Are Indonesian physicians ready for ASEAN Economic community?

Are Indonesian physicians ready for ASEAN Economic community? Tommy Dharmawan ;   A physician in Jakarta

JAKATA POST, 06 Desember 2014

                                                                                                                       

Next year, a few weeks from now, Indonesia will face the realization of Asian Economic Community (AEC) policy. More and more professionals, including foreign doctors, will come to Indonesia and have practices here. The AEC will remove substantially all boundaries on trade so that ASEAN will become a region with liberated movement of services, investment and skilled labor, including in the healthcare sector. Before the AEC policy many Indonesians went to other countries to seek better healthcare services. According to the Health Ministry, in 2014 more than 600,000 Indonesians went abroad to seek medical assistance, especially to Singapore and Malaysia. Indonesian patients have contributed more than US$600 million to those countries every year since 2003. Next year, many foreign physicians are expected to open practices in Indonesia. Many physicians here are still skeptical and defensive toward this policy. The pessimists state they will lose their patients, assuming Indonesians trust foreign doctors more. This would be because other countries’ medical professionals provide better quality aid, hospitality and professionalism than that perceived in Indonesian medical services. Moreover, Indonesian doctors still think that their position is higher than that of their patients, so they do not care about their patients’ needs or privacy; this problem affects communications between doctors and their patients. Healthcare specialists are like any other professionals; this job needs the trust of its clients. Indonesian doctors should change their attitudes so clients will trust them. Lack of time to communicate with the patient and practicing in many places are two reasons why hospitality and professionalism of Indonesian doctors has decreased. Many of our physicians practice late into the night with many patients and at several places. To prevent Indonesian doctors from practicing in multiple places, government and the private sector should raise their pay. Optimists say, to the contrary, that Indonesian customers are still quite confident in the reputations of Indonesian doctors. Despite some reports about malpractice, Indonesian doctors have the advantage of knowing the local language and are very familiar with tropical diseases that affect most Indonesians. To practice here legally foreign physicians still need to pass examinations held by the Indonesian Medical Council, including one on the Indonesian language. The main reason why the test for foreign physicians is quite difficult is ultimately to protect Indonesian customers. How can a doctor treat the patient if the doctor does not understand the patient’s language? If we correctly interview a patient about the symptoms and history of an illness this would contribute to around 80 percent of an accurate diagnosis. The last reason is related to the implementation of the universal health coverage, , which many aspire to. If it still involves cooperates with only Indonesian doctors, many Indonesians will still choose Indonesian physicians. Local physicians would only have themselves to blame if customers shift to foreign physicians. Cooperation with ASEAN countries is a must in the AEC era. With cooperation, Indonesia can organize the facilitation of medical professionals’ mobility within ASEAN, enhance exchange of information and expertise on standards and qualifications, promote adoption of best practices for professional medical services and provide opportunities for building capacity and training medical practitioners. In 2008 Indonesia implemented a new medical practice law. Our country already has a council known as the Indonesian Medical Council that regulates, monitors and maintains the quality of physicians. In the AEC era, the task will be also to monitor foreign physicians. From experiences in Europe, a national medical council must work hard. In the European Union, for instance, a physician punished and fired from his profession in one country could still practice in another country. Now Europe wants to install a Europe-wide alert mechanism to prevent such occurrences. The Indonesian Medical Council should have cooperation with all schools of medicine in Indonesia and impose on them worldwide standards of medical education. Lack of communication and empathy are among the complaints of many patients in Indonesia. So, those skills should be enhanced in the Indonesian medical school curriculum. Last week in a discussion at the Faculty of Medicine at the University of Indonesia, Akmal Taher, the directorate general at the Health Ministry, stated Indonesia is not worried about the AEC policy to liberalize the movement of foreign doctors to our country. He said the goal of this policy is to make Indonesians get the best medical service available. Thus, local physicians would only have themselves to blame if customers shift to foreign physicians. They should be angry at themselves over why their level of competency and skills lag behind foreign doctors. The AEC is a reality and foreign doctors will work in Indonesia soon. So it is high time for Indonesian doctors to change their attitudes and improve their competence to make more people trust their quality service. This is a challenge that must be answered to prevent the dignity of Indonesian doctors from shattering into pieces. ●

Stengthening surveillance key to keeping Ebola from Indonesia

Stengthening surveillance key to keeping Ebola from Indonesia Tommy Dharmawan  ;   A medical doctor who lives in Jakarta

