency Use ( by WHO) 

         Next, the drugs and other medical supplies is procured to ensure that the quantities are enough to meet the health care needs of the affected population. Besides, the quality of supplies is guaranteed and its availabilty at the time disaster happens is established. In order to anticipate or estimate the needs for supplies, a few methods or formula can be used. Below is one of the example of the formula.

             OPTIMAL STOCK = (WS + SO + LT + BS) - S

                                WS  = working stock

                                 SO  = stock out

                                 LT   = lead time

                                 BS  = buffer stock

                                  S   = stock in hand                                     ( DepKesRI, 2007)

           In addition, adequate storage conditions may make sure that health supplies retain their quality and effectiveness by creating the necessary physical, hygienic and infrastructural conditions. Besides, keeping track of stock level and monitoring regularly the expired dates of stored drugs could help in maintaining an optimal use of the available resources. Below is an example of approach for stock controlling.



                                      Fixed Order Quantity Approach: `Q' model

The above approach signifies that the order quantity can be fixed at a level depending on demand(D), value and inventory related costs. A stock level called Re Order Level (ROL) is fixed, which triggers ordering. ROL happens when safety stock/ buffer stock is sufficient to fulfill the demands rate during lead time . This approach order quantity is fixed by calculating Economic Order Quality(Q) and ROL is fixed by calculating lead-time consumption.

             Lastly, in disaster situations, a proper distribution of drugs and other medical supplies is done based on the demand for them and on the existing stock level. To ensure that the medical supplies are delivered at the right time and to the right person, the various organizations receiving supplies must coordinate their efforts, particularly with government agencies responsible for health care, such as the ministry of health. Few measures such as the availability of a reliable transport system to deliver the medical supplies, education to the patients about correct drug use and monitoring shall be carried out, the appropriateness of delivery schedules need to be considered for distribution to be conducted effectively. 

References:

1) Lecture Note by Dr Sulanto Saleh- Danu: Logistic( medical) and Disaster

2) Pan American Health Organization (PAHO), 2001: Humanitarian Supply Management & Logistic in The Health Sector, PAHO-WHO

3) QUICK, J. et al. 1997. Managing Drug Supply, MSH-WHO. Kumarian Press.

                  



Disaster Management in Indonesia

             Indonesia, a vast archipelago of 235 million people, is prone to both natural and human-made disaster. Below are the organizations which take care of disaster management in Indonesia.

             In certain cases, prevention could be carried out to avoid or to minimize the adverse impact of a  disaster.  Mitigation involve structural and non-structural measures undertaken with the aims of decreasing overall risk of a disaster. Structural measures refer to any physical construction, for instance, construction of hazard-resistant or protective infrastructure. Non- structural measures denotes policies, awareness, provision of information, participatory mechanisms and etc. In addition, preparedness which means to anticipate the occurence of disaster, require supports from the organization. For instance, space technology set up by the organization can help in hazard and risk mapping.

            If there is forewarning, certain aspects of the response may take place even before the disaster. Unfortunately, the disaster is well-known for its unpredictability, speed and swiftness. When a disaster strikes, emergency response or acute medical response may play an important role. For example, medical professionals who do preservation of life and health to those injured victims can minimize the death toll in the disaster. If confronted by numerous patients simultaneously in a disaster situation, it is easy to become overwhelmed, even for an experienced disaster worker. Hence, medical personnel are accustomed to apply the concept of triage which involves providing the most help for as many as possible.

            After a disaster, the recovery phase is crucial for the affected community and it could be a long term work to do. During this phase, actions taken aim to restore or improve the living conditions of the stricken community as well as to encourage necessary adjustments to reduce disaster risk. The recovery phase consists of rehabilitation and reconstruction. For instance, rehabilitation may involve scene withdrawal to ensure the operations of public services and community life run effectively. Whereas, reconstruction happens when the the condition of public services and community life is restored, or become even better than before the disaster. This recovery process may take place in the forms of physical, social, and economy.

          Generally,  disaster management refers to "the aggregate of all measures taken to reduce the likelihood of damage that will occur related to hazard(s) and to minimize the damage once an event is occurring or has occurred and to direct recovery from the damage."   In conclusion, the phases of disaster management can be categorized based on the disaster cycle: before, during and after the disaster.

