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Lahir di Cirebon, Jawa BaratLahir di Cirebon, Jawa BaratDokter dari UNIVERSITAS INDONESIADokter dari UNIVERSITAS INDONESIAMaster of Public Health: HARVARD-USAMaster of Public Health: HARVARD-USADoctor of Science: JOHNS HOPKINS-USADoctor of Science: JOHNS HOPKINS-USAPost Doctoral in Statistics: UNIV of MICHIGAN-USAPost Doctoral in Statistics: UNIV of MICHIGAN-USAKesibukan sekarang:Kesibukan sekarang:
Indonesian Public Health AssocIndonesian Public Health Assoc,, PresidentPresidentDept of Health Policy & Administration, UI, Dept of Health Policy & Administration, UI, ChairChairNational Team for Poverty Reduction Acceleration, Vice National Team for Poverty Reduction Acceleration, Vice
President Office, President Office, Human Resource SpecialistHuman Resource SpecialistExpert Committee on TB - MoH, Expert Committee on TB - MoH, Health Policy SpecialistHealth Policy SpecialistLocal Capacitation for HIV/AIDS program,Local Capacitation for HIV/AIDS program, ConsultantConsultantCountry Coordination & Facilitation (CCF Indonesia) for Country Coordination & Facilitation (CCF Indonesia) for
HRH pd Kantor Menko Kesra, HRH pd Kantor Menko Kesra, Head of SecretariatHead of SecretariatCtr for Health Administration & Policy Studies, UI,Ctr for Health Administration & Policy Studies, UI,
DirectorDirector
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Kebijakan Kesehatan Kebijakan Kesehatan PreventifPreventif
Peran Strategis IAKMI Di DaerahPeran Strategis IAKMI Di Daerah
Adang [email protected]
Bandar Lampung - 2012
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KEBIJAKAN KESEHATAN adalahKEBIJAKAN KESEHATAN adalah
Peraturan perundangan, dll yang meregulasi dan
disusun atas nama peningkatan derajat kesehatan
masy dan yang melibatkan berbagai kelembagaan
pemerintahan, swasta dan masyarakat madani serta
masy luas itu sendiri (Modif dari Caputo, 2004)
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• Fase PengembanganFase Pengembangan –Kegiatan mulai dr ide kebijakan sampai kebijakan tsb diterapkan
• Fase PenilaianFase Penilaian –Kegiatan evaluasi manfaat kebijakan yang ada, termasuk lessons learned yg
didapat MEMERLUKAN 2 JENIS ANALISIS KEBIJAKAN
• ex anteex ante = Penilaian dilakukan sebelum kebijakan dibuat
• ex postex post = Penilaian dilakukan sesudah kebijakan di implementasi kan
SIKLUS KEBIJAKANSIKLUS KEBIJAKAN11
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MasalahMasalahKesehatanKesehatan
EvaluasiEvaluasiKebijakanKebijakan
ImplementasiImplementasiKebijakanKebijakan
Kebijakan prioritasKebijakan prioritas
Def & UraianDef & UraianMasalahMasalah
Pilihan2 strategi & Pilihan2 strategi & kebijakankebijakan
Pemilahan kebijakanPemilahan kebijakan
SIKLUS KEBIJAKANSIKLUS KEBIJAKAN22
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KONSEPTUALISASIKONSEPTUALISASI_1_1
PREVENTIONPREVENTION: (Last M, 1995)
to promote health, to preserve health, to restore health when it is impaired, and to minimize suffering and distress
Jenisnya Primary Prevention Secondary Prevention Tertiary Prevention Contextual Prevention
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Leavell’s Levels of PreventionLeavell’s Levels of Prevention
Stage of disease Level of prevention Type of response
Pre-disease Primary Prevention Health promotion and Specific protection
Latent Disease Secondary prevention Pre-symptomatic Diagnosis and treatment
Symptomatic Disease Tertiary prevention •Disability limitation for early symptomatic disease
•Rehabilitation for late symptomatic disease
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PRIMARY PREVENTIONPRIMARY PREVENTION Action taken prior to the onset of disease, which removes
the possibility that the disease will ever occur.
It signifies intervention in the pre-pathogenesis phase of a disease or health problem.
Primary prevention may be accomplished by measures of “Health promotion” and “specific protection”
It includes the concept of "positive health", a concept that encourages achievement and maintenance of "an acceptable level of health that will enable every individual to lead a socially and economically productive life".
(WHO, 2008)
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Primary preventionPrimary prevention
Specific protection
Health promotion
Achieved byAchieved by
Health education
Environmental modifications
Nutritional interventionsLife style and behavioral changes
Immunization and seroprophylaxischemoprophylaxisUse of specific nutrients or supplementationsProtection against occupational hazardsSafety of drugs and foodsControl of env hazards, e.g. air pollution
(WHO, 2008)
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SECONDARY PREVENTIONSECONDARY PREVENTION It is defined as “ action which halts the progresshalts the progress of a
disease at its incipient stage and prevents complications.”
The specific interventions are: early diagnosis (e.g. screening tests, and case finding programs….) and adequate treatment.
