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Indonesia, with a population of 262,787,403 (July 2018) currently ranks as the fourth most populated country in the world following China, India, and the United States (CIA World Factbook, 2019). The population of Indonesia has been increasing constantly since the 1960s (population of 87,792,515 in 1960). Between 2015 and 2018, the population has grown by 4,625,290 (Subdirectorate of Statistical Demographic, 2013; World Bank, 2019a). Based on the statistics of Indonesia’s population projection, it is estimated that the population size will increase to 305,652,400 by 2035 (Subdirectorate of Statistical Demographic, 2013).

In Indonesia, children aged 0 to 14 years make up 24.63% (male: approx. 33 million; female: approx. 32 million) of the population. The group of the 15 to 24 years old, with 16.94% makes up a slightly smaller proportion (male: approx. 23 million; female approx. 22 million). The age group 25 to 54 year represents the largest share of the Indonesian population in 2018 (42.44%; male: approx. 57 million; female: approx. 54 million). The share of the 55 to 64-year-old with 8.73% is considerably smaller (male: approx. 10 million; female: approx. 12 million). The age group 65 and older reflects 7.26% of the Indonesia population. As in the age group 55-64 years, there are more older women (approx. 11 million) than men (approx. 8 million) among those aged 65 and older (CIA World Factbook, 2019). According to United Nations Population Fund’s report, Indonesia’s population older people is the sixth largest in the world (UNFPA & HelpAge International, 2012).

References:

CIA World Factbook. (2019). Indonesia. https://www.cia.gov/the-world-factbook/countries/indonesia/

Subdirectorate of Statistical Demographic. (2013). Indonesia Population Projection 2010-2035. BPS – Statistics Indonesia.

UNFPA & HelpAge International. (2012). Ageing in the Twenty-First Century: A Celebration and A Challenge. In United Nations Population Fund (UNFPA), New York, and HelpAge International, London. UNFPA-HelpAge. https://www.unfpa.org/sites/default/files/pub-pdf/UNFPA-Exec-Summary.pdf

World Bank. (2019a). Indonesia. https://www.worldbank.org/en/country/indonesia/overview

According to Indonesia’s National Coordinating Agency for Survey and Mapping, the Republic of Indonesia stretches over an archipelago of 13,466 islands out of which 922 are permanently inhabited. However, there is some debate regarding the exact number of islands (Hidayat, 2017). The five largest islands are Papua, Kalimantan (Indonesian Borneo), Sumatra, Java, and Sulawesi (Adam et al., 2019; Embassy of the Republic of Indonesia Washington DC, 2017). The country has a tropical climate, with hot and humid weather all year long (CIA World Factbook, 2019).

The majority of the population is concentrated on the islands of Java and Sumatra (CIA World Factbook, 2019). Java, one of the world’s most densely populated island, houses the majority of the Indonesian population, despite only covering 7% of the total land territory of the country (The Editors of Encyclopaedia Britannica, 2017). Just over half of the Indonesian population (55.3% in 2018) is estimated to live in urban areas. The largest urban areas are the capital Jakarta (10.517 million, 2018) Bekasi (3.2 million), Surabaya (2.9 million), Bandung (2.5 million), Medan (2.3 million), and Tangerang (2.22 million) (CIA World Factbook, 2019).

References:

Adam, A. W., Wolters, O. W., Mohamad, G. S., Legge, J. D., McDivitt, J. F., & Leinbach, T. R. (2019). Indonesia. https://www.britannica.com/place/Indonesia

CIA World Factbook. (2019). Indonesia. https://www.cia.gov/the-world-factbook/countries/indonesia/

Embassy of the Republic of Indonesia Washington DC. (2017). Facts & Figures. https://www.embassyofindonesia.org/index.php/basic-facts/

Hidayat, R. (2017, June 7). Indonesia counts its islands to protect territory and resources. https://www.bbc.com/news/world-asia-40168981

The Editors of Encyclopaedia Britannica. (2017). Java. Encyclopædia Britannica. https://www.britannica.com/place/Java-island-Indonesia

Bahasa Indonesia (Indonesian language) is the official language of Indonesia. There are more than 700 local dialects in Indonesia. Other languages spoken are English, Dutch, and local dialects (CIA World Factbook, 2019).

Statistics Indonesia reported that there are more than 1,300 ethnicities in Indonesia, which are classified into 31 ethnic groups. The largest ethnic group in Indonesia is made up by Javanese (40.22%), followed by Sundanese (15.5%) (Na’im & Syaputra, 2011). According to the CIA World Factbook, Malay, Batak, Madurese, Betawi, Minangkabau, Buginese, Bantenese, Banjarese, Acehnese, Dayak, Sasak, and Chinese are other ethnic groups that make up between four to one per cent of the population (CIA World Factbook, 2019).

There are five main religions reported to be practised in Indonesia. The majority of the population, according to 2010 estimates, identifies as Muslim (87.2%) making Indonesia the largest Islamic country, while maintaining its status as a secular country. Other religious groups in the country are Christians (almost 10%; Roman Catholic 2.9%; Protestant 7%), Hindus (1.7%) and other smaller faith groups (CIA World Factbook, 2019).

Indonesia’s culture is a mix of ancient traditions of the early settlers and Western influence brought during the Portuguese and Dutch colonial era (Fisher, 2018). The principles held highly in the Indonesian society stem from life in the village communities, such as the concept of gotong royong (mutual cooperation) and musyawarah (deliberation) in order to reach mufakat (consensus). These concepts are still very relevant and respected across the country and upheld in politics (Kawamura, 2011; Koentjaraningrat, 2009).

References:

CIA World Factbook. (2019). Indonesia. https://www.cia.gov/the-world-factbook/countries/indonesia/

Fisher, M. (2018). Indonesia People and Culture: Tradition and Custom. Equinox Publishing.

Kawamura, K. (2011). Consensus and democracy in Indonesia: Musyawarah-Mufakat revisited. IDE Discussion Paper, 308, 1–14.

Koentjaraningrat. (2009). Gotong Rojong: Some Social-anthropological Observations on Practices in Two Villages of Central Java.

Na’im, A., & Syaputra, H. (2011). Kewarganegaraan, suku bangsa, agama dan bahasa sehari-hari penduduk Indonesia hasil sensus penduduk 2010. Jakarta: Badan Pusat Statistik.

Indonesia is the fourth most populous country after China, India, and the United States, with a population of 262.79 million people in 2018 (CIA World Factbook, 2019), which is predicted to rise to 305.6 million in 2035 (Subdirectorate of Statistical Demographic, 2013). Population growth rate is estimated to be 0.83% (2018) placing Indonesia on rank 127 (out of 234) in world comparison (CIA World Factbook, 2019).

Since the 1970s, the introduction of family planning programmes and the wider access to health care have contributed to a considerable shift in demographics by reducing fertility and increasing life expectancy. Population projections assume that by 2035 fertility rates will have fallen below replacement level (Adioetomo & Mujahid, 2014, pp.2-3).

In 2010, according to Census data, 7.6 percent of the population in Indonesia (18 million people) were aged 60 year or older. Since 1971, the older population of Indonesia has increased by 3.1 per cent. The proportion of older Indonesians is expected to continue to increase by 8.2 per cent until 2035. This would mean that 15.8 per cent of the population would be aged 60 or older by 2035 (Adioetomo & Mujahid, 2014, p.xv).

In addition, looking at the demographic projections among older Indonesians shows that increasing numbers of Indonesians will be very old. Census data suggests that by 2020 the largest proportion of older people will be aged 60 to 64 years. As this group ages, the number of the older old is expected to grow and the number of younger old will start to decline (Adioetomo & Mujahid, 2014, p.15).

The increasing number of older people as a share of the Indonesian population has implications on the expected support ratio. While there were 7.7 older people supported by 100 workers in 2010, the number of dependents (including children) is expected to increase to 44 per 100 workers  (Adioetomo & Mujahid, 2014; Ministry of Health Republic of Indonesia, 2015b).

References:

Adioetomo, S. M., & Mujahid, G. (2014). Indonesia on The Threshold of Population Ageing – UNFPA Indonesia Monograph Series: No.1. (H. Posselt, Ed.; Issue 1). UNFPA Indonesia.

CIA World Factbook. (2019). Indonesia. https://www.cia.gov/the-world-factbook/countries/indonesia/

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

Subdirectorate of Statistical Demographic. (2013). Indonesia Population Projection 2010-2035. BPS – Statistics Indonesia.

In the last four decades, average life expectancy has increased dramatically, from 45 years in 1971 to 73.2 years in 2018 (70.6 for males and 76.6 for females) (Adioetomo & Mujahid, 2014; CIA World Factbook, 2019). However, the ageing pattern of Indonesia is complex. Indonesia defines older people as people aged 60 or over (Pusat Data dan Informasi Kementerian Kesehatan RI, 2014).

In provinces, where family planning policies showed greatest success, such as in East Java, the proportion of older people is higher than in other parts of the country. In comparison, in East Java the proportion of older people as part of total population growth is estimated to increase by over 24 per cent, while in East Nusa Tenggara older people are only expected to contribute 17.4 per cent to population growth (Adioetomo & Mujahid, 2014, p.xi). The largest proportion of older people in Indonesia (57%) can be found in the three most populated provinces East Java, Central Java, and West Java (over 47% of the Indonesia population). Projections based on 2010 Census data suggest that the proportion of older people will increase across all 33 provinces. This data does not include projections for the 34th province, North Kalimantan, which was only established in 2015 (Legislation no. 20/2012). The provinces, where older people make up a larger share of the population may have a higher prevalence of dementia, as ageing and non-communicable diseases are the main risk factors of reduced cognitive function (Ministry of Health Republic of Indonesia, 2015b).

Furthermore, differences in the proportion of older people can also be found between urban and rural areas. Data from the 2010 Census suggest that a greater proportion of older people (8.7%) lives in rural than in urban (6.5%) areas and people in rural areas are also likely to be older than those in urban areas. Finally, an urban-rural difference can also be found for potential support ratios, suggesting a lower ratio for urban (11.0) than rural (16.1) areas according to Census 2010 data. This difference is likely to be related to in-country migration patterns, where younger people move to urban areas for education and employment, while older people move back to rural areas for retirement (Adioetomo & Mujahid, 2014, pp.22-26).

Based on the 2010 census, it was predicted that the proportion of older people (65+) will increase from 5.0% in 2010 to 5.4% by 2015, 6.2%  by 2020 and reach 10.6% by 2050. However, it can be difficult to compare this data to information from other sources as in Indonesia ‘older people’ are defined as people aged 60 or above. Data for people aged 60 and older is more commonly available.

The dependency ratio reflects the ratio between the number of people requiring support (children and older people) to those of working age. Since 1971 the total dependency ratio for Indonesia has been declining but the curve is expected to stall over the next decade. The total dependency ratio in 2015 was estimated to be 49.2 (CIA World Factbook, 2019). However, an increasing old-age dependency ratio is likely to offset this trend after 2030. In 2015, the old-age dependency ratio was estimated to be 7.6, but by 2035 this ratio is expected to increase to 15.6 (Adioetomo & Mujahid, 2014, p.8; CIA World Factbook, 2019).

Male life expectancy at birth (70.6 years) is considerably lower than female life expectancy (76.6 years, 2018 estimate). In terms of overall life expectancy Indonesia ranks 142th in the world (CIA World Factbook, 2019).

In the last four decades, life expectancy has increased dramatically, from 45 years in 1971 to 73.2 years in 2018 (Adioetomo & Mujahid, 2014; CIA World Factbook, 2019).

The median age of the Indonesian population in 2018 was estimated to be 30 years. Males were found to be slightly younger (29.9 years median age) than females (31.1 years median age) (CIA World Factbook, 2019). Future projections suggest that median age will increase to 33.7 years by 2035 (Adioetomo & Mujahid, 2014, p.9).

Total fertility rate in Indonesia in 2016 was estimated to be 2.4. This is a considerable decrease from an estimated 5.7 in 1960 (World Bank, 2018a).

References:

Adioetomo, S. M., & Mujahid, G. (2014). Indonesia on The Threshold of Population Ageing – UNFPA Indonesia Monograph Series: No.1. (H. Posselt, Ed.; Issue 1). UNFPA Indonesia.

CIA World Factbook. (2019). Indonesia. https://www.cia.gov/the-world-factbook/countries/indonesia/

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

Pusat Data dan Informasi Kementerian Kesehatan RI. (2014). Situasi dan analisis lanjut usia (pp. 1–7).

Subdirectorate of Statistical Demographic. (2013). Indonesia Population Projection 2010-2035. BPS – Statistics Indonesia.

World Bank. (2018a). Fertility rate, total (births per woman) – Indonesia. World Development Indicators. https://data.worldbank.org/indicator/SP.DYN.TFRT.IN?locations=ID

Migration from Indonesia to other countries has a long history, with records stemming from Dutch and Japanese colonial times (Raharto, 2007). In the colonial era, beginning 1890, the Dutch government started to source workers from the Dutch East Indies for labour in the plantations of Suriname in South America. After Independence, a Ministry of Labour (later changed to Ministry of Manpower) was established to manage the placements of Indonesian migrant workers abroad (BNP2TKI, 2011). Between 2016 to 2018, there were more than 760,000 Indonesian migrant workers assigned to different countries for various types of jobs, including nurses and care workers (Pusat Penelitian Pengembangan dan Informasi BNP2TKI, 2019).

According to the CIA World Factbook the net migration rate in 2017 was -1.1 migrant(s)/1,000 population. This suggests that more Indonesians are emigrating than foreigners are immigrating, but within country migration also plays an important role (CIA World Factbook, 2019). In 2013, the five main emigration destinations for Indonesians were Malaysia, Saudi Arabia, the United Arab Emirates, Bangladesh, and Singapore. The UNICEF migration profile for Indonesia suggests that crude net migration has risen slightly from -0.20 in the period 1995 to 2000 to -0.56 in 2010-2015. Future projections suggest that crude migration will stay relatively constant between 2015-2020 (-0.53) and 2045-2050 (-0.44) (United Nations DESA-Population Division and UNICEF, 2014). Among immigrants, the majority were reported to come from China, the Republic of Korea, the UK, Timor-Leste, and Singapore.

In-country migration also plays a considerable role in Indonesia. These often-long-established patterns of migration play a role in the varied ageing patterns observed across Indonesia (Adioetomo & Mujahid, 2014 p.30; Ananta et al., 1997). As in the case of international migration patterns, within-country migration patterns were also influenced by colonial rule, which established transmigration programmes from Java to the outer islands. This policy was maintained after Indonesian independence to move landless people from highly populated areas to less populated areas. This pattern came to a halt following the fall of the New Order (Sukamdi & Mujahid, 2015, p.5).

While some ethnic groups are known for their migration patterns, overall internal migration has been found to slow down between 1995/2000 and 2005/2010 according to Census data. At the same time, those who migrated internally were found to move further away (Sukamdi & Mujahid, 2015, pp. 12-13).

The largest proportion of migrants were aged 15 to 34 years. Among older persons, the number of people migrating were generally low but more women (52.1%) than men were found to migrate at older age. Sukamdi and Muhajid (2015) suggest that women are more likely to follow their adult children when widowed or divorced while men are more likely to re-marry. The greater number of widowed women migrating may also be related to female longevity (Sukamdi & Mujahid, 2015).

References:

Adioetomo, S. M., & Mujahid, G. (2014). Indonesia on The Threshold of Population Ageing – UNFPA Indonesia Monograph Series: No.1. (H. Posselt, Ed.; Issue 1). UNFPA Indonesia.

Ananta, A., Anwar, E. N., & Suzenti, D. (1997). Some Economic Demographic Aspects of “Ageing” in Indonesia. In Indonesia Assessment: Population and Human Resources (pp. 181–203). Australian National University and Institute of Southeast Asian Studies.

BNP2TKI. (2011). Sejarah Penempatan TKI Hingga BNP2TKI. http://www.bnp2tki.go.id/frame/9003/Sejarah-Penempatan-TKI-Hingga-BNP2TKI

CIA World Factbook. (2019). Indonesia. https://www.cia.gov/the-world-factbook/countries/indonesia/

Pusat Penelitian Pengembangan dan Informasi BNP2TKI. (2019). Data Penempatan dan Perlindungan TKI Periode Bulan Desember Tahun 2018. http://www.bnp2tki.go.id/uploads/data/data_14-01-2019_043946_Laporan_Pengolahan_Data_BNP2TKI_2018_-_DESEMBER.pdf

Raharto, A. (2017). Pengambilan Keputusan Tenaga Kerja Indonesia Perempuan untuk Bekerja di Luar Negeri: Kasus Kabupaten Cilacap (Decision making to work overseas among Indonesian women labor migrants: the case of Cilacap district). Jurnal Kependudukan Indonesia, 12(1), 39–54. http://ejurnal.kependudukan.lipi.go.id/index.php/jki/article/view/275/pdf

Sukamdi, & Mujahid, G. (2015). Internal Migration in Indonesia. UNFPA Indonesia Monograph Series No.3, xii, 90.

United Nations DESA-Population Division and UNICEF. (2014). Migration Profile – Common Set of Indicators. DESA-Population Division and UNICEF. https://esa.un.org/miggmgprofiles/indicators/indicators.htm

According to the WHO (2014) non-communicable diseases are now the leading causes of mortality in Indonesia, accounting for an estimated ‘71% of total deaths’ (WHO Noncommunicable Diseases Country Profiles, 2014). NCDs, including cardiovascular diseases (35%), maternal, perinatal and nutritional conditions (21%), cancers (12%), chronic respiratory diseases (6%), injuries (6%), and diabetes (6%) account for a considerable share of mortality (WHO, 2018). Mortality due to diabetes was found to have increased by 63 per cent between 2005 and 2016. This represents the largest increase in mortality among NCDs in Indonesia. Furthermore, ‘hypertension and diabetes are primary risk factors for stroke’. The prevalence of strokes between 2007 and 2013 has increased from 8.3 strokes to 12.3 strokes per 1000 population. In 2014, approximately 15 per cent of mortality was related to strokes, which is ‘among the highest proportion’ worldwide (Agustina et al., 2019, p.82).

The cost of care for people with diabetes and stroke are expected to cause substantial burden on the Indonesian health care system. Agustina and colleagues citing data from a 2014 report by the National Institute of Health Research Development report that the cost burden for diabetes (56%), stroke (57%), hypertension (46%), and heart disease (34%) are expected to increase substantially by 2020. The financial implications have been estimated to amount to $5.80 billion for the health care system as well as increasing out-of-pocket costs (Agustina et al., 2019, p.82)

Furthermore, over the last decade, illnesses such as depression and anxiety disorders have been found to increase by 22 per cent and 18 per cent, respectively (Agustina et al., 2019, p.80). This made depressive disorders the ‘seventh largest contributor to years lived with disability in 2016’. It is reported that in 2013 approximately 400,000 people aged 15 and older lived with severe mental disorders. Despite the banning of restraints in 1977, an estimated 57,200 (14.3%) people were subject to this practice (Agustina et al., 2019, p.83; based on National Institute of Health Research and Development. Basic health research 2013).

Overview of significant NCDs

Most data on NCDs are available from the Riset Kesehatan Dasar (Riskesdas)/Basic Health Survey, conducted every five years by the Ministry of Health. Since 2018, in line with Indonesia’s One Data Policy, Riskesdas was integrated into the Survei Sosial Ekonomi Nasional (Susenas)/National Socioeconomic Survey, which is a household survey managed by Statistics Indonesia (Kementrian PPN/BAPPENAS, 2018).

Diabetes Mellitus

The prevalence of diabetes in people aged 15 or above based on previous diagnosis from healthcare professionals increased from 1.1% in 2007 to 2.1% in 2013 and decreased slightly to 2.0% in 2018 (Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI, 2013; Kementrian Kesehatan Republik Indonesia, 2018). The highest prevalence can be found in the four provinces DKI Jakarta (3.4%), DI Yogyakarta (3.1%), East Kalimantan (3.1%), and North Sulawesi (3.0%) (Kementrian Kesehatan Republik Indonesia, 2018). This is likely linked to stark increase in obesity (10% in 2007 to 21.8% in 2018 and other NCDs) (Agustina et al., 2019, p.75; Kementrian Kesehatan Republik Indonesia, 2018). According to the latest Riskesdas survey, a measurement based of blood glucose level in line with the American Diabetes Association (ADA) and PERKENI 2015 criteria was added to the survey (Kementrian Kesehatan Republik Indonesia, 2018). The national prevalence is much higher (10.9%) when the diagnosis of diabetes is based on this, although this cannot be compared to previous data.

 Hypertension

In 2018, the prevalence of hypertension was 34.11% among the population aged 18 or over (based on blood pressure measurement). This marks as a significant increase from 2013, when prevalence was recorded at 25.8%. However, there had been a 5.9% decrease between the years 2010 to 2013 (Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI, 2013).

Heart disease

In 2018, the prevalence of all types of heart disease was 1.5%. The four provinces with the highest prevalence of heart disease are North Kalimantan (2.2%), DI Yogyakarta (2.0%), Gorontalo (2.0%), and DKI Jakarta (1.9%) (Kementrian Kesehatan Republik Indonesia, 2018). Previous data in 2013 only reported coronary heart disease (1.5%) and heart failure (0.3%) prevalence in the population (Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI, 2013)

Stroke

In 2018, the prevalence of stroke in Indonesia confirmed by diagnosis was 10.9 per 1,000 people, which presents a decrease from 12.1 per 1,000 people in 2013 (Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI, 2013; Kementrian Kesehatan Republik Indonesia, 2018). To aid interpretation of this data, it is important to point out that stroke is reported as the leading cause of death in Indonesia (CDC, 2020; IHME, 2019), (thus prevalence reported here might indicate the number of survivors). However, prevalence of stroke may be underreported as some patients may not have been able to access appropriate healthcare services or were not aware of their diagnosis. Estimates based on diagnosis and interview of symptoms suggest a prevalence rate of 1.21% in 2013  (Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI, 2013), but results using this method were not reported for 2018 data.

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI. (2013). Riset Kesehatan Dasar 2013 (Vol. 6). https://doi.org/1 Desember 2013

CDC. (2020). CDC in Indonesia (Issue Cdc).

IHME. (2019). Indonesia. http://www.healthdata.org/indonesia

Kementrian Kesehatan Republik Indonesia. (2018). Riset Kesehatan Dasar 2018. https://doi.org/1 Desember 2013

Kementrian PPN/BAPPENAS. (2018). Revolusi Kebijakan One Data, Riskesdas 2018 Tampil Beda. Berita Pembangunan. https://www.bappenas.go.id/id/berita-dan-siaran-pers/revolusi-kebijakan-one-data-riskesdas-2018-tampil-beda/

National Institute of Health Research and Development. (2013). Basic health research 2013. Report: Ministry of Health Republic of Indonesia, Jakarta, 2013.

WHO. (2014). Noncommunicable Diseases Country Profiles, 2014. https://apps.who.int/iris/bitstream/handle/10665/128038/9789241507509_eng.pdf;jsessionid=26014D4B19896037A6A9EE830F4A33C4?sequence=1

WHO. (2018). NCDs Country Profiles 2018 WHO. 224. https://www.who.int/nmh/publications/ncd-profiles-2018/en/

The prevalence and burden of communicable diseases, particularly that of HIV/AIDS and TB, are considerable in Indonesia.

HIV/AIDS

Indonesia experiences the ‘fastest growing HIV epidemic’ among southeast Asian countries  (Agustina et al., 2019, p. 83). According to UNAIDS, approximately 630,000 (lower to upper estimates 540,000-740,000) people lived with HIV in 2016. By 2018, this number was estimated to have reached 640,000 (550,000-750,000). The majority of people living with HIV were aged 15 or over (620,000). Among these, an estimated 17% (15%-20%) accessed antiretroviral therapy. Furthermore, there were an estimated 48,000 (43,000-52,000) new HIV infections and 38,000 (34,000-43,000) AIDS-related deaths in Indonesia (UNAIDS, 2018).

By December 2019, cases of HIV/AIDS have been reported in 93.2% of districts and in 34 provinces across Indonesia. The provinces with the highest number of HIV infections were DKI Jakarta (65,578), followed by East Java (57,176), West Java (40,215), Papua (36,382), and Central Java (33,322) (Ditjen P2P Kementerian Kesehatan RI, 2020).