References:

1) Lecture Note:  by Dr Hendro Wartatmo :

     Conceptual Framework of Disaster& Disaster Management

2) UU Republik Indonesia no 24 Tentang Penanggulangan Bencana

3) Disaster Management in Indonesia

Pathophysiology of Disaster

            On Tuesday afternoon, Indonesia has raised the alert level at one of its dozen of volcanoes, Mount Bromo to “beware,” the highest alert level before an eruption. I am lucky enough to have visited Mount Bromo on my first year study here. I still remember that the entire top of the mountain has been blown off and the crater inside constantly belches white sulphurous smoke. The view is really breathtaking. Mount Bromo is 275 km east of Mount Merapi, which in the past month has unleashed a series of powerful eruptions leaving more than 300 people dead. The volcano's initial blast occurred less than 24 hours after a tsunami swept through the remote Mentawai islands, killing at least 428 people.



MOunt Bromo shoots ashes into the sky





MOunt Bromo Behind Me

               Indonesia is situated along the Pacific Ring of Fire that leaves it vulnerable to earthquakes and gives it more active volcanoes than any other country. Not only in Indonesia, a disaster happens somewhere in the world almost daily. In the lecture, conceptual framework of disaster, Dr Hendro Wartatmo said that the word disaster is broadly defined. The UU Republik Indonesia no 24 Tentang Penanggulangan Bencana states that a disaster is an occurence which can be induced by natural, non-natural or manmade forces that negatively affect life and causes loss of life or injury, environmental degradation, property damage or psychological impact to the community.

              At the beginning of the lecture, Dr Hendro showed us a scenario about Mount Merapi eruption. Later, the scenario is split into sentences. We were asked to match some terms of disaster pathophysiology with the sentences. All of the terms were not new to us but it is not easy to match them as they have similar meaning one to another. Below is the pathophysiology of disaster with the terms.

Hazard à Event à Impact à Damage

             A disaster happens starting with the hazards. Hazard is something contains energy or to be accurate, a potentially physical event, phenomenon or human activity which can bring destructive effect to a given area or community. There are natural hazards (geological, biological, etc.) as well as human-induced hazards (environmental degradation and technological hazards). Risks come in between hazard and event. Risk is defined as the probability of harmful consequences, or expected losses resulting from interactions between natural or human-induced hazards & vulnerable conditions.

Conventionally, risk is expressed by the notation:

                                          Risk  = Hazards x Vulnerability.

To describe disaster risk reduction, the concept of capacity which refers to a combination of all the strengths and resources available within a community that can reduce the level of risk or the effects of a disaster is included. Below is the modified notation.

   Risk =     Hazard x Vulnerability              

Capacity

Event comes after hazard or risk. Event is the realization of hazards which is followed by the impact. The term impact indicates the  contact between an event and society. Unavoidably, the impact of an event would lead to damage. For instance, damage may refer to a change of social functions within a community. 

                According to WHO, a disaster happens when “a sudden ecological phenomenon of sufficient magnitude to require external assistance ".  To differentiate between event and disaster, the keyword is that disaster calls for external aids in order to restore the pre-disaster living condition or to return to normal operations of the community while the event needs no external helps. When a disaster strikes, its destructive effects would overwhelm the ability to meet the demand for health care, as The American College of Emergency Physicians (ACEP) has pointed out. For this reason, a proper disaster management which involves pre-disaster planning, organizing, controlling, feedback and corrective action must be carried out.

References:
1) Lecture Note : by Dr Hendro Wartatmo

    Conceptual Framework of Disaster & Disaster Management   

2) UU Republik Indonesia no 24 Tentang Penanggulangan Bencana

Chronic Disease Management in PHC

      It's been a long time since I wrote my last blog. I guess the reason is that I use “I am tired” as an excuse for being lazy and having no drive to study. Lately we all have been very busy with the packed schedule. We finished our class around 5 pm almost every day. Today, after preparing for my week 4 tutorial, I decided to put up a blog post regarding what I have read for the scenario. Dr Jati, as the recent graduated medical doctor in the scenario, has faced some problem in managing a diabetic patient during his first day working at the primary health Care Centre (PHC). The keywords of this scenario would be primary health care, team work, and chronic disease management.

