Dr. FX. Suharnadi, SpPD-KEMD

Bagian Penyakit Dalam-Endokrinologi

RS Panti Rapih

Yogyakarta

Diabetes: A global emergency

Diabetes around the world

Diabetes around the world

Diabetes around the world

Diabetes around the world

Diabetes around the world

Diabetes around the world

Diabetes around the world

Diabetes around the world

Diabetes around the world

Diabetes around the world

The Indonesian Perspective

Adults with diabetes will increase from 6.9 million in

2010 to 11 million in 20301

Prevalence in urban regions was 5.7% in 20072

Rates are consistently higher in urban areas,

however many rural areas present with high rates2,3

Incidence of late diabetes complications will rise and

have huge impact on society (costs, healthcare

services, psychosocial burden)

Immediate country-wise measures to prevent and

manage diabetes are required

1. IDF Diabetes Atlas 5th Edition

2. Riskesdas (National Basic Health Research) 2007

3. Noncommunicable diseases in South-East Asia Region. WHO 2011

4. Soewondo et al. DiabCare Asia 2008 Study. Med J Indones 2010.

Global Healthcare Burden

Diabetes = 11.6% of total healthcare

expenditure in the world or at least 376 billion

USD (2010)

By 2030, expenditure will be 490 billion USD

World Diabetes Foundation 2012.

The Cost of Diabetes

Direct Costs Personal Drugs, supplies, insurance

Direct Costs Healthcare System Treatment and

rehabilitation

Hospital and healthcare professional services

Products, supplies, tests

Hospital admissions

Indirect Costs

• Loss of productivity

• Premature retirement

• Premature mortality

• Pain, anxiety and

inconvenience decrease

quality of life

• Work discrimination

• Negative effect on

relationships, mobility and

leisure activities

WHO Fact Sheet 2012

Diabetes Cost: Indonesia

Diabetes treatment at 2010 :

Total cost > 23 million US$ (384.312 patients)

DM without complications : > 9 million US$

(258.208 patients)

DM with complications : > 14 million US$

(126.104 patients)

Annual cost for each diabetes patient

Without Complications + 40 US$

With Complications + 900 US$

Health Expenditures for Health Insurance

(ASKES 2010)

1.249

1.678 2.007

2.539 2.720

3.673

4.300

-

500,00

1.000,00

1.500,00

2.000,00

2.500,00

3.000,00

3.500,00

4.000,00

4.500,00

5.000,00

2004 2005 2006 2007 2008 2009 2010

Bill

ions

Healthcare

Indonesian Ministry of Health

APA YANG HARUS KITA LAKUKAN ?

Menekan prevalensi diabetes

Mencegah timbulnya komplikasi

Mengendalikan faktor risiko

Menegakkan diagnosis secara tepat

Memberikan terapi secara adekuat

Melakukan edukasi dengan baik

Melakukan pengendalian biaya kesehatan

Melakukan kerjasama dalam team

Mengenali masalah

Identifikasi penyebab

Mengenali sumber daya

Melakukan penanganan secara tepat

Monitoring dan evaluasi

PERKENI: Standard Values of Random Blood Glucose

and Fasting Blood Glucose for Screening and

Diagnosis of DM (mg/dL)

Non DM Uncertain DM DM

Random

blood glucose

level

(mg/dL)

Venous

plasma

<100 100-199 ≥200

Capillary blood <90 90-199 ≥200

Fasting blood

glucose level

(mg/dL)

Venous

plasma

<100 100-125 ≥126

Capillary blood <90 90-99 ≥100

Note:

For high-risk groups which show no abnormal results, the test should be done

every year. For those aged > 45 years without other risk factors, screening can

be done every 3 years.

PERKENI GUIDELINES 2011

Classification of DM

T1DM

β-cell destruction, usually leading to absolute insulin deficiency, autoimmune, idiopathic

T2DM

Varied, ranging from dominant insulin resistance accompanied by relative insulin deficiency to a predominantly insulin secretory defect with insulin resistance

Other Types

Genetic defect of B-cell function, genetic defect of insulin, endocrinopathy, infection, due to drug or chemical substance, exocrine pancreatic disease

Gestational DM

Any degree of glucose intolerance with onset or first recognition during pregnancy

Main Pathophysiological Defects

in T2DM

Hyperglycemia

peripheral glucose uptake

hepatic glucose production

pancreatic insulin secretion

pancreatic glucagon secretion

gut carbohydrate delivery & absorption

incretin effect

?