Secondary prevention attempts to arrest the disease process, restore health by seeking out unrecognized disease and treating it before irreversible pathological changes take place, and reverse communicability of infectious diseases.
It thus protects othersprotects others from in the community from acquiring the infection and thus provide at once secondary prevention for the infected ones and primary prevention for their potential contacts.
(WHO, 2008)
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TERTIARY PREVENTIONTERTIARY PREVENTION It is used when the disease process has advanced
beyond its early stagesbeyond its early stages.
It is defined as “all the measures available to reduce to reduce or limitor limit impairments and disabilities, and to promoteto promote the patients’ adjustment to irremediable conditions.”
Intervention that should be accomplished in the stage of tertiary prevention are disability limitationdisability limitation, and rehabilitationrehabilitation.
(WHO, 2008)
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CONTEXTUAL PREVENTIONCONTEXTUAL PREVENTION Adalah upaya yang sistematik mencegahmencegah
epidemiological risk factors (disease determinants) menjadi tidak terkendali untuk kemudian menuju situasi “sakit”. Umumnya merupakan faktor sosio-ekonomi, budaya dan lingkungan
Literatur menyebutnya sebagai “Primordial “Primordial Prevention”Prevention” Terkesan diskriminatif-non fundamental-non
strategis
Sangat terkait dengan konsep Social Determinant of Health dan Healthy Public Policy
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UNBALANCED DIET SEDENTARY LIFE STYLE
% Lipids
FIBERSvegetablescereal
Phytoestrogensbioactivate molecules
Folate, B6
Homocysteinaemia Thrombosis
OBESITY OBESITY
DIABETES DIABETES
CHDCHDSex hormone
changes
CANCERSCANCERS: breast, : breast, endometriumendometrium
Trans fatty acids
Saturated fats
+ + +
+ +
+
-
-
Antioxidants
+
-
+
+
+
+
Total Fat
n-3 fatty acids -Atherosclerosis
BEYOND HEALTH DETERMINANTS (!)BEYOND HEALTH DETERMINANTS (!)
Modified from: WHO, Global Status Report on NCD, 2010
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Menurunnya:• kualitas hidup• produktivitas•kemampuan adaptasi• tabungan keluarga
•Meningkatnya hutang, ketergantungan
Meningkatnya •faktor resiko personal & lingkungan•Diet tdk seimbang
Menurunnya :• akses pengetahuan & informasi•akses pelayanan
POVERTYPOVERTY
POVERTY SEBAGAI RISK FACTORPOVERTY SEBAGAI RISK FACTOR
NCDNCD
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EMPOWERMENTEMPOWERMENT
KOMPONEN TERPENTING DALAM SEMUA JENJANG PREVENTIF
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KONSEP EMPOWERMENTKONSEP EMPOWERMENT11
Original definition:Original definition:
An intentional and repetitive process in which individuals with insufficient resources acquire resources in their local communities mainly through mutual respect, caring, collective participation, and critical reflections (Zimmerman 2000)
Namun, berlaku juga untuk komunitas Close community (sekolah, organisasi khusus.
dll) Open macro community
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KONSEP EMPOWERMENTKONSEP EMPOWERMENT22
Definisi yang lebih pas:Definisi yang lebih pas: The process in which individuals, organizations, and
the local community as a whole obtain the mastery over the decision-making on one’s own lives (Rappaport 1984)
Mengandung konsep Kemampuan menguatkan “POWER” (Healey, 1998) Memecahkan masalah dengan penguasaan yang
cukup atas informasi, partisipasiinformasi, partisipasi & kapasitas untuk mengintegrasi mengintegrasi dalam berbagai aspek dalam berbagai aspek kehidupan sehari-harikehidupan sehari-hari (Andersen, 2003)
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KONSEP EMPOWERMENTKONSEP EMPOWERMENT33
Definisi Kombinasi:
Kekuatan setiap anggota masy tsb dalam mengembangkan, memanfaatkan dan merubah berbagai sumber daya termasuk sosial budaya, ekonomi dan politik untuk kepentingan dan memecahkan masalah mereka sendiri
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DIMENSI DIMENSI KAPASITAS INFORMASIONALKAPASITAS INFORMASIONAL
DEFINISI:DEFINISI: Proses pemahaman diri dan lingkungannnya
secara dinamik dengan segala luaran yang dihasilkannya
Proses yang perlu diamati oleh POLICY MAKERProses yang perlu diamati oleh POLICY MAKER Perubahan individu, keluarga, kelompok dan masy-
nya dalam pemahaman segala hal secara individual dan/atau kolektif
Proses keputusan kolektif yang dinamis (formation & renewal)
Jenjang analisa kebijakan:Jenjang analisa kebijakan: Individu – komunitas – pemerintahan setempat
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DIMENSI DIMENSI KAPASITAS PARTISIPASIKAPASITAS PARTISIPASI
DEFINISI:DEFINISI: Proses keikutsertaan individu & kelompok dalam
berbagai kegiatan di dalam organisasi/ komunitasnya dan segala luaran yang dihasilkannya
Proses yang perlu diamati oleh POLICY MAKERProses yang perlu diamati oleh POLICY MAKER Perubahan psikologis dan perilaku ndividu dalam
kemampuan kepemimpinan untuk organisasi/ komunitasnya
Jenjang analisa kebijakan:Jenjang analisa kebijakan: Individu – komunitas – pemerintahan setempat
