Implementation of Aceh Health Insurance (Jaminan Kesehatan Aceh) 2013-2021: Has health equity been achieved for all Acehnese after armed conflict?

Aceh Health Insurance (Jaminan Kesehatan Aceh-JKA) has been implemented since 2010 to increase the health equity by covering the health expenses and guaranteeing that all Acehnese are covered regardless of their economic, educational, and social statuses. However, since its implementation, there has been no study on its impact on health quality, particularly regarding the utilization of the main referral hospital (Dr Zainoel Abidin Hospital located in Banda Aceh) and the effects of the geographic accessibility and the number of specialist doctors in each regency/city on hospital utilization. This retrospective study assessed the equity factors during the Aceh Health Insurance implementation and during its integration to National Health Insurance (Jaminan Kesehatan Nasional-JKN) from 2013 to 2021 using data of travel time (time spent for travelling from the origin regency/city of referred patients to the main referral center) and healthcare resources (number of specialist doctors). The data were analyzed using Student's t-tests, Kolmogorov-Smirnov or Mann-Whitney U test when appropriate. Williamson Index was calculated to determine the disparities of health equity between regencies. Our data indicated the noticeably increase of health facilities utilization since the implantation of Aceh Health Insurance. However, there was no equity in the use of main referral facility by the residents in Aceh - was dominated by residents who lived closer and from more populated regencies/cities. In conclusion, there are accessibility and financial hardship barriers in accessing the health care facilities during the implementation of Aceh Health Insurance that need to be addressed by the government to achieve the health equity for all Acehnese.

Risk factors of MDR-TB and impacts of COVID-19 pandemic on escalating of MDR-TB incidence in lower-middle-income countries: A scoping review.

The coronavirus disease 2019 (COVID-19) pandemic is affecting tuberculosis (TB) treatment in many ways that might lead to increasing the prevalence of multi-drugs-resistance tuberculosis (MDR-TB), especially in lower-middle-income-countries (LMICs). This scoping review aimed to identify the risk factors of MDR-TB and to determine the impacts of the COVID-19 pandemic on MDR-TB prevalence in LMICs. This study was reported according to the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) guideline. The relevant keywords were used to search studies in three databases (PubMed, ScienceDirect and SpringerLink) to identify the related articles. The English-written articles published from January 2012 to December 2022 that explored risk factors or causes of MDR-TB in LMICs were included. Out of 1,542 identified articles, 17 retrospective, prospective, case-control and cross-sectional studies from ten LMICs met were included in this scoping review. Twenty-one risk factors were discovered, with prior TB treatment (relapsed cases), diabetes, living area, living condition, smoking and low socioeconomic status were the main factors in developing MDR-TB during COVID-19 pandemic. The pandemic increased the MDR-TB prevalence through drug resistance transmission inside households, the distance between home and healthcare facilities and low socioeconomic status. This scoping review demonstrates how the COVID-19 pandemic has affected the rising incidence of MDR-TB in LMICs.

Advancing the discourse of Muslim politics in Indonesia: A study on political orientation of Kiai as religious elites in Nahdlatul Ulama.

The present study was designed to investigate the political interactions of Kiai of Nahdlatul Ulama (NU) in the national political arena and its current impact on the Indonesian Muslim community. The data were garnered through interviews and focus group discussions with Kiai and related parties. The results of the study suggest that the political orientation of the Kiai of NU in Indonesia is oriented to pragmatism and oriented to piety idealism in politics based on Islamic ethics. The Kiai, as a symbol of religious leaders, is expected to lead the Muslim community on a political path that is valuable and morally based. The phenomenon of Kiai interaction in practical politics is a significant leap and break that should be translated into a more comprehensive political perspective on social and historical aspects. The study findings implicate that Kiai as a religious figure, should be put on the front row for Indonesian political discourses among Nahdlatul Ulama followers.

A comprehensive assessment of the malaria microscopy system of Aceh, Indonesia, in preparation for malaria elimination.

BACKGROUND: The Health Office of Aceh aims to eliminate malaria from Aceh Province, Indonesia by 2015. Malaria was formerly common in Aceh (population 4.5 million), but has declined dramatically in recent years consequent to post-tsunami control efforts. Successful elimination will depend upon rapid and accurate diagnosis and case follow-up at community level. A prerequisite to this is widespread coverage of high quality malaria diagnosis. This study describes the results of a comprehensive assessment of the malaria diagnostic capacity in Aceh as the province moves towards malaria elimination. METHODS: The study was conducted in 23 districts in Aceh from October 2010 to July 2011. Six types of questionnaires were used to collect data on competency of microscopists and laboratory capacity. Standardized slides were used to evaluate the proficiency of all microscopists. In addition, site visits to 17 primary health centres (PHC) assessed diagnostic practice and logistics capacity. RESULTS: Five hundred and seventy four malaria microscopists have been officially registered and assigned to duty in the 23 districts in Aceh Province. They work in 345 laboratories, predominantly in PHCs (69 %) and hospitals (25 %). Three laboratories were evaluated as adequate for all 30 elements, while 29 laboratories were adequate for less than five of 30 elements. Standardized proficiency tests showed that 413 microscopists were at basic (in training) level, with 10 advanced and 9 reference level. No microscopist achieved expert level. Neither the province nor any of Aceh's districts has a standardized inventory and logistics database for malaria diagnostics, nor did any of the surveyed laboratories operate a quality assurance programme for either microscopy or rapid diagnostic tests. CONCLUSIONS: The study highlights the importance of careful assessment of diagnostic capacity when embarking upon a large-scale malaria elimination programme. Aceh's laboratories have minimal infrastructure with nearly all microscopists still in training. On the positive side, a large workforce of microscopists has been assigned to laboratories with the needed equipment. Aceh will need to embark on a large-scale comprehensive quality assurance scheme if it is to achieve malaria elimination.