TB

According to WHO, Indonesia is ranked among the countries with the highest burden of tuberculosis (WHO, 2019) . It is estimated that there are about 1 million new cases of TB per year and prevalence is estimated to be at almost 400 cases per 100,000 people (Agustina et al., 2019, p.83; WHO, 2017, p.1). According to the WHO TB report 2019, notifications of TB in Indonesia increased from ‘from 331 703 in 2015 to 563 879 in 2018 (+70%), including an increase of 121 707 (+28%) between 2017 and 2018’ (WHO, 2019, p.2).

Mortality of TB was substantial, as Indonesia was estimated to be among the group of five countries where 40 or more deaths per 100,000 population were associated with TB (WHO, 2017, p.35). This is paired with low levels of TB treatment. The WHO reports that Indonesia belongs to the group of countries with 50 per cent of less treatment coverage in 2016 (WHO, 2017, p.78). Furthermore, ‘high levels of underreporting of detected TB cases’ was found following the 2013-2014 national TB prevalence survey with Indonesia ranging among the top three countries (16% gap between TB incidence and reported cases) (WHO, 2017, pp.180).

The WHO report further shows a substantial gap between the funding required for prevention, diagnosis, and treatment and the actual funds available. In Indonesia this funding gap is estimated to amount to US $98 million (WHO, 2017, p.115). Of the available funds, 61 per cent were provided from domestic sources and 39 per cent by donors (WHO, 2017, p.117).

The previously reported growing burden of HIV/AIDS together with the high burden of TB further complicates the situation in Indonesia. In combination with the described underreporting, this leads to a situation where only 14% of people with TB had a reported HIV status and ‘less than 50% of HIV patients were started [on the recommended] ART’ treatment in 2016 (WHO, 2017). In 2019, Indonesia remained among the 20 high TB/HIV burden countries as well as among the ‘20 countries with highest estimated numbers of incident [multi-drug resistant TB] (MDR-TB) cases’ (WHO, 2017). Despite low reporting and high burden, it is reported that Indonesia had an ‘85 per cent treatment success among people with new and relapse TB’ and ’60 percent treatment success among people with new and relapse HIV-positive TB’ in 2015 as well as ’51 per cent treatment success among people with rifampicin-resistant TB in 2014’ (WHO, 2017, pp. 88,90).

Other relevant infectious diseases are malaria, with approximately 40,000 death per annum as well as arboviruses, dengue fever, chikungunya, nipa, avian influenza, and Zika (Agustina et al., 2019, pp.83).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

Ditjen P2P Kementerian Kesehatan RI. (2020). Laporan Perkembangan HIV AIDS & Penyakit Infeksi Menular Seksual (PIMS) Triwulan IV Tahun 2019.

UNAIDS. (2018). Country factsheets: Indonesia. https://www.unaids.org/en/regionscountries/countries/indonesia

WHO. (2017). Global Tuberculosis Report 2017.

WHO. (2019). Global Tuberculosis Report 2019. World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/329368/9789241565714-eng.pdf?ua=1

 

Due to Indonesia’s location on the Pacific Ring of Fire, the country experiences natural disasters in relatively high frequency. These include tsunamis, earthquakes, and volcanic eruptions (Agustina et al., 2019, p.77; International Organization for Migration, 2018). In 2004, natural disasters including ‘294 floods, 54 landslides, 11 earthquakes, two tsunamis, and five volcanic eruptions’ were accountable of 10.2 per cent of total mortality and the leading cause of injury and disability. In 2018, two earthquakes led to more than 2,000 deaths over 1,000 missing people, more than 4,000 injured people, over 223,000 displaced people as well as the destruction or damage of approximately 50 health centres. The implications of natural disasters on health infrastructure is substantial. More than 4,500 health facilities were damaged between 1990 and 2015 (Agustina et al., 2019, p.80). In addition, Indonesia has experienced several acts of terrorism over the last two decades (Agustina et al., 2019, p.78). Finally, road injuries accounted as the main cause of death among the populated aged 10 to 25 years (Agustina et al., 2019, p.80).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

International Organization for Migration. (2018). Indonesia 2018. Humanitarian Compendium. https://humanitariancompendium.iom.int/appeals/indonesia-2018

According to the World Bank, Indonesia is an emerging middle-income country and ‘the world’s 10th largest country in terms of purchasing power parity and an annual growth rate of 5.6% (Agustina et al., 2019, p.78; World Bank, 2019a). Since 1999, the poverty rate has reduced by more than half to 9.8% in 2018. Substantial progress has also been made with regards to GDP. Between the years 2000 and 2018, Indonesia’s GDP per capita steadily increased from $807 to $3,877 (World Bank, 2019a).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

World Bank. (2019a). Indonesia. https://www.worldbank.org/en/country/indonesia/overview

In 2017, the majority of GDP was produced in services (45.4%), followed by industry (41%), and agriculture (13.7%). Industry in Indonesia is active in the areas of ‘petroleum and natural gas, textiles, automotive, electrical appliances, apparel, footwear, mining, cement, medical instruments and appliances, handicrafts, chemical fertilizers, plywood, rubber, processed food, jewellery, and tourism’. Agricultural products include ‘rubber and similar products, palm oil, poultry, beef, forest products, shrimp, cocoa, coffee, medicinal herbs, essential oil, fish […] and spices’ (CIA World Factbook, 2019).

References:

CIA World Factbook. (2019). Indonesia. https://www.cia.gov/the-world-factbook/countries/indonesia/

It is estimated that public debt amounted to 28.8% of GDP in 2017 (CIA World Factbook, 2019). In Indonesia, household debt was estimated to amount to US$104 billion in 2014 (Ghose et al., 2016).

References:

CIA World Factbook. (2019). Indonesia. https://www.cia.gov/the-world-factbook/countries/indonesia/

Ghose, R., Dave, S., Shirvaikar, A., Horowitz, K., Tian, Y., Levin, J., & Ho, S. (2016). Digital Disruption: How FinTech is Forcing Banking to a Tipping Point. In Citi GPS: Global Perspectives & Solutions (Issue March). https://www.ivey.uwo.ca/media/3341211/citi-2016-fintech-report-march.pdf

The United Nations Human Development Index (HDI) of Indonesia has increased from 0.528 in 1990 to 0.694 in 2018 (Agustina et al., 2019, p.78; United Nations Development Programme, 2018). This leads to a ranking of Indonesia in place 116 out of 189 countries (United Nations Development Programme, 2018). As with other indicators, there was considerable regional variety reported for the HDI (Sukamdi & Mujahid, 2015, p.xi).

Inequality in Indonesia has widened considerably between the years 2000 (28.5) and 2013 (39.9), but slightly diminished since 2017 (Gini index:38.1) (World Bank, 2018b).

Agustina and colleagues (2019, p.78) further report that the proportion of people in Indonesia living on ‘less than $1.90 per day in PPP’ declined substantially between 1984 (70.3%) and 2017 (5.7%); however, ‘high variability across and within provinces and districts’ remains.

Due to the absence of comprehensive social protection, older people in Indonesia are extremely vulnerable. According to Kidd and colleagues (2018, p.1), the highest rate of extreme poverty can be found among people aged 65 and over, with approximately 80 per cent of this age group living ‘households with a per capita consumption below IDR 50,000’ per day (below US$4). The proportion among those aged 80 and older is considered to be even higher. Women and those without family support are particularly vulnerable (Kidd et al., 2018, p.1).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

Kidd, S., Gelders, B., & Rahayu, S. K. (2018). Implementing Social Protection for the Elderly in Indonesia. http://www.tnp2k.go.id/filemanager/files/Perlindungan Sosial Lansia/Elderly Brief – English Version.pdf

Sukamdi, & Mujahid, G. (2015). Internal Migration in Indonesia. UNFPA Indonesia Monograph Series No.3, xii, 90.

United Nations Development Programme. (2018). 2018 Statistical Update: Human Development Indices and Indicators. Human Development Reports. https://hdr.undp.org/en/content/human-development-indices-indicators-2018-statistical-update

World Bank. (2018b). GINI index (World Bank estimate) – Indonesia. World Development Indicators. https://data.worldbank.org/indicator/SI.POV.GINI?locations=ID&view=chart

As discussed above (01.02.02), environmental aspects are an important risk factor to economic productivity in Indonesia. According to the Global Facility for Disaster Reduction and Recovery, reconstruction following disaster costs the Indonesia government between $300 and $500 million annually. Costs during major disasters can amount to 0.3 per cent of national GDP and up to 45 per cent of provincial GDP. In addition, loss of life, damage to infrastructure, destruction of agricultural crops, and a reduction in income from tourism are considerable costs to bear (GFDRR, 2019). Lasting change, caused by ‘rising sea levels and changing weather patterns’, due to climate change pose a serious risk to Indonesia’s development.

Following the 2004 tsunami, the Government of Indonesia implemented a law on disaster management in 2007 and established the National Disaster Management Agency (BNBP) in 2008.  Activities to improve resilience and to reduce risk include relocation of families from high risk areas or road improvement work in areas prone to earthquake and landslides (GFDRR, 2019).

References:

GFDRR. (2019). Indonesia. Global Facility for Disaster Reduction and Recovery. https://www.gfdrr.org/en/indonesia

 

The unemployment rate in Indonesia was 5.4% in 2017 (CIA World Factbook, 2019). The World Bank estimates that total youth unemployment (15-24 years) as percentage of the labour force amounted to 15.84% in 2018 (World Bank, 2019b).

Employment in the informal economy, which means employment without formal arrangements, is estimated to make up over 60 per cent of the workforce (International Labour Organization (ILO), n.d.-a). This prevailing practice causes some difficulties in estimating employment and unemployment rates in Indonesia. Furthermore, as pointed out above (01.03.04) and further discussed under (01.04) the absence of social protection means that older people are often engaged in economic activity by formal or informal employment into very old age (Kidd et al., 2018).

References:

CIA World Factbook. (2019). Indonesia. https://www.cia.gov/the-world-factbook/countries/indonesia/

International Labour Organization (ILO). (n.d.-a). Informal economy in Indonesia and Timor-Leste. Retrieved March 9, 2019, from https://www.ilo.org/jakarta/areasofwork/informal-economy/lang–en/index.htm#banner

Kidd, S., Gelders, B., & Rahayu, S. K. (2018). Implementing Social Protection for the Elderly in Indonesia. http://www.tnp2k.go.id/filemanager/files/Perlindungan Sosial Lansia/Elderly Brief – English Version.pdf

World Bank. (2019b). Unemployment, youth total (% of total labor force ages 15-24) (modeled ILO estimate) – Indonesia. World Development Indicators. https://data.worldbank.org/indicator/SL.UEM.1524.ZS?locations=ID

Based on labour force surveys, it has been estimated that between 61 and 70 per cent of the labour force are employed in the informal sector (Alatas & Newhouse, 2010; Firdausy, 2000). Rothenberg and colleagues (2016) explain the development of the Indonesia economy and its impact on the informal sector. Since the 1970s, Indonesia has developed from a ‘primarily agriculture-based economy’ to an economy based largely on manufacturing and services. In terms of GDP, the share of agriculture declined from 45 per cent (1970) to 14 per cent in 2014. The authors further explain that the reduction in agriculture coincided initially with urbanisation that led to an increase in the informal sector within urban areas. Growth in the manufacturing and service sectors led to an increase in formal sector employment ‘from 34.7 per cent to 44.9 per cent in 1997’ (Alatas & Newhouse, 2010, p.32). However, the economic crisis in 1998 led to shift from people formerly employed in the formal sector becoming employed in the informal sector. The following political crisis, resulting in ‘a regime change and political reform’ aimed to increase minimum wages. This development is understood to have contributed to the ‘weak recovery of formal sector employment’ (Rothenberg et al., 2016, pp.99-100).

References:

Alatas, V., & Newhouse, D. (2010). Indonesia Jobs Report: Towards Better Jobs and Security for All (Vol.2): Main Report (English). http://documents.worldbank.org/curated/en/601901468285575499/Main-reportAlzheimer’sDiseaseInternational

Firdausy, C. M. (2000). The social impact of economic crisis on employment in Indonesia. http://www.ismea.org/asialist/Firdausy.html

Rothenberg, A. D., Gaduh, A., Burger, N. E., Chazali, C., Tjandraningsih, I., Radikun, R., Sutera, C., & Weilant, S. (2016). Rethinking Indonesia’s Informal Sector. World Development, 80, 96–113. https://doi.org/10.1016/j.worlddev.2015.11.005

The Indonesian system is made up of non-compulsory pre-school, compulsory primary school (Pendidikan dasar), secondary school and higher education. The compulsory primary education is made up of primary school (Sekolah Dasar) and junior secondary school. Secondary education consists of compulsory junior secondary school (Sekolah Menengah Pertama, SMP) and senior secondary school. Finally, higher education is offered at five ‘different types of institutions’. These are: universities (universitas), academies (akademi), colleges (sekolah tinggi), polytechnics (politeknik) and institutes (institute) (NUFFIC, 2017, pp.5-7).

Education for 6 years was made compulsory in 1950 and extended to 9 years in 1994 (NUFFIC, 2017, p.5). In 2016, the Ministry of Education and Cultural Affairs launched the Program Indonesia Pintar (Smart Indonesia Programme) to support the plan of raising this compulsory education to 12 years (an additional 3 years of senior high school) (Permendikbud No.19/2016 Tentang Program Indonesia Pintar (Ministry of Education and Culture’s Regulation No. 19/2016 on Smart Indonesia Program), 2016).

A number of ministries are involved in the organisation and management of the education system. The Ministry of the Interior carries responsibility for primary education, while the Ministry of National Education (Kementerian Pendidikan Nasional) looks after secondary and higher education. Islamic Education is managed by the Ministry of Religious Affairs and agricultural schools (secondary) by the Ministry of Agriculture (NUFFIC, 2017, p.5).

Private education has a significant role, with over 66 per cent of institutions in secondary and higher education operated by the private sector. Varying tuition fees create barriers to access and lead to considerable differences in the quality of education provided (NUFFIC, 2017, p.5).

According to UNESCO (2020) the literacy rate among the population aged 15 years and older has increased between 2000 and 2018 from 81.52 (males: 88.02; females 75.02) to 95.66 (males: 97.33; females: 93.99), respectively. Among the population aged 65 and older, UNICEF estimates the literacy rate to have increased from 53.22 (males: 68.65; females: 39.76) in 2004 to 74.34 (males: 84.61; females 65,69) in 2018 (UNESCO Institute for Statistics (UIS), 2020).

References:

NUFFIC. (2017). Education system Indonesia described and compared with the Dutch system. https://www.nuffic.nl/sites/default/files/2020-08/education-system-indonesia.pdf

Permendikbud No.19/2016 tentang Program Indonesia Pintar (Ministry of Education and Culture’s regulation No. 19/2016 on Smart Indonesia Program), (2016) (testimony of Kementerian Pendidikan dan Kebudayaan).

UNESCO Institute for Statistics (UIS). (2020). Indonesia. http://uis.unesco.org/en/country/id

For the past twenty years Indonesia has been working towards social assistance programmes whose endeavours were extended towards that of a national security system through legal implementation in 2004. From there, it took ten years until the implementation of the national health insurance system in 2014. In 2015, a social insurance system for employees was established (TNP2K, 2018, p.i). In the following a brief overview of key social protection schemes will be provided.

One of the earliest social protection schemes developed is ‘Raskin/Rastra’, a rice assistance programme launched during the economic crisis (1998). Since 2017, rastra no longer just provides in-kind rice and eggs, but provides electronic food vouchers (Bantuan Pangan Non Tunai (BPNT)) to the bank accounts of poor families (TNP2K, 2018, p.71).

Another programme, Program Keluarga Harapan (PKH), supports economically vulnerable families with pregnant mothers and children since 2007 through conditional cash transfers. In 2017, the ‘tax-financed social assistance for [older people] […] (Asistensi Social Lanjut Usia (ASLUT)) and the disability scheme’ (Asistensi Sosial Penyandang Disabilitas Berat (ASPDB)) became incorporated into the PKH (TNP2K, 2018, p.73). The programmes provide cash transfers. ASLUT specifically support ‘poor, abandoned and bed-ridden [older] people (from the age of 60 and above)’, while APSDB supports ‘people with severe disability’ (TNP2K, 2018, p.77).

The Government of Indonesia further runs Program Indonesia Pintar (PIP), which financially supports poor students as well as Program Keejahteraan Sosial Anak (PKSA), which aims to support children in difficult circumstances (displaced or abandoned, living with disabilities, juvenile delinquents, children living on the streets) with access to education, health care, and social rehabilitation (TNP2K, 2018, pp.75,78).

There is only a small group of the population, namely, civil servants, who have had access to old age pensions since 1969. Employees in the military, police, and Ministry of Defence are covered through PT Asabri. Employees of all other government institutions and of state-owned companies receive coverage through PT Taspen. Civil servants can access pensions, survivors’ benefits and life endowment insurance (Tunjangan Hari Tua (THT)) through their respective schemes. There is some variation in the amount of pension received; however, most receive approximately ‘70 to 75 per cent of their last monthly earnings’. Civil servants further receive a rice allowance, which continues following retirement (TNP2K, 2018, p.81).

In an effort to widen and develop protection for old age, disability, and unemployment, the Social Security Agency for Employment (Jaminan Ketenagakerjaan (BPJS)) developed four schemes:

  • savings for old age, including disability benefit (JHT),
  • ‘survivors’ benefit (JKM),
  • work injury compensation (JKK) and
  • old age pension (JP).

Members of the JHT programme are obliged to withdraw their full contributions once they reach retirement age or can withdraw partial funds before reaching retirement age, if they contributed for more than ten years. Where members experience job loss due to permanent disability, they are entitled for a life-long monthly benefit (depending on their contributions). In 2015, only 249 people received support due to disability-related job loss (TNP2K, 2018, p.79).

Members of the JT programme can receive a monthly pension once they reached retirement age after contributing to the scheme for at least 15 years. Due to the recent establishment of the programme, it is estimated that members are likely to receive reasonable pensions only after 2040 and the number of people benefitting from the programme is small due to low figures of enrolment (TNP2K, 2018, p.79).

The four schemes are accessible to formal sector employees (pekerja penerima upa (PPU)) and informal or self-employed workers (bukan penerima upa (BPU)) (TNP2K, 2018, p.80)

While formal sectors employees have to be enrolled in all programmes, non-wage recipient workers cannot participate in the older people pension programme (JP). In order for non-wage recipient workers to participate the old age saving and disability programme (JHT), they also have to enrol in the ‘survivors’ benefits and work injury compensation scheme (JKM and JKK). The Social Security Agency for employment developed special rates for informal or self-employed workers earning at least IDR 1,000,000 to increase the number of memberships (TNP2K, 2018, p.80). Further, enrolment in JKK and JKM based on government subsidies was proposed for the for the ‘poor and sick’ (TNP2K, 2018, p.80).

Finally, since 2014, Indonesia has a national health insurance programme (Jaminan Kesehatan Nasional (JKN)). This programme brings together all previously separated health insurance schemes under the umbrella of the Social Security Agency for Health (BPJS Kesehatan) (TNP2K, 2018, p.83).

Besides these national schemes, there have also been reports of regional schemes. They include grants for vulnerable children and pension schemes (TNP2K, 2018, p.91):

  • The provincial government of Papua started providing financial support (IDR 200,000 per month) for the indigenous children of Papua aged four or younger (Bangun Generasi dan Keluarga Papua Sejahtera (BANGGA Papua)) (TNP2K, 2018, p.91).
  • In the Aceh province, all school-aged children have access to Sabang education grants (IDR 2,000,000) to support education-related expenses (Bantuan Pendidikan Kota Sabang)) (TNP2K, 2018, p.91).
  • In the Aceh Jaya district members of the community aged 70 or older received IDR 200,000 per month since 2014 (Program ASLURETI). A similar grant was recently introduced in DKI Jakarta (Kartu Lansia Jakarta). This grant supports 14,520 people aged 60 or older with a monthly stipend of IDR 600,000 (Kidd et al., 2018, p.4; TNP2K, 2018, p.91).

Indonesia has several long-standing partnerships with development partners and international donors, working towards developing and improving social protection schemes in the country. Among these partners are WHO, ILO, the World Bank, GIZ, AUSAID, USAID, IDB, ADB, the Global Fund, and UNICEF (Mahendradhata et al., 2017, pp.26-27). These development partners operate in many different sectors. The list below provides an overview of key social protection schemes developed in partnership with international donors.

The World Health Organization (WHO)

The WHO has been involved in the development of social protection schemes in Indonesia for many years. A report from 2018 (Kaasch et al., 2018, p.4), reports that the WHO currently focuses on communicable and non-communicable diseases, the promotion of health across the life course, as well as supporting development of the health system, surveillance, and emergency response. The organisation specifically supports the establishment of UHC through ‘building the capacity of middle management officials in the government, facilitating the monitoring-evaluation and assessment of UHC implementation at different levels, supporting National Health Accounts training and institutionalization and supporting the development of clinical governance and guidelines for improving the quality of the health system’.

The International Labour Organization (ILO)

From 2012 to 2017 ILO activities focused on the “Better Work Indonesia” programme, which focuses on the improvement of ‘working conditions and productivity in targeted employment-intensive sectors’. Furthermore, the organisation was involved in the “Decent Work for Food Security and Sustainable Rural Development” project, which focused on improved working conditions, social protection and the creation of jobs (2014-2016). In addition, the ILO worked on the “Single Window Service” project (Pelayanan Satu Atap), which aimed to support domestic workers, children and widows, and contributed to proposals for the modification of social security programmes (Kaasch et al., 2018, p.5).

The World Bank

The social safety net for the poor working in the informal sector was established in the 1990s as a condition of the structural adjustment programme the World Bank provided. In addition, the World Bank has been working in collaboration with the WHO and UNICEF to improve health and social security in the country (Kaasch et al., 2018, pp.5-6).

Deutsche Gesellschaft fuer Internationale Zusammenarbeit (GIZ) GmbH

The GIZ supports Indonesia in extending statutory health cover to population groups that do not yet receive coverage and in developing financial sustainability of the scheme. The organisation also offers advice to the Ministry of Social Affairs on ‘professionalising and expanding the national social assistance programme’ for vulnerable families as well as providing support in rolling out ‘organisational reform, piloting electronic cash transfers and introducing e-learning for social workers’. The inclusion of people with disability and the re-integration of people with occupational injuries into the workforce are other areas of GIZ activity (GIZ, 2017).

The Government of Australia

Australia closely works with the Indonesian government on the ‘National Team for the Acceleration of Poverty Reduction’ (Australian Embassy Indonesia, n.d.; TNP2K, 2018b). The group works on the development and integration of programmes to reduce poverty across ministries and institutions, oversees their implementation, offers technical advice on the implementation of new schemes, and maintains the Unified Database (UDB) (TNP2K, 2018, p.71). The country further provides support to civil society organisations working with marginalised groups on aspects of health, education, and poverty reduction (Australian Embassy Indonesia, n.d.).

The PKH, a programme including conditional cash transfers to poor families as well as social assistance for older people and people with disabilities was reported to have supported ‘150,000 older people and 50,000 people with disabilities’ with IDR 2,000,000,000 per annum (TNP2K, 2018, p.73). Among these, ASLUT supported about 30,000 people aged 60 and over with IDR 200,000 per month, while ASPDB supported 22,500 people with severe disabilities with IDR 300,000 per month in 2016. In 2017, the two programmes reached 150,000 and 50,000 people, respectively (TNP2K, 2018, p.77). While this reflects considerable improvement, Kidd and colleagues remark (2018, p.1) that around 85 per cent of older people in Indonesia remain without income security.

Beneficiaries of the Program Keularga Harapan (conditional cash transfer) increased from 3.5 million to 10 million household between 2017 and 2018. In 2018, households received an annual benefit of IDR 1,890,000. An additional top-up can be received if the family support older people or family members with disability. The programme will be revised in 2019 and base funding on the number of children per household (TNP2K, 2018, p.73).

