Factors Related to the Evaluation of Essential Medicines Use in Health Facilities in Indonesia

Background: Indonesia has recently implemented a national policy to ensure equitable access to medicines, promote their rational use, and maintain a reliable and quality supply, specifically for essential medicines. Several organizations have conducted evaluations on essential medicines use but have yielded varying results and cannot reflect the actual situation. Objectives: This study aims to discover the current situation regarding essential medicines and identify the most important factors to be considered during future indicator-based evaluations in health facilities in Indonesia. Methods: This qualitative study was carried out using FGDs and interview from January to February 2022. The sample population consisted of ten experts selected based on predetermined criteria. The discussions were recorded and transcribed verbatim in the original language, thematically coded with Nvivo, and analyzed for common themes. Results: This study found 32 factors related to the use of essential medicines in Indonesia, divided into three categories of components, namely access, medicine handling quality, and rational use. Furthermore, a total of 10, 8, and 14 main factors were related to access, handling quality, and rational use, respectively. The discussion provided various perspectives on measuring drug use, specifically essential medicines. Based on expert opinions, evaluating the utilization of essential medicines by relying on existing guidelines was insufficient due to superficiality and irrelevance within the Indonesian health system. Conclusion: Based on the results, one of the crucial factors to consider during evaluation was the accessibility of medicines, which encompassed their availability in health facilities and affordability to patients... (AU)

Cost Analysis of Chronic Kidney Disease Patients in Indonesia.

Objective: The cost of treating chronic kidney disease requires large funds. Chronic kidney disease financing ranks 2nd in BPJS as the highest financing. All cost components in the treatment of chronic kidney disease are considered high, so adjustments and efficiency are needed. This study aims to perform a cost analysis in chronic kidney patients. In this article, we will discuss the cost components in treatment and see whether there are differences in the cost of treatment in each hospital. Methods: The study used a cross-sectional design with a hospital perspective and was conducted in 6 hospitals selected based on class in different regions: Sardjito Central General Hospital (class A), Yogyakarta Regional General Hospital (class B) and PKU Muhammadiyah Hospital (private class) represent hospitals in regional 1. Meanwhile, Makassar Central General Hospital (class A), Labuang Hospital Baji (class B) and Faisal Islamic Hospital (private class) represent hospitals in regional 3. The study lasted for 14 months from October 2019-December 2020. The total sample involved in this study was 582 samples. The cost components analyzed include hemodialysis costs, serious procedures and operations, services, radiology, laboratories, blood transfusions, drugs, medical devices, hospitalization and supplies. Results: Chronic kidney patient profile data, calculations and cost components are presented descriptively. The Mann-Whitney test was used to see whether there were differences in costs between hospitals in each region. The results showed that the total cost of treating chronic kidney disease was higher in class A hospitals compared to class B and private class hospitals. Conclusion: The highest cost component is the cost of hemodialysis, followed by severe procedures and services. The highest total cost of hemodialysis reached Rp. Rp.840,132,546, heavy action Rp. 423,156,000 and services Rp. 792,155,000. The results of statistical tests showed that there were differences in the cost of treating chronic kidney disease in hospitals in regional 1 and regional 3 (p < 0.05).

The 5-Year Disease-Free Survival of Third Generation Aromatase Inhibitor for Postmenopausal Women with HR-Positive HER2-Negative Non-Metastatic Breast Cancer.