JAKARTA POST, 23 Agustus 2014

                                                

Ebola is still a threat to Indonesia despite the location of the current outbreak being in west Africa. Unlike swine flu (H1N1) and the severe acute respiratory syndrome (SARS) epidemics that directly affected Indonesia or the latest MERS (Middle East Respiratory Syndrome) CoVirus outbreak, which it is feared may affect many Indonesians on pilgrimage to Saudi Arabia, Ebola has yet to affect Indonesians and only a few Indonesians visit west Africa. Nevertheless preventive measures are still urgently required to prevent Ebola entering Indonesia – the virus has reportedly reached nearby Vietnam. The World Health Organization (WHO) has stated that more than 1,000 people have died in the Ebola outbreak in west Africa. The Ebola virus is spread to people by contact with the skin or bodily fluids, such as sweat, saliva and blood, of a patient afflicted with Ebola. The first symptoms will be similar to flu but later can directly affect other human organs. There is still no vaccine and no clinically proven treatment. The WHO has declared the outbreak “a public health emergency of international concern”. In human history viruses like the flu have caused global pandemics. In 1918 the flu infected 500 million people across the world and killed 50 million of them. Ebola has a higher fatality rate, at 90 percent. This means that of 10 people affected by Ebola, nine are likely to die, so the WHO should work hard to prevent Ebola outbreaks from becoming a worldwide pandemic. Viral diseases, including Ebola, SARS and swine flu, pose a serious threat when the virus transmits from human to human. The WHO recommends countries take preventive measures, such as strengthening surveillance at airports and issuing travel advisories. Therefore, the Ministry of Health should reinforce inspections especially at arrival points such as airports or harbors for people returning from Africa, for instance, or pilgrims returning from the Middle East, where many other pilgrims also come from Africa. If Ebola develops into a major outbreak in the Middle East, the Indonesian government should announce a travel warning as soon as possible, including for haj and umrah, or minor haj, pilgrims. There should be thermal detectors at every airport and seaport to detect flu symptoms in those coming from affected countries. Health officials in those areas should be aware of every person with flu symptoms. If a foreigner is found to be infected with Ebola, he or she should not be allowed to enter Indonesia and immediately deported to their country. If Indonesians come back from affected countries with Ebola symptoms, they should be hospitalized to specific referral hospitals that have quarantine wards for highly contagious infectious diseases. The government should continue to increase awareness of Ebola, including among all health workers. Ebola is transmitted through close contact. There have been cases of virus transmission in healthcare facilities in several West African countries, particularly from patients to healthcare providers. Health Minister Nafsiah Mboi has stated the government has alerted its embassies in affected countries to be cautious when issuing visas. Immigration offices have said that visa issuance will be tightened and potential visitors will be required to go through health checks. This is a good policy to counter and prevent Ebola from entering this country. Given the difficulty of detecting patients with Ebola in the early phases without lab tests, it is important for health workers to apply universal precautions to suspected patients although universal precautions are the standard nowadays in hospitals all across Indonesia. Contact precautions should be added to standard procedures when providing care to patients with flu symptoms coming from countries reporting incidences of Ebola. Of course self-awareness is important. Indonesians returning from African countries or pilgrimages should tell health officials if they are suffering from symptoms of flu. The Health Ministry should advise travelers who develop flu symptoms after their return from African or Middle East countries to minimize their contact with others to prevent virus transmission. Suspected Ebola cases will pose a threat to other people if they do not go to hospital; thus increasing the transmission rate. The cooperation between the Indonesia government and the WHO should be strengthened, to gather information and resources on management and prevention of this illness, as in the case of the viral-sharing agreement in H1N1 cases. At that time, Indonesia wanted a mutual-sharing agreement between developing countries and developed countries regarding the virus and its treatment research. Indonesia as a developing country would have an equal share of information on treatment of H1N1 in the event of a worldwide outbreak. In the case of Ebola, developing countries like Indonesia should have the same access to the virus treatment if necessary. We can achieve that if we have strong cooperation and diplomacy with the WHO. No vaccine or specific treatment is currently available for Ebola. Several drugs that have been produced are limited and only boost the immune system. The WHO has said that the basic prevention of Ebola transmission is finding and isolating Ebola patients, those who have been in contact with the patient and the performance of strict hospital infection control. Strengthening surveillance at harbors and airports is the best way to prevent Ebola from entering Indonesia. ●