The food programmes (Rastra/BPNT) supported 15.6 million officially registered beneficiaries in 2018 and amounted to 0.18 per cent of GDP. However, in practice approximately 28.6 million household are likely to have benefitted due to allocation of resources across communities. Despite this considerable coverage, it is estimated that about 45 per cent of the poorest households (15.5 million households) were not included in the scheme in 2017 (TNP2K, 2018, pp.71-72).

In 2016 the civil service pensions PT Taspen and PT Asabri benefited 2.2 million and 48,407 members, respectively. By 2017, 4.2 million active civil servants in PT Taspen supported 2.5 million pensioners (TNP2K, 2018, p.82). Despite coverage of certain groups, it is estimated that an estimated 13 per cent of older people in Indonesia receive a pension, leaving 87 per cent without access to social protection.

Furthermore, the old age pension (JP), due to its recent establishment (2014) will only be able to support pensioners minimally from about 2033. While this can provide protection for future older generations it leaves current older people unprotected. In recognition of the vulnerability of its older population, Indonesia provides health care to approximately 85 per cent of this group (TNP2K, 2018, pp.86-90).

The report also found high vulnerability of people with disabilities of working age. It is estimated that over 90 per cent of this group does not have access to direct financial support. Despite this high number of people without financial support, some progress has been made. In 2017, 112,490 people with disability or work injuries received benefits through the Social Security Agency for Employment and 47,100 people with disabilities received an additional, yet small benefit through the PKH (TNP2K, 2018, p.88).

References:

Australian Embassy Indonesia. (n.d.). Development partnership with Indonesia. Retrieved May 13, 2019, from https://indonesia.embassy.gov.au/jakt/cooperation.html

GIZ. (2017). Social Protection (SPP). https://www.giz.de/en/worldwide/16688.html

Kaasch, A., Sumarto, M., & Wilmsen, B. (2018). Indonesian social policy development in a context of global social governance UNRISD (No. 2018–6; UNRISD Working Paper). https://www.econstor.eu/bitstream/10419/186116/1/1024298469.pdf

Kidd, S., Gelders, B., Rahayu, S.K., Larasati, D., Huda, K. & Siyaranamual, M. (2018) Implementing Social Protection for the Elderly in Indonesia, Jakarta Pusat: Sekretariat Tim Nasional Percepatan Penanggulangan Kemiskinan. http://www.tnp2k.go.id/filemanager/files/Perlindungan%20Sosial%20Lansia/Elderly%20Brief%20-%20English%20Version.pdf

Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., MArthias, T., Harimurti, P., & Prawira, J. (2017). The Republic of Indonesia Health System Review (Vol. 7, Issue 1). https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf

Tim Nasional Percepatan Penanggulangan Kemiskinan (TNP2K). (2018) The Future of the social protection system in Indonesia, Jakarta Pusat: Office of the Vice President of the Republic of Indonesia. https://www.developmentpathways.co.uk/wp-content/uploads/2018/11/44293181123-SP-ReportFinal-ENG-web.pdf

TNP2K. (2018b). The future of the social protection system in indonesia: social protection for all (pp. 1–15). http://tnp2k.go.id/download/24864181129 SP Exe Summary ENG-web.pdf

The Republic of Indonesia is a presidential republic that was founded in 1945 and gained full independence in 1949. A Federal Constitution was established in 1949, then briefly abandoned and reinstated in 1959. The Constitution regulates relationships with other states but also outlines responsibilities and powers, such as relations between state institutions (legislative, executive, and judiciary) within the country (Qatar Embassy in Jakarta – Republic of Indonesia, 2018). There were several upheavals until 1967 General Suharto became president. The ‘New Order’ regime was in power until 1998, following the Asian crisis in 1997. Between 1998 and 2000 the country underwent major political and governmental reform, including four amendments to the constitution and reorganisation of legislative and judiciary authorities to decentralise power. In 1999, for the first time, free elections were held in Indonesia. Aburrahman Wahid became elected president and stayed in power until 2001, when he was dismissed by parliament. He was superseded by Megawati Sukarnoputri. She was unseated in the 2004 elections by former general Susilo Bambang Yuhoyono. In 2014, Joko Widodo became president (BBC, 2019; CIA World Factbook, 2019; Qatar Embassy in Jakarta – Republic of Indonesia, 2018).

In Indonesia, executive powers lie with the ‘president, vice president, and the cabinet of ministers’. In the presidential cabinet, ministers do not represent their political parties but report to the president (The Embassy of Indonesia – Prague, 2015). Legislative powers lie with the People’s Consultative Assembly (MPR), which is made up of two parts. First, the Parliament which represents elected members of political parties. Second, the Regional Representative Council (DPD), which is made up of four elected delegates per province. According to the Embassy of Indonesia to the Czech Republic, ‘the MPR has 550 members from the parliament and 128 members form the’ DPD (The Embassy of Indonesia – Prague, 2015). Judiciary powers lie with the Supreme Court (The Embassy of Indonesia – Prague, 2015).

References:

BBC. (2019). Indonesia profile – Timeline. BBC. https://www.bbc.com/news/world-asia-pacific-15114517

CIA World Factbook. (2019). Indonesia. https://www.cia.gov/the-world-factbook/countries/indonesia/

Qatar Embassy in Jakarta – Republic of Indonesia. (2018). Political System. http://jakarta.embassy.qa/en/indonesia/political-system

The Embassy of Indonesia – Prague. (2015). The Government of the Republic of Indonesia. http://www.indonesia.cz/the-government-of-the-republic-of-indonesia/

Between 1670 and 1942 Indonesia was a Dutch colony. During the second World War (1942) Indonesia was occupied by Japan. Following Japanese surrender, Indonesia declared independence. After several years of guerrilla warfare, the Dutch recognised Indonesian independence in 1949.

In 1969 West Papua becomes the Indonesian province Irian Jaya. Six years later, in 1975, Indonesia invades and annexes East Timor after the country was given independence by Portugal. This lasts until 1999. In 1997, the Asian economic crisis has considerable consequences on Indonesian economic performance and development.

In 2002, the first major jihadist attack occurred in Bali. Others followed in 2011 and 2018. Military chief general Gatot Nurmantyo reported in 2017 that Islamic State groups were present in almost all provinces. As discussed previously, Indonesia, due to its location on the Ring of Fire, frequently experiences natural disasters causing substantial destruction and loss of lives (BBC, 2019).

References:

BBC. (2019). Indonesia profile – Timeline. BBC. https://www.bbc.com/news/world-asia-pacific-15114517

Presidential and legislative elections were held in April 2019. Joko Widodo was sworn into his second term of presidency for 2019-2024. There was quite a major reshuffle of the cabinet, including a change in the Minister of Health. Current Minister of Health is Terawan Agus Putranto (Kementerian Komunikasi dan Informatika Republik Indonesia, 2019). The next elections are anticipated to be in 2024 (BBC, 2019; Qatar Embassy in Jakarta – Republic of Indonesia, 2018).

References:

BBC. (2019). Indonesia profile – Timeline. BBC. https://www.bbc.com/news/world-asia-pacific-15114517

Kementerian Komunikasi dan Informatika Republik Indonesia. (2019). Didominasi Profesional, Inilah Menteri Kabinet Indonesia Maju. https://www.kominfo.go.id/content/detail/22321/didominasi-profesional-inilah-menteri-kabinet-indonesia-maju/0/berita

Qatar Embassy in Jakarta – Republic of Indonesia. (2018). Political System. http://jakarta.embassy.qa/en/indonesia/political-system

In 2018, Indonesia scored 38 out of 100 on the Corruption Perception Index Score, hosted by Transparency International. This shows a positive development in comparison to previous years and leads to rank 89 out of 180 countries compared (Transparency International, 2018).

References:

Transparency International. (2018). Corruption Perceptions Index 2018. https://www.transparency.org/en/cpi/2018#

The World Bank indicator for political stability and absence of violence/terrorism ranks Indonesia at -0.5 in 2017. This shows a slight deterioration from the 2016 estimate (-0.4), but overall a trend towards more stability can be observed since 2008 (-.1.1) (World Bank, 2019c).

References:

World Bank. (2019c). Worldwide Governance Indicators. World Development Indicators. https://databank.worldbank.org/source/worldwide-governance-indicators/Type/TABLE/preview/on

Indonesia introduced universal health care through the National Health Insurance System (Jaminan Kesehatan Nasional (NHIS)) in 2014. Services covered under the NHIS can be provided by the government-owned health facilities and registered private providers (Agustina et al., 2019, pp.75,89).

The system was created by bringing together a number of existing, but still fragmented, health insurance and social assistance schemes under the umbrella of a single payer, the Social Security Agency for Health (Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS)) and covers a range of services from simple procedures to ‘open heart surgery […] and cancer therapies’ (Agustina et al., 2019, pp.76,89). Furthermore, reproductive, maternal, neonatal, child health as well as emergency services are fully covered, and medicines and medical supplies can be received without co-payment if the patient adheres to procedures. The system does not cover cosmetic procedures, self-inflicted injuries, and services provided outside pre-approved providers, unless they are emergencies (Agustina et al., 2019, p.89).

The system covers civil servants, private sector employees and provides for socio-economically vulnerable members of the community. Government subsidises for 109.5 million socio-economically vulnerable account for 61 per cent of those with insurance coverage. Civil servants, private sector employees and others providing independent contributions make up 39 per cent of those insured. (TNP2K, 2018, p.83).

By October 2018, the systems served 203 million members, representing the ‘largest single-payer scheme in the world’. In 2017, 223.4 million consultations were recorded, amounting to US$20.15 billion (US$ PPP) (Agustina et al., 2019, p.75).

As over half of members of the BPJS receive government subsidies and among those contributing independently, members often only pay during periods of illness, which poses challenges for the financial sustainability of the programme. It was reported that claims exceeded contributions by 600 per cent in 2014 (TNP2K, 2018, p.84).

The system in Indonesia consists of three main service tiers, these are:

Community health centres (Puskesmas)

The Puskesmas programme was introduced under president Suharto in 1968. By 1970, community health centres were established in all subdistricts (Agustina et al., 2019, p.77). The Puskesmas provide frontline primary health care. From there, patients with more complex needs can be referred to hospitals or other services. In 2015, 9,754 Puskesmas were in operation, covering 92% of subdistricts. However, particularly in the eastern part of the country, some subdistricts did not have Puskesmas. There are also concerns regarding quality. According to Agustina and colleagues (2019, pp.84-95), ‘only 74% of community health centres met preparedness requirements’. Quality standards were found to be better in urban than in rural areas (Agustina et al., 2019, pp.84-85).

Integrated community health service post (Posyandu)

The Posyandu were introduced shortly after the Puskesmas (1980), with a focus on preventive health services (Agustina et al., 2019, p.77). The Posyandu are staffed by a midwife, a nurse assistant, and a vaccinator and are facilitated by health volunteers (kaders) in each community. These teams visit hamlets or village subdivisions on a monthly basis and provide ‘basic reproductive, maternal, neonatal, and child health services’, although later on several Posyandu Lansia focusing on older people’s health have been set up. It is estimated that almost 300,000 Posyandu are held every month (Agustina et al., 2019, p.84).

Hospitals

The number of hospitals almost doubled between 2005 and 2015, from 1,268 to 2,488 (Agustina et al., 2019, pp.84-85). As outlined above, subsidised members can access third-class hospital rooms without co-payments, while self-employed members can access first to third-class rooms in accordance with their insurance plan. Those earning more than $300 a month are entitled to first-class rooms. BPJS members can upgrade their hospital room through payments or private insurance (Agustina et al., 2019, p.89). In the end of 2021, the government has announced the plan to erase this classing system in BPJS, and will only offer a standardised class, following the health equity principle. It will be implemented gradually starting in 2023 (Hasibuan, 2022).

The Ministry of Health further regulates geriatric services in Indonesia’s public hospitals (Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 Tentang Pelayanan Geriatri Di RS), 2014). By 2015, six hospitals on Java Island and one hospital in Bali, Sumatra, and Sulawesi islands provided older people with ‘integrated geriatric services’ (Pusat Data dan Informasi Kementerian Kesehatan RI, 2014, 2016b).

Data from the Ministry of Health shows that the number of private hospitals has grown more rapidly than that of public hospitals. However, private hospitals remain mostly concentrated on the Java islands where there are larger urban and peri-urban centres.

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

Hasibuan L. (2022). Siap-siap! Kelas 1,2,3, BPJS Kesehatan Dihapus, Ini Gantinya. CNBC Indonesia. https://www.cnbcindonesia.com/news/20220220094223-4-316764/siap-siap-kelas-123-bpjs-kesehatan-dihapus-ini-gantinya

Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 tentang Pelayanan Geriatri di RS), (2014) (testimony of Ministry of Health Republic of Indonesia).

Ministry of Health. 2012–2017. Ministry of Health Annual Health Sector Profile 2011–2016. Jakarta, Indonesia: Ministry of Health.

Pusat Data dan Informasi Kementerian Kesehatan RI. (2014). Situasi dan analisis lanjut usia (pp. 1–7).

Pusat Data dan Informasi Kementerian Kesehatan RI. (2016b). Situasi Lanjut Usia (Lansia di Indonesia).

Tim Nasional Percepatan Penanggulangan Kemiskinan (TNP2K). (2018) The Future of the social protection system in Indonesia, Jakarta Pusat: Office of the Vice President of the Republic of Indonesia. https://www.developmentpathways.co.uk/wp-content/uploads/2018/11/44293181123-SP-ReportFinal-ENG-web.pdf

The healthcare infrastructure in Indonesia is dominated by private players. As of 2017, 1,767 out of 2,776 hospitals were privately-owned (Deloitte Indonesia, 2019). After the introduction of the national health insurance programme (JKN), the capacity of the private hospital sector in Indonesia has expanded. Approximately 75% of hospitals contracted by BPJS (social security agency for health) increased the types of services they offer, for instance the number of outpatient and inpatient departments, the number of beds, and investment into equipment (X-ray, CT scan, MRI, and incubator) (Ross et al., 2018).

Key health areas and services include non-communicable diseases (cardiovascular disease diagnosis and management, orthopaedic services, dialysis, cancer diagnosis and management, and chemotherapy), reproductive, maternal and newborn health (antenatal and postnatal services, immunization, family planning counselling and services, obstetric care, C-sections, and neonatal emergency care), tuberculosis services (diagnosis, outpatient and inpatient treatment), and diagnostic tests (X-ray, CT scan, MRI, and GeneXpert).

From 1993 to 2014, the inequality in accessing private hospitals and services has narrowed. In 1993, public and private outpatient care services were utilised at similar level, but private outpatient care utilisation continued to increase until 2014. This includes an increase in utilisation of inpatient care in the private sector by the lowest income group, which in 1993 was virtually non-existent (Mulyanto et al., 2019).

References:

Deloitte Indonesia. (2019). The Clouds Covering the Healthcare Business are not Always Grey: Welcoming the Future of Indonesia’s Healthcare Business in 2019. In Deloitte Indonesia Perspectives (Issue September).

Mulyanto, J., Kringos, D. S., & Kunst, A. E. (2019). The evolution of income-related inequalities in healthcare utilisation in Indonesia, 1993–2014. PLOS ONE, 14(6), e0218519. https://doi.org/10.1371/journal.pone.0218519

Ross, R., Koseki, S., Dutta, A., Soewondo, P., & Nugrahani, Y. (2018). Results of a Survey of Private Hospitals in the Era of Indonesia’ s Jaminan Kesehatan Nasional: Impact of Contracting with National Health Insurance on Services, Capacity, Revenues, and Expenditure. http://www.healthpolicyplus.com/ns/pubs/8224-8400_JKNPrivateHospitalSampleSurveyreport.pdf

Patients access primary care practitioners through the Puskesmas. There is a maximum ratio of 5,000 patients per primary care practitioner to encourage quality of care. Furthermore, primary care practitioners have been trained on ‘standard care competencies for the most common 144 diagnoses and 11 medical conditions’ by the Indonesian Medical Council. Where patients present with other conditions, they receive a referral to a specialist based in a lower-class hospital. Only from there, patients can be referred to higher class hospitals (Agustina et al., 2019, p.89).

Lack of knowledge on how to access services has been reported among subsidised members of the National Health Insurance System (NHIS) (Agustina et al., 2019, p.94).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

Despite its recent introduction (2014), the NHIS is reported to have reached almost 70 per cent of the population (Agustina et al., 2019, p.76).

However, there appear to be substantial gaps in terms of coverage of the so-called ‘missing middle’, even though considerable subsidies and improved access to health care for those living in poverty have been established. This ‘missing middle’  represents approximately 34.4 million people who are working in informal employment but not living in poverty. While some argue that this group does not seek insurance cover due to the required premiums, others suggest that ‘availability of services and poor understanding of health insurance’ stops people from signing up (Agustina et al., 2019, p.94)

Agustina and colleagues (2019, p.76) further report that the availability and quality of primary care services, drugs, and medical supplies as well as the poor and disassociated health information systems pose challenges to the provision of universal health care in Indonesia.

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

The NIHS/BPJS is a single quasi-government entity and the biggest single-payer system globally (Agustina et al., 2019, pp.76,88). The system is financed from three sources. First, contributing members pay insurance premiums. Second, for non-contributing members the insurance premiums are covered by the government of Indonesia. Third, additional revenue is received from income tax, tobacco tax, district-level payments as well as grants from overseas development agencies (Agustina et al., 2019, p.88). However, a World Bank report maintains that despite reform, out of pocket spending for health continues to be one of the main financing mechanisms of the health care system (World Bank, 2016b, p.4).

The NIHS/BPJS system contracts primary care providers as well as hospital providers directly. Primary care providers are paid through a capitation system and advance payments, while secondary providers (hospitals) are reimbursed through diagnosis-based group (CBG) tariffs allocated by the Ministry of Health (Agustina et al., 2019, pp.76,88). The direct contracting system enabled the NHIS to enrol 20,000 primary care providers, 907 public and 1,106 private hospitals as well as pharmacists, dispensaries, laboratories, and radiology centres (Agustina et al., 2019, p.89).

In terms of allocation of funding, it is clear that political emphasis lies on curative and rehabilitative care. The largest share of health expenditure accounts for hospital care (over 65%), with approximately 50% financing in-patient and 15% percent financing outpatient care. A further 20% of health expenditure support care in the Puskesmas and in private clinics. Less than one per cent of the budget are allocated for prevention and health promotion (World Bank, 2016b, p.5).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

World Bank. (2016b). Indonesia Health Financing System assessment: spend more, spend right & spend better. Available at: http://documents.worldbank.org/curated/en/453091479269158106/pdf/110298-REVISED-PUBLIC-HFSA-Nov17-LowRes.pdf

 

It is estimated that 16 per cent of the Indonesian population was not covered by health insurance in 2017. The NIHS covered 70 per cent of the population and approximately 14 per cent of the population were covered through private health insurance (Agustina et al., 2019, p.90).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

Yes. The Ministry of Health in Indonesia pursues a five-step Strategic Plan (2015-2019). The key aspects on the agenda are the ‘revitalization of community health centres (puskesmas)’, continuation of care, and ‘specific solutions for specific health problems’. Planned changes to the financing strategy have only been outlined for community health centres. The Ministry of Health declared the aim to ‘increase […] the budget for facilities and support for puskesmas’ but it did not explicitly outline how this will be approached (Claramita et al., 2017, p.9). The Ministry of Health further states the aim to reduce ‘household burden [due] to finance health services’ from 37 per cent to 10 per cent (Ministry of Health Republic of Indonesia, 2015a, p.45).

References:

Claramita, M., Syah, N. A., Ekawati, F. M., Hilman, O., & Kusnanto, H. (2017). Primary Health Care Systems (PRIMASYS): Comprehensive case study from Indonesia. World Health Organization. https://www.who.int/alliance-hpsr/projects/AHPSR-PRIMASYS-Indonesia-comprehensive.pdf

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

The World Bank suggests that health care spending has been ‘accorded a generally low priority’ in Indonesia given that expenditure of total government budget amounted only to 4.7 per cent, which is lower than that of neighbouring countries such as the Philippines, China, and Thailand (World Bank, 2016b, p.4). In 2015, the Government of Indonesia passed legislation that requires 5 per cent of the national budget to be allocated to the health sector. This target was reached by 2016. In addition, district governments must spend 10 per cent of their budget on health-related issues (Agustina et al., 2019, p.85). Despite these allocations, spending on health in Indonesia is comparatively low (3% of GDP) in comparison to other LMICs and other countries in the Association of Southeast Asian Nations (Agustina et al., 2019, p.85).

In an effort to provide communities with greater ability to respond to local needs, the Village Law (Law Number 6/2014) and a law to strengthen the role of provinces (Law Number 23/2014) have been enacted.  The Village Law regulates the transfer of an estimated one billion rupiahs per village to 77,548 villages. These funds may also contribute to improvement of community-based healthcare and lifestyle interventions. The law strengthening the role of the provinces creates a closer link between provincial governors and central governments and offers an opportunity for provinces to be responsible for monitoring Minimum Service Standards in health care. Besides monitoring activities, provinces can impose sanctions on district/city level to enforce adherence to Minimum Service Standards (Ministry of Health Republic of Indonesia, 2015b, p.36).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The President of the Republic of Indonesia. (2014). Law of the Republic of Indonesia Number 6 of 2014 concerning village https://www.kemenkeu.go.id/sites/default/files/pdf-peraturan/16.pdf

The President of the Republic of Indonesia. (2014). Law of the Republic of Indonesia Number 23 of 2014 about local government http://extwprlegs1.fao.org/docs/pdf/ins160168.pdf

World Bank. (2016b). Indonesia Health Financing System assessment: spend more, spend right & spend better. Available at: http://documents.worldbank.org/curated/en/453091479269158106/pdf/110298-REVISED-PUBLIC-HFSA-Nov17-LowRes.pdf

 

Every five years, the Ministry of National Development Planning (BAPPENAS) issues a medium-term national spending plan (Rencana Pengeluaran Jangka Menengah Nasional (RPJMN)). Based on this and taking into consideration the macroeconomic framework as well as the president’s instructions, the ministries, including the Ministry of Health have to submit an annual work plan (Rencana Kerja Pemerintah (RKP)), along with their budget to the Ministry of Finance. The combined budgets are then discussed and approved by the legislative body (Dewan Perwakilan Rakyat (DPR)). This process occurs annually between October and November for the following year (Kementrian Keuangan, 2015).

The previous RPJMN covered the years 2014 to 2019. From 2020 onwards the RPJMN 2020-2024 will be the reference for upcoming budgets (Kementrian PPN/BAPPENAS, 2019).

References:

Kementrian Keuangan. (2015). Pedoman Proses Perencanaan, Penganggaran, dan Pelaksanaan APBN. http://www.anggaran.depkeu.go.id/content/publikasi/buku pedoman perencanaan.pdf

Kementrian PPN/BAPPENAS. (2019). Rancangan Teknokratik Rencana Pembangunan Jangka Menengah Nasional 2020 – 2024.

The priorities for funding are set by the Ministry of Health based on the RPJMN as mentioned above. For the RPJMN 2020-2024, one of the directions of policy and strategy is to increase access and quality of health service and to work towards universal health coverage with an emphasis on the strengthening of primary care. This was to be achieved through several action plans, including those focusing on disease control for HIV/AIDS, Tuberculosis, malaria, heart disease, stroke, hypertension, diabetes, cancer, emerging diseases, diseases with outbreak potential, overlooked tropical disease (lepra, filariasis, schistosomiasis), mental health, injury, vision problems, and mouth and dental problems. Dementia and ageing were not mentioned in this document; however, they might be seen as part of the wider mental health agenda (Kementrian PPN/BAPPENAS, 2019).

The Government of Indonesia prioritised funding of health insurance for low-income and vulnerable income groups as well as for the strengthening of primary care (Puskesmas) and the enhancing of specific programmes, such as maternal and child health and family planning (Agustina et al., 2019, p.90; Mahendradhata et al., 2017, p.241).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

Kementrian PPN/BAPPENAS. (2019). Rancangan Teknokratik Rencana Pembangunan Jangka Menengah Nasional 2020 – 2024.

Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., MArthias, T., Harimurti, P., & Prawira, J. (2017). The Republic of Indonesia Health System Review (Vol. 7, Issue 1). https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf

As outlined above, most health care spending is allocated to hospital care, with only 20 per cent of funds allocated at primary care level. This creates considerable inequity in access to health. Treatment for complex illnesses, such as diabetes, hypertension, or cancer are covered by the health budget; however, many adult vaccinations and screening tests needed to establish the prevalence of these illnesses at primary care level are not (Claramita et al., 2017, p.21). In addition, limited availability of data causes difficulties in detailed understanding of budget allocation in primary and secondary care settings (Claramita et al., 2017, p.21).

The combination of central government and district level financing leads to a complex and fragmented system. By Law (law number 26/2009), local governments (province, district, and city) have to allocate at least 10 per cent of their regional budget to health. According to the Ministry of Health, regions slightly underspend, allocating on average 9.37 per cent (2012). However, according to 2012 data, some provinces have spent up to 16 per cent of their budget on health. At district/city levels almost half (42.2%) allocated more than 10 per cent of their budget for health (Ministry of Health Republic of Indonesia, 2015b, pp.29-30). This leads to considerable variation in health expenditure between districts causing considerable inequities (World Bank, 2016b, p.5). We are unable to identify how local governments allocate their spending on health.

Despite the considerable share of out-of-pocket expenditure, voluntary health insurance uptake has been relatively consistent between 2010 and 2017, at 3-4% of current health expenditure. Meanwhile, the proportion of household out-of-pocket expenditure has been declining, amounting to 34% of current health expenditure in 2017. This may be an indicator that government schemes including the National Health Insurance introduced in 2014 are starting to reduce out-of-pocket expenditure.

References:

Claramita, M., Syah, N. A., Ekawati, F. M., Hilman, O., & Kusnanto, H. (2017). Primary Health Care Systems (PRIMASYS): Comprehensive case study from Indonesia. World Health Organization. https://www.who.int/alliance-hpsr/projects/AHPSR-PRIMASYS-Indonesia-comprehensive.pdf

Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., MArthias, T., Harimurti, P., & Prawira, J. (2017). The Republic of Indonesia Health System Review (Vol. 7, Issue 1). https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

World Bank. (2016b). Indonesia Health Financing System assessment: spend more, spend right & spend better. http://documents.worldbank.org/curated/en/453091479269158106/pdf/110298-REVISED-PUBLIC-HFSA-Nov17-LowRes.pdf

In Indonesia, there are two pooling mechanisms that allocate and disperse health budgets across the country. First, central government funds are pooled and then transferred to provincial and district governments. Second, the BPJS pools social insurance funds (Mahendradhata et al., 2017, p.87).

Pooling of central government funds means that the State Revenue and Expenditure Budget (APBN) determines allocation of funds centrally. For health funds, this allocation is decided by the Ministry of National Development Planning of the Republic of Indonesia (BAPPENAS) in consultation with the Ministry of Heath and the Ministry of Finance. The final allocation of funds needs to be approved by the national parliament (DPR). The budget allocation is based on:

  1. ‘Historical budgets,
  2. Proposal by ministries,
  3. Calculation of local needs according to population size’ (Mahendradhata et al., 2017, p.87).

It is noteworthy that non-technical and political considerations by the House of Representatives (DPR) that influence the indicate budget levels, play a role as well. (Mahendradhata et al., 2017, p.87).

The Ministry of Health distributes the health budget to central-level departments and health agencies as well as to provincial and district governments. The fund allocation includes:

  1. Dana dekon (de-concentration fund) is allocated to provincial health offices to manage health functions in its districts and to ‘build capacity of [district health offices] in national priority programmes’.
  2. Tugas perbantuan (assisting task fund) is given to district health offices for spending related to carrying out assisting/operational tasks around the puskesmas.
  3. Dana alokasi khusus (special allocation fund) is ‘allocated […] to local governments and earmarked for specific health infrastructure construction such as […] puskesmas, sub-puskesmas, and district hospitals’. For health, this fund can used for financing primary health care, referrals to secondary and tertiary care, and pharmacy services (including generics procurement) (Mahendradhata et al., 2017, p.88).

In addition to central resources mechanism, provincial and district government also prepare plans and budget proposals (bottom-up approach). Local government’s revenue and expenditure budget (APBD) is divided into indirect expenditure (salaries of civil servants in health facilities) and direct expenditure (operations of health services and programmes and allowances of health services staff). However, indirect expenditure can take up more than 80% of the total budget allocation, which may limit funding for operational expenditure (Mahendradhata et al., 2017, pp.88-89).

The second mechanism represents the distribution of social insurance funds through the BPJS. All social insurance contributions of the population, including government funds, are pooled into a single trust fund (Dana Amanat). ‘The allocation of revenue from central government to the BPJS is based on the number of members entitled to have their contribution paid by the government (PBI members), and the agreed premium to be paid by the government’. ‘The PBI contribution is then allocated to districts based on the number of PBI members in each district’ (Mahendradhata et al., 2017, p.88).

References:

Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., MArthias, T., Harimurti, P., & Prawira, J. (2017). The Republic of Indonesia Health System Review (Vol. 7, Issue 1). https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf

In 2017, life/health insurance made up 6.66% of all financial products owned by Indonesians aged 18 and older. However, this figure dropped to 4.47% in 2018 (Mahendradhata et al., 2017, p.44). (Please note the percentages are out of all respondents and there were 23.59% and 24.86% of people who did not have any forms of financial products in 2017 and 2018, respectively).

In 2013, BPJS established a coordination of benefits with some of the leading private health insurance providers to provide a top-up option for middle- and high-income members of the JKN, which may increase the uptake of private insurance in Indonesia (Mahendradhata et al., 2017, p.44). In 2019, BPJS and 11 insurance providers (members of Forum Asuransi Kesehatan Indonesia) signed a Coordination of Benefit agreement to simplify the process of adding on private insurance policies to their existing BPJS schemes (Kartika & Walfajri, 2019).

References:

Kartika, H., & Walfajri, M. (2019). Gandeng perusahaan asuransi, peserta BPJS Kesehatan bisa naik kelas gratis.

Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., MArthias, T., Harimurti, P., & Prawira, J. (2017). The Republic of Indonesia Health System Review (Vol. 7, Issue 1). https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf

Private insurance companies operate under the supervision of the Ministry of Finance (House of Representatives, 1992) (Mahendradhata et al., 2017, p.44). Otoritas Jasa Keuangan Republik Indonesia is the regulatory body for private insurance and re-insurance companies. Peraturan OJK no. 71/POJK.05/2016 regulates on the financial health of the companies, determining areas of investments allowed with its assets, governing its liabilities, etc. (Otoritas Jasa Keuangan Republik Indonesia, 2016). Note that there are also some non-profit insurance companies with sharia type products (Mahendradhata et al., 2017, p.96).

References:

Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., MArthias, T., Harimurti, P., & Prawira, J. (2017). The Republic of Indonesia Health System Review (Vol. 7, Issue 1). https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf

Otoritas Jasa Keuangan Republik Indonesia. (2016). Peraturan Otoritas Jasa Keuangan (POJK) No 71 Tentang Kesehatan Keuangan Perusahaan Asuransi dan Perusahaan Reasuransi. 50. https://www.ojk.go.id/id/kanal/iknb/regulasi/asuransi/peraturan-ojk/Documents/Pages/POJK-tentang-Kesehatan-Keuangan-Perusahaan-Asuransi-dan-Perusahaan-Reasuransi/SAL-POJKKesehatan Keu PA PR -.pdf

Out-of-pocket expenditure in Indonesia is significant and despite the introduction of social health insurance in 2014 remains one of the main funding sources for health care. In 2013, it was estimated to be 49 per cent out of total health expenditure; however, the figure has been reported to have declined to 34 per cent in 2017.

Despite this high proportion, the share of families facing catastrophic out-of-pocket expenditure (more than 25% of household expenditure) remains at only about 1 per cent. On the other hand, approximately 7 million households (8% of households) were reported to have been impoverished due to health-related out-of-pocket payments (World Bank, 2016b, p.4). The WHO, therefore, groups Indonesia among countries with high out-of-pocket expenditures (Agustina et al., 2019, p.85; WHO, 2017, pp.126,133; World Bank, 2016b, p.4).

Even though access to services is increasing, there appears to be a lack in uptake with about 50 per cent of those entitled to outpatient care and 20 per cent of those entitled to inpatient care not taking up services. This may be due to issues with access, waiting times, quality of care, and providers falsely charging for treatments and medication (Agustina et al., 2019, p.90).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

World Bank. (2016b). Indonesia Health Financing System assessment: spend more, spend right & spend better. http://documents.worldbank.org/curated/en/453091479269158106/pdf/110298-REVISED-PUBLIC-HFSA-Nov17-LowRes.pdf

World Bank. (2017). Indonesia Can Improve Opportunities for and Protection of Its Migrants Working Abroad. Press Release. https://www.worldbank.org/en/news/press-release/2017/11/28/indonesia-can-improve-opportunities-for-and-protection-of-its-migrants-working-abroad

According to the World Bank, remittances play an important role in Indonesia. The World Bank states that almost seven per cent of Indonesia’s labour force (9 million people) worked overseas in 2016. They sent more than IDR 118 trillion ($8.9 billion), which amounts to about one per cent of GDP, in remittances. It remains unclear what proportion is spent on health care (World Bank, 2017).

Research has found that remittances positively contribute to the health status of adult recipients in rural areas. It was reported that adults in household with family members who were labour migrants were ‘40% less likely to be underweight than those in non-migrant households’. This suggests that remittances may improve the overall health of families (Lu, 2013; UNESCO, 2017, p.6).

References:

Lu, Y. (2013). Household Migration, Remittances and Their Impact on Health in Indonesia 1. International Migration, 51, e202–e215. https://doi.org/10.1111/j.1468-2435.2012.00761.x

UNESCO. (2017). Overview of Internal Migration in Indonesia. Unesco.

World Bank. (2017). Indonesia Can Improve Opportunities for and Protection of Its Migrants Working Abroad. Press Release. https://www.worldbank.org/en/news/press-release/2017/11/28/indonesia-can-improve-opportunities-for-and-protection-of-its-migrants-working-abroad

External sources of financing, including donations, are considered to be the fourth largest source of health care funding in Indonesia. However, they are estimated to amount to only about between one to four per cent of the health budget (Mahendradhata et al., 2017, p.98; World Bank, 2016b, p.5).

The Asian Development Bank, followed by the World Bank, have been considered as the biggest donors for Indonesia in 2012. Donations from Japan were ranked on third place. Japan is considered to be the largest single donor country supporting Indonesia, accounting for 45% of the cumulative total of official development assistance (ODA) since 1960 (Japan International Cooperation Agency, 2018). Other significant donors include the Australian Agency for International Development, the Global Fund to fight Aids, Tuberculosis and Malaria, the Agence Française de Développement, the United States Agency for International Development, the United Nations, the Millenium Challenge Corporation, and the Federal Ministry for Economic Cooperation and Development. However, it is unclear what these donations were allocated for.

External health financing and technical assistance in Indonesia appears to be targeted at specific interventions, such as immunization, HIV, TB, and malaria. According to the Ministry of Health, external funding accounted for 60 per cent of spending on TB and 10-15 per cent on vaccination in 2015. Changes in funding over time may reflect the government’s ability to sustain programmes independently as well as donor interests (Mahendradhata et al., 2017, p.98; World Bank, 2016b, p.5).

References:

Japan International Cooperation Agency. (2018). Indonesia’ s Development and Japan’ s Cooperation : Building the Future Based on Trust (Issue April). https://www.jica.go.jp/publication/pamph/region/ku57pq00002izqzn-att/indonesia_development_en.pdf

Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., MArthias, T., Harimurti, P., & Prawira, J. (2017). The Republic of Indonesia Health System Review (Vol. 7, Issue 1). https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf

World Bank. (2016b). Indonesia Health Financing System assessment: spend more, spend right & spend better. http://documents.worldbank.org/curated/en/453091479269158106/pdf/110298-REVISED-PUBLIC-HFSA-Nov17-LowRes.pdf

The largest share of the healthcare workforce in Indonesia is made up by nurses (38%). The second largest group are medical doctors (19%), followed by midwives (17%), pharmacists (6%), and public health personnel (7%). The remaining 13 per cent represent ‘physiotherapists, nutritionists, clinical psychologists, and other health professionals’ (Claramita et al., 2017, p.24). The Ministry of health declared that in 2013 among medical doctors, 33 per cent were geriatric specialists, 32 per cent were surgical specialists, 29 per cent were paediatric specialists, and 27 per cent were obstetric and gynaecologic specialists (Ministry of Health Republic of Indonesia, 2015b, p.28).

Overall, density of health care professionals is small in comparison to world average. The OECD estimates that in 2012 Indonesia had 0.3 physicians (OECD average 3.2) and 1 nurse per 1,000 population (OECD average 8.8) (OECD Health Statistics Database, 2014). As of 2015, the World Bank (World Bank, 2015) does not record any community health workers (per 1,000 people) for Indonesia. While internationally there were 16 physicians on average available per 10,000 populations, there were only 2.9 in Indonesia in 2016 (Claramita et al., 2017, pp.24,27). We are unable to identify the number of, social workers, neurologists, or geriatricians per 100,000 population by public and private sector. As discussed previously, there are large differences in the availability of healthcare workers between urban and rural areas. To address the low provision of medical doctors, education of primary care physicians has been on the policy agenda following the National Act No. 20 in 2013 (Claramita et al., 2017, pp.24,27).

References:

Claramita, M., Syah, N. A., Ekawati, F. M., Hilman, O., & Kusnanto, H. (2017). Primary Health Care Systems (PRIMASYS): Comprehensive case study from Indonesia. World Health Organization. https://www.who.int/alliance-hpsr/projects/AHPSR-PRIMASYS-Indonesia-comprehensive.pdf

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

OECD Health Statistics Database. (2014). OECD Health Statistics 2014 How does Indonesia compare ? http://www.oecd.org/els/health-systems/Briefing-Note-INDONESIA-2014.pdf

World Bank. (2015). Community health workers (per 1,000 people) – Indonesia. World Health Organisation’s Global Health Workforce Statistics, OECD. https://data.worldbank.org/indicator/SH.MED.CMHW.P3?locations=ID

One of the issues in the provision of health care faced by Indonesia concerns the disparities between the number of health care workers available in urban and rural areas. For example, in 2006, there were 36.18 physicians per 100,000 residents available in urban parts of Indonesia, while there were only 5.96 in rural areas. These disparities were greatest in provinces outside Java and Bali (Rokx et al., 2010, p.43).

Since the 1970s, physicians and midwives are allowed to operate in dual practice. This means that while working in the public system, they can get additional income from working in private practices outside public working hours. It was hoped that this would improve health worker retention, particularly in rural and remote areas as well as to increase the supply for service by incentivising the provision of longer work hours. In 2007, almost 70 per cent of puskesmas physicians and approximately 90 per cent of midwives were reported to have taken up additional private practice (Rokx et al., 2010, p.42).

The dual practice policy, however, may have not been entirely successful as it has been reported that the number of new graduates seeking employment in rural and remote areas has decreased, perhaps because there are fewer opportunities for private practice. Instead, shortening the mandatory service period as part of one of the governments contracting programmes (PTT) from three years to six months increased the number of health workers willing to take up remote postings (Rokx et al., 2010, pp.17,42).

A second issue faced by the Indonesian health system concerns the high turnover rates. According to a study investigating patterns of nurse turnover rates in a private hospital in East Java, turnover rates were higher than acceptable (between 12-34%) (Dewanto & Wardhani, 2018, p.1). Factors associated with the risk of turnover include being aged up to 30 years, unmarried, and working for more than 3 years in the hospital. Personal drivers were most commonly cited as motivating the nurses’ resignation (e.g., moving locations to follow their spouses or families, getting married, having children, following a pregnancy program, and continuing their education). Other drivers to turnover are accepting job offers from other organizations and dissatisfaction with the original hospitals’ working conditions. Nurse turnover rates have consequences for patients, doctors, the other nurses, and the hospitals.

This results in a gap between the manpower available to respond to current and projected needs for different professions within public hospitals. The ‘Development Plan for Healthcare Manpower 2011-2025’ also offers estimates around the cost of human resources planning in healthcare at national level. Estimates include cost for training and education for each profession.

References:

Dewanto, A., & Wardhani, V. (2018). Nurse turnover and perceived causes and consequences: A preliminary study at private hospitals in Indonesia. BMC Nursing, 17(Suppl 2), 1–7. https://doi.org/10.1186/s12912-018-0317-8

Kementerian Kesehatan Republik Indonesia. (2011). Rencana Pengembangan Tenaga Kesehatan Tahun 2011 – 2025. September.

Rokx, C., Giles, J., Satriawan, E., Marzoeki, P., Harimurti, P., & Yavuz, E. (2010). New Insights Into the Provision of Health Services in Indonesia: A Health Workforce Study. https://books.google.com/books?id=7l7NnxfGfycC&pgis=1

Emigration of health professionals has doubled between 2011 and 2013 to more than 5,600 across professions. This suggests that migration does affect the availability of healthcare workers in Indonesia, given that the number of healthcare workers across the population, and particularly in remote, rural parts or the country are already very low (Pusat Data dan Informasi Kementerian Kesehatan RI, 2014).

References:

Pusat Data dan Informasi Kementerian Kesehatan RI. (2014). Situasi dan analisis lanjut usia (pp. 1–7).

Indonesia is in the process of developing a public Long-Term Care (LTC) system. Policies developed under the umbrella of long-term care fall into services that would commonly be identified as social security mechanisms (i.e. old age pensions), and services that fall under the realm of health care (i.e. services and interventions to delay or reduce the number of people with long-term care needs), while other care services (i.e. day care, respite care, institutional care) are limited in availability (UNESCAP, 2014, p.12). BAPPENAS describes this split between health care and social security mechanisms as the provision of financial (social security) and non-financial (health care, long-term care, and legal protection) (Kementrian Koordinator Bidang Pembangunan Manusia dan Kebudayaan RI, 2020).

The core features of the Indonesian long-term care system are based on the Puskesmas (community health centres providing primary health care services) and Posyandu (integrated community health service posts that focus on preventive health services provided by midwives, nurse assistants, vaccinators, and health volunteers who visit communities monthly) system. Both types of services fall under the regulation of local governments (Pusat Data dan Informasi Kementerian Kesehatan RI, 2014). In 2009, the Ministry of Health and the Ministry of Home Affairs declared the Puskesmas Santuan Lansia to be the first-line providers of health and long-term care for older people. Furthermore, between 2018-2019, the Ministry of Health has issued a LTC guideline for the Puskesmas (Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat, 2018) that provide directions on the implementation of LTC in Puskesmas.

Even though the Ministry of Health and the Ministry of Home Affairs already in 2009 declared the Puskesmas Santuan Lansia to the core service provider for older people, insufficient support from provinces and cities meant that only around 42.3% of Puskesmas were able to implement the concept by 2011 (Badan Litbangkes Kementrian Kesehatan RI, 2012). Furthermore, it has been reported that there is a shortage in services provided through Puskesmas in the East of the country and in more rural regions due to concerns about workforce availability and quality (Kadar et al., 2013). Shortages could also be found in the provision of Posyandu Lansia services. The Ministry of Health stated that in 18 out of 34 provinces there were no Posyandu Lansia services available, and 11 provinces did not provide health services through the Puskesmas Ramah Lansia (Pusat Data dan Informasi Kementerian Kesehatan RI, 2017).

Ministry of Health Data (from December 2018) states that there were Puskesmas and Posyandu Lansia available in all provinces (Kementerian Kesehatan Republik Indonesia, 2019a). However, a study from 2018 suggests that there are varying levels of functioning among posyandu lansia across provinces (Pratono & Maharani, 2018). There is anecdotal evidence from the cities Malang and Surabaya about the lack of regular services, volunteers, and health workers, which suggests limited interest and commitment by the community members in the posyandu lansia. Posyandu lansia also sometimes charge additional transaction costs although services are supposed to be free. Based on data from the Program Report of the Directorate of Family Health (2017), there were 3,645 Puskesmas that provided santun lansia services (Kementerian Kesehatan Republik Indonesia, 2018).

Lack of coordination on national level, public underfunding, and high out-of-pocket expenditure are creating barriers to accessibility and availability of services for older people in Indonesia, where the government allocated only about 0.1 per cent of GDP (2006-2010) to long-term care (Rahardjo & Yerly, 2014; Scheil-Adlung, 2015, p.xi). The report further elaborates, that in Indonesia, as of 2015, 87.3% of the population aged 65 and older were excluded from accessing LTC services because of financial resource deficits (Threshold, 1.451.8 PPP$) (Scheil-Adlung, 2015, p.83).

Regulations and bills

Between 2009 and 2018 nine regulations and bills have been activated under the umbrella of long-term care to support older people with care needs.

In addition, the provision of long-term care to older people was included in the National Medium-term Development Plan 2015-2019 and is expected to also be included in the consecutive long-term development plan. Responsibility for LTC policy was given to the National Commission for Older People, which was established in 2004 (UNESCAP, 2014).

References:

Badan Litbangkes Kementrian Kesehatan RI. (2012). Ringkasan Hasil Riset Fasilitas Kesehatan (Rifaskes) 2011.

Kadar, K. S., Francis, K., & Sellick, K. (2013). Ageing in Indonesia – Health Status and Challenges for the Future. Ageing International, 38(4), 261–270. https://doi.org/10.1007/s12126-012-9159-y

Kementerian Kesehatan Republik Indonesia. (2018). Provil Kesehatan Indonesia 2017 (Vol. 1227, Issue July). https://doi.org/10.1002/qj

Kementerian Kesehatan Republik Indonesia. (2019a). Data Dasar Puskesmas.

Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat. (2018). Pedoman untuk Puskesmas dalam Perawatan Jangka Panjang bagi Lanjut Usia. Kementerian Kesehatan RI.

Kementrian Koordinator Bidang Pembangunan Manusia dan Kebudayaan RI. (2020). Tanggapan Terkait White Paper “Pemenuhan hak-hak lansia untuk hidup setara, sejahtera dan bermartabat.” Presentasi.

Pratono, A. H., & Maharani, A. (2018). Long-Term Care in Indonesia: The Role of Integrated Service Post for Elderly. Journal of Aging and Health, 30(10), 1556–1573. https://doi.org/10.1177/0898264318794732

Pusat Data dan Informasi Kementerian Kesehatan RI. (2014). Situasi dan analisis lanjut usia (pp. 1–7).

Pusat Data dan Informasi Kementerian Kesehatan RI. (2017). Analisis Lansia di Indonesia.

Rahardjo, T. B. W., & Yerly, A. N. (2014). A trend for establishing community care system in Indonesia. Forum on Conception of Harmonization of Long Term Care Certificate Between Japan and Indonesia.

Scheil-Adlung, X. (2015). Long-term care protection for older persons: A review of coverage deficits in 46 countries. In Extension of Social Security (Issue 50). http://www.ilo.org/wcmsp5/groups/public/—ed_protect/—soc_sec/documents/publication/wcms_407620.pdf

UNESCAP. (2014). Report of the Regional Expert Consultation on Long-term Care of Older Persons. https://www.unescap.org/sites/default/files/Report%20Reg-Consultation.pdf

The Indonesian long-term care policy emphasises the care of older people on kekerabatan, which refers to care through a kinship system in multi-generational households and bases its support structure on this assumption (Setioko & Pandelaki, 2015, p.57; Rahardjo & Yerly, 2014). This may explain the limited number of LTC services, such as day care, respite care, institutional care services. The Indonesian family focused approach is not without problems, as migration patterns outlined previously show that larger family structures become fragmented when younger generations move for employment opportunities and the traditional family unit providing LTC may not always be a feasible and appropriate assumption.

Puskesmas

According to  the Ministry of Health’s Director of Mental Health Development, out of the 9,599 puskemas in the country, there are about 528 puskesmas across 231 cities equipped with “santun lansia”/geriatric-friendly facilities (not dementia-specific) that include ground-floor rooms, toilets suitable for older people, and prioritisations of older patients in registration and medicine dispensing (Herman, 2015).

