Better Asthma Care in Puskesmas Improves Disease Control and Reduces Economic Burden

In line with Indonesia's National Health Coverage (BPJS)'s objective to strengthen government primary healthcare clinics (Puskesmas), as well as to improve the referral system to reduce BPJS's economic burden[1]; AstraZeneca in collaboration with the Ministry of Health, Project HOPE, and the University of Gadjah Mada through the Healthy Lung Programme, identified gaps in asthma treatment in Puskesmas through a formative research project in 2018. In 2019, the intervention phase has started in order to address the multidimensional gaps in across 71 Puskesmas in three cities.

4.5% of the Indonesia population suffer from asthma, with a cumulative number of asthma cases of around 11,179,032 sufferers.[2] Meanwhile, the Ministry of Health's Health Research and Development Survey (Balitbangkes) in 2015 noted that chronic lung disease is one of the 10 biggest causes of death in Indonesia.

It is predicted that Non Communicable Diseases including asthma contributes to economic burden for Indonesia's National Health Coverage (BPJS), which triggers BPJS deficit of IDR 28.5 trillion by the end of 2019.[3] Strengthening the Puskesmas role in treating asthma diseases is expected able to increase health cost efficiency while providing better health care service to the community.

Given these conditions, AstraZeneca has collaborated with several stakeholders to improve asthma management through interventions through the Healthy Lung Programme. Rizman Abudaeri, Director of PT AstraZeneca Indonesia, explained: "As part of our Healthy Lung programme, we are proud to be working with the Ministry of Health (Kemenkes) and Project HOPE to conduct a series of intervention activities to address the gaps we found in our formative research to drive better outcomes for patients with asthma. By improving health care service for asthma in Puskesmas level, hence the asthma treatment will be more efficient."

Phase one: Understanding the asthma treatment gaps through a formative research in Indonesia

As a strategic partner of Healthy Lung, Project HOPE supported AstraZeneca in conducting formative research conducted in Bandung, West Java (20 clinics); Bantul, Yogyakarta (27 clinics); and Gowa, South Sulawesi (24 clinics), to address the gaps in asthma management last year. The research found 5 multi dimensional gaps in the management of asthma at the Puskesmas, which include: (1) GP education on Asthma Management on disease and therapy; (2) Dissemination of asthma guidelines by Ministry of Health; (3) Develop Asthma Patients book and train the trainer; (4) Clinical Mentoring by Pulmonologists; (5) Availability of medicines and infrastructure.

Phase two: Rolling out a pilot intervention to address treatment gap findings from formative research

Subsequently, Project HOPE continued to roll out the pilot intervention programme, a collaborative effort with the Health Office (Dinas Kesehatan) conducted in Bandung, West Java (20 clinics); Bantul, Yogyakarta (27 clinics); and Banjar, South Kalimantan (24 clinics). This intervention programme has been rolled out since January this year, and the data has been recorded since April.

Intervention activities have been carried out through conducting stakeholder meetings and collaborations at the district level to address the following (1) availability of appropriate infrastructure and medicines; (2) uplifting the general practitioners' knowledge about the latest asthma diseases and treatment therapies; (3) providing refreshment of asthma management SOP based on asthma handbooks by the Ministry of Health; (4) developing information, education, and counseling books for asthma patients; and (5) providing clinical mentoring by pulmonology doctors.

Improved outcomes from the intervention programme

To date, the intervention programme has uplifted over 500 HCP who had clinical mentoring and over 4000 patients were trained to be adherent to treatment. Based on the results of the intervention programme from five months (April to August) in 3 districts, there has been an increasing trend of 0.6X new asthma patients coming to Puskesmas every month. However, 90% of patients with asthma is still both uncontrolled and partially controlled, with only about 10% are controlled. The intervention programme also found that most of asthma patients coming to Puskesmas are within the productive age with 20% of these are from 6-19 years old and 46% from working group ranging from 20-55 years.

"The results of this intervention programme are expected to be the government's consideration when providing solutions to improve asthma treatment at Puskesmas in Indonesia. Project HOPE will generate a Project Learning as an output of the Intervention Programme. The project learnings will cover the objectives from the intervention, which is to improve asthma control status at the Puskesmas' level, in order to reduce the patients' referral to the hospitals, demonstrating that Puskesmas could treat the patient at the first medical contact. As the next step, we will continue to engage the Ministry of Health, AstraZeneca and other stakeholders to identify the needs to scale up the intervention programmes to other cities and districts as required," said Agus Soetianto, MIPH., MHM.; Country Representative of Project HOPE Indonesia.

Bandung, the city with the 3rd highest number of asthma patients in Indonesia, has already witnessed positive outcomes in the targeted Puskesmas. dr. Rosye Arosdiani Apip, M.Kom; Kabid P2P Dinkes Kota Bandung, explained: "We found that many asthma patients go directly to hospitals instead of visiting a Puskesmas first in the hope of getting better asthma treatment. However, by improving the quality of care during the intervention programme, patients who use controller inhalation treatment demonstrated improved and more controlled asthma results than those who use only used oral drugs. We also found that, during intervention activities, patients who were not referred to the hospital tend to increase. This is aligned with our goal to improve asthma treatment at Puskesmas in Bandung."

In addition, to coincide with the annual Healthy Lung Summit, AstraZeneca will also provide the latest updates and the continuation of the 'Healthy Lung' programme framework throughout Asia. Building on the continued success of the Healthy Lung Programme, today AstraZeneca and Business Sweden -- The Swedish Trade & Invest Council host the 3rd Heathy Lung Summit, bringing together the Healthy Lung Taskforces from Indonesia and other Asian countries as well as Swedish and international experts to discuss progress and strategize for 2020.

[1] BPJS Kesehatan (Healthcare and Social Security Agency) article

[2] Article from Directorate General of Health Services, Indonesia Ministry of Health, 2018

[3] BPJS statement , Finance Director of BPJS Kesehatan (Healthcare and Social Security Agency), August 2019.

About AstraZeneca

AstraZeneca is a global, science-led biopharmaceutical company that focuses on the discovery, development and commercialisation of prescription medicines, primarily for the treatment of diseases in three therapy areas - Oncology, Cardiovascular, Renal & Metabolism and Respiratory. AstraZeneca operates in over 100 countries and its innovative medicines are used by millions of patients worldwide.

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