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DIMENSI DIMENSI KAPASITAS SINERGISTIKKAPASITAS SINERGISTIK
DEFINISI:DEFINISI: Proses saling keterkaitan dan kebersamaan yang
menguatkan masing-masing individu dalam berbagai formasi-kebersamaan yang kreatif dan segala luaran yang dihasilkannya
Proses yang perlu diamati oleh POLICY MAKERProses yang perlu diamati oleh POLICY MAKER Peran kelembagaan setiap individu dalam
komunitasnya Proses dan materi keputusan dalam berbagai
kebijakan Jenjang analisa kebijakan:Jenjang analisa kebijakan:
Individu – komunitas – pemerintahan setempat
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Perkiraan Perkiraan Efek Tdk Efek Tdk
MenguntungkanMenguntungkan
Perkiraan Perkiraan Efek Efek
MenguntungkanMenguntungkan
TingkatTingkatPertisipasiPertisipasi
ArtikulasiArtikulasiMasalahMasalah
KesehatanKesehatan
MerencanakanMerencanakanPemberdayaanPemberdayaan
TingkatTingkatKepercayaanKepercayaan
TindakTindakKemandirianKemandirian
Modifikasi Paton, McIver, Johnston, 2007
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KEBERHASILAN PREVENTIFKEBERHASILAN PREVENTIF TERGANTUNG FAKTOR:
Pemahaman kausalitas dan faktor kontekstual Dinamika perkembangannya Identifikasi faktor risiko dan kelompok rentan Ketersediaan teknologi efektif untuk setiap tahap
preventif Kesiapan organisasi dalam melaksanakan
kebijakan & program preventif KemandirianKemandirian melalui proses pemberdayaan yang
konsisten dan berlanjut Dukungan sistem untuk monev dan
inovasi/pembaruan untuk lebih efektif
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PENDEKATAN DALAM PENDEKATAN DALAM KEMANDIRIANKEMANDIRIAN
An analytical tool for empirical studies about the developmental reconstruction of local communities (Song, 2005)
3 Pendekatan teoritis (theoretical framework) Pendekatan psikologis motivasional Pendekatan organisasional Pendekatan keterkaitan(relasional)
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STUDI KASUS STUDI KASUS TOBACCO CONTROLTOBACCO CONTROL
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ECOSOC/UNESCWA/WHO Western Asia Ministerial Meeting, (Doha, Qatar, May 2009)
Global Risk Assessment 2009Global Risk Assessment 2009World Economic ForumWorld Economic Forum
Asset price collapseRetrenchment from globalization
Oil and gas price spike
NCD
Flu pandemicFiscal crisis
Food crisis
Infectious disease
PROBABILITAS
TIN
GK
AT
KEP
AR
AH
AN
(dlm
USD
)
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Commonality factors…Commonality factors…
Tobacco
Diet
Physical Activity
Alcohol
Cardiovascular
Cancers
Diabetes
Chronic Respiratory
Osteoporosis
Oral Health
Mental Health
Source: WHO, Global Status Report on NCD, 2010
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INDONESIA RANK 3INDONESIA RANK 3rdrd ►of 1.3Billions smokers►of 1.3Billions smokers
(WHO, Report on Global Tobacco Epidemic,2008)
Est 62 millions smokers
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ASEAN: 46% Smokers in ASEAN: 46% Smokers in INDONESIAINDONESIA
Est No.deaths related to tobacco*):
-427,948/yr
-1,172/day
*)Kosen, 2004. An Economic Analysis on Tobacco Use in Indonesia
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53.4
62.2 63.1 65.6
1.7 1.34.5 5.2
2731.5 34.4
34.2
0
10
20
30
40
50
60
70
1995 2001 2004 2007
Laki
Perempuan
Total
INCREASING TREND IN INDONESIAINCREASING TREND IN INDONESIA
Sourse: Susenas 1995, 2001,2004 dan Riskesdas 2007
Smoker Prevalences among adultsIndonesia, 1995, 2001, 2004, dan
2007
MenWomen
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SMOKERS ARE GETTING SMOKERS ARE GETTING YOUNGERYOUNGER
0,60,4
1,8
0
0,5
1
1,5
2
%
1995 1998 2001 2004
5 - 9 yrs
Trend among age group 5-9 yrs oldTrend among age group 5-9 yrs old
Case from a village:“Aldi (5yrs old) is addicted,” his mother said. “..if he could not get cigarette and smoke, he will cry so hard and bang his head to the wall.. “
Source Dr Widaystuti Soerojo, 26 Juli 2010
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13.7
24.2
32.8
37.3
0.3 0.2 1.9 1.67.1
12.7
17.3 18.8
0
5
10
15
20
25
30
35
40
1995 2001 2004 2007
Laki
Perempuan
Total
Source: Susenas tahun (1995, 2001, 2004) dan Riskesdas 2007
Indonesia, 1995, 2001, 2004, 2007
SAME PATTERNS AMONG 15-19 SAME PATTERNS AMONG 15-19 YRS OLDYRS OLD
MenWomen
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ECONOMIC LOSSECONOMIC LOSS
• 2005:• Expenditure for tobacco:
• 23Mi packs= Rp 103.5T = US$ 11,5Bi • Est Health care costs:
• 11 diseases (Cancers, CVD, etc)• = Rp 1.99T = US$ 221M
• Est. economic loss (Macro) • Rp 61.6T = US$ 6,8Bi
• Est. Death rates: • 399,000
• Productivity loss related to deaths: • US$ 4.9B
• Productivity loss related illness: • US$ 1.9B
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ECONOMIC LOSSECONOMIC LOSS • Total economic loss related to tobacco
consumption• Rp 167.1T = US$ 18,5B• 5.1 times greater than state income from
tobacco tax
Kosen,2007 unpublished data presented in IPHA National Congress 2007
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ConclusionConclusionIN INDONESIA:
Tobacco is un-controlled and un-regulated consumption good
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ROOT CAUSES?ROOT CAUSES?