Background: Several studies showed the superiority of aromatase inhibitor (AI) as first-line therapy for patients with hormone-receptor (HR)-positive breast cancer (BC). For the clinician, studies in the real world are warranted to determine treatment based on the efficacy of each drug. We compared a 5-y disease-free survival (DFS) of each AI in terms of survival benefit. Materials and Methods: We evaluated 450 medical records of postmenopausal women who were diagnosed with HR-positive HER2-negative BC (stage I - III) at Dr. Sardjito General Hospital from January to December 2019. All patients had undergone surgery and chemotherapy or radiation therapy. Moreover, study participants received anastrozole, letrozole, or exemestane for at least one year. Kaplan Meier estimation survival curve was used to analyze the survival rate. Result: Of 79 patients meeting inclusion criteria, there were 21.52% distant metastases documented. Time to disease progression of anastrozole, letrozole, and exemestane was 49 months, 58 months, and 53 months, respectively. Letrozole was found better than anastrozole (hazard ratio (HR)=4.342, 95% CI 0.95-19.95; p=0.038). Letrozole versus exemestane (HR=2.757, 95% CI 0.53-14.33; p=0,206) and anastrozole versus exemestane (HR=1.652, 95% CI 0.56-4.84; p=0.351) were found not significantly different. 5-y DFS rate of letrozole was better found (87.5%) than exemestane (73.7%) and anastrozole (61.4%). Conclusion: 5-year letrozole administration could be proposed as first-line therapy for postmenopausal women with HR-positive HER2-negative BC. A considerable subject and long-term follow-up are needed for validation.

Cost effectiveness of cervical cancer prevention strategies in Indonesia

Background: The development of several HPV-related control techniques for the prevention of cervical cancer followed the identification of a link between high-risk human papillomavirus (HPV) infection and the occurrence of cervical cancer. Objective: The objective of the current study was to determine how cost-effective the different cervical cancer screening programs and HPV vaccinations in Indonesia. Methods: The lifetime costs and effects of vaccination among adolescent girls or screening with either the VIA, Papanicolaou, or HPV DNA test at various time intervals in a hypothetical cohort of 30-65 years-old women were estimated using a Markov model based on a societal perspective. Results: Based on statistics on transition probabilities, efficacy of HPV vaccination, and diagnostic accuracy of screening procedures. The findings of this study, specifically the cost-effectiveness of preventing cervical cancer with vaccination, revealed that each woman’s vaccination cost was $16. The amount of disease-adjusted life years (DALYs) that may be saved was $213, and the averted cost per death was $1.438. Conclusion: Early cervical cancer screening using the IVA test method has a net cost of $576 for years of quality-adjusted life saved and costs $18 each examination for each woman, $1,532 for each preventable death. When the group of teenage girls who received the HPV, vaccine reaches the age of 30, the VIA screening frequency should be decided depending on the cohort’s overall HPV vaccination coverage. (AU)

Translation, cultural adaptation, and psychometric validation of the Persian hypertension self-management questionnaire in South Sumatera, Indonesia

Background: Poor self-management has been associated with uncontrolled blood pressure in hypertensive patients. A valid instrument is needed to assess the self-management of hypertensive patients, especially to measure self-management changes after health workers’ intervention. Objective: To examine the psychometric properties Persian Hypertension Self-Management Questionnaire among patients with hypertension in Indonesia. Methods: Data collection was carried out cross-sectionally using convenience sampling; obtained 407 hypertensive patients in ten primary health centers in South Sumatra Province. The translation of the questionnaire has been carried out by applying forward-backward methods. The Face validity test based on respondents’ responses to each question item was evaluated descriptively. We evaluated content validity by an expert with qualitative and quantitative; known group validity was analyzed using chi-square. Internal consistency reliability test using Cronbach alpha and test-retest reliability using Pearson correlation test or Pearson Spearman rank correlation. Results: Content validity by the expert shows sentence improvement, and CVI value = 1.00. Face validity shows that respondents can understand well to the questionnaire, and the known group validity was considered very good, as indicated by a significant relationship between the level of self-management and blood pressure control (p <0.001). The reliability assessment on internal consistency was 0.823 with a range of values for each domain, namely 0.710 - 0.823, and Test-retest reliability of 0.707 (p <0.001) with values ranging from 0.600 - 0.906. Conclusions: The Persian Hypertension Self-Management Questionnaire has been translated into the Indonesian version and has satisfactory validity and reliability for assessing self-management in hypertensive patients in Indonesia. (AU)

Breast, cervical, and lung cancer: A comparison of real healthcare costs and INA-CBGs rates in the era of national health insurance.