Posyandu

The second important long-term care role was given to the Posyandus, however, in contrast to the Puskesmas no specific role was outlined in the National Strategic Plan for older people (No.25/2016) (Pratono & Maharani, 2018). This community service, which is run by midwives and volunteers, initially focused on family planning and maternal health (Posyandu Balita). In recent years, the community service received an optional second task: the provision of health ‘promoting and preventive’ services to senior citizens (Posyandu Lansia). These include regular basic health services as well as other community activities, such as taking a medical history, physical examination, assessing people’s ability to complete activities of daily living independently, basic laboratory tests as well as the provision of information on nutrition and some services may provide home visits, health promotion activities, legal and social aid, day care, and social activities as well as religious and mental spiritual services (Metkono et al., 2017; Pusat Data dan Informasi Kementerian Kesehatan RI, 2014; Rahardjo & Yerly, 2014; UPTD Puskesmas Kandangan, 2015).

According to regulation No. 7/2007 issued by the National Ministry of Home Affairs, each Posyandu should cover between 30 and 50 households and be run by five to 10 volunteers.

Some Posyandu Lansia may also provide home care services in the community, however, the level of service provision was reported to vary considerably between areas. According to Rahardjo and Yerly (2014), there are 70,000 Posyandu Lansia services available in Indonesia. Another source suggests that there are 52,450 Posyandu Lansia operating in the province of East Java, while ten provinces are reported (Aceh, West Sumatra, Bengkulu, Gorontalo, Riau Islands, Lampung, South Kalimantan, Southeast Sulawesi, West Sulawesi, West Nusa Tenggara, and Papua) to not have any (Pusat Data dan Informasi Kementerian Kesehatan RI, 2014)

Placing the responsibility of the Posyandu Lansia services on midwives led to challenges of expertise versus the high expectations of the local community, where midwives without appropriate training were expected to ‘provide guidance on preventive measures such as early detection of diseases, hypercholesterolemia and hypertension, as well as health and psychological counselling’ (Pratono & Maharani, 2018, p.1569). Shortage of medical workforce in some areas may exaggerate this as well as create overlap in workload between medical professions.

Pratono & Maharani (2018), following their study of role of posyandus in LTC in the East Java Province identified several limitations. It appears that in rural areas the monthly posyandus provide only social events as LTC (e.g., dance, prayer, and recreation) services in addition to basic health care provision. While health care services are free, participants are expected to pay for uniforms or to provide a contribution fee for their participation in activities, which limits accessibility. In addition, the reliance of volunteers means that posyandus may be run by religious groups, which may lead to exclusion of population groups (Handayani & Wahyuni, 2012; Pratono & Maharani, 2018, p.1566). Furthermore, the authors raised issues regarding accessibility of services due to distance and transportation costs as well as quality of services. They highlighted a report by the Ministry of Health (2015) that showed that ‘only 10% of Posyandu met the minimum standard and only 1% of Posyandu were able to independently manage their financial resources’ (Pratono & Maharani, 2018, p.1571). Reliance on volunteers meant that many Posyandu were unable to provide regular activities due to lack of volunteers and capability (Pratono & Maharani, 2018). ‘The long-term care requires health cadres or caregivers who support the health workers, however, health cadres or caregivers need to conceive a decent knowledge regarding long-term care on the elderly’ (Aquino Amigo & Nekada, 2019). Rahardjo et al,. presented in an LTC expert dialogue forum in Kitakyushu, Japan (2019), hosted by Economic Research Institute for ASEAN and East Asia the results of their unpublished data from West Jakarta, in which they found the lack of training for volunteers and low understanding of LTC among the volunteers (60%), despite previous training.

Nursing homes

In addition to the health focused Puskesmas and Posyandu, the Ministry of Social Affairs provides nursing homes (Panti Wredha). These nursing homes services are provided to people without access to family or community support and in need of long-term care. Volunteers are likely to identify eligible people (Kadar et al., 2013). There are only very few publicly funded shelters and nursing homes managed by the Ministry of Social Affairs available to older people in Indonesia, as these services are not yet fully developed. Local governments, on the other hand, have been found to have established nursing homes across several provinces. However, there were some regions, including Bangka Belitung, East Nusa Tenggara, Central Sulawesi, and West Sulawesi that do not yet have institutional care facilities.

References:

Aquino Amigo, T. E., & Nekada, C. D. Y. (2019). Pengaruh Edukasi Perawatan Jangka Panjang Pada Lansia Dengan Pengetahuan Kader Kesehatan Di Area Komunitas. Jurnal Ilmu Keperawatan Komunitas, 2(2), 1. https://doi.org/10.32584/jikk.v2i2.408

Handayani, D., & Wahyuni. (2012). Hubungan Dukungan Keluarga Dengan Kepatuhan Lansia Dalam Mengikuti Posyandu Lansia Di Posyandu Lansia Jetis Desa Krajan Kecamatan Weru Kabupaten Sukoharjo. Gaster, 9(1), 49–58. https://jurnal.aiska-university.ac.id/index.php/gaster/article/view/32/29

Herman. (2015). Puskesmas Didorong Beri Layanan Penyakit Pikun. Hero, Supermarket Ramah Lansia Pertama di Indonesia. (2018, June). PalapaNews.

Kadar, K. S., Francis, K., & Sellick, K. (2013). Ageing in Indonesia – Health Status and Challenges for the Future. Ageing International, 38(4), 261–270. https://doi.org/10.1007/s12126-012-9159-y

Metkono, Y. S., Nusawakan, A. W., & Sujana, T. (2017). STRATEGI INTERVENSI KESEHATAN LANSIA DI POSYANDU. IKESMA, 13(1), 22–24. https://doi.org/10.19184/ikesma.v13i1.7026

Pratono, A. H., & Maharani, A. (2018). Long-Term Care in Indonesia: The Role of Integrated Service Post for Elderly. Journal of Aging and Health, 30(10), 1556–1573. https://doi.org/10.1177/0898264318794732

Pusat Data dan Informasi Kementerian Kesehatan RI. (2014). Situasi dan analisis lanjut usia (pp. 1–7).

Rahardjo, T. B. W., & Yerly, A. N. (2014). A trend for establishing community care system in Indonesia. Forum on Conception of Harmonization of Long Term Care Certificate Between Japan and Indonesia.

Setioko B. & Pandelaki, E. E. (2015). Toward Housing for the Elderly in Indonesia. International Journal of Humanities and Social Science. 5(6). Pp. 53-60. http://www.ijhssnet.com/view.php?u=http://www.ijhssnet.com/journals/Vol_5_No_6_June_2015/7.pdf

UPTD Puskesmas Kandangan. (2015). Pedoman Pelaksanaan Posyandu Lansia di UPTD Puskesmas Kandangan.

The private long-term care sector in Indonesia provides community services, such as home care and training for family carers, as well as nursing homes, including hospice and respite care opportunities. For example, besides the regionally managed Posyandu LTC, services in the community are also provided by local non-profit organisations providing home care services, such as Cita Sehat in Yogyakarta, Emong Lansia in Jakarta, Vina Dulcedo in East Nusa Tenggara, and many more (Rahardjo & Yerly, 2014).

The provision of care in nursing or care homes, however, is surrounded by considerable stigma. The stigma, that nursing home care cannot provide the same kind of care as that provided by family members, is fueled by government officials. For instance, the former Minister of Social Affairs, Khofifah Indar Parawansa, appealed to the public not to send their older family members into nursing homes (Firmanto, 2016). The stigmatisation of institutional care leads to a flourishing, unregulated market of live-in carers, where family hire carers, predominantly women, to provide care to their older family members in their own homes (Kadar et al., 2013).

Nevertheless, some private long-term care providers have entered the market and provide services ranging from home care visits and carer training to hospice and respite care. However, data on the services provided is not well documented (Mahendrata et al., 2017, p.133). In 2004, there were 118 privately owned older person social service homes across the regions in Indonesia (Abikusno, 2007).

Particularly the upper socioeconomic class may benefit from assisted living, as provided by Rukun Senior Living in West Java. The organisation offers long-term care support for people in a retirement village. Their services are based on four aspects of wellness, namely the physical, mental, social, and spiritual. The facilities include a café, a gym, swimming pool, jacuzzi, and jogging track as well as a fishing pond. Social activities such as dancing, karaoke and music are encouraged within the facilities, while health services such as physiotherapy, hydrotherapy, and health checks are available from doctors and nurses. Regular pick-up and drop-off services are available for members wishing to go out to places of worships and on group outings/excursions. Members are provided with a private room including room services as well as physical and mental health assessment from doctors (Iskandar, 2016).

Another example of private LTC provider affiliated with ALZI is Wulan 247 Health Care in Bekasi, in the province of West Java. Wulan 247 offers Hospice Care, Home Care visits by certified nurses or caregivers with medical background, medical equipment lease, wound care and training for new health care providers and caregivers (247 Wulan Healthcare – About Us, 2017).

References:

247 Wulan Healthcare – About Us. (2017). http://247wulanhealthcare.com/about.html

Abikusno, N. (2007). Long term care support and services for older persons : Case study of Indonesia. ESID/SPAG/4. http://libprint.trisakti.ac.id/145/1/2007%287%29-Abikusno.pdf

Firmanto D. (2016). Menteri Sosial Imbau Lansia Tak Dirawat di Panti Jompo. Jakarta: Tempo.co. Available at: https://nasional.tempo.co/read/809454/menteri-sosial-imbau-lansia-tak-dirawat-di-panti-jompo/full&view=ok

Iskandar, E. D. (2016). Bisnis Panti Jompo Kelas Atas. https://swa.co.id/swa/profile/profile-entrepreneur/bisnis-panti-jompo-kelas-atas

Kadar, K. S., Francis, K., & Sellick, K. (2013). Ageing in Indonesia – Health Status and Challenges for the Future. Ageing International, 38(4), 261–270. https://doi.org/10.1007/s12126-012-9159-y

Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., MArthias, T., Harimurti, P., & Prawira, J. (2017). The Republic of Indonesia Health System Review (Vol. 7, Issue 1). https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf

Rahardjo, T. B. W., & Yerly, A. N. (2014). A trend for establishing community care system in Indonesia. Forum on Conception of Harmonization of Long Term Care Certificate Between Japan and Indonesia.

The Indonesian long-term care system is funded through a combination of national and local government funding. For instance, Law No. 36/2009 article 171-172 regulates that a minimum of 5% of national government’s budget and a minimum of 10% of local government’s budget have to be used for public health services prioritizing poor people, older people, and neglected children (Regulation No. 36/2009 on Health (UU No. 36/2009 Tentang Kesehatan), 2009). In addition, the Ministry of Home Affairs established Regulation No. 130/2018, which establishes that a minimum of 5 per cent of the local government’s budget has to be used to develop public facilities on Kelurahan (urban village) level (Ministry of Home Affairs Regulation No. 130/2018 on Development of Facilities and Infrastructure and Community Empowerment in Kelurahan Level (Permendagri No. 130/2018 Tentang Kegiatan Pembangunan Sarana Dan Prasarana Kelurahan Dan Pemberdayaan Masyarakat, 2018).

Besides the establishment of national law and the provision of funding to local government bodies, the Indonesian government has placed responsibility for the public long-term care system largely in the hands of local governments. At the national level, the national government’s budget (Anggaran Pendapatan Belanja Nasional (APBN)) is regulated by the central government and the National House of Representatives.

Local governments receive a budget (Anggaran Pendapatan Belanja Daerah (APBD)), funded out of taxes, provincial taxes (retributions), grants, and other legal resources. These resources are then used to fund, the city’s health departments, local laboratory facilities, emergency ambulance units, regional/local public hospitals, public health facilities, social, and welfare department, city’s social departments and other departments depending on the local governments’ policies. Puskesmas Santun Lansia, Posyandu Lansia, Panti Werdha, geriatric services in public hospitals and any other public long-term care services are funded out of this budget (Ministry of Health Regulation No. 61/2017 on Technical Guideline of Use of Special Non-Physical Health Fund Allocation for Budget Year 2018 (Permenkes No. 61/2017 Tentang Petunjuk Teknis Penggunaan Dana Alokasi Khusus Nonfisik Bidang Kesehatan Tahun Angga, 2017).

Some provinces and cities allocated additional proportions of their local government budget towards services for older peoples. The central government is supportive of these visionary developments. For example, the Mayor of Depok city in the province of Jawa Barat implemented an act, which aimed to increase of budget to further develop services available through Posyandu Lansia in each of the Kelurahan (Syarif, 2019).

However, while the integration of LTC into health care may have some policy benefits, Scheil-Adlung (2015) reports that allocations of funds for the provision of LTC fall short. The report states that public expenditure on LTC was 186.3 PPP$ per year and person aged 65 and older (Scheil-Adlung, 2015, p.34). Translated into GDP, this means that only 1.9% of GDP per capita was public expenditure on LTC for the population 65 and older (Scheil-Adlung, 2015, p.83).

References:

Ministry of Health Regulation No. 61/2017 on Technical Guideline of Use of Special Non-physical Health Fund Allocation for Budget Year 2018 (Permenkes No. 61/2017 tentang Petunjuk Teknis Penggunaan Dana Alokasi Khusus Nonfisik Bidang Kesehatan tahun Angga, (2017) (testimony of Ministry of Health Republic of Indonesia).

Ministry of Home Affairs Regulation No. 130/2018 on Development of Facilities and Infrastructure and Community Empowerment in Kelurahan level (Permendagri No. 130/2018 tentang Kegiatan Pembangunan Sarana dan Prasarana Kelurahan dan Pemberdayaan Masyarakat, (2018) (testimony of Ministry of Home Affairs Republic of Indonesia).

Regulation No. 36/2009 on Health (UU No. 36/2009 tentang Kesehatan), (2009) (testimony of Republic of Indonesia).

Scheil-Adlung, X. (2015). Long-term care protection for older persons: A review of coverage deficits in 46 countries. Geneva: International Labour Organization. Available at: https://ideas.repec.org/p/ilo/ilowps/994886493402676.html

Syarif, M. (2019). Walikota Depok Usulkan Kelurahan Dapat Tambahan APBD Rp173,25 Miliar – Jelang Tahun Anggaran 2020. Neraca. http://www.neraca.co.id/article/112832/walikota-depok-usulkan-kelurahan-dapat-tambahan-apbd-rp17325-miliar-jelang-tahun-anggaran-2020

As described above, both central government and local government are responsible for allocating available funds for LTC system. The national government develops targets and provides a budget. The institutions involved are the Ministry of Health, the Ministry of Social Affairs, the Ministry of Home Affairs and both the National and Regional Houses of Representatives. The local governments, on the other hand, are responsible for managing funds, implementation, and operation of services. In addition, local government, within their budget, can decide to allocate more funding towards long-term care.

Local governments receive an allocated budget (effective for one year) on an annual basis. Local governments submit their financial plan to the Regional House of Representatives six months before the beginning of the new financial year for approval. The process is monitored by the Ministry of Home Affairs (Proses Penyusunan APBD, 2016).

References:

Proses Penyusunan APBD. (2016). Media Riset, Diklat, Dan Konsultan Lembaga Kajian Nasional Kementerian Dalam Negeri. http://diklat.org/proses-penyusunan-apbd/

As previously explained, we understand that priorities for funding are set autonomously by the local governments and monitored by the central government through the Ministry of Home Affairs and with guidance from other ministries involved.

No repository listing all program areas related to long-term care in Indonesia was found. However, a specific program called ASLUT (Program Asistensi Sosial Penduduk Lanjut Usia Terlantar) is available for neglected or poor elderly individuals. The criteria for eligibility are:

  1. aged 60 years and above
  2. having physical ailments that forbid performing daily activities
  3. not having a source of income
  4. being neglected and in poverty
  5. not being a recipient of the Keluarga Harapan Program.

The budget for the ASLUT program is derived from the social assistance funds of the Ministry of Social Affairs. ASLUT program is managed by the Directorate of Elderly’ Social Rehabilitation, the Director General of Social Rehabilitation, and the Ministry of Social Affairs. In 2017, the budget allocation for beneficiaries of the ASLUT program was at IDR 60 billion. This budget is fully allocated as a grant of Rp. 200,000 per person per month to 30,000 ASLUT beneficiaries (TNP2K, 2018, p.132).

References:

Tim Nasional Percepatan Penanggulangan Kemiskinan (TNP2K). (2018) The Future of the social protection system in Indonesia, Jakarta Pusat: Office of the Vice President of the Republic of Indonesia. https://www.developmentpathways.co.uk/wp-content/uploads/2018/11/44293181123-SP-ReportFinal-ENG-web.pdf

The main health financing insurance in Indonesia is regulated through the national independent social insurance institution (Badan Penyelenggara Jaminan Sosial (BPJS)). In the health sector BPJS or BPJS-Kesehatan covers the health care costs of all members, irrespective of their age. However, the LTC guideline for Puskesmas explained that most components of LTC services are still not covered under the national health insurance or other insurances, and therefore they might be covered by donations or out-of-pocket expenses (Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat, 2018).

As LTC services are aimed towards increasing quality of life by assisting with daily activities, there is a link with services provided by BPJS-Kesehatan, specifically BPJS-Prolanis, which aim to increase quality of life of members with chronic illnesses, such as diabetes and hypertension. This scheme provides services such as screening, reminders to visit healthcare facilities and home visit as well as public activities and projects for people previously identified to be eligible to be part of ‘Prolanis Clubs’ (BPJS Kesehatan, 2014). These services do have LTC components in them, however, are not classified as LTC services or geriatric services.

References:

BPJS Kesehatan. (2014). Panduan Praktis PROLANIS (Program Pengelolaan Penyakit Kronis)/PROLANIS Guideline. In BPJS Kesehatan.

Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat. (2018). Pedoman untuk Puskesmas dalam Perawatan Jangka Panjang bagi Lanjut Usia. Kementerian Kesehatan RI.

No data found (27 February 2020) on the proportion of population incurring out of pocket expenditures, or the amount. However, the LTC guideline for Puskesmas explained that most components of LTC services are still not covered under the national health insurance or other insurances, and therefore might be covered by donations or out-of-pocket expenses (Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat, 2018).

References:

Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat. (2018). Pedoman untuk Puskesmas dalam Perawatan Jangka Panjang bagi Lanjut Usia. Kementerian Kesehatan RI.

Indonesia is nearing the end of its National Medium-term Development Plan 2015-2019. Long-term care is expected to also be included in the consecutive long-term development plan. However, it is unclear whether this involves reforms to the organisation and financing of the long-term care system (UNESCAP, 2014, p.12).

References:

UNESCAP. (2014). Report of the Regional Expert Consultation on Long-term Care of Older Persons. https://www.unescap.org/sites/default/files/Report%20Reg-Consultation.pdf

 

We cannot identify the size and structure of the long-term workforce. No data has been reported on LTC workers (Scheil-Adlung, 2015, p.24).

References:

Scheil-Adlung, X. (2015). Long-term care protection for older persons: A review of coverage deficits in 46 countries. In Extension of Social Security (Issue 50). http://www.ilo.org/wcmsp5/groups/public/—ed_protect/—soc_sec/documents/publication/wcms_407620.pdf

There is no professional training and qualification system specific for the national LTC workforce yet. In the LTC guideline for Puskesmas, certification or registration with a professional body is indicated for GPs, nurses, and other health care workers such as nutritionists or physiotherapists, but not for caregivers (Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat, 2018). Trainings aimed at volunteers (cadres) providing LTC services through the Posyandu Lansia have been done by local governments in collaboration with universities, such as in Malang and Depok (Kartika et al., 2019; Nugraha et al., 2019). There has been LTC training in Puskemas level too, such as in Sungailiat, Bangka District (Dinas Kesehatan Kabupaten Bangka, 2019). However, these initiatives seem to be at regional coordination level, and thus the training provision might not yet be standard nationally.

On the international level, professional training and qualification systems are managed by the National Agency for the Protection and Placement of International Migrant Workers (Badan Nasional Penempatan dan Perlindungan Tenaga Kerja Indonesia or BNP2TKI for short). This international collaboration offers training and certification on certain skills. For example, an annual placement program between Indonesia and Japan provides both skills and language training for Indonesian nurses or people undertaking diplomas and bachelor’s degrees in nursing (BNP2TKI, 2011). The Indonesia-Japan Economic Partnership Agreement (IJEPA), launched in 2008 (Ministry of Trade, 2018), established a system for ‘Indonesian health care workers to work as nurses and certified care workers in Japan’ (Nugraha et al., 2017, p.54). The length of training (6 months in Indonesia and 6 months in Japan) might not be sufficient, as it is heavily focused on nursing and language skills, while less on the use of technology and attitude in care service (Arianti, 2013).

Other sources of professional training for the LTC workforce are trainings held via third sector associations focusing on carers, people with dementia, or the provision of long-term care. Organisations providing training include Alzheimer Indonesia, Wulan 247, Indonesia Ramah Lansia or Yayasan Emong Lansia (Sabdono, 2015).

References:

Arianti, R. K. (2013). Pengaruh Profesionalisme, Pelatihan dan Motivasi terhadap Kinerja Nurse dan Caregiver Indonesia. MIX, III(2), 121–132.

BNP2TKI. (2011). Sejarah Penempatan TKI Hingga BNP2TKI. http://www.bnp2tki.go.id/frame/9003/Sejarah-Penempatan-TKI-Hingga-BNP2TKI

Dinas Kesehatan Kabupaten Bangka. (2019). Laporan Kegiatan Kesehatan Keluarga Pertemuan Perawatan Jangka Panjang (PJP Care Giver Lansia) Sungailiat 02 April 2019 http://dinkes.bangka.go.id/node/199

Kartika, A. W., Choiriyah, M., Kristianingrum, N. D., Noviyanti, L. W., & Fatma, E. P. L. (2019). Pelatihan Tugas Perawatan Kesehatan Keluarga Caregiver Lansia dalam Pogram RURAL (Rumah Ramah Lansia). Jurnal Pengabdian Kepada Masyarakat (Indonesian Journal of Community Engagement), 5(3), 448. https://doi.org/10.22146/jpkm.45139

Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat. (2018). Pedoman untuk Puskesmas dalam Perawatan Jangka Panjang bagi Lanjut Usia. Kementerian Kesehatan RI.

Ministry of Trade. (2018). Fact Sheet Indonesia-Japan Economic Partnership Agreement (IJEPA).

Nugraha, S., Agustin, D., Rahardjo, T. B. W., & Yuko, H. (2019). Pelatihan Bagi Kader Posbindu Tentang “Long Term Care” ( Perawatan Jangka Panjang ) Bagi Lanjut Usia Kota Depok. PAMAS, 3(2), 113–120.

Nugraha, S., Honda, S., & Hirano, Y. (2017). The change in mental health status of Indonesian health care migrant worker in Japan. Kesmas, 12(2), 53–89. https://doi.org/10.21109/kesmas.v0i0.1698

Sabdono, E. (2015). Commentary on Indonesia’s domain ranks in the 2015 Global AgeWatch Index.

There is no regulatory body for care workers operating in Indonesia. Members of the public long-term care workforce, such as those working as volunteers for Puskesmas and Posyandu Lansia, are bound by the guidelines of their local healthcare provider. Similarly, members of the private long-term care workforce operate within the guidelines of the private sector (Pratono & Maharani, 2018). The BNP2TKI, however, operates a regulatory body for care workers working overseas (BNP2TKI, 2011).

References:

BNP2TKI. (2011). Sejarah Penempatan TKI Hingga BNP2TKI. http://www.bnp2tki.go.id/frame/9003/Sejarah-Penempatan-TKI-Hingga-BNP2TKI

Pratono, A. H., & Maharani, A. (2018). Long-Term Care in Indonesia: The Role of Integrated Service Post for Elderly. Journal of Aging and Health, 30(10), 1556–1573. https://doi.org/10.1177/0898264318794732

No resource could be identified that showed an association between migration rates and the availability of the LTC workforce in Indonesia. However, there is evidence of cases, such as in Cilap city in the province of Central Java, where it was found that large numbers of women from the city work as carers and nannies overseas due to economic reasons (Raharto, 2017). These case studies are confirmed by BNP2TKI data (January 2018) that shows that considerable numbers of Indonesians contribute to the long-term care workforce in other countries (Pusat Penelitian Pengembangan dan Informasi BNP2TKI, 2019). This pattern is facilitated through bilateral agreements, such as between Indonesia and Japan, which enables Indonesian nurses to stay in Japan after the completion of their nursing training there (UNESCAP, 2014).