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STRATEGIC LOSTSTRATEGIC LOST
Advocacy (-)
Brokering Knowledge (-)
Effective convening stakeholders (-)
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Kepemimpinan & AliansiKepemimpinan & Aliansi
TANTANGAN-KELEMAHAN: Desentralisasi yang kompleks
lumpuh dlm hadapi MDG-NCD Sektoral belum terkoordinasi SDH kompleks, tmsk
“diasapi” shg NCD menuju “communicated diseases”
Regulasi berbagai sektor untuk NCD blm dikompilasi-kodifikasi secara sistematik
PELUANG-KEKUATAN:NCD Summit sbg momentumKomitmen pimpinan KemenkesAliansi civil society dengan
legislator (mis: Kaukus Kes di DPR), perlu dikembangkan sampai kab/kota
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COSTED PLAN COSTED PLAN
TANTANGAN-KELEMAHAN: Kemampuan pusat dan
daerah untuk perencanaan MDG-NCD terintegrasi antar sektor blm eksis
Pilar R&D belum efektif mendukung
PELUANG-KEKUATAN:Perencanaan programatik
sudah ada tetapi perlu sinergi melaui strategi Health in All Policy Development
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LEARNING CAPACITYLEARNING CAPACITY TANTANGAN-KELEMAHAN: Sektoral blm terkapasitasi,
daerah idem ditto Regulasi lebih lanjut harus
dilakukan untuk kepentingan Integrated MDG-NCD actions.
Sisfokes MDG-NCD msh hrs diharmonisasi sec sinergis, dan jg utk eval
Litbangkes blm tersosialisasi utk MDG-NCD
PELUANG-KEKUATAN:Menko Kesra siap jadi tempat
utk mekanisme koordinasiHSS dari GF bs jd entry untuk
kapasitasi stakeholdersSedang disusun SKN baru
memasukkan sub-sistem Litbangkes tersendiri, peluang utk Knowl Mgmt MDG-NCD
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SCALING-UP &INVESTMENTSCALING-UP &INVESTMENT
TANTANGAN-KELEMAHAN: Pusat masih rowing (!fair
enough for starter), daerah blm tau NSPK arah kedepan
NCD terkait industri (rokok, makanan, susu formula, kebugaran, dll): LAWAN ATAU KAWAN dalam scaling up?
PELUANG-KEKUATAN:CSR dan donor lain sdh ada
walau minimal (inadequate)Fundamen untuk yan sdh ada
(yankes primer & rujukan)UKBM tinggal ditingkatkan lagi
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HRH SKILLSHRH SKILLS
TANTANGAN-KELEMAHAN: Kompetensi
comprehensive PH (Inter-professional education)
Continuing Public Health Education blm terstruktur disemua jenjang
PELUANG-KEKUATAN:MTKI-MTKP dapat menjadi
jalur utk kepentingan standarisasi kompetensi dan harmonisasi global Nakes
LAM mandiri untuk profesi kesehatan
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HEALTH HEALTH PERFORMANCESPERFORMANCES
TANTANGAN-KELEMAHAN: Indikator sukses NCD
belum ditetapkan, terkait paradigma sehat, quality of life termasuk untuk pemulihan (3rd level prevention)
Budaya “hari esok lebih baik dlm pengetahuan” blm eksis
PELUANG-KEKUATAN:HSS dari GF baru dimulaiRAN & RAD MDG sudah ada
tinggal mengisi komponen NCD
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FRAMEWORKSFRAMEWORKS
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STAR FRAMEWORKSTAR FRAMEWORKFor SynergismFor Synergism
TCTCMISSIONMISSION
SKILLS &SKILLS &MINDSETSMINDSETS
TYPE OF HIERARCHY
TCTCINCENTIVESINCENTIVES
WORKINGWORKINGPROCESSPROCESS
SYNERGISM FOR TC
1
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GOVERNINGGOVERNINGTC AT LEVELSTC AT LEVELS
StructureAnd
Mechanism
Contextualfactors
Competencies & Capabilities
RelatedSupporting
facilities
TCTCTARGETTARGET
The DynamicsThe Dynamics 2
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TC LEADERSHIPTC LEADERSHIP
PH is politicSynergism(effective alliances)
Knowledge Mgmt
VISIONING
RegulationsRegulations &Policies&Policies ResourcesResources
Program & Program & servicesservices
Effective Effective TCTC
SOFT SKILLS
3
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Inclusive Process Inclusive Process Inclusive Process Inclusive Process
Dat
a pr
ojec
tions
and
sce
nario
sSYNTHESIS, SYNTHESIS, CONSOLIDACONSOLIDA
TION AND TION AND VALIDATIONVALIDATION