JKN : An imperfect milestone Tommy Dharmawan  ;  A Physician in Jakarta

JAKARTA POST,  07 Januari 2014

                                                                                                                       

Santoso was a cardiac patient in a government hospital who routinely used Askes, the previous national health insurance.  In the first week of January he went to the hospital’s cardiac clinic, but to his surprise he only got half of his regular medication.  The hospital staff said this was because the insurance coverage rate for his medication was only enough to pay for half of the medication due to the implementation of the new national health insurance (JKN) on Jan. 1. Since then, he has visited the clinic twice a week to get his full package of medication, but this has also cost him more in transportation expenses. Eka, a cardiologist, is pessimistic about the JKN. He cannot make full prescriptions as most of the medication he usually prescribes is not on the national list of JKN accepted drugs. He said that many patients came by but he only received minimal payment.  The JKN is a part of the national social security system that uses a mandatory social health insurance scheme to fulfill the basic health rights of all citizens. President Susilo Bambang Yudhoyono officially launched the program last Dec. 31 in West Java; problems are abundant and it has been criticized as an immature health program.  To be fair, the JKN has some positives. First, it represents the implementation of human rights stated in our Constitution. No one in Indonesia can be rejected by a medical provider just because he or she is poor. No one in this country can become poor because of high medical costs.  The entire population should be covered by the program by 2019. In the first stage, according to Coordinating People’s Welfare Minister Agung Laksono, around 121 million people will automatically be registered, namely civil servants, military and police personnel, workers covered by the Jamsostek health insurance program and participants of the former government-funded Jamkesmas social protection program.  The government also said that it would allocate Rp 19.3 trillion (US$1.6 billion) to cover the premiums of those considered to be in the “impoverished” or “near-impoverished” categories.  Second, the health system will be more efficient. Patients must first go to community health centers or Puskesmas. If necessary, the Puskesmas will refer the patient to the district government hospital and so on.  Patients cannot go directly to the government hospital except in emergency cases. The medical expense system will change from the direct pocket of the patient to the third party, the Social Security Agency or BPJS Kesehatan. The other positive thing is that we will get accountability reports from hospital managements. Hospitals must therefore make on-time and accurate reports to BPJS Kesehatan, or they will not be reimbursed. Hospital staff are forced to become efficient and adhere to standard operational procedures in patient management. Easy access is another positive aspect. Agung said that about 1,700 out of 2,300 hospitals nationwide had signed agreements with the government to provide medical services for the program’s participants.  Indonesians not covered by this program yet can access services by filling the member forms online, with ease of use. The program will not use a reimbursement system. Participants only need to show their BPJS cards at hospitals.  The implementation of the JKN will also save trillions of rupiah. Sulastomo, a health economic expert, said the government had lost the opportunity to mobilize up to Rp 278 trillion ($23 billion) for welfare because of the seven-year delay. So, the longer we delay, the more Indonesia loses. Of course, there are some drawbacks. From the patient’s perspective, this program may not fulfill their medication needs, requiring them to pay more to get their full prescriptions, thereby involving more costs.  This makes the aim of the JKN questionable as medical providers also do not receive sufficient payment for services rendered because medication prices are far below the costs determined under the JKN.  The other drawback is that the national health budget accounts for only 2.2 percent of the total national budget and the budget allocation for the JKN is only Rp 19 trillion, not enough to cover all of the JKN’s expenses. It must be adjusted to the level mandated in the 2009 Health Law, which is 5 percent, or even up to 15 percent as per WHO standards.  The monthly contributions in the JKN is also very low. The contribution for informal workers is Rp 25,500; for third-class medical facilities Rp 42,500 (second class) and Rp 59,500 (first class).  The low budget from the government for the JKN will force the BPJS to cut expenses, eventually reducing reimbursements to hospitals and leading to low quality services.  The other drawback is late government campaigning of the program. Most patients and medical providers are still in the dark on details.  Lastly, this program has been implemented only a few months before this year’s elections, leaving the impression that the President is in a big hurry to stamp his legacy before stepping down.  We still need some time to wait for the full implementation of the JKN, but ready or not, the JKN has already started. We cannot stop the brilliant and optimistic idea of the JKN, to ensure the health rights of all citizens. We only can improve its implementation. ●