Background: In Indonesia, the cost of cancer treatment has been determined by the Indonesian Case Base Groups (INA-CBGs) based on a code called the INA-CBG's rates. However, a fair claim should be based on the severity of the disease and the class of treatment in the hospital, not on the rates of code. In fact, the real cost of therapy for cancer is influenced by several factors including stage, comorbidity, and severity (INA-CBGs coding, type of hospital, hospital class, treatment grade, side effects, and length of stay), so in many cases, there are reported differences between the real costs and the INA-CBGs rates charged to patients. Objective: This study aims to investigate the difference between real treatment costs and INA-CBG's rates for cases of lung cancer, cervical cancer, and breast cancer at a cancer center hospital in Indonesia. Methods: This work uses an observational study, and the data were taken retrospectively from hospital financial data and patient medical records. The data were then analyzed using a one-sample t-test to determine the difference between real costs and INA-CBGs costs. Results: The results showed that there was no significant difference between real costs and INA-CBG's cost on stage II lung cancer treatment in grade 2 with a sig. value of 0.683; code C-4-13-II in grade 3 with a sig. value of 0.151; and code C-4-13-III in grade 3 with a sig. value of 0.650; where the significance level (t alpha) is more than 0.05. Furthermore, the treatment costs for cervical cancer with codes C-4-13-I and C-4-13-II in grade 1 had sig. values of 0.155 and 0.720 respectively. Lastly, the treatment cost for breast cancer patients with codes C-4-12-II in grade 3 had a sig. value of 0.145 and code C-4-13-II in grade 3 showed a sig. value of 0.091. Conclusion: Although statistical evaluation showed a significant difference for some cases and not significant for other cases, in real conditions, there is a difference between the INA-CBGs and the real costs that must be evaluated by the government and stakeholders to provide justice for cancer patients.

Breast, Cervical, and Lung Cancer: A comparison of Real Healthcare Costs and INA-CBGs Rates in the Era of National Health Insurance

Background: In Indonesia, the cost of cancer treatment has been determined by the Indonesian Case Base Groups (INA-CBGs) based on a code called the INA-CBG’s rates. However, a fair claim should be based on the severity of the disease and the class of treatment in the hospital, not on the rates of code. In fact, the real cost of therapy for cancer is influenced by several factors including stage, comorbidity, and severity (INA-CBGs coding, type of hospital, hospital class, treatment grade, side effects, and length of stay), so in many cases, there are reported differences between the real costs and the INA-CBGs rates charged to patients. Objective: This study aims to investigate the difference between real treatment costs and INA-CBG’s rates for cases of lung cancer, cervical cancer, and breast cancer at a cancer center hospital in Indonesia. Methods: This work uses an observational study, and the data were taken retrospectively from hospital financial data and patient medical records. The data were then analyzed using a one-sample t-test to determine the difference between real costs and INA-CBGs costs. Results: The results showed that there was no significant difference between real costs and INA-CBG’s cost on stage II lung cancer treatment in grade 2 with a sig. value of 0.683; code C-4-13-II in grade 3 with a sig. value of 0.151; and code C-4-13-III in grade 3 with a sig. value of 0.650; where the significance level (t alpha) is more than 0.05. Furthermore, the treatment costs for cervical cancer with codes C-4- 13-I and C-4-13-II in grade 1 had sig. values of 0.155 and 0.720 respectively. Lastly, the treatment cost for breast cancer patients with codes C-4-12-II in grade 3 had a sig. value of 0.145 and code C-4-13-II in grade 3 showed a sig. value of 0.091. (AU)

Treatment Outcomes of Multidrug-Resistant Tuberculosis Patients in East Java, Indonesia: A Retrospective Cohort Analysis.

