Challenges in Providing Care for

Vulnerable Patients

Yanri Wijayanti Subronto, MD, PhD

(Internist – Infectiologist)
Dept. of Internal Medicine Universitas
Gadjah Mada
 Short CV
 MD – Faculty of Medicine, UGM
 PhD – Leiden University, The Netherlands
 Internist – Faculty of Medicine, UGM
 Infectiologist – Collegium

Working experiences:
 Primary care MD at Puskesmas Tawangsari, Central Java
 Staff at the Faculty of Medicine, UGM
 Head of HIV Clinic Dr. Sardjito Hospital
 Member of HIV Expert Panel, Ministry of Health Indonesia
 Board of Expert – The Association of Indonesia Health Office (Asosiasi
Dinas Kesehatan Seluruh Indonesia)
 Short-term consultancies for WHO, Ministry of Public Work, DFAT, etc
 HIV clinician and researcher
 Setting up the scene –
1. The HATI Study
 HATI – HIV AIDS Test & Treat Indonesia
 Conducted in 4 cities (Jakarta, Bandung, Jogjakarta,
Denpasar)
 Subjects: MSM, Sex worker, Transgender, IDU’s
 Aim to:
 Identify barriers to HIV testing
 Identify barriers to immediate HIV treatment

 Identify barriers to good adherence

 Develop intervention to decrease those gaps

 What do we identify and Intervene
 Structural Barriers:
 No National Identity card
 No health insurance
 Medical Barrier:
 Pre-ARV lab tests
 Severe condition
 Infrastructure barrier:
 Different place of Test and
Treatment
 Others:
 Lack of support
 Lack of knowledge
 Lack of responsibility
 Interventions:
 Testing Oral Fluid Test to
increase testing uptake
 Same day and same place
for Testing and Treatment
(puskesmas, NGO,
hospital)
 Community-lead services
(NGO in collaboration
with Puskesmas)
 SMS reminder to increase
adherence coverage
 Setting up the scene
2. Clinical Case
 Woman, 47 y.o.
 Brought to Emergency Room Dr. Sardjito Hospital on
December 4, 2017
 Referred from Puskesmas Tegal Rejo
 Condition: weak and dehydrated
 HIV patient loss of ARV treatment for 3 months
 Situation – Magda will tell

 Puskesmas Tegalrejo called HIV Buddy (Magda) to refer

the patient to Dr. Sardjito hospital
 The patient was accompanied by a man, who turned out
to be not her formal husband, but he was gone afterward
 About the health insurance  Jaminan Kesehatan Sosial
(Jamkesos Jogjakarta Province)
 Three days before her death, the hospital look for her
family
 Medical condition

 Patient was suspected to be TB-HIV coinfected  from

Chest X-ray: milliary TB
 Start Anti-TB Therapy (ATT) but developed side effect
(High Bilirubin level)  change ATT until bilirubin was
back to normal  back to the normal regiment
 Oral candidiasis and yeast in the urine  need for Anti-
Fungal therapy
 Medical Condition (cont…)

 After two weeks of treatment, patient developed

neurological symptoms and consulted to the
neurologist  suggest to conduct head CT-scan with
contrast
 This require consent from patient (ineligible) or family  NO
FAMILY stays with her since the beginning
 Suggested for MRI (less invasive) but scheduled on January 2,
2018
 Patient become agitated and consulted to psychiatry 
organic halusination
 Patient died on Dec 31, 2017 due to intracranial
infection
 Problem(s) in this patient (Vulnerabilities)

Medical
• HIV positive
• 3 months no ARV treatment
• TB-HIV
• Suspected of Intracranial
infection  can not perform
CT Scan due to absence of
signed consent
• Fungal infection  can not
receive immediate anti fungi
due to health insurance
• Psychotic syndrome
Non-medical
 Woman – no formal
marriage status
 Almost middle age, no
(formal) family
 Expired National ID card
 No health insurance on
hospitalization
 Abandon by family
 Is this patient “vulnerable”

• Vulnerable populations include:

– Economically disadvantaged

– Racial and ethnic minorities

– The uninsured

– The elderly

– The homeless (abandoned by family)

– Those with HIV

– Those with other health condition, including severe mental

illness
 Challenges in Providing Care for this patient

 Delay of diagnosis  can not perform CT Scan in the

absence of signed consent from family
 Delay of treatment  anti fungi can only be given after
the insurance was settled (patient
 Being woman, no formal marriage, HIV positive 
abandoned by the family
 What should we do in those scenarios?

 Give YOURSELF  really “understand’ what the patient

experience and go through
 Develop a good team, consisting medical and non-
medical personnel inside the hospital and with outside
stakeholders
 Allign medical care to the highest standard according to
the available insurance scheme (physician should
understand the insurance scheme)
 Health Insurance in Indonesia and in
Jogjakarta Province
• National Health Insurance (BPJS)  the patient
does not have ID
• The patient was registered to the Provincial Health
Insurance (Jaminan Kesehatan Sosial – Social
Health Insurance)
– For the poor people with health problems: HIV/AIDS,
malnourished children, Major Thalasemia, Poor post-
discharged psychotic patient
– This scheme supports the National Insurance
– Only used once (while needed), no member card
– There need a verification by the Social Office or by appointed
organization
Is the existing existing National Health Insurance
fund “enough”

• Ministry of Health Regulation No 59 Year 2014:

No INA-CBG Description 3rd class 2nd class 1st class

code

1. A-4-15-I Mild HIV 5.426.900 6.512.300 7.597.700

infection
2. A-4-15-II Moderate HIV 8.123.400 9.748.100 11.372.800
infection
3. A-4-15-III Severe HIV 10.194.200 12.233.000 14.271.900
infection

There is possibility that the cost is bigger than the available

funds (HIV, meningitis, schizophrenia, TB-HIV)
Is the National Insurance Scheme “accessible” for
everybody and for all activities?

• HIV patients now are predominantly from MSM

community
• Many do not access Nat’l Health Scheme because of the
requirement that it should register the Whole Family 
afraid to be known as HIV, particularly for MSMs (Man
Having Sex with Man) / young gay
• Many need transportation money
 Recommendations
 Overcome structural barriers
 More user-friendly health insurance
 Provide home-based care, including incentives for medical
personnel  not yet included in National Insurance Scheme
 Develop network and community partnership  mostly from
foreign donor  ADINKES is developing guidance for local
governments to provide funding for HIV activities
 Provide Non-health care services, such as transportation money
 Provide community-based care such as shelter, hospice
 Good coordination between health and social offices (provide
appropriate health care in social camps)
 Prepare primary care
 Train medical personnel
 Needs and Solutions
“solid collaboration and communication between stakeholders”

 Volunteer / buddies – Guardian Angels

 Bring the patient to the hospital
 Putting the patient in to the health insurance
 Find the family
 Provide place to stay
 Summary

Providing Care for (Vulnerable) patients:

It is NOT MERELY MEDICINE ….

It Takes MUCH MORE ……
 Teaching the HEART

In Kebaya (family of Transgender in Jogjakarta) drop-in

house with internal medicine registrars
 THANK YOU for the
BOTTOM of My
HEART

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