Jakarta health card pits doctors against poor patients

Jakarta health card pits doctors against poor patients Tommy Dharmawan  ;   A Medical Doctor

JAKARTA POST, 07 April 2013

“Doctors should not steal money from poor patients,” said Jakarta Deputy Governor Basuki “Ahok” Tjahaja Purnama when responding to public complaints about health services last month. For most doctors, the statement hurt them as it was only based on assumptions.  Ahok did not seem to realize that since the inception of the Jamkesmas health insurance program, the government has paid medical bills for the poor, including doctor’s fees. Such a statement is dangerous as it comes from a public leader and will sow distrust of hospitals and doctors. Since Governor Joko “Jokowi” Widodo and Ahok launched the Jakarta Health Card (KJS) program, hospitals and doctors have fallen victim to unbalanced media reports. The case of a child who died after 10 overcrowded hospitals denied him access due to lack of medical facilities is just one example. Following the launch of the KJS, Jakartans have flooded government hospitals. The problem is that the Jakarta administration initiated the program without knowing the capacity of the hospitals. So how come the hospitals and doctors were blamed for this? Jakartans should blame Jokowi and Ahok for not carefully preparing the program in detail. The system for the populist program is basically not ready yet. Often people simply regard hospitals as the assets of doctors, so if a hospital commits a mistake doctors are held responsible. In fact, in many hospitals the management is run or owned by persons without medical backgrounds. Another flaw of the KJS program is the Jakarta administration’s demand that doctors serving in public hospitals and community health centers work professionally. The administration disregards the fact that the doctors have to see 150 patients over eight working hours, which means that each patient only receives an average four minutes’ consultation with the doctor. How pathetic is this? Doctors must grill their patients about symptoms, examine them and write up laboratory examinations and prescriptions in only four minutes. The process normally takes 10-15 minutes to complete. Governor Jokowi has stated that this situation will only last a couple of months and that the number of patients attending healthcare establishment will decline in the future. Was that statement accurate and based on evidence or merely assumptions?  Another mistake concerns doctors’ salaries. Jokowi and Ahok want doctors to work professionally but they do not think about the doctors’ salaries. Jakarta’s leaders should know that most civil service doctors in Jakarta earn only Rp 1.9 million (US$195) in basic salary per month, which is less than minimum wage and even Transjakarta bus drivers who receive Rp 7 million.  This fact should straighten out public misperceptions that all doctors are rich. Many young doctors who were angered by the way the Jakarta administration dealt with healthcare shared on social media their intention to hold a demonstration.  First and foremost, if Jokowi and Ahok wish to provide the best healthcare for all, they should stop making statements based on assumptions. They should admit that the KJS has many drawbacks and was not fully prepared. Therefore, they should revise the scheme.  The administration needs to boost primary healthcare and fix the referral system, so that Jakartans will go to primary healthcare providers first if they fall sick. They will be referred to hospital if doctors at the primary healthcare centers cannot handle their cases. As a result, patients will be distributed according to the level of their ailments and hospitals will no longer be overwhelmed. The Jakarta administration cannot rely solely on the KJS program. It should promote preventive and family doctor programs as the basis of healthcare. A free-of-charge health service like the KJS will prompt people to make health their last priority. They will think it is okay to fall sick because the government will cover the medical fees anyway. They will not feel guilty if they smoke or skip exercise.  Preventive programs would make people feel that health is their top priority, therefore, fewer people will get sick and the health budget would automatically be reduced. The government should force people to live a healthy life, for example by excluding smokers from the KJS scheme. Preventive measures also require sanctions. A tuberculosis patient who does not consume the medicine appropriately for six months should face fines or perhaps jail because his or her ignorance may endanger others and society. Lastly, despite the advantages of the KJS, there are still many loopholes that need improvement. Jokowi and Ahok cannot just stop at blaming doctors and hospitals, but rather rearrange the scheme so that it benefits all stakeholders in the health sector. ●

The need to improve Jakarta’s healthcare system

The need to improve Jakarta’s healthcare system Tommy Dharmawan and Tiara Bunga Mayang Permata ;   Tommy Dharmawan is a physician; Tiara Bunga Mayang Permata is a graduate of the School of Hospital Administration, University of Indonesia