ADJUST/ITERATE ADJUST/ITERATE AS NECESSARYAS NECESSARY
Final Final PlanPlan
MONITORING & EVALUATIONMONITORING & EVALUATION
HEALTH HEALTH SYSTEMSYSTEM
AND OTHER AND OTHER CONTEXTUAL CONTEXTUAL
FACTORSFACTORS
SUR
VEIL
L &
CO
UN
TER
MSU
RVE
ILL
& C
OU
NTE
R M
SWOT SWOT ANALYSISANALYSIS
TC KEY & PRIMARYTC KEY & PRIMARYSTAKEHOLDERS MTGSSTAKEHOLDERS MTGS
REGULATORY
PLENARY PLENARY DISCUSSIONDISCUSSION
STRATEGIES & STRATEGIES & ACTIVITIESACTIVITIES
Dat
a co
llect
ion
& a
naly
sis
Initi
atio
n w
ithin
Cor
e Te
am
Dis
cuss
ion
of b
asel
ines
Stra
tegi
es a
nd K
PIs SYS CAP
RES-DEVT
4
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Global – R
egioanl – National - Local
Universities-Research Institutions
Know & Tech
Learning & InnovationLearning & Innovation
Universities & research
institutions have ability and skills in KNOWLDEGE
CREATION & PRESERVATION
benefit to all
TobaccoSupplyTobaccoSupply
Tobacco DemandTobacco Demand
TC Providers (Healthcare etc)
TC dynamics
Tacit & embedded knowlTacit & embedded knowlOpp &Opp &
ThreatsThreats
5
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VISION-MISSION-VISION-MISSION-STRATEGIESSTRATEGIES
Based on the SWOT and the frames
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VISION & MISSIONSVISION & MISSIONS
VISION: Tobacco control for community self-reliance in
achieving productive health
MISSIONS: Community empowerment in establishing TC Financing TC including for promotive, protective,
curative, cessation and rehabilitation Good governance for TC, including innovation in
TC for TC development
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SWOT STRATEGIESSWOT STRATEGIES
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““Partus Macet”Partus Macet”
Increase Tobacco taxes and price
Graphic Health Warnings
Total ban for promoting smoking
Non-smoking areas
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3 Burning Issues3 Burning Issues
NATIONAL REGULATIONS (!)Approval of the Implementation Regulation draft
(PP draft) by the President, with provision of 100% smoke-free indoor environment and at least 50% pictorial health warnings
Absence (up and down process) of a comprehensive Tobacco Control Bill
Indonesia has not ratified the Framework Convention on Tobacco Control (FCTC)
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Transparancies-Accountability-Mutual Understandings-Effective Collaboration
Regulation Infrastructures
Devt
Community Empowerment
For TC
TC surveillence & counter measures
HC facilitiesfor TC
Regulatory Devt Prog
Public Awareness & Counter Measres
DataClearinghouse
LEADERSHIP & TC ALLIANCES
Policy Development &Program improvement
Advocacies & KnowledgeBrokering
Capacitating TC
system
Tobacco use control
NCD outcomes & sattisfaction
Budget support
Comm TC efforts
Policy analysis capacity
STRATEGIC MAPPINGSTRATEGIC MAPPING????
TC advocacy &
Financing
Trainings &Educ
TC networks
Regulatory BodyLinks
Res & Devt on
TC
TC Financing
Health care for TC
Econ measuresFor tobacco use
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Strategy Objectives & Strategy Objectives & ActivitiesActivities
1 etc
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YEARLY TARGETS AND YEARLY TARGETS AND COSTED ACTIVITIESCOSTED ACTIVITIES
Based on established KPIs
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STAKEHOLDERS’ MATRIXSTAKEHOLDERS’ MATRIX
Critically Important for
Strategic Map Excecution
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The MatrixThe Matrix Key and Primary Stakeholders’name
Interests and its description
Strengths and weaknesses
Role expected from them
Advocacy process needed to approach them
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STUDI KASUS STUDI KASUS KESEHATAN JIWAKESEHATAN JIWA
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WHO Definition of HealthWHO Definition of Health
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (1948).