Background: The drug regimen for the treatment of multidrug-resistant tuberculosis (MDR-TB) has lower potency, is more costly, and has a greater risk of adverse effects than first-line anti-TB drugs. We aimed to compare the treatment outcomes of patients using standard shorter regimen (STR regimen) versus bedaquiline (BDQ)-containing individual regimen in a high TB-burden setting. Methods: This was a retrospective cohort study using secondary data from the medical records in the hospital. The study population were patients with MDR-TB who started treatment in 2016-2018. Treatment outcomes were classified as successful (cured/completed treatment) or unsuccessful (failure/death/loss to follow-up/not evaluated). Categorical data were presented as frequencies and percentage, whereas continuous data were presented as mean± standard deviations. Risk ratio (RR) was obtained by using the Chi-square statistical test with 95% confidence interval (CI) and P < 0.05 set as a significant result. Results: We included 99 patients out of 444 registered patients in 2016-2018. The overall success proportion was 41.4%. Success was more likely in patients who received BDQ regimen than those receiving STR regimen (52.9% vs. 35.4%, RR: 1.496, 95% CI: 0.948-2.362). Factors that influenced the treatment outcomes were smear status and sputum culture status. Conclusions: The success rate of the STR regimen and the BDQ regimen in this study is still below the national and global figures due to the high rate of lost to follow-up. The success was higher in the BDQ regimen, although not statistically significant. Further research is needed on adverse effects, quality of life, and costs during treatment.

Does Trastuzumab Offer Good Value for Money for Breast Cancer Patients with Metastasis in Indonesia?

OBJECTIVE: Breast cancer is the most common cancer in Indonesia, with Indonesia's breast cancer mortality rate being the highest among Southeast Asian countries. This study aims to evaluate the cost-effectiveness and budget impacts of adding trastuzumab to chemotherapy versus chemotherapy alone for HER2-positive breast cancer patients in Indonesia. METHODS: We performed a Markov model-based economic evaluation to assess cost-effectiveness, cost-utility, and budget impact. Utility data, direct medical costs, and indirect costs were obtained primarily from interviewing patients. Clinical effectiveness data, on the other hand, were obtained from systematic reviews and real-world data and represented through progression free survival, overall survival, and quality-adjusted life years (QALYs). RESULT: From a healthcare provider's perspective, the total costs for the combined group were USD 14,516, while chemotherapy alone cost USD 7,489. While the cost-effectiveness analysis showed that the combination group had a higher total cost by USD 7,027, PFS was longer in the chemotherapy alone group, with a difference of 2.2 months. The ICER was USD 17,307 for every QALY gained. The total cost of adding trastuzumab over a 5-year period was USD 589 million. CONCLUSION: In conclusion, this economic evaluation suggests that the addition of trastuzumab to standard chemotherapy is not cost-effective in terms of PFS and OS compared with chemotherapy alone.
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Prediction of Productivity Costs Related to Cervical Cancer Mortality in Indonesia 2018.

Background: Cervical cancer is the second leading cause of death in Indonesia, causing a significant societal burden. This study aims to quantify the burden of cervical cancer in terms of years of life lost (YLL) and productivity cost to support the idea that cervical cancer has substantial economic implications. Methods: Using an epidemiological approach on the prevalence data of 2018, the productivity cost and YLL were estimated by calculating the number of cervical cancer deaths, life expectancy, annual earnings and employment participation rate. Cervical cancer mortality data were obtained from the Global Cancer Observatory (GLOBOCAN) 2018, life expectancy for Indonesia from the WHO Life Tables (2019), and the annual earnings and participation rate of Indonesia were retrieved from the National Statistics Bureau (2018). Results: In 2018, there were 17,253 deaths due to cervical cancer in Indonesia, resulting in 246,350 YLL with a total productivity cost of Indonesian Rupiah (IDR)23,174 trillion. The age group of 50 years old-64 years old experienced the greatest loss of earnings (IDR12,149 trillion), followed by the 35 years old-49 years old (IDR8,944 trillion) and 20 years old-34 years old (IDR8,944 trillion) age groups. Conclusion: The productivity impact of loss of earning due to cervical cancer mortality is significant. This information may assist decision makers in allocating scarce resources among competing priorities.