References:

Pusat Penelitian Pengembangan dan Informasi BNP2TKI. (2019). Data Penempatan dan Perlindungan TKI Periode Bulan Desember Tahun 2018. http://www.bnp2tki.go.id/uploads/data/data_14-01-2019_043946_Laporan_Pengolahan_Data_BNP2TKI_2018_-_DESEMBER.pdf

Raharto, A. (2017). Pengambilan Keputusan Tenaga Kerja Indonesia Perempuan untuk Bekerja di Luar Negeri: Kasus Kabupaten Cilacap (Decision making to work overseas among Indonesian women labor migrants: the case of Cilacap district). Jurnal Kependudukan Indonesia, 12(1), 39–54. http://ejurnal.kependudukan.lipi.go.id/index.php/jki/article/view/275/pdf

UNESCAP. (2014). Report of the Regional Expert Consultation on Long-term Care of Older Persons. https://www.unescap.org/sites/default/files/Report%20Reg-Consultation.pdf

The organisation of the Posyandu Lansia is built mostly on volunteers. Volunteers are also involved in activities run by the Puskesmas (Departemen Kesehatan RI, 2006). We are unable to find any information about the organisation of the workforce.

References:

Departemen Kesehatan RI. (2006). Pedoman Umum Pengelolaan Posyandu. Departemen Kesehatan RI.

The Ministry of Health through its Mental Health Directorate and Family Health Directorate work on dementia. The Ministry of Health also launched the National Dementia Plan, which identified other ministries as stakeholders for the action steps, which include the Coordinating Ministry for Human Development and Cultural Affairs, Min. Domestic Affairs, Min. Family Planning, Min. Social Affairs, Min. Education, Min. Finance, and Social Insurance Administration Organisation (Ministry of Health Republic of Indonesia, 2015b). The Ministry of Social Affairs also has a social rehabilitation program for older people, named PROGRES LANSIA, which includes installation/rehabilitation centre for dementia/Alzheimer (Ministry of Social Affairs Republic of Indonesia, n.d.).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

Ministry of Social Affairs Repulbic of Indonesia. (n.d.) Program Rehabilitasi Sosial Untuk Lanjut Usia (Progres Lansia). Central Jakarta: Ministry of Social Affairs Republic of Indonesia. Available at: https://intelresos.kemensos.go.id/v4/user/registration/progres/point/2

The Ministry of Health carries primary responsibility for Dementia. The recognition of dementia as part of the ministry’s portfolio was shown through the launch of the National Dementia Strategy. In addition, the Coordinating Ministry for Human Development and Cultural Affairs, the Ministry of Social Affairs, and the Ministry of Home Affairs (which coordinates plans in advocating local and regional policies) collaborate with the Ministry of Health in the development and implementation of the dementia action plan.

Furthermore, there are two independent commissions reporting to official bodies that are involved in shaping the dementia policy landscape:

  • the National Commission of Older People (Komisi Nasional Lanjut Usia), which was established in 2004 as an independent, non-structural coordinating body between the government and the people, focusing on giving advice and consideration to the President in policy-making regarding older people’s social welfare improvement and assisting the President in coordinating the implementation. Despite being stated as independent, the presidential decree establishing it described that the head of the commission is a Minister who is responsible to government affairs in the social field (Presidential Decree No.52/2004 on National Commitee on Elderly (Keppres No. 52/2004 Tentang Komisi Nasional Lanjut Usia), 2004). The Komisi Nasional Lanjut Usia is no longer active since 2018. It was disbanded by the Ministry of Administrative and Bureaucratic Reform of the Republic of Indonesia due to “bureaucracy simplification and lack of performance” (Sitohang, 2019);
  • the Regional Commissions of Older People (Komisi Daerah Lanjut Usia) whose responsibility includes monitoring and evaluation of regional programmes on older people’s welfare and report to their local governors (Permendagri No. 60/2018 Tentang Pedoman Pembentukan Komisi Daerah Lanjut Usia Dan Pemberdayaan Masyarakat Dalam Penangangan Lanjut Usia Di Daerah, 2008).
References:

Permendagri No. 60/2018 tentang Pedoman Pembentukan Komisi Daerah Lanjut Usia dan Pemberdayaan Masyarakat dalam Penangangan Lanjut Usia di Daerah (Ministry of Home Affairs Regulation No. 60/2008 on Guideline on the formation of regional commission on elde). (2008). (Testimony of Ministry of Home Affairs Republic of Indonesia).

Presidential Decree No.52/2004 on National Commitee on Elderly (Keppres No. 52/2004 tentang Komisi Nasional Lanjut Usia). (2004). (Testimony of President of Republic of Indonesia).

Sitohang, M. Y. (2019). Matinya Komnas Lansia dan Jalan Lain Meningkatkan Kesejahteraan Lansia Indonesia. Pusat Penelitian Kependudukan LIPI.

 

Dementia falls under the responsibility of two directorates in the Ministry of Health: The Directorate of Mental Health and the Directorate of Family Health.

A dementia-specific national strategic plan was launched by the Ministry of Health in March 2016 (Ministry of Health Republic of Indonesia, 2015).

References:

Ministry of Health Republic of Indonesia. (2015). Strategi Nasional Penanggulangan Penyakit Alzheimer dan Demensia Lainnya: Menuju Lanjut Usia Sehat dan produktif. Jakarta: Ministry of Health Republic of Indonesia. Available at: https://www.neurona.web.id/paper/Rencana%20Aksi%20Nasional%20Demensia%202015.pdf

An article on the ADI website suggests that the government allocated approximately $105,000 for the first-year implementation (Alzheimer’s Disease International, 2016).

References:

Alzheimer’s Disease International. (2016). National Dementia Plan launched in Indonesia. https://www.alz.co.uk/news/national-dementia-plan-launched-in-indonesia

There are several indicators to measure output for each of the policy action steps. Monitoring and evaluation of the policy implementation is planned to be conducted through collaboration of the central government with relevant sectors, provincial and district governments and with relevant governmental departments, as well as through the National Commission of Older People (Komisi Nasional Lanjut Usia).

Monitoring and evaluation of technical aspects of the implementation is the responsibility of Komisi Nasional Lanjut Usia, professional organisation, academics, NGO, and relevant sectors. The results of these should advise on the improvement of the policy (Ministry of Health Republic of Indonesia, 2015b). However, the plan does not mention specific time milestones that could be monitored, and we have learnt informally that the Komisi Nasional Lanjut Usia is currently inactive.

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The Indonesian dementia national plan aims to manage Alzheimer’s disease and other dementias, and to enable healthy and productive ageing. The plan has three main objectives:

  1. Mainstreaming efforts to achieve healthy brains for productive ageing through a life-cycle approach at every level of national development,
  2. Improvement of service quality towards cognitive impairment and dementia,
  3. Strengthening of managerial aspects to optimize efforts towards healthy brains.

The strategy uses a life-cycle approach, with emphasis on quality-of-service improvement and strengthening managerial capacity (Ministry of Health Republic of Indonesia, 2015b).

There are seven action steps in this national dementia strategy:

  1. ‘Campaign on Public Awareness and Promotion of Healthy Lifestyles,
  2. Advocacy of human rights for people with dementia and their caregivers,
  3. Ensuring access and information of quality services,
  4. Implementation of early detection, diagnosis, and holistic management of cognitive disorders and dementia,
  5. Establishment of System to Reinforce professional and sustainable human resources,
  6. Establishment of System to Reinforce Cognitive Health Programs as main factor to increase literacy of nation based on life course approach,
  7. Implementation and Application of Research on cognition and dementia’ (Ministry of Health Republic of Indonesia, 2015a, pp.5-6).
References:

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

There is no mention in national plan that people living with dementia were directly involved in its development. However, families/carers were represented during the development through non-governmental associations, Alzheimer’s Indonesia (ALZI), which was one of the actors involved in making the national strategic plans (Juliyah & Andry, 2016).

The second action step of this national strategy advocates the human rights of people with dementia and their caregivers. The key indicators to achieve this are protection of people with dementia through existing regulations such as those formulated by the Ministry of Home Affairs, advocacy efforts on human rights, formation of regional caregiver support groups, and realisation of health referral system for dementia (Ministry of Health Republic of Indonesia, 2015b).

References:

Juliyah, & Andry, G. (2016). Strategi Nasional Penanggulangan Demensia dan Alzheimer Diluncurkan. Info Publik. http://infopublik.id/read/148368/strategi-nasional-penanggulangan-demensia-dan-alzheimer-diluncurkan-.html

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

No specific operational resources were mentioned in the plan, but the seven action steps were meant to be backed up by increasing resources from both the central and local governments. According to information from the ADI website, the government aimed to invest approximately $105,000 during the first year, but no information could be found on the specific posts for this budget (Alzheimer’s Disease International, 2016). Several sources of funding at national level were mentioned in the plan: the national budget (Anggaran Pendapatan dan Belanja Nasional), the regional government budget (Anggaran Pendapatan Belanja Daerah), international organisations, NGOs and community-based organisations, private sector, and businesses, but there was no mention of the amount of funding from each of the sources (Ministry of Health Republic of Indonesia, 2015c).

References:

Alzheimer’s Disease International. (2016). National Dementia Plan launched in Indonesia. https://www.alz.co.uk/news/national-dementia-plan-launched-in-indonesia

Ministry of Health Republic of Indonesia. (2015c). Strategic Planning Ministry of Health 2015-2019. In Ministry of Health RI. Available at: http://www.nationalplanningcycles.org/sites/default/files/planning_cycle_repository/indonesia/restra_2015_translated_1.pdf

There has not been any document indicating direct consequences of not implementing the policy. However, existing regulation on older people’s welfare mentions legal consequences for people/institutions deliberately not providing service to improve older people’s welfare (UU no. 13 No. 1998) (Undang-Undang Republik Indonesia No. 13 Tahun 1998 Tentang Kesejahteraan Lanjut Usia (Constitution of Republic of Indonesia No. 13/1998 on Older People’s Welfare), 1998). The national dementia plan protects people with dementia through existing regulation, provided that the person with dementia qualifies as an older adult.

References:

Undang-undang Republik Indonesia No. 13 tahun 1998 tentang Kesejahteraan Lanjut Usia (Constitution of Republic of Indonesia No. 13/1998 on Older People’s Welfare). (1998).

Dementia has not been mentioned in other national plans, not even in the national plan of Older People’s Health (Ministry of Health Regulation No. 25/2016 on National Action Plan on Older People’s Health, 2016). However, diabetes and hypertension, two chronic conditions which are risk factors of dementia are covered by the Prolanis program (BPJS Kesehatan, 2014).

References:

BPJS Kesehatan. (2014). Panduan Praktis PROLANIS (Program Pengelolaan Penyakit Kronis)/PROLANIS Guideline. In BPJS Kesehatan.

Ministry of Health Regulation No. 25/2016 on National Action Plan on Older People’s Health (Permenkes No. 25/2016 tentang Rencana Aksi Nasional Kesehatan Lanjut Usia 2016-2019). (2016). (Testimony of Ministry of Health Republic of Indonesia).

In the Prolanis programme, dementia is not specifically mentioned. However, it addresses the risk reduction aspect (by managing diabetes and hypertension) (BPJS Kesehatan, 2014).

References:

BPJS Kesehatan. (2014). Panduan Praktis PROLANIS (Program Pengelolaan Penyakit Kronis)/PROLANIS Guideline. In BPJS Kesehatan.

There have not yet been many dementia-specific documents, although age-friendly policies have been implemented at regional levels. A good example of a specific regional policy is the dementia-friendly village of Ketewel in Bali (Radha, 2018). There are also clinical guidelines on diagnosis and management of dementia issued by the Indonesian Neurologists Association (PERDOSSI) in 2015 (PERDOSSI, 2015).

References:

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

Radha, W. (2018). Penuhi hak lanjut usia, TP PKK Prov. Bali Dorong Pemberdayaan Lansia melalui Kegiatan Produktif. MetroBali. http://metrobali.com/penuhi-hak-lanjut-usia-tp-pkk-prov-bali-dorong-pemberdayaan-lansia-melalui-kegiatan-produktif/

Dementia is discussed in a clinical context in PERDOSSI’s clinical practice guideline. This guideline advises on promotion, prevention, diagnostic, and treatment aspects of dementia starting from the primary care level up to the third-level referral. It was developed based on adapting existing guidelines from other countries (including Singapore, Malaysia, Philippines, and the UK) to the local context, and was planned to be renewed in 2017 (PERDOSSI, 2015). However, to the best of our knowledge, there are no updated versions of the guideline or of other clinical guidelines publicly available.

References:

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

Yes, particularly action step 2: ‘Advocacy of human rights for people with dementia and their caregivers’ (Ministry of Health Republic of Indonesia, 2015a, p.5).

References:

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

Yes, this plan emphasised equity of diagnostic and care services through equal improvement in knowledge of all healthcare workers and non-health workers through education and trainings in all levels of care with emphasis on primary care (Ministry of Health Republic of Indonesia, 2015a).

References:

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

Yes, the plan emphasises community empowerment and intergenerational approach for dementia care coordination (Ministry of Health Republic of Indonesia, 2015a).

References:

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

Yes, chapter 5 of the dementia national strategy document is dedicated on discussing intersectoral stakeholders relevant to the policy.

The national plan reflects some aspects of the sustainable development goals, particularly goal number 3 (good health and wellbeing), 4 (quality education), 11 (sustainable communities), and 17 (partnerships for the goals), although these may not be explicitly stated (Ministry of Health Republic of Indonesia, 2015b). In 2015, the United Nations declared the prevention and treatment of non-communicable diseases (NCDs) and the promotion of physical and mental health and well-being with behavioural, developmental, and neurological disorders as one of their key goals in achieving sustainable development (United Nations, 2015). Indonesia’s national plan addressed the challenges of a growing ageing population and increasing number of people living with dementia through seven action steps.

 References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

United Nations. (2015). Goal 3: Ensure healthy lives and promote well-being for all at all ages. https://www.un.org/sustainabledevelopment/health/

People with dementia and their family carers are recognised in all action plans. However, the second action plan, advocacy on human rights for people with dementia and their carers specifically call for their recognition as part of its achievement indicators, which include protection of people with dementia through existing regulations and formation of support group for people with dementia and their carers.

The other action plans advise on development of a guidebook and a training programme to educate carers and people with dementia about dementia as well as the planning of financial strategies and improvement of services (including implementation of standards for older people, an effective referral system, and an increase in the quantity and quality of day and home care) (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The national dementia policy/plan has not directly addressed the issue of mistreatment and abuse of people with dementia and its prevention. However, the national plan lists existing regulations that serve to protect older people from abuse as one of the indicators for the second action step (advocacy of human rights for people with dementia and their carers) (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The national strategic plan aims to ensure that older people stay healthy and productive and therefore can continue to support the nation’s social system and economy. This is encouraged through a life-cycle perspective, which emphasises prevention by encouraging and supporting people in reducing risks of dementia to maintain healthy and active brains (Ministry of Health Republic of Indonesia, 2015b). Indicator 1.9 in the fourth action step, outlines the aim that an increased proportion of older people with physical or cognitive limitations should still be able to take part in physical, social, and spiritual activities (Ministry of Health Republic of Indonesia, 2015b). However, this seems to support the underlying aim of diagnosing more people at an earlier stage, as the plan does not describe in detail people with dementia could be supported in maintaining an active role in the community as the disease progresses.

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

Although not explicitly stated, this is mainly addressed in the fourth action step (early diagnosis and management). These are the indicators which support people with dementia in maintaining self-management:

  • Indicator 1.5 all referral facilities should have neurorestoration service (rehabilitation based on neuroscience principles). This serves as a mean to help the person with dementia maintain their independence.
  • Indicators 1.6 and 1.7 refer to the increased number and quality of day care and home care services. This will support people who are no longer in good health and need assistance in staying active and in performing daily activities of living.
  • Indicator 1.9 increased proportion of older people with disability (physical or cognitive) who can continue participating in physical, social, and spiritual activities. This serves as a secondary prevention effort.
  • Indicators 2.1 and 2.2 refer to the presence of a guideline on dementia care and training for caregivers (Ministry of Health Republic of Indonesia, 2015b).
References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

 

The national dementia policy has not discussed this issue explicitly (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The policy document sets national targets as indicators of standardised, good quality of care. Examples of such targets are the initiation of a national training centre in cognitive health and dementia treatment, the development of standard operational procedure of older people’s care (to be implemented in all healthcare facilities), the implementation of an instrument for the screening of cognitive impairment and diagnosis of dementia among people at risk of developing it, the initiation of a referral system for people with dementia embedded in all primary healthcare facilities (alongside with screening, diagnosing and counselling), neurorestoration care in all referred healthcare facilities and ultimately supporting the development of long term care insurance (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The health and long-term care workforces are represented especially in the fifth action step: establishing a system to strengthen professional and sustainable human resources. This is described in their indicators, particularly:

  • ‘Indicator 1.1 All medical and nursing schools are expected to include older people’s cognitive health in their curriculum.
  • Indicator 1.2 Doctors and other healthcare workers who are trained in dementia management are present in all Puskesmas, hospitals, and senior homes.
  • Indicator 1.3 There are healthcare workers who have been trained to be trainers for dementia management’ (Ministry of Health Republic of Indonesia, 2015a, p.22).

The Long-term care workforce appears to be represented by the Ministry of Social Affairs in the same action step. The plan describes the need to develop a strategy to ensure health care workers understand the role of care partners in dementia care coordination. The indicators are:

  • ‘Indicator 2.1 There are regular meetings of all healthcare workers and care partners involved in dementia management
  • Indicator 2.2 There is a dementia care coordination’ (Ministry of Health Republic of Indonesia, 2015a, p.22)
References:

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

The plan describes the main stakeholders/key actors as:

  • the National Commission on Older People,
  • the government (through the Coordinating Ministry for Human Development and Cultural Affairs),
  • community involvement (Ministry of Health Republic of Indonesia, 2015b).
References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The policy document states the target to implement standard operational procedures across all healthcare facilities. Furthermore, the document emphasises the standardization of instruments, the value of screening, diagnosis, and treatment of people with dementia in primary healthcare facilities and through appropriate referral to secondary and tertiary healthcare facilities. Secondary and tertiary healthcare services are expected to provide integrated geriatric services and neurorestoration services (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The policy outlines that efforts to achieve healthy and productive brains must be supported through balanced nutrition, physical activities, and cognitive, spiritual and social stimulations. The efforts should be supported by families, society, and the environment. These efforts are supposed to create a healthy lifestyle that reduces risk factors and reduces the risk of developing cognitive impairment in older people (Ministry of Health Republic of Indonesia, 2015b). The policy did not explicitly state the intersection with mental health care.

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

Equity is incorporated in the policy by upholding the national law on health, which ensures that all people have equal access to healthcare, as the national dementia plan operates within the universal healthcare system. The strategic plan emphasises the availability of standardized care for all older people across healthcare facilities. This includes public access to screening, diagnosis, and treatment. In addition, rights of the workforce alongside with patients’ rights are mentioned (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The policy states that dementia prevention can be achieved through a reduction of risk factors of degenerative diseases and the enhancement of factors supportive to achieve healthy and productive brain. These targets are also covered in the first action plan, which focuses on public awareness campaigns. These programmes are coordinated jointly by the Ministry of Home Affairs, the Ministry of Health, and actors, such as public and private companies, governmental and non-governmental organizations with the goal to intensify campaigns and education in schools, among families, and across society (and including the workforce) (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

Multi-disciplinary stakeholders were involved in developing the policy, which included clinicians, academics, carer, NGO, and other stakeholders. NGOs with international outlook have a focus on aligning the national policy with international goals (for example, early diagnosis is also a priority in Indonesia’s national strategic plan). A monitoring report on the policy has not yet been published but the document suggests that monitoring and evaluation should be conducted by all stakeholders including central and local governments, Komisi Lanjut Usia, the involved universities, professional organizations, and NGOs (Ministry of Health Republic of Indonesia, 2015b). There are tangible outcome indicators for each of the action steps in the policy (Ministry of Health Republic of Indonesia, 2015a, pp.25-35).

References:

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The document does not mention specific timeline/milestones. There are no instruments mentioned to monitor (Ministry of Health Republic of Indonesia, 2015b) and yet, no national evidence of evaluations linked to the national policy have been published.

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The Ministry of Health is the primary stakeholder in creating the national strategic plan. The roles of the other key stakeholders are outlined for each action steps.

Overview of stakeholders involved in the seven action steps

Action step Stakeholders
1. “Campaign on Public Awareness and Promotion of Healthy Lifestyles Min. Health

Min. Home Affairs

Min. Population and Family Planning (BKKBN)

2. Advocacy of human rights for people with dementia and their caregivers Min. Home Affairs (leader)

Min. Health

 

3. Ensuring access and information of quality services Min. Social Affairs

Coordinating Ministry for Human Development and Cultural Affairs

Min. Population and Family Planning

4. Implementation of early detection, diagnosis and holistic management of cognitive disorders and dementia Min. Health

Min. Home Affairs

Min. Social Affairs

Min. Population and Family Planning

5. Establishment of System to Reinforce professional and sustainable human resources Min. Education and Culture

Min. Social Affairs

Min. Health

Min. Population and Family Planning

Min. Finance

BPJS

6. Establishment of System to Reinforce Cognitive Health Programs as main factor to increase literacy of nation based on life course approach Min. Health

Min. Population and Family Planning

Min. Home Affairs

Min. Social Affairs

7. Implementation and Application of Research on cognition and dementia” Health Research and Development (Litbangkes) of Min. Health

Indonesian Academy of Sciences (AIPI)

Indonesian Institute of Sciences (LIPI)

Min. Higher Education

Other research institutes

 

Source: (Ministry of Health Republic of Indonesia, 2015a, pp.18-25).

References:

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

Raising awareness of dementia through dementia awareness campaigns was set as the first action point of the policy. These campaigns are supposed to be held by revising older programmes and creating new programmes that promote healthy lifestyles, as well as raise awareness of risk factors and protective factors. The campaigns are set to be distributed through schools, families, and society. However, the policy does not provide information about their anticipated content or whether it aims to reduce stigma and/or support the creation of dementia-friendly communities (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The third action step focuses on dementia prevention and risk. It emphasises the accessibility of information on healthcare services which comply with the minimum standard for older people. This is consistent with the health promotion emphasised in the first action step, which focuses on the promotion of a healthy lifestyle (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The fourth action step focuses on early diagnosis and management. However, post-diagnostic support outlined second action step appears to be more focused on caregivers and provides little information about post-diagnostic support and care for people living with dementia (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The fifth action step mentioned the inclusion of dementia in the training curriculum for doctors and nurses (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

Support for carers is outlined under both, the second action step, indicated by the description of a support group for caregivers and the fourth action step, indicated through a guideline and training for caregivers (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The presence of a monitoring/surveillance system is mentioned as one of the indicators for the seventh action step (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The seventh action step focuses on research on cognitive function and dementia (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

There has not been dementia-specific legislation at the national level. However, there are a number of legislations that support older people’s health and welfare in general:

  • Constitution No. 13/1998 on Older People’s Welfare (Undang-Undang Republik Indonesia No. 13 Tahun 1998 Tentang Kesejahteraan Lanjut Usia (Constitution of Republic of Indonesia No. 13/1998 on Older People’s Welfare), 1998)
  • Constitution No. 39/1999 on Human Rights (UU No. 39/1999 Tentang Hak Asasi Manusia (Law No. 39/1999 on Human Rights), 1999)
  • Constitution No. 11/2009 on Social Welfare (Undang-Undang Republik Indonesia No. 11 Tahun 2009 Tentang Kesejahteraan Sosial (Constitution of Republic of Indonesia No. 11/2009 on People’s Welfare), 2009)
  • Constitution No. 36/2009 on Health (Regulation No. 36/2009 on Health (UU No. 36/2009 Tentang Kesehatan), 2009).