      First of all, primary health care (PHC) defines community-based health services that are usually the first point of contact that patients make with the health services. As we know, the health care workers who work as a team in PHC comprise of multi- professional background. They are general practitioners, nurses, pharmacists, midwives, administrative officers and so on. In terms of professional team, each health care worker is responsible for different tasks. They have the obligations to cooperate with other health care team members in delivering health services. None of them shall do an overlapping job or duplication one to another. Whereas, each of health care team has their own professional standard, own professional culture and own  professional mechanism.

'multi- professional background in Puskesmas'

       There's often blurring of lines among one professional roles and responsibilities working in a team. Task shifting in the health care settings might happen as a response to health workers shortage. For instances, if there are many patients waiting and doctors couldn’t handle them all, experienced nurses would be allowed to prescribe medications. Hence, teamwork, also known as collaborative approach ought to be carried out to tackle the above problem. Effective collaboration involves rational distribution of tasks among health workforce teams. Everyone would understand their specific roles and work for one common goal and orientation. This is just one of the examples where team work would make more efficient use of the available human resources for health.

       In the scenario, the patient suffered from diabetes (an increasingly prevalent chronic disease) come for a visit to the PHC. So, why primary care? A.A Rothman and Edward HW (2003) have suggested a few reasons. First, most patients with chronic disease has less severe condition. Moreover, these patients often need a limited number of widely used and relatively nontoxic medications. Therefore, PHC can readily meet their clinical needs. Third, primary caregivers usually have more general training and clinical experience. This would be an advantage for the patients as most of them have more than one chronic condition. Forth, primary caregivers, especially recent graduates undergo more training in educating patients about behavioural change and self-management support. This is a key to comprehensive chronic disease management.

      Nowadays, more and more patients with chronic disease seek health care in PHC, there must be some system changes which PHC could adapt to support more effective chronic illness care. A Cochrane Collaboration review (2001) concluded that four areas where interventions implemented to improve diabetes performance in PHC have reached a success. First, activities directed at changing health workers’ behaviour. For example, clear guidelines and sufficient expertise would help the doctors making clinical decision. Second, changes to the organization of practice. Strong leadership, appropriate incentives and effective improvement strategies are important to maintain a health care organization. Third, information system is enhanced so that patients’ knowledge, skills in handling chronic illness would be improved. Last but not least, educational and supportive programmes are targeted at the patients to achieve an effective self-management support.

"System changes to improve quality of chronic care management"

References:

1) Rothman A.A. & Wagner E.H. 2003. Chronic Illness Management: What is the Role of 

    Primary Care? Ann. Internal Medicine 2003; 138:256-261

2) Renders C.M. et al. 2001. Interventions to Improve the Management of Diabetes in

    Primary Care, Outpatient, and Community Settings: A Systematic Review. Diabetes

    Care. 2001;24:1821-33.

3)  Eccles,M.P et al. 2009. Improving the Delivery of Care for Patients with DIabetes 

     through Understanding Optimised Teamwork and Organization in Primary Care. BMC

     HSR Implementation Science,2009, 4:22.

What is Managed Care?

           Corresponding to my previous blog post, here I would like to explain why managed care health plans is recommended. First, lets see what people define "managed care". 

" Managed care combines financing and delivery of health care in a single entity with the aim of

improving quality of care while controlling costs."

Bashir mamdani, Meenal Mamdani ( Managed care in the USA: history and structure)

         A reminder here, the problems within health insurance system that I have mentioned in my previous post. First, non-insureds can't afford high expenses on health care. Second,quality of care in public health centers is impaired due to lack of competition or its status as non-profit clinic. From the definition above, we know that managed care aims to reduce the costs of healthcare and to ensure continuing quality of care. Thus, by implementing managed care, it is hoped that the problems would be solved. " Kill two birds with one stone" so goes this adage, seriusly, is it that easy?

               Lets have a look how managed care works. Basically, the concept applied in managed care is to modify doctors' (or other professionals initiating care) actions in giving healthcare. This is to eliminate inappropriate treatments and to ensure a cost-effective healthcare practise provided. Below are the examples of measures which can be carried out to support managed care.