Dikuti dari: Unutzer, 2011
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1999 Disease or Injury 2020 Disease or Injury
TREN DALY 1999-2020TREN DALY 1999-2020
DALY = Disability-adjusted life year
1. Acute lower respiratory infections2. HIV/AIDS3. Perinatal conditions4. Diarrhoeal diseases5. Unipolar major depression6. Ischaemic heart disease7. Cerebrovascular disease8. Malaria9. Road traffic injuries10. Chronic obstructive pulmonary disease11. Congenital anomalies12. Tuberculosis13. Falls 14. Measles15. Anaemias
1. Ischaemic heart disease2. Unipolar major depression3. Road traffic injuries4. Cerebrovascular disease5. Chronic obstructive pulmonary disease6. Lower respiratory infections7. Tuberculosis8. War9. Diarrhoeal diseases10. HIV11. Perinatal conditions12. Violence 13. Congenital anomalies14. Self-inflicted injuries15. Trachea, bronchus and lung cancers
Source: WHO, Evidence, Information and Policy, 2000
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Released October 4, 2001 http://www.who.int/whr
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World Health Report 2001World Health Report 2001
Messages (1-3)Messages (1-3)
Mental health is relevant to all of health.
Mental disorders are real, diagnosable, common and universal. If left untreated, they can produce suffering and severe disability in individuals, and major social and economic losses.
Mental disorders are treatable. Prevention and treatment are possible and feasible, but currently most sufferers are unreached.
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Recommendations1. Provide treatment in primary care2. Make psychotropic medications available3. Give care in the community4. Educate the public5. Involve communities, families, and consumers6. Establish national policies, programs, and legislation7. Develop Human resources8. Link with other sectors9. Monitor community mental health10. Support more research.
World Health Report 2001
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Prev Gg Mental (LAMPUNG: 6,8%)Prev Gg Mental (LAMPUNG: 6,8%)
Riskesdas, 2007
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Adverse Childhood ExperienceAdverse Childhood Experience (ACE) (ACE)
Kekerasan pd anakKekerasan pd anakKekerasan emosional Kekerasan emosional berulangberulang Kekerasan fisik berulangKekerasan fisik berulang Kekerasan seksualKekerasan seksual
Lingkungan keluarga Lingkungan keluarga traumatiktraumatik Adiksi NapzaAdiksi Napza PerceraianPerceraian Anggota keluarga depresiAnggota keluarga depresi KDRT thd ibuKDRT thd ibu Anggota keluarga dipenjaraAnggota keluarga dipenjara Kehilangan keluargaKehilangan keluarga
Anak yg terabaikanAnak yg terabaikan Pembiaran fase tumbuhPembiaran fase tumbuh Kebutuhan fisik, sosial dan Kebutuhan fisik, sosial dan emosional terabaikanemosional terabaikan
* Setiap jenis berkontribusi * Setiap jenis berkontribusi dalam skor ACE dalam skor ACE
Dampak traumat & Perilaku Dampak traumat & Perilaku Beresiko akibat ACEBeresiko akibat ACE
Efek NeurobiologisEfek Neurobiologis Pertumbuhan neurol terggPertumbuhan neurol tergg Kesulitan menahan amarahKesulitan menahan amarah HalusinasiHalusinasi DepresiDepresi Reaksi panikReaksi panik KecemasanKecemasan Msalah somatikMsalah somatik Sulit tidurSulit tidur Lemah ingatanLemah ingatan Memori menakutkanMemori menakutkan DisosiasiDisosiasi
Perilaku BeresikoPerilaku Beresiko MerokokMerokok Makan berlebihanMakan berlebihan Tdk mau beraktifitasTdk mau beraktifitas Niat bunuh diriNiat bunuh diri AlkoholAlkohol NapzaNapza Pasangan sesksual berlebihPasangan sesksual berlebih Trauma ulanganTrauma ulangan Melukai diriMelukai diri Makan tdk adekuatMakan tdk adekuat Kekerasan thd org lainKekerasan thd org lain
Efek Jangka Panjang dr ACEEfek Jangka Panjang dr ACE
Penyakit & KecacatanPenyakit & Kecacatan Penyajit Jantung KoronerPenyajit Jantung Koroner KankesKankes Peny Paru KronisPeny Paru Kronis EmfisemaEmfisema AsAsmama Peny HatiPeny Hati RfakturRfaktur Kualitas kesehatan rendahKualitas kesehatan rendah STDSTD HIV/AIDSHIV/AIDSTekanan sosial Tekanan sosial HomelessnessHomelessness PelacuranPelacuran Kekerasan, kriminalitasKekerasan, kriminalitas Tdk mampu bekerjaTdk mampu bekerja Kekerasan berulangKekerasan berulang Kemampuan mengasuh kel Kemampuan mengasuh kel tbtstbts Kekerasan antar-generasiKekerasan antar-generasi Ketergantungan pada Ketergantungan pada yankes kronisyankes kronis
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Korelasi Depresi Mental Korelasi Depresi Mental Dengan Skor ACEDengan Skor ACE
0
10
20
30
40
50
60
70
80
% W
ith a
Life
time
His
tory
of
Dep
ress
ion
0 1 2 3 >=4
ACE Score
Women
Men
Jenning, 2011N = 8,022 p<0.001N = 8,022 p<0.001
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Korelasi Percobaan Bunuh Diri Korelasi Percobaan Bunuh Diri Dengan Skor ACEDengan Skor ACE
0
5
10
15
20
25%
Att
empt
ing
Sui
cide
ACE Score
11
22
00
33
4+4+
Jenning, 2011N = 8,022 p<0.001N = 8,022 p<0.001
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0
2
4
6
8
10
12
0 1 2 3 4 5 6 >=7
NoYes
ACE Score
Ever
Hallu
cin
ate
d*
(%)
Adiksi Napza/Alkohol
*Adjusted for age, sex, race, and education.