+

-

-

Adapted from: Inzucchi SE, Sherwin RS. In: Cecil Medicine 2011 .

Many Organs Involved

in Glucose Balance

○ Absorb food

○ Produce incretin hormone to induce insulin release

○ Produce insulin to increase glucose absorption

○ Produce glucagon, which is involved in glucose

production during fasting

○ Store glucose in form of glycogen need insulin

○ Produce glucose from glycogen need glucagon

○ Major site for glucose metabolism (70 – 80%) need

insulin

○ Site for deposition of excessive calories need insulin

Blood

Glucose

• Absorption

• Gluconeogenesis

• Insulin hormone

• Glucose usage

• Store energy (lypogenesis)

• Incretin hormone

• Glycogenesis

• Glucagon hormone

• Release energy (lypolysis)

Many Organs Involved

in Glucose Balance

Blood

Glucose

Glucose

uptake

Incretin

β-cell:

insulin

α-cell:

glucagon

Lipolysis

Lipogenesis

Glycogenesis

Gluconeogenesis

Alfa-glucosidase

Adipocytes

Pancreas Muscle

Many Organs Involved

in Glucose Balance

T2DM is a Progressive Disease Characterized by

Insulin Deficiency and Insulin Resistance

Inherited/acquired factors Overweight, inactivity

(inherited/acquired)

Gluco-

lipotoxicity

Glucose uptake

Insulin resistance Insulin deficiency

Hyperglycemia

T2DM

FFA

Glucose production in the liver

Yki-Järvinen H.

In: Textbook of Diabetes 1, third edition.

Oxford, UK: Blackwell; 2003: p22.122.19.

Insulin Deficiency is Often Already

Established when T2DM is Diagnosed

20

15

10

5

0

10 5 0 5 10 15 20 25 30 Years

Insulin level

Insulin resistance

-cell failure

250

200

150

100

50

0 Rela

tive

-ce

ll

fun

cti

on

(%

)

Fasting glucose

Postprandial glucose

Glu

co

se

(mm

ol/

l)

Clinical

features MICROVASCULAR CHANGES

MACROVASCULAR CHANGES

DIAGNOSIS

Adapted from Rhodes CJ. Science. 2005;307:380-4.

Genetics T2DM

In most cases involves environmental

influences (e.g. diet, lifestyle) on a

susceptible genetic background.

Family history is an important risk factor

Genetic factors likely to play a role in the

propensity to develop insulin resistance and in

the risk of β-cell failure.

Environmental & genetic factors can lead to risk

factors of high BMI and/or abdominal fat

ADA. Medical Management of Type 2 Diabetes. 7th Edition. 2012

Risk of Developing Diabetes

• ADA Risk Test assigns points in the

following criteria:

Age

Gender

History of gestational diabetes

Family history of diabetes

Physical activity

Weight relative to height Daly A, Power MA. Medical Nutrition

Therapy. Diabetes Mellitus and Related

Disorders; Medical Management of Type 2

Diabetes, 7th Edition. American Diabetes

Association, 2012.

http://www.diabetes.org/diabetes-basics/prevention/diabetes-risk-test/?loc=DropDownDB-RiskTest

ADA Risk Test

If you get over a specific score, the test

indicates that you are at increased risk

for T2DM.

Recommends seeing a doctor to:

• Screen for T2DM or prediabetes

• Discuss ways to reduce your risk

http://www.diabetes.org/diabetes-basics/prevention/diabetes-risk-test/?loc=DropDownDB-RiskTest

Risk Factors

Risk

Factors

Family history

History of gestational diabetes

High BMI/abdominal obesity

High blood pressure

Sedentary lifestyle

It is important to try to identify patients at

the prediabetes stage to help prevent the development

of T2DM and associated complications.

http://www.diabetes.org/diabetes-basics/prevention/diabetes-risk-test/?loc=DropDownDB-RiskTest

PERKENI: Standards of Care

Diabetes care must be:

Continuous, not episodic

Proactive, not reactive

Planned, not sporadic

Patient centered rather than provider centered

Population based, as well as individual based

Team care

PERKENI: Standards of Care

Ideal core team members:

A physician or other primary care provider

A nurse

A dietician (at least one of whom is certified

diabetes educator)

Other team members will vary according to the

patient need, patient load, organization constraints,

resources, clinical setting and professional skills

e.g.: podiatrist, pharmacist, psychological or social

workers

Mensing C. Diabetes Care 2000:23:682-9.