Health related quality of life among postmenopausal woman with hormone responsive HER2- breast cancer in Indonesia.

OBJECTIVES: Breast cancer (BC) in women could decrease health-related quality of life (HRQoL). HRQoL becomes important to be assessed to design a relevant treatment that could improve patient outcomes. Furthermore, assessing HRQoL by measuring health state utilities becomes pivotal for health economic evaluation. This study aimed to describe the HRQoL of postmenopausal women with hormone responsive (HR+) HER2- BC using the EQ5D5L instrument in Indonesia. METHODS: A cross-sectional study was conducted among 126 patients in Dr. Sardjito Hospital in Indonesia. The HRQoL was assessed by interviewing BC patients using the EQ5D5L questionnaire, and the utility index was calculated using the Indonesian value set. Information regarding clinical characteristic and socio-demographic were gained from patient medical records. One-way ANOVA and post-hoc Scheffe's test was performed to compare the utility score within the health state. RESULTS: Of the 126 patients, a mean ± SD for the age of 59.2 ± 6.1 years. The major problems of patients were pain/discomfort (75.4%) followed by anxiety/depression (54.8%). The mean (SD) of EQ5D VAS was 76.64 (14.91). Mean (SD) of utility score was 0.87 (0.10), 0.77 (0.19) and 0.58 (0.44) for free metastasis (FM), locoregional metastasis (LM) and distant metastasis (DM), respectively. Poor QoL was observed at DM health state (p<0.05). CONCLUSIONS: HRQoL of postmenopausal women with HR+ HER2- BC was low. The major reported problems were pain/discomfort and anxiety/depression.

Economic Evaluation of Adding Bevacizumab to Chemotherapy for Metastatic Colorectal Cancer (mCRC) Patients in Indonesia.

OBJECTIVE: Since 2016, bevacizumab has been widely used to treat metastatic colorectal cancer (mCRC) in Indonesia. Nevertheless, the high cost of bevacizumab has raised the question of whether the therapy is considered cost-effective and should be included in the national health insurance system. This study aimed to assess the cost-effectiveness of bevacizumab plus chemotherapy versus chemotherapy alone for the treatment of mCRC patients. METHODS: A Markov model was applied using the perspective of the Indonesian healthcare system to assess cost-effectiveness. The health outcomes were expressed in terms of quality-adjusted life years (QALY) using the validated EuroQoL-5D-5L instrument. Data for medical costs were collected from hospital billings in four hospitals located in three different cities in Indonesia. Meanwhile, data for utility were obtained from interviewing 90 patients who came to the hospital. We compared those mCRC patients who received chemotherapy alone either with FOLFOX or FOLFIRI, versus patients who received the addition of bevacizumab. RESULTS: With the perspective of societal, the incremental cost-effectiveness ratio (ICER) of adding bevacizumab was USD 49,312 per QALY gained using secondary data and USD 28,446 per QALY using real world data. CONCLUSION: Using either a healthcare or societal perspective, the addition of bevacizumab for mCRC treatment was considered not cost-effective.

Health-Related Quality of Life Among Children With Pneumonia in Indonesia Using the EuroQoL Descriptive System Value Set for Indonesia.

OBJECTIVE: In Indonesia, no study has been published to evaluate the utility scores among children with pneumonia. This study aims to quantify the health-related quality of life (HRQOL) of children with pneumonia in Indonesia using the EuroQoL Descriptive System (EQ-5D-5L) value set for Indonesia. METHODS: A hospital-based cross-sectional survey was conducted between September 2017 and March 2018. Children aged <14 years old who were hospitalized for pneumonia in 11 hospitals in Yogyakarta were recruited for this study. The EQ-5D-5L and visual analogue scale (EQ-VAS) were applied to the parents (proxy-assessment). RESULTS: A total of 384 patients were hospitalized with pneumonia. Among those patients, 338 (88.02%) were without congenital diseases; and 46 (11.98%) were with congenital diseases. The mean of utility scores in all patients was 0.67 ± 0.28, while the mean of visual analog scale (VAS) score was 67.66 ± 21.98. The mean of utility scores and VAS scores decreased among those with congenital diseases, which is 0.51 ± 0.51 and 65.41 ± 19.42, respectively. However, the utility score and VAS scores among patients without congenital diseases were higher than the category of all patients. Showing the number of,0.69 ± 0.23 and 68.0 ± 22.3, respectively. CONCLUSIONS: This study confirmed that children with pneumonia had a negative impact on HRQOL. The HRQOL could be used for future economic evaluation studies.