JAKARTA POST, 02 Maret 2013

Dera, a premature baby, was born without an oesophagus, the first part of the human digestive system. Dera needed special treatment in the Neonatal Intensive Care Unit (NICU). But, her parents could not find her a place because all 10 NICU hospitals in Jakarta were full at that time. Unfortunately, Dera died before she received proper treatment. The Jakarta Health Agency clarified that it was true that all NICU facilities in the 10 hospitals were really full and that none of them refused Dera due to financial reasons. The agency’s clarification was a response to some media reports that public hospitals in Jakarta refused Dera as her parents only had a Jakarta Health Card (KJS) and that hospitals had turned into profit-oriented companies. The deputy governor of Jakarta, Basuki Tjahaja “Ahok” Purnama, even said that the health service in Jakarta public hospitals had become worse and that he would order an audit on doctors in public hospitals. Ahok’s statement is only a political statement. He should see the service in public hospitals for himself. He should know that since KJS was launched in November last year, more Jakartans have been directly to public hospitals, even with only a minor illness. Most Jakartans do not want to go to the community healthcare center (puskesmas) first before going to hospitals because they think that the quality of service in puskesmas is very bad. So, health officials in public hospitals are serving so many patients that their quality of service will surely be decreasing. His statement about having an audit on doctors in public hospitals was apparently based on unconfirmed reports that doctors in Jakarta steal money from poor people. The deputy governor should know that most state doctors in Jakarta have a basic salary of only Rp1.2 million (US$123.5) per month. It is far below the labor wage of Rp 2.2 million per month. He should remember that to be a doctor, one needs six years of study at a cost of hundreds of millions of rupiah in tuition fees, only to be paid a state doctor’s salary of Rp1.2 million. Thank god there have never been street rallies by doctors in Jakarta. One Jakarta councilor said that there should be a NICU in every puskesmas. It is once again only a political statement. For sure, she does not know the real facts about NICU. A NICU should have well-trained health officials such as neonatologist doctors and specialist nurses. There are only a few neonatologists right now in Indonesia and they mostly work in Type A public hospitals. To be a neonatologist, a doctor should be a pediatrician first for five years and then take a fellowship in neonatology for almost two years. It is not that simple. Also, it would be very expensive to build NICU in all 341 puskesmas across Jakarta. Jakartans should know that it is easy to blame bureaucracy, but it is very hard to implement change. If Governor Joko “Jokowi” Widodo wants a free health care service for every Jakartan, he should change first the referral system. People with only a minor illness should not go directly to public hospitals, but to puskesmas first. Every puskesmas should have an emergency and inpatient ward. So, every minor illness could be handled by puskesmas staff. Also, government should prepare to improve the quality of health officials in puskesmas, as well as their quantity. Public hospitals should reject non-emergency patients who do not have a referral card from puskesmas. There should be an online system set up by the Jakarta health agency that will connect puskesmas with hospitals and among hospitals themselves. So that every puskesmas and hospital in Jakarta could see the availability of facilities in the hospital that they want to refer the patient to. There are also tales of hospitals that are reluctant to provide full healthcare services to the poor. Many KJS-card holders are usually put at the bottom of operating waiting lists. In this case, Indonesia needs more regulations and concrete action to protect the rights of low-income people to healthcare. Assigning more class III wards in hospitals for impoverished people could be one solution. The Health Ministry should increase its ratio of beds for the poor to more than 50 percent. The public view about this issue also needs to be changed. A typical Indonesian wants a quick service, but does not want to wait until the system works. If they think a health service is not very smooth, they immediately assume that the hospital official wants some money. They think that they do not get quick service because they do not have money or only have KJS cards. Jakartans should know that there are a lot of patients in Jakarta public hospitals, whether they use KJS cards or not, thus creating a long queue for service. The media should have a balanced view about this sensitive health issue, while politicians should not make statements without knowing the real facts. If they want to talk about health issues, they should first see the real implementation of health programs in the hospitals. Do not just blame the hospitals and their staff. Meanwhile, for every hospital official, they must give the best service even though there are minor problems outside. Just give the very best of yourself to the patients. For doctors and hospital staff, they should learn how to communicate well, so that patients and their families can understand the diagnosis and proper treatment. Jakarta, despite having hundreds of hospitals, 341 puskesmases and more than 4,000 integrated health service posts (posyandu), is still battling with health issues. We need more improvement in the health system so that every Jakartan will be able to access health care services properly. ●