The Ministry of Health also issued several regulations on healthcare:

  • Ministry of Health Regulation No. 75/2014 on Community Health Centre (Primary Care) (Ministry of Health Republic of Indonesia, 2014)
  • Ministry of Health Regulation No. 79/2014 on Geriatric Care in Hospital (Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 Tentang Pelayanan Geriatri Di RS), 2014)
  • Ministry of Health Regulation No. 67/2015 on Healthcare of Older People in Community Health Centre (Ministry of Health Republic of Indonesia, 2015a)
  • Ministry of Health Regulation No. 25/2016 on National Strategy on Older People’s Health 2016-2019 (Ministry of Health Regulation No. 25/2016 on National Action Plan on Older People’s Health (Permenkes No. 25/2016 Tentang Rencana Aksi Nasional Kesehatan Lanjut Usia 2016-2019), 2016a)

In addition, there are regional efforts:

  • The governor of Bali has issued a legislation on older people’s welfare (No. 11/2018). However, it does not mention dementia explicitly (Bali Regional Regulation No. 11/2018 on Older People’s Welfare (Peraturan Daerah Provinsi Bali No. 11/2018), 2018).

None of the legislations and regulations above mentions dementia explicitly.

References:

Bali Regional Regulation No. 11/2018 on Older People’s Welfare (Peraturan Daerah Provinsi Bali No. 11/2018), (2018) (testimony of Governor of Bali Province).

Ministry of Health Regulation No. 25/2016 on National Action Plan on Older People’s Health (Permenkes No. 25/2016 tentang Rencana Aksi Nasional Kesehatan Lanjut Usia 2016-2019), (2016) (testimony of Ministry of Health Republic of Indonesia).

Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 tentang Pelayanan Geriatri di RS), (2014) (testimony of Ministry of Health Republic of Indonesia).

Ministry of Health Republic of Indonesia. (2014). Ministry of Health Regulation No. 75/2014 on Public Health Center (Permenkes No. 75/2014 Tentang Pusat Kesehatan Masyarakat).

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

Regulation No. 36/2009 on Health (UU No. 36/2009 tentang Kesehatan), (2009) (testimony of Republic of Indonesia).

Undang-Undang Republik Indonesia No. 11 Tahun 2009 Tentang Kesejahteraan Sosial (Constitution of Republic of Indonesia No. 11/2009 on People’s Welfare). (2009).

Undang-undang Republik Indonesia No. 13 tahun 1998 tentang Kesejahteraan Lanjut Usia (Constitution of Republic of Indonesia No. 13/1998 on Older People’s Welfare). (1998).

UU no. 39/1999 tentang Hak Asasi Manusia (Law no. 39/1999 on Human Rights), (1999) (testimony of Republik Indonesia).

For people who are perceived as not having capacity to make legal and financial decisions, the nomination of a trusted person is regulated under the Indonesian Civil Code, which is still largely based on the Dutch colonial legal system (Hariyanto, 2019). The process is known as pengampuan (Dutch: curatelle, English: conservatorship), and the legal basis are Article 433, 434, 437, 438, 439, 440, 441, 442, 449 of the Indonesian Civil Code (Indonesia: Civil Code, 1847) which are further described below. The fact that this is based on a legal system dating a century back might explain the use of a stigmatising and derogatory language [dungu (English: stupid) translated into ‘simple-mindedness’; and gila (English: crazy), translated into ‘insanity’).

Legal basis for pengampuan/curatelle/conservatorship:

  • Who is eligible to be put under conservatorship: ‘Article 433. An adult, who is in a continuous state of simple-mindedness, insanity, or rage, shall be placed under conservatorship, notwithstanding that he might have mental capacity from time to time. An adult individual may be placed under conservatorship as a result of improvidence.’ (Indonesia: Civil Code, 1847, p.65)
  • Who can have the conservatorship (trusted to make decisions): ‘Article 434. Each blood relative shall be authorized to request conservatorship on behalf of one of his relatives, due to his simple-mindedness, insanity, or rage. Conservatorship in respect of a person who is improvident may only be requested by the blood relatives in direct line, and by those in a collateral line up to and including the fourth degree. Due to one or more reasons, one spouse may request to put the other under conservatorship. An individual, who feels unable to take proper care of his affairs, due to limited mental capacity, may himself request to be placed under conservatorship.’ (Indonesia: Civil Code, 1847, p.66).
  • Time of the conservatorship being effective:
  • Article 446. The conservatorship shall be effective as of the date that the judgment or decision is passed. All acts committed thereafter by the individual placed in conservatorship shall be invalid by law….
  • Article 447. All acts committed as a result of simple-mindedness, insanity or rage, prior to the judgment granting conservatorship, may be invalidated if the grounds for seeking guardianship appeared to have existed at the time that the acts were committed’ (Indonesia: Civil Code, 1847, p.67).
  • Supporting documents needed to apply for conservatorship:
  • ‘Article 437. The events, which demonstrate simple-mindedness, insanity, rage, or improvidence, shall be specifically described in the letter of request, and the evidential documents as well as a submission of one of the witnesses shall also be enclosed…
  • Article 438. If the court of justice is of the opinion that the events are sufficiently significant to lead to a conservatorship, then the court shall conduct a hearing of the blood relatives or relatives by marriage…
  • Article 439. The court of justice shall, after a hearing or proper summons of the individuals as referred to in the previous article, question the individual whose conservatorship has been requested; in the event that he is immobile, the questioning shall take place in his residence by one or more judges designated thereto, accompanied by the court clerk, and in all matters, in the presence of the prosecution counsel… The prosecution counsel is not required to be present at this questioning; minutes shall be drawn up of the questioning of which an authentic copy shall be submitted to the court of justice… The questioning shall not take place before the letter of request as well as the report containing the views of the blood relatives, have been notified to the individual whose conservatorship is requested.’
  • Others
  • ‘Article 440. In the event that the court of justice, after the hearing or proper summons of the blood relatives or relatives by marriage, or after having heard the individual whose conservatorship is requested, decides that it has been adequately informed, the court shall, without any further formalities, deliberate upon the letter of request; in the event that it decides otherwise, the court shall instruct the hearing of the witnesses for the purpose of clarifying the matters presented.
  • Article 441. Following the questioning mentioned in article 439, the court of justice shall, in the event that there are grounds therefor, nominate a provisional administrator, to take care of the personal matters and assets of the individual, whose in conservatorship has been requested.
  • Article 442. The judgment upon a request for conservatorship shall be passed in a public court session, after a hearing or proper summons of the parties, and pursuant to the conclusions of the prosecution counsel…
  • Article 449. Upon the judgment in respect of conservatorship obtaining legal validity, the court of justice shall appoint a conservator. The appointment shall be immediately notified by the court to the Orphans’ Chamber. The supervising conservatorship shall be assigned to the Orphans’ Chamber… In this regard, the provisional administrator’s involvement shall cease, and he shall be required to submit an account of his administration; in the event that he is appointed as conservator, the account shall be submitted to the supervising conservator’ (Indonesia: Civil Code, 1847, p.66-67).
References:

Hariyanto, E. (2019). BURGELIJK WETBOEK (Menelusuri Sejarah Hukum Pemberlakuannya di Indonesia). Al-Ihkam: Jurnal Hukum Dan Pranata Sosial, IV(1), 141–152.

Indonesia: Civil Code. (1847).

Human rights of all persons (including safeguarding against exploitation, violence, or abuse) are regulated by the Law no. 9/1999 on Human Rights. There is an independent legal body called the National Commission on Human Rights (Komnas HAM) whose function is to carry out assessment, research, counselling, monitoring, and mediation. It has the capacity to receive appeals/complaints, to run investigations, and to perform monitoring-evaluations when needed (UU No. 39/1999 Tentang Hak Asasi Manusia (Law No. 39/1999 on Human Rights), 1999).

There is also a law pertaining domestic violence, which is applicable to abuse committed within the household. There is no mention of different approaches in cases where the victim is an older person or a person living with dementia (UU No. 23/2004 Tentang Penghapusan Kekerasan Dalam Rumah Tangga (Law No. 23/2004 on Elimination of Domestic Violence), 2004).

References:

UU No. 23/2004 tentang Penghapusan Kekerasan Dalam Rumah Tangga (Law No. 23/2004 on Elimination of Domestic Violence), (2004) (testimony of Republik Indonesia).

UU no. 39/1999 tentang Hak Asasi Manusia (Law no. 39/1999 on Human Rights), (1999) (testimony of Republik Indonesia).

In the LTC guideline for Puskesmas, transitional/subacute care (from hospital to community care) is recognised as an important part of LTC. However, it is not yet widely available in Indonesia and needs further development (Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat, 2018).

References:

Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat. (2018). Pedoman untuk Puskesmas dalam Perawatan Jangka Panjang bagi Lanjut Usia. Kementerian Kesehatan RI.

The Ministry of Social Affair monitors institutions providing care to older people through direct visits, supervision, and regular evaluation to ensure the provision of sustainable quality care adhering to standards (Ministry of Social Affairs Republic of Indonesia, 2018).

References:

Ministry of Social Affairs Republic of Indonesia. (2018). Ministry of Social Affairs Regulation No. 5/2018 on National Standard of Older People Social Rehabilitation (Permensos No. 5/2018 tentang Standar Nasional Rehabilitasi Sosial Lanjut Usia).

There is no specific regulation regarding coercive practices targeted at people with dementia. However, stigma in mental illnesses often results through physical restraining of people living with mental illness, especially in areas where healthcare can be difficult to access. The practice is known as pasung (shackling) and can still be found in Indonesia despite being banned since 1977 (Human Rights Watch, 2016). In 2017, the Ministry of Health has issued a regulation which covers the prevention of the practice as well as management and rehabilitation guidelines for people affected by these practices. Management of ending of the practice is approached not only through advocacy and education, but also by making pharmacological and non-pharmacological interventions accessible. This is done by facilitating the registration of people affected with the NHIS as well as through home visits and home care, day care and vocational rehabilitation (Permenkes No. 54/2017 Tentang Penanggulangan Pemasungan Pada Orang Dengan Gangguan Jiwa (Ministry of Health Regulation No. 54/2017 on Countermeasures of Shackling Practice on People with Mental Illness), 2017).

References:

Human Rights Watch. (2016). Living in Hell: Abuses against People with Psychosocial Disabilities in Indonesia. Human Rights Watch.

Permenkes No. 54/2017 tentang Penanggulangan Pemasungan pada Orang dengan Gangguan Jiwa (Ministry of Health regulation No. 54/2017 on Countermeasures of Shackling Practice on People with Mental Illness). (2017). (Testimony of Ministry of Health Republic of Indonesia).

There is no specific legislation found regarding advanced care directives.

There is no specific provision for people with dementia. However, Law No. 8/2016 protects the rights of people living with disability to be free from discrimination, including in the workplace. The regulation ensures the rights of people with disabilities, including non-discrimination in the labour market (e.g., the right to have the same job and salary as people without disability and to receive the required support to work optimally to avoid losing their job due to their disability) (UU No. 8/2016 Tentang Penyandang Disabilitas (Law No. 8/2016 on People with Disability), 2016).

References:

UU No. 8/2016 tentang Penyandang Disabilitas (Law No. 8/2016 on People with Disability). (2016). (Testimony of Republik Indonesia).

There is no specific legislation or provisions found regarding ending discrimination against family carers (of people with dementia or other disability).

There is a conditional cash transfer programme to support poor families, with additional amount available for families providing care to an older person living in the household (Program Keluarga Harapan) (Kementerian Sosial Republik Indonesia, 2019). However, no regulations are found that make specific provisions to protect the rights of families and other unpaid carers, such as a right for education or a right for respite.

References:

Kementerian Sosial Republik Indonesia. (2019). Program Keluarga Harapan. https://kemsos.go.id/program-keluarga-harapan-pkh

Yes, Law no. 1/1974 (article 46) on marriage, states that an adult child is obliged to care for his/her parents and other family members in the vertical family line within his/her capacities if they need his/her help (UU No. 1/1974 Tentang Perkawinan (Law No. 1/1974 on Marriage), 1974).

References:

UU No. 1/1974 tentang Perkawinan (Law No. 1/1974 on Marriage). (1974). (Testimony of Republik Indonesia).

Provision exists to support decision-making. According to the legal requirements for curatorship listed previously, its award starts with the day of the judgment. No time duration is not mentioned, thus we can assume that it is awarded permanently, unless revoked.

There is a clinical guide-book on dementia, which has been published by the Association of Neurologists in Indonesia (Perhimpunan Dokter Spesialis Saraf Indonesia (PERDOSSI)) in 2015. The book contains guidelines, protocols, and recommendations for all types of healthcare facilities (PERDOSSI, 2015).

References:

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

The PERDOSSI guideline is used as a reference by all neurologists practicing in Indonesia, thus, it can be considered a national guideline. To date (27 February 2020), no national guideline on dementia has been issued by the government.

The PERDOSSI guideline was not issued by the government, but nationally accepted as it was issued by a professional organisation operating under the country’s legal framework.

The clinical practice guideline was developed by Indonesia’s Neurologist Association (PERDOSSI) in 2015 (PERDOSSI, 2015).

References:

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

No information on this in the guideline (PERDOSSI, 2015).

References:

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

 

Subjectively, the use of traditional medicine and spiritual healers seems to be quite popular among the general public. Pratono & Maharani (2018) report the preference of many older people in the Malang Regency of consulting traditional medicine/healers as opposed to modern healthcare providers, although this work did not specifically focus on dementia. There has been no information on how traditional or alternative medicine for dementia are communicated or how the patients access them. However, other study on traditional medicine for other health problems reported that most patients find the information about it from family (33.3%), friends (25%), religious group (22.2%), mass media (16.7%), and neighbours (2.7%) (Devy & Aji, 2006).

References:

Devy, S. R., & Aji, B. (2006). Faktor Predisposing, Enabling dan Reinforcing pada Pasien di Pengobatan Alternatif Radiesthesi Medik Metode Romo H. Loogman di Purworejo Jawa Tengah. Indonesian Journal of Public Health, 3(2), 35–44.

Pratono, A. H., & Maharani, A. (2018). Long-Term Care in Indonesia: The Role of Integrated Service Post for Elderly. Journal of Aging and Health, 30(10), 1556–1573. https://doi.org/10.1177/0898264318794732

PERDOSSI recommends care pathways that enable people with dementia (and their families) to have access to assessments through multidisciplinary teams as well as to psychosocial interventions. It is recommended that each patient suspected to have dementia at primary care level should be referred to the specialistic/secondary level of healthcare (neurology/psychiatry/geriatrics) or a memory clinic. Memory clinics should have multidisciplinary teams including neurologists, psychiatrists, geriatricians, psychologists, nurses, occupational therapists, physiotherapists, and (additional) general practitioners, home care workers, nutritionists, social workers, speech therapists, pharmacists, and local Alzheimer group representatives. The guideline does recommend one care provider to be the key care coordinator (PERDOSSI, 2015).

References:

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

The National Dementia Plan coordinated planning at the national level (Ministry of Health Republic of Indonesia, 2015b). In the recently drafted National Plan of Older People’s Health 2020-2024, the action plan draft also describes roles of the sub-national level government institutions (provincial, city, Kecamatan levels).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The national strategy document declares the stakeholders across sectors responsible for providing care for people with dementia. Although the development of this document was led by the Ministry of Health, it supposedly serves as a joint plan. However, there is no care coordination pathway across sectors for dementia that can be found in this document (Ministry of Health Republic of Indonesia, 2015b). In the recently drafted National Action Plan of Older People’s Health for 2020-2024, the action plans and indicators are described along with the responsible stakeholders, and this will serve as an additional joint plan to the National Dementia plan document.

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

It was not mentioned whether there are provisions to ensure provider continuity (e.g., for a patient to be seen by the same GP at every visit).

Yes, it is expected at all levels. Care coordination involving a multidisciplinary team is expected to be provided at the secondary and tertiary level of healthcare facilities, covered by the universal healthcare scheme. All these healthcare facilities are subject to the central government’s regulations. However, the National Dementia Plan encourages capacity building programmes to medics and non-medics to be emphasised in the primary care level (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The Asian Development Bank (ADB) is running a regional project on Developing Innovative Community-Based Long-Term Care Systems and Services, which includes Indonesia. The project is running from 2016-2020 (ADB, 2020; Kementrian PPN/BAPPENAS & ADB, 2018). This might lead to a change in policy particularly regarding long-term care in the next few years.

References:

ADB. (2020). Regional: Developing Innovative Community-Based Long-Term Care Systems and Services. https://www.adb.org/projects/53370-001/main

Kementrian PPN/BAPPENAS, & ADB. (2018). Workshop on Development of the National Strategic Plan for Long-term Care. Workshop on Development of the National Strategic Plan for Long-Term Care.

The development of an LTC system is driven by the ADB. ‘The country diagnostic studies conducted… in six countries (Indonesia, Mongolia, Sri Lanka, Thailand, Tonga, and Vietnam) have revealed large deficits in LTC services, especially those providing affordable and quality care. In each country, developing community-based services has emerged as a priority’ (ADB, 2020).

References:

ADB. (2020). Regional: Developing Innovative Community-Based Long-Term Care Systems and Services. https://www.adb.org/projects/53370-001/main

The Ministry of National Development Planning is currently drafting a National Plan on Older People’s Welfare (Kementrian Koordinator Bidang Pembangunan Manusia dan Kebudayaan RI, 2020) and dementia might be included in this plan.

References:

Kementrian Koordinator Bidang Pembangunan Manusia dan Kebudayaan RI. (2020). Tanggapan Terkait White Paper “Pemenuhan hak-hak lansia untuk hidup setara, sejahtera dan bermartabat.” Presentasi.

Yes, as the PERDOSSI clinical guideline was planned only to be effective until 2017 (PERDOSSI, 2015). However, no new guidelines have yet been published (27 February 2020).

References:

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

All sectors of government are expected to bring about policy change.

  • Central government has supporting bodies, such as the Ministry of Health with BKKBN and the public health directorate focusing on older people which work on ageing and mental health issues. The Ministry of Social Affairs has one directorate focusing on older people’s social rehabilitation.
  • Local governments can also bring policy change through their local programmes including Social Service or Health Service. Both programmes also work hand in hand with central government, the Ministry of Social Affairs, and the Ministry of Health.

Alzheimer Indonesia (ALZI)’s campaigns played a big role in raising the government’s concern on dementia. The Kick-starting Alzheimer’s Awareness project started in 2014 and aimed to promote Alzheimer awareness through an integrated campaign: bombarding the public with key messages through social and conventional media, learning activities with experts and experienced caregivers, and media engagement. In less than two years the awareness-raising efforts brought a significant increase in understanding and recognition of Alzheimer’s disease among the general public, the government, the private sector, and the media (Grand Challenges Canada, 2015).

For the past six years, ALZI has worked with various stakeholders to create a public awareness campaign called “Jangan Maklum Dengan Pikun” (Do Not Underestimate Memory Loss), which aims to raise awareness of dementia (Virgianti, 2014). The “Jangan Maklum Dengan Pikun” public awareness campaign has been disseminated through social media platforms, radio, TV, prints (Flyer, Poster, Infographic). The main target audience is the general public.

ALZI receive funding from donors and partner institutions. For example, a collaboration with the DKI Jakarta provincial government allows the organisation to spread the message through LED billboards/videotron across 30 spots in Jakarta as well as through lighting up the National Monument in purple during September, the World Alzheimer month (Sukarno, 2015). It also collaborates with public relations/communications firm (Maverick, 2017) and public awareness and media consultancy NGO (OnTrackMedia, 2014). The organisation funds the campaign from donations and grants, such as Grand Challenges Canada (Grand Challenges Canada, 2015) and the Twinning Project supported by the Dutch Ministry of Health, Welfare, and Sports which was initiated with the help of Alzheimer’s Disease International (ADI) (Alzheimer Indonesia, 2018).

The campaign aims to raise awareness of dementia and reduce stigma and discrimination towards people with dementia. In March 2016, the Indonesian Ministry of Health launched the National Action Plan on Dementia and Senior Citizens, and Alzheimer’s Indonesia is one of the stakeholders involved in the drafting of the document (Ministry of Health Republic of Indonesia, 2015b), signalling the success of the organisation’s campaign and advocacy efforts.

References:

Alzheimer Indonesia. (2018). Twinning Program Report. Available at: https://alzined.org/twinning-program/

Grand Challenges Canada. (2015). Raising Awareness to Improve the Lives of People with Alzheimer’s Disease. https://www.grandchallenges.ca/2015/kickstarting-alzheimer-awareness/

Maverick. (2017). The race against dementia with Alzheimer’s Indonesia. Maverick.

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

OnTrackMedia. (2014). 10 Tanda Demensia Alzheimer. https://youtu.be/DymN8tviXEQ

Sukarno, P. A. (2015). Monas Berwarna Ungu Selama Bulan September. Bisnis.Com. https://jakarta.bisnis.com/read/20150902/77/468162/monas-berwarna-ungu-selama-bulan-september

Virgianti, K. (2014). Alzi Peringati Hari Alzheimer Sedunia. Satu Harapan. http://www.satuharapan.com/read-detail/read/alzi-peringati-hari-alzheimer-sedunia

Alzheimer Indonesia conducts trainings for family caregivers and for the volunteers of their organisations. Besides that, the organisation also collaborates with regional governments. For instance, training 413 social workers of the DKI Jakarta province Department of Social Affairs to be first responders when there is a missing older person or when a person with dementia experiences difficulties to get home (Jakarta Resmikan Pasukan Ungu Bantu Penderita Demensia, 2016).

Dementia education sessions have been conducted in junior high schools, senior high schools, and vocational schools in DKI Jakarta in July 2015 and 2016, at the beginning of the academic year, in collaboration with the provincial government. Approximately 20,000 students were reached through this programme (Alzheimer’s Indonesia, 2019b). Based on the organisations’ internal correspondence documents, in 2016, Alzheimer Indonesia had also provided training for bank/financial service staff and developed a dementia education module for staff of Bank Tabungan Pensiun Negara (National Pension Bank) who often tend to deal with clients with cognitive impairments. The organisation has also collaborated with private sector providing service in retail, such as Hero, a local supermarket chain, in which training was conducted for their grocery store staff to be able to better support their older clients (Hero, Supermarket Ramah Lansia Pertama Di Indonesia, 2018).

References:

Alzheimer’s Indonesia. (2019b). Tentang Alzheimer Indonesia.

Hero, Supermarket Ramah Lansia Pertama di Indonesia. (2018, June). PalapaNews.

Jakarta Resmikan Pasukan Ungu Bantu Penderita Demensia. (2016). BeritaSatu. https://www.beritasatu.com/kesehatan/387342/jakarta-resmikan-pasukan-ungu-bantu-penderita-demensia

In Indonesia, there is very limited public understanding of dementia. Most of the public considers dementia to be a normal process of ageing, which leads to a low sense of urgency to seek treatment and care (Alzheimer’s Disease International, 2014; Suriastini et al., 2016). A study in 2002 highlighted how families often feel ashamed about having a family member with dementia and some hide them from the wider community. People with dementia sometimes get neglected by their families, as they are seen to be causing disturbance or inconvenience. Decline in cognitive functions and memory of older people continues to be normalised and expected (Yuniati, 2017). In Indonesian culture, the role of the caregiver is typically undertaken by older adults in the family, such as the father, mother, or grandparents who are able to provide care. There is also an expectation for women to take care of their ailing parents-in-law (Widyastuti et al., 2011). Some caregivers described the changes in the person they care for as funny and normal. Caregivers generally do not expect that the condition of older people will be cured and just hope the treatment can delay the deterioration. In 2018, a study found that stigma around older people is persisting in general; older people are sometimes viewed negatively as unproductive members by their immediate surroundings (Yulianti, 2018). However, adult children in Indonesia have a sense of obligation and loyalty that drives them to continue caring. Older people are traditionally seen as authorities of wisdom, worthy of respect, with a wealth of knowledge and experience.

References:

Alzheimer’s Disease International. (2014). Dementia in the Asia Pacific region.

Suriastini, Turana, Y., Witoelar, F., Supraptilah, B., Wicaksono, T., & Dwi, E. (2016). Policy Brief Angka Prevalensi Demensia: Perlu Perhatian Kita Semua. SurveyMETER, Maret, 1–4.

Widyastuti, H., Sahar, J., & Permatasari, H. (2011). Pengalaman Keluarga Merawat Lansia Dengan Demensia. Jurnal Ners Indonesia.

Yulianti. (2018). Dampak Program Elderly Day Care Service terhadap Kesejahteraan Lansia Studi kasus di Panti Sosial Tresna Werdha Budi Dharma Bekasi.

Yuniati, F. (2017). Pengalaman Caregiver dalam Merawat Lanjut Usia dengan Penurunan Daya Ingat. Jurnal Bahana Kesehatan Masarakat, 1(1), 27–42.