Translation, Cultural Adaptation, and Validation of Short-Form 6D on the General Population in Indonesia.

OBJECTIVES: This study aims to translate, culturally adapt, and validate the Short-Form 6D (SF-6D) instruments for measuring quality of life as outcome parameters in pharmacoeconomic studies. METHODS: The forward-backward methods were applied to translate the SF-6D questionnaire. A preliminary Indonesian version of SF-6D questionnaire was field tested in samples of 470 adult general population. Test-retest reliability was assessed by using Spearman rank correlation coefficient and internal consistency with Cronbach α. Face validity was assessed descriptively based on the response of the respondents to all items in SF-6D. The construct validity test included internal construct validity and convergent validity, which was assessed by examining the correlation between the questionnaire and Euro-Quality of life-5D based on the scale of each domain. The known group method was used to test discriminant validity. Mann-Whitney U test was employed for comparing the utility score on dichotomous variables and Kruskal-Wallis H test was used for polychromatic variables. RESULTS: The SF-6D was a valid and reliable questionnaire, indicated by the reliability coefficient of 0.725 and the value of each item ranging from 0.698 to 0.750. Construct validity indicated a strong correlation between physical functioning, role limitation, social functioning, pain, and mental health with the SF-6D utility score. Convergent validity showed a weak and moderate correlation between dimensions on SF-6D and Euro-Quality of life-5D. CONCLUSIONS: The SF-6D questionnaire has been translated into Indonesian version. The SF-6D questionnaire is valid and reliable. Known group validity shows that the SF-6D could differentiate utility scores by age group and history present illness.

Translation, cultural adaptation, and validation of the quality of well being self-administered questionnaire in general population in Indonesia.

Background The quality of well being self-administered (QWB-SA) questionnaire is one of the generic instruments which can be used to measure the utility score to assess the quality-adjusted life years (QALYs) as an outcome parameter in pharmacoeconomics study. This research aimed to study the translation, cultural adaptation, and validation of the QWB-SA questionnaire in Indonesian language. Methods This research was conducted among the general population of 459 people in Yogyakarta city. The translation was done using the forward-backward method by independent linguists, and then reviewed by a team consisting of linguists, methodologists, and pharmacists. The psychometric evaluations included face validity, internal-construct validity, convergent validity, and known-group validity tests, while the reliability test was the test-retest of reliability with the Spearman's rank correlation and Pearson test. Results The translation results and cultural adaptations were modified from the aspect of idiomatic, semantic and conceptual equivalence of the items on the QWB-SA questionnaire. The internal-construct validity showed a very strong and moderate correlation among dimensions and the QWB utility index. The convergent validity showed moderate-to-weak correlation compared to the Euro-quality of life-5 dimension questionnaire. The reliability test showed the Cronbach alpha coefficient of 0.626, and the test-retest of reliability showed a strong and moderate correlation. Conclusions The QWB-SA questionnaire is valid and reliable, and can be used as an alternative to measure utility as a QALY's parameter in the health-economic evaluation.

Health- Related Quality of Life for Multiple Myeloma Patients with Bone Metastases in Indonesia: A Cross-Sectional Study.

