Geriatric health care needs funding as private clinic opens

By Jules Bell

JAKARTA (JP): Geriatric patients require very specialized health care. Couple this with the World Health Organization's (WHO) prediction that from 1990 to 2020 there will be a 415 percent increase in the number of elderly people in Indonesia, the fastest growth rate for this demographic group in any country throughout the world.

Add to this, the fact that geriatric medicine has only been taught to undergraduate medical students since 1997. Finally, consider that in the opinion of specialists, limited funding is directed toward geriatric health care at present; particularly in the context of Indonesia's economic crisis.

"It's a serious problem," said Dr. Czeresna Soejono, secretary of the Indonesian Society for Gerontology - a non government organization established in 1996.

Geriatric health care has been overshadowed by more pressing health problems in the past said the specialist from Cipto Mangunkusomo Hospital's geriatric outpatient clinic - "the only formal clinic in Jakarta".

"In the last 10 years or so we have succeeded in combating infection and undernutrition, especially in children under five," he said. "That is why in the last five to seven years there has been some growth in health care for the elderly."

Dr. Soejono's opinion that geriatric health care requires a significant increase in funding, is strongly supported by statistical analysis.

Data from the Ministry of Population released in 1995 estimates a 96 percent increase in the number of elderly Indonesians, from 1980 to 2000. Forty-six percent is the comparative increase in overall population growth for the same 20 year period. Further, WHO estimates by 2010 the number of people over 60 will equal the number children under 5 years.

Figures and data aside, aged people experiencing illness have very specific health needs in comparison to younger patients. Geriatric specialist, Dr. Siti Setiati from Cipto Mangunkusomo Hospital, defined the term geriatric.

"They are patients over 60 years diagnosed with multiple health problems, such as urinary disease in conjunction with heart disease associated with declining organ function," she said.

Such patients experience degenerative diseases including osteoporosis and related disabilities such as immobility or instability. Also associated with the aging process, is cognitive disease in the elderly - most commonly manifesting itself as Alzheimer's disease or dementia.

Early assessment of geriatric patients is particularly important stressed Dr. Soejono, because they have no "reserve" if treated to late.

"Their presenting symptoms and signs are totally different from the classic," he explained. As an example he cited experiences where he had seen geriatric patients present with pneumonia, but showing none of the classic symptoms such as fever, coughing and shortness of breath.

"(Patients) often present with falls," he explained, "loss of consciousness, anorexia or disabilities."

From May this year Jakarta's elderly have had an option other than the public health system for geriatric care; Menteng Geriatric Center.

Working at both Cipto Mangunkusomo Hospital and the new private outpatient clinic, Dr. Setiati treats patients from both sides of the system. She describes the Menteng Geriatric Center as an "ideal" model for geriatric health care, whilst simultaneously expressing frustration with the "lack of funds" for public health system patients.

"The government's health priority is presently mothers and young children," Dr. Setiati said, "but a focus on the health of Indonesia's elderly will be necessary in the future."

So what is this ideal model for geriatric health care? According to Dr. Setiati it is where patients are treated by an integrated team of specialists in one location. This allows a co- coordinated assessment and management of the patient with optimal facilities and equipment.

In addition, she said, the team should have the resources and expertise to focus on the patient and their health as a whole person. "We focus on treating the patient with a holistic approach," she said, "and also focus on communication and recreation."

In her opinion, this has distinct advantages. It reduces "polypharmacy" or over-prescription of multiple drugs to patients she said, and fulfills patients' medical, social, family, psychological and spiritual needs.

"We had a patient recently who was dehydrated because she was incontinent, and was afraid that her family would get angry at her if she lost control of her bladder," related Dr. Setiati.

Immediacy of treatment and the convenience of geriatric specialists in one location is invaluable, she said.

Mrs. Chang would no doubt agree. The thin 85 year old is suffering pneumonia, anorexia, a stomach disorder, problems with her balance and some immobility due to severe leg pain. She has walked through hot, busy passageways to queue at separate locations in Cipto Mangunkusomo Hospital for X-rays, rehabilitation and consultations.

For comparison, this is rather different from having a specialist come to her whilst she rests in a quiet air- conditioned room at Menteng Geriatric Center, having waited in no lines nor had to visit on numerous occasions.

Premium private health care comes at a price though. A complete first time check-up costs patients "around Rp 350,000 (about US$46)" at the private Menteng clinic, according to Dr. Setiati. This includes consultations and examinations for 10 to 14 days. Subsequent consultations are about Rp 50,000 she said.

Menteng Geriatric Center is more expensive than government hospitals, and does differentiate patients on the basis of socioeconomic status said Dr. Setiati.

"We have tried at Cipto Mangunkusumo General Hospital," she said, "but as a government hospital it has many limitations. There is just not enough money to support (such a model)."

One thousand rupiah is what it costs patients per visit at Cipto Mangunkusomo Hospital's clinic. A complete first time examination including laboratory tests, X-rays and heart tests using an ECG costs Rp 146,000. Public and private health patients generally pay for their own medication, some of which is covered by health insurance.

This discrepancy in cost obviously reflects the quality of the facilities and equipment available to patients. Dr. Soejono said the limitations of the public clinic include the lack of grouped doctors and patients in one location, and a need for more equipment.

From statistical and professional warnings to an "ideal model", geriatric health care is not an island in its need for funding. These patients are unique though, not least in their fast increasing numbers. Will health services - particularly those in rural communities - be prepared or will families be forced to absorb the cost?