A new breakthrough on tobacco control

A new breakthrough on tobacco control Tommy Dharmawan ;  A General Physician Who Lives in Jakarta

JAKARTA POST, 26 Januari 2013

Ahmad, 53, is a fisherman with lung cancer. He used to smoke a pack of cigarettes a day from the age of 17. He earned only Rp 100,000 (less than US$10) fishing out on the sea for three days to support his three children, including a baby who has been diagnosed with malnutrition.  Ati, 50, a mother of four, is a passive smoker and also has lung cancer. Her husband smokes half a pack of cigarettes a day, a habit he has maintained since they married many years ago.  They are just two of the many victims of mild tobacco regulations in Indonesia. About 30 percent of the country’s population comprises smokers. Indonesia is the third-largest market in the world for the tobacco industry.  Despite intensifying campaigns promoting the hazards of smoking, the population of male smokers in Indonesia has increased from 30 percent in 1995 to almost 70 percent in 2011. Female smokers increased by five times, from 1 percent to 5 percent during the same period. In addition, there are 100 million passive smokers in this country.  Although a pack of cigarettes is not cheap, according to a survey from the University of Indonesia in 2009, cigarettes are only second to rice in terms of priority spending among poor families. Almost 60 percent of poor families allocate a budget for cigarettes.  On Dec. 24, 2012, President Susilo Bambang Yudhoyono signed Government Regulation No. 109/2012 on tobacco product monitoring. Although it came more than three years late, lagging behind our Southeast Asian neighbors, the regulation has been deemed as a breakthrough in the country’s tobacco control program. The regulation aims to protect Indonesians from the health risks of smoking cigarettes. A politician criticized the regulation, which he said was not pro-job, pro-poor and pro-growth. His argument, however, is completely wrong as through the regulation, the government intends on helping poor families restrict cigarette spending . The National Economy Survey conducted by the Central Statistics Agency (BPS) in 2011 revealed a disturbing fact, which stated that more than 220 billion cigarettes are consumed by people of the lower economic bracket.  The government has been very loose on tobacco control partly because of its addiction to easy-to-get revenue from the cigarette tax excise, which in 2010 reached Rp 55 trillion ($5.72 billion). But, the government should push for tobacco control because, according to the health minister, health expenditures on smoking-associated diseases hit Rp 231 trillion in 2010 alone. The government could use these health expenditures to create jobs or improve infrastructure to stimulate economic growth.  Under the new regulation, warnings on the health-related effects of smoking should comprise 40 percent of cigarette box packaging. Words such as “light” and “mild” can no longer be printed on packaging as they suggest that those products are less harmful. Packs should contain at least 20 cigarettes, thereby increasing its price. Under the regulation, smoking is banned in buildings and public facilities in an aim to further protect people. The regulation also requires cigarette producers to warn children below 18-years-old and pregnant women on the hazards of smoking via packaging. A national survey in 2007 revealed that the number of child smokers had multiplied by six times since 1995. With the new regulation, parents are also not allowed to ask their children to purchase cigarettes on their behalf. Arist Merdeka Sirait from the National Commission for Child Protection said the regulation should also ban children below 18 from selling cigarettes on the street. The regulation prohibits tobacco companies from sponsoring sports and music programs. Nowadays, the tobacco industry has developed a strategy to increase sales by encouraging the younger generation to smoke through the sponsorship of music concerts and sporting events. The industry knows that its sponsorships help create a positive among the young, thereby multiplying its sales.  What the regulation lacks is that it does not stipulate any sanction or fine for people or cigarette companies who fail to heed the regulation, reducing it to a paper tiger. The health minister, therefore, needs to strengthen the regulation with ministerial regulation that can impose penalties on offenders. The Food and Drug Agency and the police should be mandated to monitor the implementation of the regulation. Indonesia needs a strong government to control tobacco distribution due to its adverse impacts on the health of citizens and the well-being of the nation as a whole. The regulation, however, is just a start to a long and winding road to changing Indonesia’s reputation as a haven for smokers and the tobacco industry. ●

Indonesia and tobacco industry

Indonesia and tobacco industry

Tommy Dharmawan ; A Physician

SUMBER :  JAKARTA POST, 31 Mei 2012

This year, the World Health Organization (WHO) is taking momentum from the World No Tobacco Day on 31 May 2012 to remind the world of the tobacco industry’s efforts to weaken the WHO Framework Convention on Tobacco Control (FCTC).