1) Developing networks and seeking preferred providers. Standards in selcting providers are established.
2) Financial incentives to encourage health providers to pratice more efficiently.
3) Establishing clear guildlines to help in making clinical decision.
4) An emphasis on preventive medicine
5) Using utilization review and quality improvement programmes.

          I believe that the above measures are not hard to be understood, except for the last one. What is utilization review? It is actually a retrospective review where treatments or services given that are recorder in medical files, are re-evaluated in comparison with treatment guidelines. Usually, this utilization review is used by the insurance company to determine clinical guidelines for a given condition. 

       So much for the ideal ways of how managed care works. The reality is that there is still some problems existed within this system. For instance, in Indonesia, Askes is one comprehensive social insurance scheme which is conducted based on managed care system. This programme is compulsory for civil servants (PNS, PTT, etc.) either still working or retired , retired military and police officers, veterans, and national patriots and their families to take part by making payment or premium and get a Kartu Askes. 

       Generally, managed care has some disadvantages due to the limited capacities:-

1) patient's access to care and their freedom

2) provider's ability to decide which diagnostic test and treatment to be ordered.

          The patients who pay premium to be covered by Askes will go the healthcare centers insured by Askes. Sometimes, the health facility or health services doesn't meet the patients' expectation. For instance, the bed in hospital is not enough, doctor always come late and so on. Those patients who can afford, may choose to go private healthcare centers. Indirectly, this mean Askes programme has failed. Besides, patients found out that the drugs given are not paid by Askes sometimes. Why this is so? That is probably because some doctors has some kind of cooperations with private pharmaceutical company who agree to accept extra profits- the incentives. Again, the  patients become dissapointed over the insurance programme.

          In the lecture, Pak Gatot Subroto from PT Askes Jogja has said that Askes programme need support from the community, only if Askes make more than 50% of the hospital income, Askes could make some changes in those healthcare center.  I think that it is more efforts should be implemented to cope with the internal problems within the hospital itself first. If patients found those hospitals or puskesmas provide a good quality of health care at minimum cost, they wouldn't have hesitated to get themselves insured by Askes.

References:

1) Lecture note by Pak Gatot Subroto :Managed care 

2) AB Casto, 2006, Principle of Healthcare Reimbursement, American Health Information
     Association
3) ASKES INDONESIA

Problems of Drugs Shortage and its Management in PHC Indonesia

         

            Studies have found out that drugs are comprising 40%-50% of the total hospital revenue. The main problems related to drug management at the health care unit are drugs shortage and expired drugs. Today, I am going to talk about the problems of drugs shortage corresponding to an article that I have read recently.

               According to Fox and his associations (2009), some of the contributing factors to drugs shortage in hospitals and health system are recognized as below:

1) unavailability of raw and bulk materials used in pharmaceutical.

2) manufacturing difficulties and regulatory issues,

3) changes in product formulation or manufacturers

4) manufacturer's production decisions and economic

5) lack of communication and transportation deficiency throughout the supply chain,

6) unexpected increases in demand and shifts in clinical practice

7) natural disaster

 

Process for decision-making in the management of drugs shortages

               In addition, Fox et al. has recommended a systemic process (as shown above) which would solve problems in drugs shortage. It is not hard to digest the diagram above. So, i would just highlight a few methods carried out by Puskesmas Indonesia which could help in eliminating the problems of drugs shortage.           

               A better drug inventory management may play an important role. One of the effort taken by puskesmas in Indonesia is to develop a drug formulary. The drug formulary is a list of drug information. As what was told by Dr. Erna, Puskesmas has essential drug list, generic drugs and brand drugs list. The prescription of common drugs in puskesmas mostly refer to essential drug list, sometimes generic drug and only 10% for brand drugs . As for the essential drug list, Indonesia adopted it from WHO essential medicines & pharmaceutical policies. 

              Besides, Dr. Erna also pointed out that there is approximately 150 types of essential drugs in puskesmas Indonesia. To develop a drug formulary, below is the VEN system that can be found in Puskesmas Indonesia.

1) Vital (V)                 : potentially life-saving

2) Essential (E)         : most common drug prescribed, proven beneficial

3) Non essential (N) : high cost,  for minor self-limited disease

           Another way to cope with the problems of drugs shortage is to manage the drug inventory. To determine a target inventory, Indonesia use ABC (activity based costing) analysis which classify drugs into 3 groups.