PERKENI: Screening

Screening is conducted on those who have diabetes risks, but do not show any symptoms of DM.

Screening seeks to capture undiagnosed DM or prediabetes so it can be managed earlier and more appropriately.

Mass screening is not recommended considering the costs, which are generally not followed by action plan for those who were found abnormal.

PERKENI: Diabetes Prevention

High-risk population at

< 30-year old

• Family history of DM

• Cardiovascular disorder

• Overweight

• Sedentary life style

• Known IFG or IGT

• Hypertension

• Elevated triglyceride, low

HDL or both

• History of Gestational DM

• History of given birth

> 4000g

• PCOS

• Medical Nutritional

Therapy

• Physical activity

• Weight reduction

• If overweight,

reduce body

weight by 5-10%

• Physical exercise

for 30 minutes,

5 times/week

• Not yet

recommended

Early Detection Lifestyle Changes Pharmacology

Therapy

Periodic Blood

Glucose & Risk

Factor Monitoring

• Hypertension

• Dyslipidemia

• Physical health

• Body weight

control

• 2-hour OGTT is the most

sensitive method for early

detection and a

recommended screening

test procedure

Management

Target of Treatment

Risk CVD (-) Risk CVD (+)

BMI (kg/m2) 18.5 – <23 18.5 – <23

Blood Glucose

• FPG (mg/dL) <100 <100

• Post Prandial BG (mg/dL) <140 <140

A1C (%) <7.0 <7.0

Blood Pressure <130/80 <130/80

Lipid

Total Cholesterol (mg/dL) <200 <200

Triglyceride (mg/dL) <150 <150

HDL Cholesterol (mg/dL) >40 / >50 >40 / >50

LDL Cholesterol (mg/dL) <100 <70

PERKENI GUIDELINES 2011

PERKENI: Patient Education

• Daily activities

Be active most of the time

Be productive

Self-management skills

Preparing pills, insulin

Follow drug schedule

Side effect awareness

Foot care

Daily foot care & appropriate shoes

Medical checkup

PERKENI: Patient Education

Healthy eating: healthy food choices, food composition

(carbs, protein, fat, fiber)

Body weight maintenance: achieved target of BMI or

reduced 5 – 10% of body weight

Exercise

Monitoring: self-monitoring of blood glucose, A1C

Hypoglycemia: awareness & self-treatment

Self-Monitoring

of Blood Glucose (SMBG)

PERKENI Guideline 2011

SMBG: one tool to assess therapy in diabetic patients that is

recommended especially in:

Patients that will undergo insulin therapy

Patients receiving insulin therapy

Patients with A1C level did not reach the target

Women planned for pregnancy / pregnant women with

hyperglycemia

Patients with recurrent hypoglycemia.

Class Mechanism Advantages Disadvantages Cost Biguanides • Activates AMP-

kinase • Hepatic glucose production

• Extensive experience • No hypoglycemia • Weight neutral • ? CVD

• Gastrointestinal • Lactic acidosis • B-12 deficiency • CKD

Low

SUs / Meglitinides

• Closes K-ATP- channels • Insulin secretion

• Extensive experience • Microvasc. risk

• Hypoglycemia • Weight gain • Low durability • ? Ischemic preconditioning

Low

TZDs • PPAR-g activator • insulin sensitivity

• No hypoglycemia • Durability • TGs, HDL-C • ? CVD (pio)

• Weight gain • Edema / heart failure • Bone fractures • ? MI (rosi) • ? Bladder ca (pio)

High

Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of print]

DPP-4 inhibitors

• Inhibits DPP-4 • Increases GLP-1, GIP

• No hypoglycemia • Well tolerated

• Modest A1c • ? Pancreatitis • Urticaria

High

Properties of anti-hyperglycemic agents

Class Mechanism Advantages Disadvantages Cost a-GIs • Inhibits a

glucosidase • Slows carbohydrate absorption

• No hypoglycemia • Nonsystemic • Post-prandial glucose • ? CVD events

• Gastrointestinal • Dosing frequency • Modest A1c

Mod.