Progress towards malaria elimination in Sabang Municipality, Aceh, Indonesia.

BACKGROUND: Indonesia has set 2030 as its deadline for elimination of malaria transmission in the archipelago, with regional deadlines established according to present levels of malaria endemicity and strength of health infrastructure. The Municipality of Sabang which historically had one of the highest levels of malaria in Aceh province aims to achieve elimination by the end of 2013. METHOD: From 2008 to 2010, baseline surveys of malaria interventions, mapping of all confirmed malaria cases, categorization of residual foci of malaria transmission and vector surveys were conducted in Sabang, Aceh, a pilot district for malaria elimination in Indonesia. To inform future elimination efforts, mass screening from the focal areas to measure prevalence of malaria with both microscopy and PCR was conducted. G6PD deficiency prevalence was also measured. RESULT: Despite its small size, a diverse mixture of potential malaria vectors were documented in Sabang, including Anopheles sundaicus, Anopheles minimus, Anopheles aconitus and Anopheles dirus. Over a two-year span, the number of sub-villages with ongoing malaria transmission reduced from 61 to 43. Coverage of malaria diagnosis and treatment, IRS, and LLINs was over 80%. Screening of 16,229 residents detected 19 positive people, for a point prevalence of 0.12%. Of the 19 positive cases, three symptomatic infections and five asymptomatic infections were detected with microscopy and 11 asymptomatic infections were detected with PCR. Of the 19 cases, seven were infected with Plasmodium falciparum, 11 were infected with Plasmodium vivax, and one subject was infected with both species. Analysis of the 937 blood samples for G6PD deficiency revealed two subjects (0.2%) with deficient G6PD. DISCUSSION: The interventions carried out by the government of Sabang have dramatically reduced the burden of malaria over the past seven years. The first phase, carried out between 2005 and 2007, included improved malaria diagnosis, introduction of ACT for treatment, and scale-up of coverage of IRS and LLINs. The second phase, from 2008 to 2010, initiated to eliminate the persistent residual transmission of malaria, consisted of development of a malaria database to ensure rapid case reporting and investigation, stratification of malaria foci to guide interventions, and active case detection to hunt symptomatic and asymptomatic malaria carriers.

The baseline distribution of malaria in the initial phase of elimination in Sabang Municipality, Aceh Province, Indonesia.

BACKGROUND: Sabang Municipality, in Aceh Province, Indonesia, plans to initiate a malaria elimination programme in 2013. A baseline survey of the distribution of malaria in the municipality was conducted to lay the foundations for an evidence-based programme and to assess the island's readiness to begin the elimination process. METHODS: The entire population of the municipality was screened for malaria infection and G6PD deficiency. Specimens collected included blood slides, blots and tubes for selected households. RESULTS AND DISCUSSION: Samples were collected from 16,229 residents. Microscopic examination of the blood smears revealed 12 malaria infections; 10 with Plasmodium falciparum and 2 with Plasmodium vivax. To confirm the parasite prevalence, polymerase chain reaction (PCR) diagnosis was performed on the entire positive cases by microscopy and randomized 10% of the microscopically negative blood samples. PCR revealed an additional 11 subjects with malaria; one P. falciparum infection from the village of Paya Keunekai, and nine P. vivax infections and one mixed P. falciparum/P. vivax infection from the village of Batee Shok. The overall slide positivity rate was 0.074% (CI 95%: 0.070-0.078) and PCR corrected prevalence 0,590% (CI 95%: 0.582-0.597). Analysis of 937 blood samples for G6PD deficiency revealed two subjects (0.2%) of deficient G6PD. Analysis of several genes of the parasite, such as Pfdhfr, Pfdhps, Pfmdr1, Pfcrt, Pfmsp1, Pfmsp2, Pvdhfr, Pvdhps, Pvmdr1 and host gene, such as G6PD gene revealed that both P. falciparum and P. vivax carried the mutation associated with chloroquine resistance. CONCLUSION: Malariometric and host genetic analysis indicated that there is a low prevalence of both malaria and G6PD deficiency in the population of Sabang Municipality. Nevertheless, malaria cases were clustered in three rural villages and efforts for malaria elimination in Sabang should be particularly focused on those three villages.