Korelasi Halusinasi Dengan Korelasi Halusinasi Dengan Skor ACESkor ACE
Jenning, 2011
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Korelasi Kemampuan Korelasi Kemampuan Mengingat Dengan Skor ACEMengingat Dengan Skor ACE
ACE Score
ACE Score
1 2 3 4 5
Jenning, 2011N = 8,022 p<0.001N = 8,022 p<0.001
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Korelasi Merokok Korelasi Merokok Dengan Skor ACEDengan Skor ACE
0
2
4
6
8
10
12
14
16
18
20
0 1 2 3 4-5 6 or more
ACE Score
%
Jenning, 2011N = 8,022 p<0.001N = 8,022 p<0.001
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Korelasi Menjadi Penasun Korelasi Menjadi Penasun Dengan Skor ACEDengan Skor ACE
0
0,5
1
1,5
2
2,5
3
3,5
% H
ave
Inje
cted
Dru
gs
0 1 2 3 4 or more
ACE Score
N = 8,022 p<0.001N = 8,022 p<0.001Jenning, 2011
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KDRT Dengan Skor ACEKDRT Dengan Skor ACE
N = 8,022 p<0.001N = 8,022 p<0.001 Jenning, 2011
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Pasangan Seksual >50org Pasangan Seksual >50org Dengan Skor ACEDengan Skor ACE
0
1
2
3
4
Ad
just
ed O
dd
s R
atio
0 1 2 3 4 or more
ACE Score
N = 8,022 p<0.001N = 8,022 p<0.001 Jenning, 2011
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Kehamilan Tak Terencana Kehamilan Tak Terencana Dengan Skor ACEDengan Skor ACE
0
10
20
30
40
50
60
70
80
%
have
Uni
nten
ded
PG
, or A
B
0 1 2 3 4 or more
ACE Score
Unintended Pregnancy
Elective Abortion
N = 8,022 p<0.001N = 8,022 p<0.001 Jenning, 2011
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0
5
10
15
20
25
30
35
Not 16-18yrs 11-15 yrs <=10 yrs abused Age when first abused
Perc
en
t w
ho im
pre
gn
ate
d
a t
een
ag
e g
irl
1.3x 1.4x
1.8x
1.0 ref
ACE pada Anak Laki ACE pada Anak Laki Dengan Menghamili OrangDengan Menghamili Orang
Jenning, 2011
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Performansi Ditempat Kerja Performansi Ditempat Kerja Dengan Skor ACEDengan Skor ACE
Jenning, 2011
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Kesimpulannya?Kesimpulannya?
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Masa Kanak Berkelainan (Adverse Child Experiences)
Masa Kanak Berkelainan (Adverse Child Experiences)
Perkembangan sistem syaraf terganggu
Perkembangan sistem syaraf terganggu
Gangguan kognitif, emosional,
Gangguan kognitif, emosional, & sosial& sosial
Kehidupan sosial Kehidupan sosial beresiko kesehatan
beresiko kesehatan
Masalah sosial, Masalah sosial, Diabilitas & peny
Diabilitas & peny
KematianKematiandinidini
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Dikuti dari: Unutzer, 2011
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Mental Health / Substance Abuse
NeurologicDisorders
10-20%
Diabetes
10-30%
Heart Disease
10-30%
Chronic Physical Pain
25-50%
Cancer
10-20%
Smoking, Obesity, Physical Inactivity
40-70%
Timbal Balik (Vice Versa)Timbal Balik (Vice Versa)
Unutzer, 2011
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Determinan Kesehatan JiwaDeterminan Kesehatan Jiwa
Kesehatan Biologis Perilaku individual Lingkungan sosial Lingkungan fisik Akses ke layanan kesehatan dasar & rujukan Kebijakan kesehatan dan program Kebijakan sosial dan kesejahteraan
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Masalah Masalah KeswaKeswa
Masalah Masalah Kes fisikKes fisik
Adiksi Adiksi NapzaNapza
KemiskinanKemiskinanPengangguranPengangguran
homeless homeless
Kekerasan &Kekerasan &KriminalitasKriminalitas
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LINGKUNGANLINGKUNGAN
PERSONALPERSONAL
PERILAKUPERILAKU
Social Learning/Social Cognitive
Theory
Kontribusi terbesar perilaku (abnormal) adalah
LINGKUNGAN
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Kunci Sukses Kunci Sukses IMPLEMENTASIIMPLEMENTASI
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Input Output Outcome Impact
Intermediate Final
FinansialSarPras
Goods and services produced by inputs (Yankes di Puskes, Pustu, dll)
Access to, use of, and satisfaction with services (Cakupan, Kepuasan)
Effect on dimension of well-being (Kesakitan/ Kematian)
Pendekatan sistem dlm Pendekatan sistem dlm evalevaluasiuasi kebijakan kebijakan
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Jebakan dlm prosesJebakan dlm proses
Uraian masalah
Kerangka kebijakan
Kebijakan prioritas
Program yg harus dikerjakan
Kata siapa?