GLP-1 receptor agonists

• Activates GLP-1 R • Insulin, • glucagon • gastric emptying • satiety

• Weight loss • No hypoglycemia • ? Beta cell mass • ? CV protection

• GI • ? Pancreatitis • ? Medullary cancer • Injectable

High

Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of print]

Insulin • Activates insulin receptor • peripheral glucose uptake

• Universally effective • Unlimited efficacy • Microvascular risk

• Hypoglycemia • Weight gain • ? Mitogenicity • Injectable • Training requirements • “Stigma”

Variable

Properties of anti-hyperglycemic agents

ADA/EASD Position Statement

The American Diabetes Association and the European

Association for the Study of Diabetes position

statement on the management of hyperglycemia in

T2DM focuses on:

A patient-centered approach

Antihyperglycemic therapy

Implementation strategies

Other considerations

Future directions/research needs

Diabetes Care, Diabetologia June 2012

ADA/EASD Position Statement

Patient-Centered Approach

“…providing care that is respectful of and responsive

to individual patient preferences, needs, and values –

ensuring that patient values guide all clinical

decisions.”

Diabetes Care, Diabetologia June 2012

Principles of Glycemic Control

Initiate treatment program when

hyperglycemia first diagnosed

Define appropriate target goal; glucose

targets should be near normoglycemia

Diabetes education is essential

Dungan KM. Rationale for Management of Hyperglycemia

Principles of Glycemic Control

Monitor glycemic control

Initiate lifestyle modification

Use stepwise/combination

pharmacotherapy

Dungan KM. Rationale for Management of Hyperglycemia

A Stepwise Approach for the Treatment of

Patients with T2DM

Once daily

(optimized)

One prandial

for largest

glucose

excursion

Two prandial

for largest

glucose

excursion

Basal +

three prandial

OHA mono

or

combination

therapy

Diet and

exercise A1C

uncontrolled

A1C uncontrolled, FBG on target

PPBG>8.8 mmol/l (>160 mg/dl)

Basal Insulin

Basal

Bolus Basal

Plus Basal

Plus

A1C <7.0%

Preprandial capillary PG 70–130 mg/dl

Peak postprandial capillary PG <180 mg/dl

ADA-2012

Time

PERKENI 2012; Raccah D. Diabetes Ob Met 2008;10:76-82.

Initiation and Titration of Basal Insulin

Bedtime or morning long-acting insulin

OR

Bedtime intermediate-acting insulin

Daily dose: 10 U or 0.2 U/kg

Increase dose by 2 U every 3 days until

FBG is 3.9–7.2 mmol/L (70–130 mg/dL)

If FBG is >10 mmol/L (>180 mg/dL),

increase dose by 4 U every 3 days

Continue regimen and

check HbA1c every 3 months

In the event of hypoglycemia or

FBG level <3.9 mmol/L (<70

mg/dL), reduce bedtime insulin

dose by ≥4 units, or by 10% if

>60 units

Check

FBG daily

Nathan DM et al. Diabetes Care 2009;32:193-203.

Initiate insulin with a single injection of a basal insulin,

such as insulin glargine

Anti-hyperglycemic Therapy

Glycemic targets

A1C <7.0% (mean PG ~150 – 160 mg/dL

[8.3 – 8.9 mmol/l])

Pre-prandial PG <130 mg/dL (7.2 mmol/l)/

Post-prandial PG <180 mg/dL (10.0 mmol/l)

Anti-hyperglycemic Therapy

Individualization is key

Tighter targets (6.0 – 6.5%) –

younger, healthier

Looser targets (7.5 – 8.0%+) – older,

comorbidities, hypoglycemia prone, etc.