OBJECTIVE: Multiple myeloma (MM) with bone metastases causes a skeletal-related event (SRE), and decreases health-related quality of life (HRQoL). HRQoL needs to be evaluated for health technology assessment (HTA). Furthermore, HRQoL is calculated as a health state utility and is used in the Markov Model for HTA. Therefore, this study aimed to describe the HRQoL of MM patients with bone metastases, using The EuroQol five-dimension five levels (EQ -5D-5L) in Indonesia. METHODS: a cross-sectional, multicenter study for MM patients with bone metastases (aged over 18 years old) that consulted a physician between November 2018 - May 2019 was conducted. The calculated HRQoL illustrated the health state utility, which was assessed using the EQ-5D-5L questionnaire, with the Indonesian value set. In addition, Mann-Whitney analyses were performed to determine the difference in utility scores at different points within the Durie-Salmon staging system and skeletal condition. RESULTS: in 93 patients who completed the questioner, pain was their major concern with prevalence of over 60% (all levels inclusive). Moreover, the mean utility of patients in stage II and III were 0.735 (SD = 0.205) and 0.383 (SD = 0.555), and those without SRE was 0.753 (SD = 0.213) while patients with SRE was 0.302 (SD = 0.562). Therefore, the lessened values were observed at stage III and SRE condition (p<0.05). CONCLUSION: MM patients with bone metastases have poor HRQoL, with pain as the most frequently reported challenge, which is associated with an advanced stage of MM and SRE event.

Estimating Premature Mortality Cost of Cancers Attributable to Obesity in Indonesia

Obesity is one of the risk factor of non-communicable diseases, one of them is cancer. It may lead to the escalation of mortality. Indonesia is the top 10 country with the highest prevalence of cancer burden due to obesity. The chance of cancer caused by obesity is estimated epidemiologic descriptive and prevalence-based estimation with obesity attributable cancer mortality and Premature Mortality Cost as indicators. Obesity-related cancer mortality is calculated by multiplying Obesity Attributable Fractions (OAFs) rate by cancer death rate, which OAFs rate obtained by calculating obesity prevalence data and relative risk of each disease. Premature Mortality Cost was calculated by multiplying obesity-related cancer mortality, life expectancy, and Indonesian average income. The highest total mortality's rate for obesity-related cancer and overweight-related cancer are colon cancer (929 deaths), ovarian cancer (599 deaths), and pancreatic cancer (190 deaths). The highest value of Premature Mortality Cost are IDR 61,118 million for ovarian cancer, IDR 56,651 million for colon cancer, and IDR 15,472 million for pancreatic cancer. The estimation of cancer burden due to obesity shall be done to help the government determines the health programs and decrease the number of cancer burden due to obesity in Indonesia.

Comparison of Real Cost Versus the Indonesian Case Base Groups (INA-CBGs) Tariff Rates Among Patients of High- Incidence Cancers Under the National Health Insurance Scheme

Background: The national health insurance of Indonesia has implemented the Indonesian Case Base Groups (INA-CBGs) tariff rates for healthcare payment. However, there is still problem of difference between the real cost of healthcare and the INA-CBGs tariff rates. This study aimed to evaluate the real cost of healthcare in comparison with the INA-CBG's tariff rates and to analyze factors associating with the real cost. The study focus on healthcare cost of non-chemotherapy expenditure among patients of high-incidence cancers having chemotherapy covered by the national health insurance. Methods: The study was conducted from the perspective of healthcare provider. Costs data was obtained from hospital billing of Sanglah hospital, a referral hospital in Bali Provincein the period of January ­ July 2014. The data involved 383, 161, and 152 of in-patient breast cancer cases, cervical cancer cases, and nasopharyngeal cancer cases, respectively. Descriptive statistic was used to analyze patients characteristics, one sample t-test was used to analyze the mean difference of healthcare cost based on real cost and INA-CBG's tariff rates, and finally, bivariate analysis was used to examine relationship between patients' characteristics and the real cost. Results: The study shows there were significant differences of non-chemotherapy expenditures based on the real cost and INA-CBG's tariff rates, in which the costs were lower for the real cost. Factors which significantly associated with the real cost were number of procedure, type of hospitalized room, and length of stay. Conclusions: The study supports the necessary of evaluation of the INA-CBG's tariff rates to adjust to the real healthcare expenditure. On the other hand, the hospital needs to evaluate the service quality of patient treatment by optimizing budget allocated by the health insurance.