According to the WHO, the tobacco industry today is daring to fight the government’s tobacco-control program. The WHO states that, in its bid to resist the adoption of health warnings on packets of tobacco products, the industry has filed a lawsuit against individual countries under bilateral investment treaties, claiming that the warning intrudes companies’ rights to use their legally-registered brands.

The tobacco industry has aggressively tried to halt the FCTC due to the potentially destructive impact it can have on the industry. The core demand-reduction provisions in the FCTC are price and tax measures, and non-price measures to reduce the demand for tobacco, such as protection from exposure to tobacco smoke; regulation of the contents of tobacco products; regulation of tobacco-product disclosures; packaging and labeling of tobacco products; education, communications, training and public awareness; tobacco advertising, promotion and sponsorship; and demand-reduction measures concerning tobacco addiction and cessation.

Indonesia currently has 57 million smokers, equivalent to 36 percent of its total population. It is a big market for the tobacco industry. Despite the increasing number of campaigns on the hazards of smoking, according to a survey, cigarettes are only second to rice in terms of priority spending among poor families.

Altough it is explicitly stated that smoking can cause a number of diseases, ranging from coronary heart disease to sexual dysfunction, still cigarette consumption increases.

Nowadays, the major concern about smoking in Indonesia is the increasing number of women and child smokers. According to the Health Ministry, only 1-2 percent of all smokers were women in 2007 but during the intervening four years, that number has risen to 6 percent.

Imam Prasodjo, a sociologist from the University of Indonesia (UI), says that if the number of female smokers continues to climb, Indonesia’s future generation will be at risk as many children will be born unhealthy, having been subjected to cigarette smoke while in the womb.

Similarly, the national survey in 2007 revealed that the number of child smokers had multiplied by 6 times since 1995, to 426,000. According to Arist Merdeka Sirait from the independent National Commission for Child Protection, the growth of child smokers in the country has reached an alarming level. We can see how easily a student can buy cigarettes in the mini market near his school or watch a video posted on YouTube of a young Indonesian child who smoked almost one pack of cigarettes a day.

The other cause for concern is the tactics employed by the tobacco industry, which cleverly encourages the younger generation to smoke. There are still a great deal of music concerts and sporting events sponsored by the tobacco industry. The industry knows that its sponsorship will help it build a good image among the young and thereby multiply its sales of cigarettes.

Furthermore, local and foreign musicians do not feel ashamed if their concerts are sponsored by the tobacco industry, despite their responsibility as role models. In Europe, this is a big issue as evinced in the social fine handed down to Real Madrid player Fabio Coentrao who was banned for several games after the media spotted him smoking.

These facts should provide justification to the Indonesian government to do more to fight and control tobacco. But, why does our government remain hesitant to ratify the FCTC and appear submissive in the face of the tobacco industry?

One of the reasons is because of the government’s addiction to easy-to-get revenue from cigarette tax excise, which last year reached Rp 16.5 trillion (US$1.75 billion). But, if the government calculates well, it should push for tobacco-control programs because, according to the Health Ministry, health spending on smoking-associated diseases hit Rp 127.4 trillion in 2004 alone.

Without any bold anti-tobacco regulations, the government will only leave the tobacco industry uncontrolled while, at the same time, children, women and adolescents remain unprotected from smoking hazards.

Concrete action should be taken in the form of regulations; moral sanctions; awareness campaigns; advertising prohibitions; tax increases on packs of cigarettes; raising awareness of the diseases associated with smoking spelled out on cigarette packets; building clinics to help people stop smoking and training more counselors for people who want to quit smoking.

Indonesia can learn from the Uruguay Ministry of Health and its Egyptian counterpart, which respectively require compulsory health warnings to be printed on cigarette packs and have increased tobacco excise duty to 70 percent. The two ministries won Bloomberg awards during the World Conference of Tobacco or Health in 2012.

Indonesia needs a strong government to tackle the tobacco industry’s intervention in the tobacco-control program. To honor World No Tobacco Day, the government should act to control tobacco. ●

Welcoming the age of disease prevention

Welcoming the age of disease prevention

Tommy Dharmawan, A GENERAL PHYSICIAN, WHO LIVES IN JAKARTA

Sumber : JAKARTA POST, 17 Desember 2011

While Indonesia’s socioeconomic status is improving, more people in the country are suffering from degenerative diseases such as cardiovascular problems that are becoming the number one killer.