Avoidance of hypoglycemia

Anti-hyperglycemic Therapy

Therapeutic options: lifestyle

Weight optimization

Healthy diet

Increased activity level

Diabetes Care, Diabetologia June 2012

Anti-hyperglycemic Therapy

Therapeutic options: oral agents &

non-insulin injectables

• Metformin • Meglitinides

• Sulfonylureas • a-glucosidase inhibitors

• Thiazolidinediones • Bile acid sequestrants*

• DPP-4 inhibitors • Dopamine-2 agonists

• GLP-1 receptor agonists* • Amylin mimeticsC

*Not available in Indonesia

Diabetes Care, Diabetologia June 2012

Anti-hyperglycemic Therapy

Implementation strategies

Initial therapy

Advancing to dual combination therapy

Advancing to triple combination therapy

Transitions to and & titrations of insulin

Diabetes Care, Diabetologia June 2012

Creation of Innovative Partnerships

PEDI

PERDAMI

PERKENI

PERSADIA

• Provide education

• Strengthen curriculum

• Support training

educators

• Network to provide

referral and treatment

• Recommend patients

screening for DR

• Patient follow up

• Encourage more patients

to become members

• Improve awareness

The benefits of good glycemic control are clear

Good control is HbA1c ≤ 7.0% HbA1c measures the average blood glucose level over the last three months

Source:UKPDS = United Kingdom Prospective Diabetes Study. Stratton IM et al. BMJ. 2000;321(7258):405-412.

Deaths related to diabetes

Microvascular complications

Myocardial infarction

-14%

-37%

-21%

HbA1c

-1%

GSH

+

Intensive Insulin *

+

2 drugs combination

Met, SU, AGI, Glinid,

TZD

+

Basal Insulin

+

3 drugs combination

Met, SU,

AGI, Glinid,

TZD, DPP IV

+

2 drugs combination

Met, SU,

AGI, Glinid,

TZD, DPP IV

+

Monotherapy

Met, SU,

AGI, Glinid,

TZD, DPP IV

HLS

Healthy Lifestyle

• Reduced BW •Healthy Diet • eExercise

HbA1c

<7% <7-8% <8-9% 9-10% >10%

* Intensive insulin : basal bolus approach

HLS

HLS

HLS

HLS

HLS

Indonesian Society of Endocrinology , 2011

Type-2 DM Drug Treatment Guideline

Diabetes Self-Management

Team Care:

Physician

Nurse

Dietitian

Educator

Role of Team Members

To prepare people with

diabetes to make

self-management

decisions on their own People with diabetes

are at the center of

the health team and

can learn to

self-manage

their diabetes

Who’s teaching the diabetics? Etzwiler DD. Diabetes 1967:16:111-7.

PERMASALAHAN KITA

Kurangnya waktu untuk edukasi (jumlah pasien yang meningkat dan waktu terbatas)

Tidak tersedia team khusus management diabetes secara paripurna

Keterbatasan fasilitas pemeriksaan (HBA1C, profil lipid, faal ginjal) maupun obat (acarbose, TZD, Insulin) di faskes primer/sekunder

Keterbatasan apotik yang bekerjasama dengan BPJS

Kepercayaan masyarakat terhadap fasilitas kesehatan

Sistem rujukan berjenjang yang dipandang merepotkan pasien dan keluarga

Perubahan kebijakan yang mendadak dan kurangnya sosialisasi

Kebutuhan untuk Diselenggarakannya

Sistem Rujukan

RS Rujukan

Sekunder dan Tersier “menjadi Puskesmas Raksasa”

Publik tidak percaya pada pelayanan primer

Meningkatnya pembiayaan kesehatan Daerah (jamkesda)

Jaminan Kesehatan Semesta melalui BPJS (Jan 2014)

• Kualitas

pelayanan di

RS Menurun

• Meningkatnya

Jumlah

Kematian di RS

• Kurang

siaganya

pelayanan kes

primer

• Gangguan

Fiskal

(APBN/D)

• Pembelanjaan

pengeluaran

kesehatan

pada keluarga

meningkat

Isu

Strategis

Sebab Dampak

Low

Quality

of Life

Perlu Standarisasi dan Pembenahan Sistem

Rujukan

Self Care

Primary Care

Secondary

Tertiary

Tertiary Care

Rujukan -

Kewenangan

Management of Chronic Disease Program (PROLANIS)

Family Doctor

PROLANIS

Gate-keeper

Manager

Consultant Monitoring

Prescription

Info Askes, edisi Mei 2010

TERIMAKASIH

ADA Recommendations: Testing for

Diabetes in Asymptomatic Patients

Consider testing overweight /obese adults (BMI ≥ 25 kg/m2)

24 kg/m2 in South Asians

• In those without risk factors, begin testing at age 45 years (B)

If tests are normal:

• Repeat testing at least at 3-year

intervals (E)

• Use A1C, FPG, or 2-h 75-g OGTT

(B)

In those with increased risk for future

diabetes:

• Identify and, if appropriate, treat

other CVD risk factors (B)

OGTT = oral glucose tolerance test

ADA. II. Testing in Asymptomatic Patients. Diabetes Care 2014;37(suppl 1):S13.