Estimating the Burden of Cancer and Treatment Cost Related to Alcohol Consumption in Indonesia: a Descriptive Study

Background: Alcohol consumption has become one of the most common cancer risk factors after smoking. Nowadays, estimation of the burden of disease attributable to alcohol has become standard in documenting the impact of health problems, but it has been rarely performed in Indonesia. The aim of this study was to estimate treatment cost of cancer related to alcohol consumption among the Indonesian population. Methods: This research design was descriptive with a prevalence-based approach using secondary data. Proportions of cancers were calculated using an alcohol-attributable fractions (AAF) formula. Treatment costs for eight types of cancer were assessed according to average treatment cost per patient from the national universal health coverage database for 2016. Result: The top three AAFs for males were cancers of the pharynx, esophagus and larynx (17.5%, 15.3% and 7.98%, respectively), while in females they were cancers of the esophagus, pharynx and stomach (2.15%; 1.39%; 0.83%). Among the eight types of cancer studied, the highest incidence in males was noted for liver cancer (132 cases) while colorectal cancer was the most common among females (31 cases). Treatment cost for cancers related to alcohol consumption were highest for colorectak cancer followed by laryngeal and liver cancer (116,083, 98,325 and 93,253 USD, respectively. Conclusion: The expenditure for treatment of cancers related to alcohol consumption accounts for about 1.71% of total cancer treatment cost. Since cancers related to alcohol consumption can be considered having an economic impact in Indonesia, it becomes important for the government to control alcohol consumption so that related healthcare expenditure can be minimized.

Knowledge, Perception, and Acceptance of HPV Vaccination and Screening for Cervical Cancer among Women in Yogyakarta Province, Indonesia

Objective: To determine knowledge, perception, and acceptance related to cervical cancer, HPV vaccination and screening for cervical cancer among Indonesian women, particularly in Yogyakarta province. Methods: A convenience sample of 392 women consists of 192 young women, 100 mothers of girls aged 12 ­ 15 years, and 100 adult women in Yogyakarta province, Indonesia was participated in this study. A self-administered paper-based questionnaire was used to determine demographics characteristics of respondents, as well as their knowledge ­ perception ­ acceptance related to cervical cancer, HPV vaccination, and screening for cervical cancer. Data collection were conducted during December 2013 to March 2014. Descriptive statistics was used to analyze description of demographics characteristics, knowledge, perception, and acceptance; while crosstab analysis using Chi-Square was used to analyze the relationship between demographics characteristics versus knowledge, perception, and acceptance. Results: This study found that knowledge and perception regarding cervical cancer, HPV vaccination, and screening for cervical cancer among women in Indonesia, particularly in Yogyakarta Province were still insufficient, however the acceptance was good. Among female young women, 64% had good knowledge, 62% had positive perception of cervical cancer and HPV vaccination, and 92% tended to accept HPV vaccination. Among mothers of girls aged 12 ­ 15 years, 44% had good knowledge, 46% had positive perception of cervical cancer and HPV vaccination, and 91% tended to accept HPV vaccination for their daughters. Among adult women, 68% had good knowledge, 57% had positive perception of cervical cancer and screening for cervical cancer, and 90% tended to accept cervical cancer screening. In general, demographics characteristics of having experience and exposure to information had significant relationship with knowledge, perception, and acceptance of HPV vaccination and screening for cervical cancer. Conclusions: Either knowledge or perception of cervical cancer and strategies toward it among Indonesian women particularly in Yogyakarta province were still unsatisfied. Efforts should be improved for supporting cervical cancer prevention and control in Indonesia through such as education on cervical cancer disease and strategies toward it.