Kacamata siapa?
Tradisi kebijakan sbg kendala (bounded)
Kapasitas & kompetensi yg dimiliki
‘‘Bounded rationality’ Bounded rationality’ (Simon) – (Simon) –
Berupaya betul untuk rasional tetapi terkendala oleh Berupaya betul untuk rasional tetapi terkendala oleh kompleksitas, ketidakpastian, ideologi/paradigma dan kompleksitas, ketidakpastian, ideologi/paradigma dan kepentingankepentingan
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Nilai2 Dalam AnalisisNilai2 Dalam Analisis
Nilai-Nilai
Analisis Kebijakan
Realitas
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SOLUSI?SOLUSI?_1_1
INCREMENTAL & ITERATIVEProses kebijakan adalah perubahan sosial
Melangkah step by step & win-winTidak terikat pada framework yg kakuKesalahan merupakan lessons learned berharga
Proses kebijakan adalah proses belajar yg berulangKumpulan cerita pengalamanBangunan pengertian pihak berkepentinganMenguji solusi pd skala kecilBerujung pd shared vision, norms, practices
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Disadur dari Issacs, 1999Disadur dari Issacs, 1999
Instrumentasi utk Instrumentasi utk DDialogialog
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Morisson, 2005Morisson, 2005
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SOLUSI?SOLUSI?_2_2
FEASIBILITY
Sec teknis kebijakan mampu laksanaTidak bertentangan dengan kebiasan dan kebijakan yang adaMemecahkan kendala & menguntungkan di masa depan
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PROSES DIHARAPKANPROSES DIHARAPKAN
3 KAPASITASI
Kapasitasi untuk rasional (‘evidence based’)
Kapasitasi dlm mencari dukungan dan implementasi
Kapasitasi dlm siklus kebijakan untuk improvement
3 PROSES KEBIJAKAN:
Riset kebijakan
Drafting
Sensitisasi & formulasi
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Kapasitasi utk RasionalKapasitasi utk Rasional Formulasi tujuan-tujuan pengembangan
kebijakan Pengumpulan data (riset kebijakan)
Rasionalisasi permasalahan yg ada (pohon masalah kaitkan dengan teori, bila ada)
Formulasi berbagai skenario
Membandingkan berbagai skenario Memutuskan skenario pilihan, program dan
komitmen
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Kapasitasi dlm dukunganKapasitasi dlm dukungan
Membangun aliansi, sekutu dan mitra
Mereduksi faktor oposisi
Ikuti prosedur sosialisasi dalam implementasi kebijakan
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Kapasitasi dlm implementasi Kapasitasi dlm implementasi kebijakankebijakan
Asumsi suatu kebijakan: Disusun berdasarkan data yang (terbatas) ada Kontekstual yang memiliki tk ketidakpastian
tertentu
Oleh karena itu perlu kapasitasi dalam implementasi: Kemampuan riset kebijakan Kapasitas sisfo program Kapasitas diklat
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PERAN IAKMI DI PERAN IAKMI DI DAERAHDAERAH
Analisis Organisasi & Strategi
Pengembangan
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KELEMAHAN INTERNALKELEMAHAN INTERNAL Struktur yang aktif:
32 dari 33 Propinsi Sedikit sekali kab/kota yang sudah miliki
kepengurusan Keanggotaan masih merupakan masalah Continuing Public Health Education belum jalan
Kebutuhan (need) sudah jelas Harapan (demand) eksplisit disebutkan
Aliansi dengan pemerintah belum efektif
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PELUANG YANG TERBUKAPELUANG YANG TERBUKA
HPEQ mendorong perbaikan sisi suplai PT kesmas, dalam hal Standarisasi pendidikan kesmas Akreditasi Kelulusan yang efektif
MTKI-MTKP mendorong profesi untuk Registrasi nakes Kelulusan efektif dan berstandar
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PELUANG YANG TERBUKAPELUANG YANG TERBUKA
Permenkes ttg perlunya pemimpin kesehatan miliki ketrampilan manajemen kesehatan Peta jalan perlu disusun, yaitu: Penguatan IAKMI di daerah Registrasi anggota (termasuk survei
kebutuhan anggota) STR anggota melalui MTKP Continuing PH education (termasuk
pendidikan profesi) Advokasi sektor kesehatan untuk posisi
profesi yg lebih strategis
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CLOSING POINTCLOSING POINT
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AliansiAliansi Jangka Panjang Jangka Panjang
Pemerintah
Kebijakan yg mendorong
Keterbukaan thd sinergisme
Penyediaan sumber daya
Akademisi
Riset kebijakan yg efektif
Pendampingan implikasi riset
Berorientasi outcome kesehatan
Organisasi Profesi
Pelayanan & advokasi
Penyediaan sumberdaya
Translasi ilmu ke praktek
Penyediaan sumberdaya
Political pressure thd pemerintah
Infrastruktur yg bersifat global
Donor termasuk swasta
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IAKMI di daerahIAKMI di daerah? ? Program kerja? Program kerja? duh…duh…
Mari kita diskusi..