1. Developing a Foundation for Family Medicine in Indonesia Jason Wilbur, M.D. Lisa Soldat, M.D. October 4, 2015

2. 2 Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. [list all presenters and authors ] have indicated they have no relevant financial relationships to disclose.

3. Goals Understand the current state of family medicine and primary care in Indonesia. Describe ongoing efforts in Indonesia to build a strong primary care workforce on the foundation of family medicine principles. 3

4. 4

5. Indonesia: Background Population ~ 250,000,000 Life expectancy ~ 69/73 (male/female) Top 3 causes of death: –Stroke –Ischemic heart disease –Diabetes complications 5

6. Health Trends: 2000 – 2012 Decreased –Infant/child mortality rate –Maternal mortality rate –TB mortality rate –Overall infectious disease mortality rate Longer life expectancy by 4 years Increased health care spending Improved DTP immunization rate Increased –Mortality due to HIV –Mortality due to malaria –Mortality due to chronic diseases: CV disease DM complications Cirrhosis Kidney disease 6

7. 7

8. Healthcare Delivery Primary care is provided by: –General practitioners – no additional training required beyond medical school –Midwives – uncomplicated obstetrical and gynecologic care –Nurses – often under direction of GPs Additional training in internal medicine, pediatrics, obstetrics requires a paid residency. As of 2014, no residencies existed for family medicine 8

9. Healthcare Delivery 80,000 GPs 17,000 islands 250 mil people Made ridiculously simple: –4.7 GPs per island (distribution fallacy) –3,125 persons per GP (distribution fallacy) 9

10. Primer on Indonesian Health Insurance Until 2014, ~80% of Indonesians lacked health insurance… But healthcare subsidized by the government at about 80% of cost via “supply-side” model… Resulting in “regressive” model of cost- shifting towards lower income persons. 10

11. Primer on Indonesian Health Insurance Law of Social Insurance was passed in 2004 but did not take effect until 2014. It will roll out in phases until complete in 2019. This is a single-payer system with no opting out but will still allow private pay for additional services. It will be the largest single-payer system in the world. 11

12. Insurance + Delivery System The additional persons covered under the Law of Social Insurance will add burden to an already overextended primary care system. 12

13. Enter, the GP 13

14. Indonesian GPs 6 years of medical training after high school Outpatient clinics Morning “public” clinics; evening “private” clinics Often leave their communities after required service obligation (2-3 years) to pursue specialty training – –Resulting in a primary care / community medicine “brain drain” 14

15. Comparison Indonesian GP –Community health leader –No residency training –Outpatient only –Minimal education on biopsychosocial model –Rarely provides OB and women’s health services –Comfortable treating 1/3 – 1/2 of patient complaints –Training focuses on acute illnesses US FP –Community health leader –3-year residency –Care in multiple settings –Education grounded in biopsychosocial model –Able to provide OB and women’s health services –Comfortable diagnosing and treating 90-95% of patient complaints –Training focuses on chronic and acute illnesses 15

16. Family Medicine in Indonesia 16

17. Perceived Needs of Indonesian GPs Improved knowledge of chronic diseases – screening, diagnosis, treatment Patient-centered approach to care Biopsychosocial framework Communication within cultural context 17

18. Family Medicine Meeting the Need Family Medicine rotations in medical schools (not currently required) Family Medicine Masters Degree programs at Faculties of Medicine Academic departments of Family Medicine (new in 2015) Family Medicine residency programs Annual updates (continuing education for GPs) 18

19. Family Medicine Meeting the Need Goal: –13 Centers of Excellence to educate 340 Family Physicians per year –These FPs would then train other GPs as community mentors and primary care experts (“train the trainer” model) 19

20. Collaborations 2011 – Fulbright Scholar, Mark Graber, assisted in assessing GP needs and developing training in FM principles 2011 – present: Iowa FM educators serve as consultants for FM training programs (masters program, FM rotations, academic departments) 2011 – present: Iowa FM educators provide annual updates (CME) for practicing GPs 20

21. Collaborations 2012 – present: Indonesian GPs/FM educators visit Iowa to observe FM education and care delivery. 2013 – 2014: Fulbright Scholar, Mora Claramita, studied FM education and delivery models in Iowa. 21

22. Barriers to FM in Indonesia Cost of residency training Reimbursement model that favors other specialties over primary care Fears of GPs: cost, time commitment, changes in expectations Large knowledge gaps to bridge Few mentors with FM skill set Luke-warm support from Universities and government 22

23. Signs of Hope in 2015 National Board for Primary Care National organizations for family medicine (College and Association)\ A Standard of Competencies for Indonesian Family Medicine Specialists Development of FM residency programs 23

24. Terima kasih! 24

25. Acknowledgements Mora Claramita, M.D., PhD. (Gadjah Mada University) Mark Graber, M.D. (University of Iowa) Wahyudi Istiono, M.D. (Gadjah Mada University) Gadjah Mada University Faculty of Medicine University of Iowa Affiliated Family Medicine Residency Programs 25