ADA Recommendations:

Prevention/Delay of T2DM

Refer patients with IGT (A), IFG (E),

or A1C 5.7 – 6.4% (E) to ongoing support

program

Targeting weight loss of 7% of body weight

At least 150 min/week moderate physical activity

Follow-up counseling important for success

(B)

ADA. IV. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2012;35(suppl 1):S16.

ADA Recommendations:

Prevention/Delay of T2DM

Based on cost-effectiveness of diabetes prevention,

third-party payers should cover such programs

Consider metformin for prevention of T2DM if IGT,

IFG, or A1C 5.7 – 6.4%

Especially for those with BMI > 35 kg/m2, age < 60 years

and women with prior GDM

In those with prediabetes, monitor for development

of diabetes annually

ADA. IV. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2014;37(suppl 1):S20.

Review of the Physiologic

Insulin Profile

Daly A, Power MA. Medical Nutrition Therapy.

Diabetes Mellitus and Related Disorders;

Medical Management of Type 2 Diabetes, 7th

Edition. American Diabetes Association, 2012.

BP=blood pressure;

QOL=quality of life

Smooth, steady

basal insulin profile

Breakfast

Seru

m In

su

lin

(m

U/L

)

0800 1200 1600 2000 2400

0

10

20

30

40

50

0400 0800

Lunch Dinner

Mealtime insulin excursions Rapid rise; short duration

Adapted from Kruszynska Y et al. Diabetologia 1987;30:16.

Insulin in Indonesia

PERKENI Consensus Guidelines, 2011.

Type of Insulin Onset of

Action

Peak of

Action

Duration of

Action Presentation

Insulin Prandial (Meal-Related)

Insulin Short-Acting

Regular (Actrapid®, Humulin® R) 30-60 min 120-180 min 5-8 hour Vial,

Pen/Cartridge

Insulin Analog Rapid-Acting

Insulin Lispro (Humalog®) 5-15 min 30-90 min 3-5 hour Pen/Cartridge

Insulin Glulisine (Apidra®) 5-15 min 30-90 min 3-5 hour Pen

Insulin Aspart (Novorapid®) 5-15 min 30-90 min 3-5 hour Pen, Vial

Insulin in Indonesia (Cont’d)

Type of Insulin Onset of

Action

Peak of

Action

Duration of

Action Presentation

Insulin Intermediate-Acting

NPH (Insulatard®, Humulin® N) 2-4 hour 4-10 hour 10-16 hour Vial,

Pen/Cartridge

Insulin Long-Acting

Insulin Glargine (Lantus®) 2-4 hour No Peak 20-24 hour Pen

Insulin Detemir (Levemir®) 2-4 hour No Peak 16-24 hour Pen

Insulin Campuran

70% NPH 30% Regular

(Mixtard®, Humulin® 30/70) 30-60 min Dual 10-16 hour Pen/Cartridge

70% Insulin Aspart Protamin

30% Insulin Aspart (Novomix® 30) 10-20 min Dual 15-18 hour Pen

75% Insulin Lispro Protamin

25% Insulin Lispro (HumalogMix® 25) 5-15 min Dual 16-18 hour Pen/Cartridge

PERKENI Consensus Guidelines, 2011.

Restrukturisasi pelayanan Kesehatan

Regionalisasi Pelayanan Kesehatan

Regionalisasi Sistem Rujukan

Rujuk Balik Sistem Rujukan

Rujukan SOP di beberapa level Pelayanan Kesehatan

Persiapan Regulasi Sistem Rujukan

Sosialisasi media

Alur rencana sistem rujukan

Pengaturan alur pembinaan yankes rujukan Provinsi

•RAWAT INAP

•RAWAT JALAN

•GAWAT

DARURAT

•PROMOTIF

•PREVENTIF

•KURATIF

•REHABILITAT

IF

•PELATIHAN

•PEDIDIKAN

•PENELITIAN

•PENGEMBANGA

N