A Class  : 10 - 20% of total drugs consumed , 70-80% of spendings on medication

B Class : > 20% of total drugs consumed, 10 - 20% of spendings on medication

C Class : 60 - 80% of total drugs consumed, 5 -25% of spendings on medication

          For instance, drugs categorized into A class will be given the highest attention as they make most profit to the health center, around 70 - 80% of the income contributed by patients' medication bills. Let say we reduce the level of A class  drugs inventory as it only comprises 10 to 20% of total drugs presribed. Doctors could presribe A class drugs  more frequently and in a small amount each time. As a result, an overall inventory cost can be regulated. Since different categories of stock that need different management has been identified, workload for pharmaceutical department in controlling drugs stock level could be reduced as well.

I think that is all for what i want to share today. You can study more on lecture notes. =)

References;

1) Lecture note by Dr. Erna kristin, Drug management and Policy in Primary Health Care

2) Adi Utarini, Gertrud Schmidt-Ehry, and Peter Hill. Hospital Management Training, New ways to improve services in Indonesia, A text book and Guide, 1st edition

3) Fox et al. 2009. ASHP Guidelines on Managing Drug Product Shortages in Hospitals and Health Systems, January 15, 2009

4) http://en.wikipedia.org/wiki/Time_management#abc_analysis

5) http://en.wikipedia.org/wiki/Pareto_principle

6) http://en.wikipedia.org/wiki/ABC_analysis

Insurance- an umbrella during raining days?

               Due to the fact that cost of health care is getting higher and higher, issue has been raised in health imbursement methodology, especially in health insurance policy. In fact, just not long ago, last year, there is one insurance company in my country refused to pay compensation fees to the insureds who passed away from the influenza A virus infection. At the end, the Malaysian government has to stand up and negotiate with the insurance company. The insureds were paid and the problem got settled. However, the reflection of the case above is that the issues with health insurance companies is still there that concerns need to be raised to re-evaluate and improve the current situation.

              Malaysia has developed national health insurance system where the governement will help paying parts of the medical care cost for all of the population. At the same time, people continue buying private insurance. For instance, nowadays, more and more people who can afford, started to purchase medical card. Medical card is like an umbrella during raining days. The question is why Malaysians want to take out money from their own pocket to get a medical card since they can always turn to the government hospital for health care services?

     

"Insurance is like an umbrella during raining days?"

            Like I mentioned earlier, health care cost at private health care centers has been increasing over the years as they are profit-driven centers. This could have caused some patients who are not so rich to go back to public health care services, for example, government hospital. More and more patient go to government hospital, but the total hospital beds and number of doctors employed by the government do not increase at the same time. As a result, patients have to wait longer to see the doctors and medical attention given is lesser. Who would like to wait in pain or in a sick condition? By paying an affordable amount of premium, you are covered by insurance which mean now you can go for a better quality of healthcare, so why not?

           In this case, the population is now divided generally into two groups. First group, who have good insurance, receive a good quality of medical care, cost is no longer a worry. Another group, who have poor insurance or none at all, receive very little. Due to competition, a private health center is more likely to give a better healthcare services. While, in the government hospital, payment to health providers is based on salary system which means medical treatment is not influenced by incentives. This may result in a drop of quality of health care. Hence, for those without insurance who couldn't afford private healthcare cost, they loss assess to a better healthcare services which may produce a desireable disease outcome.

             In addition, those who are under insurance coverage pay a fixed amount of money for premium per month. They may think that it will be a waste if they don't utilize the health benefit. There will be no hesistance in seeing a doctor for treatment as all the medical cost is covered by insurance. If this becomes a trend, it would pose a threat to the health system. The health care sector would become a larger fraction of the economy, more health care spending is thus washed out. Besides, medical resources can be wasted too. As a result, the health care system in one country may become inefficient due to the poor health insurance system. 

            So, what is the soulution for the above problems? Probably, managed care health plan can be considered. Read more about managed care in my next post. =)

References:

1) Lecture note by Prof. Laksono Trisnantoro,Dr. Sigit Riyarto :Provider Payment Mechanism

2) AB Casto, 2006, Principle of Healthcare Reimbursement, American Health Information
     Association