Most degenerative diseases are related to unhealthy lifestyles such as a sedentary life, smoking, junk food consumption, a high intake of salt and carbohydrates and a lack of exercise.

Those lifestyles are modifiable risk factors for degenerative disease and the government can directly intervene through preventive health actions.

The government should further act by issuing regulations, building infrastructure and promoting healthy lifestyles. The positive impact of these initiatives is not only for society’s sake but also for the government itself as it will curb the curative health budget.

In terms of regulation, Indonesia can emulate Denmark which has introduced a regulation that promotes low consumption of sugar, salt and refined carbohydrates.

Denmark has also just introduced the first fat-food tax in the world by imposing a surcharge on foods that contain more than 2.3 percent saturated fat.

Many similar taxes on fat, soda, calories, sugar, salt, fast foods and processed foods have been proposed in a bid to combat obesity and the many health problems associated with excess weight such as heart disease and diabetes.

Such taxes have managed to reduce tobacco use and change alcohol consumption in many countries.

Why not put a tax on fat, calories or sugar? Such a tax is justified in changing people’s food choices and eating patterns with the funds from the tax used to help cover the huge cost of excess weight to the health budget.

The taxes are expected to raise about 2.2 billion Danish Krone (US$220 million) and reduce consumption of saturated fats by about 10 percent.

Another European country, Hungary, has recently imposed a tax on packaged foods that contain unhealthy concentrations, such as beverages containing more than 20 mg of caffeine per 100 ml. The government, however, is afraid of restricting cigarette consumption due to its contribution to state revenues.

For Indonesia, the good news is the government will raise cigarette excise in 2012. The bad news is the government is reluctant to ban cigarette advertising.

Indonesia can learn from Australia which prohibits the cigarette industry from advertising. The tobacco industry is forced to use plain, logo-free packaging for its products in a bid to make them less attractive to smokers under legislation that will take effect on July 1, 2012.

A government health warning will be prominently displayed on cigarette packs instead, with the brand name relegated to a small, generic font at the bottom. The government also announced it would raise cigarette excise by 25 percent.

Besides the regulation on tax and advertisement restrictions, the regulation on smoking in public areas should be made stricter. The government should also educate society and promote the hazards of smoking especially among the younger generation.

In infrastructure, the government could build a comfortable pedestrian and city park for people to walk, jog and bike in. With good promotion of healthy lifestyles from our leaders, we hope Indonesians can implement healthy lifestyles.

Government can also revitalize the role of Puskesmas (Community Health Centers) as the backbone of health promotion and preventive action. The usage of health cards, immunization, promotion of environmental health and food supplement programs in Puskesmas should be repackaged to suit community needs.

In health prevention, it is not only the government who can play an important part; we also need a big contribution from society. The government should make regulations on the prohibition of food with dangerous coloring and preservatives and restrict licensing of fast food restaurants.

Society, especially schools, can make healthy canteens without junk food and food with coloring and
preservative agents. Schools can also promote exercise and other health promotion through school health units.

Society should also support the no-smoking regulation in public places. The family is another promoter of healthy lifestyles because through the family we can teach non-smoking, how to choose healthy foods and other healthy lifestyles to the children.

There is considerable research to show that it would work. Research has shown that taxing pizza and soft drinks can reduce the amount of calories that are consumed from these foods.

A study of more than 5,000 young adults aged 18-30, found that a 10 percent tax on soda drinks resulted in a 7 percent reduction in calorie intake and 10 percent on pizza produced a 12 percent reduction in calories eaten through pizzas.

The researchers in this study suggested that an 18 percent tax on soda drinks and pizza could cut daily calorie intake by about 60 calories for each person in the population, and could lead to an average weight loss of about 5 lb (2 kg) for every person per year.

Another study tested whether providing calorie information to 178 University students and imposing taxes on the total number of calories bought affected food choices. Increasing prices of high-calorie foods reduces the total calories chosen for lunch meals.

Too many people in Indonesia are not reaching their full health potential because of preventable diseases. The government and the House of Representatives must respond to this need by enacting a preventive health policy.

We believe that the policy will increase the health status of every Indonesian. Preventing is always better than a cure, isn’t it? ●