One of the results of the public awareness raising campaign is that more people contacted ALZI to seek for information on or help with dementia. It shows that there is a change in the perception towards dementia. Since life expectancy in Indonesia has increased over the last decades, the public has become more aware of dementia. They understand that it is important to have early recognition of the signs and symptoms of dementia.

We were unable to find evidence that focused on issues about perceptions on dementia in Indonesia (via MOH, academic journals in Bahasa and English, as well as news articles in both languages). However, one study discussed the relationship between economic status, education, family harmony, and awareness of dementia among family members (Wahyuliati, 2010). The study found that formal education attainment correlates significantly with awareness of dementia, while economic status and levels of familial harmony are not correlated significantly. There is an understanding that family and community can play an important role in changing the perception towards dementia in Indonesia. However, many continue to think that memory loss is part of the aging.

References:

Wahyuliati, T. (2010). Hubungan antara Status Ekonomi, Status Pendidikan dan Keharmonisan Keluarga dengan Kesadaran Adanya Demensia dalam Keluarga The Relation Between Economic Status, Educational Status and Family Harmony to Awareness of Dementia in Family. Mutiara Medika, 10(1), 44–48.

The training described in question 05.03. covers information about signs of dementia, dementia risk reduction, and how to help people with dementia and their carers (Alzheimer’s Indonesia, 2019b).

References:

Alzheimer’s Indonesia. (2019b). Tentang Alzheimer Indonesia.

We have learnt from Alzheimer Indonesia that an impact evaluation project is currently taking place and is expected to provide results around the end of 2020.

There have been various initiatives in Indonesia aimed to increase the elderly’s access to public transportation services and to increase their general mobility. In 2017, the City Government of Bandung plans to eliminate fees for the use of public transportation for elderly citizens. The mayor ensured that the Bandung City Government was committed about empowering its elderly citizens, such as through the creation of the Elderly Regional Commission (Komda Elderly) of the City of Bandung (Pemerintah Provinsi Jawa Barat, 2017).

In 2020, DAMRI, a State-Owned Enterprise supported the Government of West Java to become an operator of Scania Low Deck buses. This type of bus is accommodated to the needs of elderly and disabled population (Humas DAMRI, 2020).

References:

Humas DAMRI. (2020). DAMRI Operasikan Bus Scania Low Deck Ramah lansia, Difabel dan Lingkungan.

Pemerintah Provinsi Jawa Barat. (2017). Hormati Lansia, Pemkot Bandung Gratiskan Transportasi.

The Ministry of Social Affairs has led various ad-hoc initiatives to renovate residences of elderly living in villages. However, as of 2014 the renovation funding allocated per house was only IDR 10 million. The Minister of Social Affairs then argued that this budget is limited to evoke a sense of community spirit in the villages and entice neighbours to help the rebuilding process, thus saving labour costs (Marbun, n.d.).

References:

Marbun, J. (n.d.). Kementerian Sosial Terus Perbaiki Rumah Lansia. 2014.

There has been no widely available assistive technology to compensate for loss of capacity. However, the DKI Jakarta province developed an electronic reporting system through an application called Qlue, where people can report problems encountered in the city, including if they are finding an older person who is lost (Jakarta Resmikan Pasukan Ungu Bantu Penderita Demensia, 2016).

References:

Jakarta Resmikan Pasukan Ungu Bantu Penderita Demensia. (2016). BeritaSatu. https://www.beritasatu.com/kesehatan/387342/jakarta-resmikan-pasukan-ungu-bantu-penderita-demensia

There exist senior clubs where older people can meet and do social activities together. For instance, Griya Adiyuswa in Bintaro offers various activities, including cognitive stimulation therapy for prevention of dementia (Komunitas Lansia Griya Adiyuswa, n.d.).

References:

Komunitas Lansia Griya Adiyuswa. (n.d.). Komunitas Lansia Adiyuswa Senior Club. 2019.

In 2015, the governor of Jakarta, Basuki Tjahja Purnama, invested in developing capacity for dementia including accessibility initiatives. He was awarded by Alzheimer’s Disease International for his efforts on investing into the programmes. Some of Purnama’s initiatives included the construction of taman lansia (a garden for the older people) and a villa for older people in Ciangir, Tangerang (Bogiarto & Martiyanti, 2015). He declared Jakarta to become a dementia-friendly city (Florentin, 2015). However, he has since lost his political power and was imprisoned (Mazrieva, 2019). It remains to be seen whether the successors will prioritise dementia.

References:

Bogiarto, W., & Martiyanti, E. (2015). DKI Terima Penghargaan Ramah Demensia dan Lansia.

Florentin, V. (2015). Ahok Declares Jakarta as Age and Dementia Friendly City.

Mazrieva, E. (2019). ‘Ahok’ Case Highlights Indonesia’s Blasphemy Law.

There is no routinely monitored data about the number of people with dementia by the Ministry of Health or other ministries. The only recent data on dementia prevalence resulted from ADI’s prediction (Prince et al., 2015) and two separate studies in two provinces of Indonesia conducted by an independent research institution, Surveymeter (Suriastini et al., 2016, 2018). More information on incidence and prevalence estimated from these studies can be found in part 2.

References:

Prince, M., Wimo, A., Guerchet, M., Ali, G.-C., Wu, Y.-T., Prina, M., & Alzheimer’s Disease International. (2015). World Alzheimer Report 2015 The Global Impact of Dementia: An analysis of prevalence, incidence, cost and trends. https://www.alz.co.uk/research/WorldAlzheimerReport2015.pdf

Suriastini, Turana, Y., Sukadana, W., Sikoki, B., Witoelar, F., Lesmana, C. B. J., Mulyanto, E. D., Hermoko, R., & Anandari, G. A. A. A. (2018). Menggugah Lahirnya Kebijakan Kelanjutusiaan Menggugah Lahirnya Kebijakan Kelanjutusiaan.

Suriastini, Turana, Y., Witoelar, F., Supraptilah, B., Wicaksono, T., & Dwi, E. (2016). Policy Brief Angka Prevalensi Demensia: Perlu Perhatian Kita Semua. SurveyMETER, Maret, 1–4.

ADI’s prediction for Indonesia’s national prevalence of dementia in 2015, 2030, and 2050 can be found in the World Alzheimer Report 2015, available on ADI’s website (Prince et al., 2015). For the regional prevalence data of Yogyakarta and Bali province, the estimates can be accessed in the policy briefs issued by Surveymeter, available on their website (Suriastini et al., 2016, 2018).

References:

Prince, M., Wimo, A., Guerchet, M., Ali, G.-C., Wu, Y.-T., Prina, M., & Alzheimer’s Disease International. (2015). World Alzheimer Report 2015 The Global Impact of Dementia: An analysis of prevalence, incidence, cost and trends. https://www.alz.co.uk/research/WorldAlzheimerReport2015.pdf

Suriastini, Turana, Y., Sukadana, W., Sikoki, B., Witoelar, F., Lesmana, C. B. J., Mulyanto, E. D., Hermoko, R., & Anandari, G. A. A. A. (2018). Menggugah Lahirnya Kebijakan Kelanjutusiaan Menggugah Lahirnya Kebijakan Kelanjutusiaan.

Suriastini, Turana, Y., Witoelar, F., Supraptilah, B., Wicaksono, T., & Dwi, E. (2016). Policy Brief Angka Prevalensi Demensia: Perlu Perhatian Kita Semua. SurveyMETER, Maret, 1–4.

Data from the World Alzheimer Report 2015 estimates that there were 1.2 million people living with dementia in Indonesia in 2015. The report does not provide data disaggregated by gender, geographical area, or type of dementia (Prince et al., 2015, p.25). Surveymeter’s data on Yogyakarta was presented by age group (per 10 years starting 60 years), gender, and urban/rural area (Suriastini et al., 2016). The data on the province of Bali were presented by age group, gender, level of education, urban/rural area, district, comorbidities, occupation, and social participation (Suriastini et al., 2018).

References:

Prince, M., Wimo, A., Guerchet, M., Ali, G.-C., Wu, Y.-T., Prina, M., & Alzheimer’s Disease International. (2015). World Alzheimer Report 2015 The Global Impact of Dementia: An analysis of prevalence, incidence, cost and trends. https://www.alz.co.uk/research/WorldAlzheimerReport2015.pdf

Suriastini, Turana, Y., Sukadana, W., Sikoki, B., Witoelar, F., Lesmana, C. B. J., Mulyanto, E. D., Hermoko, R., & Anandari, G. A. A. A. (2018). Menggugah Lahirnya Kebijakan Kelanjutusiaan Menggugah Lahirnya Kebijakan Kelanjutusiaan.

Suriastini, Turana, Y., Witoelar, F., Supraptilah, B., Wicaksono, T., & Dwi, E. (2016). Policy Brief Angka Prevalensi Demensia: Perlu Perhatian Kita Semua. SurveyMETER, Maret, 1–4.

The earliest report estimated that the dementia prevalence in Indonesia comes from a joint report of ADI Asia-Pacific members in 2005. The report stated a prevalence of 606,100. The same source reported an incidence of 191,400, which was predicted to increase to 314,100 by 2020 and to 932,000 by 2050 (Access Economics, 2006).

 The most recent estimates based on regional prediction published in the revised World Alzheimer Report 2015 stated that in 2015, approximately 1.2 million people in Indonesia were living with dementia and this number was expected to increase up to almost 4 million by 2050 (Prince et al., 2015).

Other studies identified reported regional dementia prevalence rates.

Yesufu (2009, p.12) reported a dementia prevalence of 4.1% among those aged 60 and older. The research further found that the prevalence of people living with Alzheimer’s Disease was 3.1% in the same age group, while that of all other dementias (‘including Vascular Dementia, possible secondary dementia, and other non-assessed sub-types) was estimated to be 5.4% (age range 52-98 years)’. This research had been conducted in Sumedang (West Java) and Borobodu (Central Java) as well as urban sites in Central and South Jakarta (Northwest Java).

Hogervorst (2011, p.8), studying similar areas to Yesufu (the study was conducted in West and Central Java as well as at an urban site in Jakarta) and who aimed to validate two short dementia screening tests in Indonesia reported a ‘suspected dementia prevalence’ of 8% among those aged 60 and 65 years. The author reports that they found a very high rate (16-21%) possible dementia cases in Borobudur, Central Java, which raised the overall estimated prevalence rate.

Surveymeter, an independent research institution, investigated the prevalence of dementia in the province of Yogyakarta (Suriastini et al., 2016) and Bali (Suriastini et al., 2018). Yogyakarta is located in Java, which is the most densely-populated island in Indonesia (The Editors of Encyclopaedia Britannica, 2017), and currently is the province with the highest percentage of older people among all provinces in Indonesia  (Pusat Data dan Informasi Kementerian Kesehatan RI, 2017). Surveymeter’s data from Yogyakarta showed a dementia prevalence of 20.1% (Suriastini et al., 2016). No data regarding incidence in Yogyakarta were found.

A similar study conducted in 2018 in the province of Bali showed a higher prevalence of dementia at 32.16% (Suriastini et al., 2018). This high prevalence might be related to the proportion of older population in this province. Among provinces outside of Java Island, Bali has the highest number of older people outside of Java (Pusat Data dan Informasi Kementerian Kesehatan RI, 2017). There were no data found regarding incidence in this province either. Surveymeter’s data is based on household surveys in the province of Yogyakarta (Suriastini et al., 2016) and Bali (Suriastini et al., 2018). Both studies were conducted using structured questionnaire and instruments of cognitive screening and functional status assessment such as MMSE, ADL and IADL for both the patients and caregivers in villages or sub-districts.

References:

Access Economics. (2006). Demensia Di Kawasan Asia Pasifik: Sudah Ada Wabah. https://www.alz.co.uk/research/files/apreportindonesian.pdf

Hogervorst, E. (2011). Validation of two short dementia screening tests in Indonesia. IN: Jacobsen, S.R. (ed.) Vascular Dementia: Risk Factors, Diagnosis and Treatment, New York: Nova Science, pp. 235-256.

Prince, M., Wimo, A., Guerchet, M., Ali, G.-C., Wu, Y.-T., Prina, M., & Alzheimer’s Disease International. (2015). World Alzheimer Report 2015 The Global Impact of Dementia: An analysis of prevalence, incidence, cost and trends. https://www.alz.co.uk/research/WorldAlzheimerReport2015.pdf

Pusat Data dan Informasi Kementerian Kesehatan RI. (2017). Analisis Lansia di Indonesia.

Suriastini, Turana, Y., Sukadana, W., Sikoki, B., Witoelar, F., Lesmana, C. B. J., Mulyanto, E. D., Hermoko, R., & Anandari, G. A. A. A. (2018). Menggugah Lahirnya Kebijakan Kelanjutusiaan Menggugah Lahirnya Kebijakan Kelanjutusiaan.

Suriastini, Turana, Y., Witoelar, F., Supraptilah, B., Wicaksono, T., & Dwi, E. (2016). Policy Brief Angka Prevalensi Demensia: Perlu Perhatian Kita Semua. SurveyMETER, Maret, 1–4.

The Editors of Encyclopaedia Britannica. (2017). Java. Encyclopædia Britannica. https://www.britannica.com/place/Java-island-Indonesia

Yesufu, A. O. (2009). Demographic and modifiable risk factors for age related cognitive impairment and possible dementia. Loughborough: Loughborough University

According to the Global Health Data Exchange, the YLL of Alzheimer’s disease and other dementias in Indonesia in 2017 is 522,067.55 (Global Health Data Exchange, 2019).

References:

Global Health Data Exchange. (2019). GBD Results Tool. http://ghdx.healthdata.org/gbd-results-tool

According to the Global Health Data Exchange, the YLD of Alzheimer’s disease and other dementias in Indonesia in 2017 is 139,446.64 (Global Health Data Exchange, 2019).

References:

Global Health Data Exchange. (2019). GBD Results Tool. http://ghdx.healthdata.org/gbd-results-tool

There has been not enough evidence to conclude a dementia prevalence nationally. However, Surveymeter’s studies showed higher prevalence in rural areas both in Yogyakarta (23.0%) and Bali (36.1%) (Suriastini et al., 2016, 2018).

References:

Suriastini, Turana, Y., Sukadana, W., Sikoki, B., Witoelar, F., Lesmana, C. B. J., Mulyanto, E. D., Hermoko, R., & Anandari, G. A. A. A. (2018). Menggugah Lahirnya Kebijakan Kelanjutusiaan Menggugah Lahirnya Kebijakan Kelanjutusiaan.

Suriastini, Turana, Y., Witoelar, F., Supraptilah, B., Wicaksono, T., & Dwi, E. (2016). Policy Brief Angka Prevalensi Demensia: Perlu Perhatian Kita Semua. SurveyMETER, Maret, 1–4.

We could not identify data on the average age of dementia onset in Indonesia.

We could not identify data on the average life expectancy of people living with dementia.

Data from the studies in both Yogyakarta and Bali showed a higher prevalence of dementia in women (22.0% and 38%, respectively) than men (17.9% and 25.7%, respectively) (Suriastini et al., 2016, 2018). This is consistent with other, international data on dementia, which suggests that this condition affect more women than men (Erol et al., 2015).

We found no data on differences between ethnic groups.

References:

Erol, R., Brooker, D., & Peel, E. (2015). Women and Dementia A global research review. 52.

Suriastini, Turana, Y., Sukadana, W., Sikoki, B., Witoelar, F., Lesmana, C. B. J., Mulyanto, E. D., Hermoko, R., & Anandari, G. A. A. A. (2018). Menggugah Lahirnya Kebijakan Kelanjutusiaan Menggugah Lahirnya Kebijakan Kelanjutusiaan.

Suriastini, Turana, Y., Witoelar, F., Supraptilah, B., Wicaksono, T., & Dwi, E. (2016). Policy Brief Angka Prevalensi Demensia: Perlu Perhatian Kita Semua. SurveyMETER, Maret, 1–4.

 

We found no data on the average number of years lived by people living with dementia.

We found non data on the national prevalence or incidence of specific type of dementias.

There is no evidence of association between dementia and poverty in Indoensia.

Badan Pusat Statistik (Statistics Indonesia) uses a basic needs approach to define poverty. Living in poverty is defined as monthly per capita expense (food and non-food commodities) lower than the established poverty line. As of March 2019 the poverty line in Indonesia was Rp 425.250,-/capita/month. Approximately 25.14 million people (9.41% of the national population) were defined as living in poverty. This number in 2019 represents a historically all-time low (Badan Pusat Statistik, 2019a). Although there has been no evidence regarding association between dementia and poverty in Indonesia, Yogyakarta is one of the provinces with high rates of poverty (11.7%) (Badan Pusat Statistik, 2019a). However, this is not the case for Bali. Therefore, it is not possible to draw a conclusion based on these data.

References:

Badan Pusat Statistik. (2019a). Berita Resmi Statistik.

In 2014, Alzheimer’s Indonesia (ALZI) in collaboration with On Track Media Indonesia and Juara Agency started the #JanganMaklumDenganPikun campaign to raise awareness and reduce risk of dementia. “Jangan maklum dengan pikun” means “Do not underestimate memory loss”. This campaign was supported by Grand Challenges Canada and resulted in various communication materials, including the 10 Tanda Demensia Alzheimer (10 Warning Signs of Alzheimer’s) video and leaflet (Virgianti, 2014). The leaflet lists the 10 common signs of Alzheimer’s disease, while the video has an additional explanation on how to reduce risks of dementia, for example, through routine physical activities of at least 150 minutes per week, consuming a healthy and balanced diet as well as mental stimulation, positive thinking, and engaging in productive, creative activities (OnTrackMedia, 2014).

In 2015, the Minister of Health issued a regulation on the management of non-communicable diseases. Based on this, the Ministry of Health launched the campaign ‘CERDIK’ to reduce risk of non-communicable diseases. CERDIK is an acronym of Cek kesehatan rutin (routine health check-up), Enyahkan asap rokok (eliminate smoking), Rajin aktivitas fisik (routine physical activity), Diet sehat dan gizi seimbang (healthy diet and balanced nutrition), Istirahat cukup (Enough rest/sleep), and Kelola stres (Managing stress) (Ministry of Health Republic of Indonesia, 2015a). Aligning with this campaign, the most current version of ALZI’s 10 Tanda Demensia leaflet includes CERDIK as the advice regarding risk reduction for dementia (Alzheimer’s Indonesia, 2019a).

In 2016, the national dementia strategy was launched. The national strategy has seven action steps, in which the first is ‘Campaign of public awareness and promotion of healthy lifestyle’ (Ministry of Health Republic of Indonesia, 2015a, p.25). This step has four activities, which are:

  • [To] ‘Strengthen the existing programs and creating new programs to promote healthy and productive older persons, [to address] risk factors, and protective factors, including healthy lifestyle
  • [To] Intensify healthy and productive older persons campaign
  • [To] Strengthen education program on older people in schools, community, occupational health programmes
  • [To] Promote cognitive health using [a] coordinated training model at the national level’.
References:

Alzheimer’s Indonesia. (2019a). 10 Gejala Awal Demensia Alzheimer. https://alzi.or.id/10-gejala-awal-demensia-alzheimer/

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

OnTrackMedia. (2014). 10 Tanda Demensia Alzheimer. https://youtu.be/DymN8tviXEQ

Virgianti K. (2014). Alzi sebarkan info Alzheimer gandeng pemerintah. Satu Harapan. Available at: https://www.satuharapan.com/read-detail/read/alzi-sebarkan-info-alzheimer-gandeng-pemerintah

The national dementia strategy document mentioned several risk factors which can affect brain health negatively over the life course. These including congenital anomaly, genetics, smoking, alcohol, malnutrition, non-communicable and communicable diseases, metabolic diseases, vascular, and neurological disorders (Ministry of Health Republic of Indonesia, 2015b).

Surveymeter’s study in Bali shows that 47.6% of respondents diagnosed with dementia reported a comorbidity with stroke, followed by 40% with cancer, 38.8% heart disease, and 34.6% hypertension. However, the study did not investigate the association between these possible risk factors with dementia (Suriastini et al., 2018). Other studies in different populations have also reported the association with hypertension (Fitri & Rambe, 2018), diabetes (Kayo et al., 2012), and dyslipidemia (Maryam & Sahar, 2019). Moreover, according to Turana et al., 2019, the highest estimated population-attributable risks are low education, smoking, and physical inactivity (Turana et al., 2019).

References:

Fitri, F. I., & Rambe, A. S. (2018). Correlation between hypertension and cognitive function in elderly. IOP Conference Series: Earth and Environmental Science, 125(1). https://doi.org/10.1088/1755-1315/125/1/012177

Kayo, A. R., Wimala, A. R., Angela, N., & Rashid, I. binti A. (2012). Random blood glucose level as predictor of cognitive impairment in elderly. Universa Medicina, 31(2), 131–138. https://doi.org/10.1805/UnivMed.2012.v31.131-138

Maryam, R. S., & Sahar, J. (2019). Determining factors of dementia in elderly individuals residing in the special capital region of Jakarta. Enfermería Clínica.

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

Suriastini, Turana, Y., Sukadana, W., Sikoki, B., Witoelar, F., Lesmana, C. B. J., Mulyanto, E. D., Hermoko, R., & Anandari, G. A. A. A. (2018). Menggugah Lahirnya Kebijakan Kelanjutusiaan Menggugah Lahirnya Kebijakan Kelanjutusiaan.

Turana, Y., Tengkawan, J., Suswanti, I., Suharya, D., Riyadina, W., & Pradono, J. (2019). Primary Prevention of Alzheimer’s Disease in Indonesia. International Journal of Aging Research, 1–8. https://doi.org/10.28933/ijoar-2019-06-2506

According to the National Socioeconomic Survey/Survey Sosioekonomi Nasional (Susenas) conducted in March 2018, among the population aged 15 years and older, 32.48% have completed primary school education. In urban areas, the proportion of males in this age group whose highest educational attainment is completion of primary is 19.34%, while it is 20.85% for females. In the rural areas, the proportion of males in this age group with primary school as their highest educational qualification is 33.06%. while it is 31.91% for females (Badan Pusat Statistik, 2019a).

References:

Badan Pusat Statistik. (2019a). Berita Resmi Statistik.

Data from Susenas (March 2018) also states that among those 15 years and older, 21.60%, declare their highest education attainment to be secondary (junior high) school, 13.82% completed senior high school and 5.63% vocational high school. A total of 4.49% have a university degree (including: diploma for 1-3 years education, bachelor’s degree, and postgraduate degrees).

In urban areas, among males in this age group, 20.97% declared junior high school to be their highest educational attainment for males, 27.97% reported senior high school, 8.80% vocational high school, and 12.06% a university degree. For females, these percentages are 20.92%, 24.65%, 5.92%, and 12.35%, respectively. In rural areas, 22.22% of males reported junior high school to be their highest educational attainment. 15.42% completed senior high school, 4,36% vocational high school and 4.16% a university degree. For females, these percentages were 20.98%, 12.22%, 2.61%, and 4.82%, respectively (Badan Pusat Statistik, 2019a).

References:

Badan Pusat Statistik. (2019a). Berita Resmi Statistik.

There are two different estimates of the proportion of the population living with hypertension in Indonesia. One estimate suggests that prevalence of hypertension among people older than 18 years is 8.8% (Riset Kesehatan Dasar (Basic Health Survey). This estimate is based on clinical diagnosis or current use of hypertension medication. The second estimate is based on blood pressure measures taken as part of the survey and suggests a significantly higher proportion (34.1%) (Ministry of Health Republic of Indonesia, 2018). It is important to consider the probability of white-coat hypertension (people exhibiting higher blood pressure than normal when examined in medical settings) in interpreting this data.

References:

Ministry of Health Republic of Indonesia. (2018). Riset Kesehatan Dasar 2018. Jakarta: Lembaga Penerbit Badan Penelitian dan Pengembangan Kesehatan. Available at: http://labdata.litbang.kemkes.go.id/images/download/laporan/RKD/2018/Laporan_Nasional_RKD2018_FINAL.pdf

Approximately 21.8% of the Indonesian population is considered to be obese. Obesity was defined as a Body Mass Index of 27.0 or higher (Ministry of Health Republic of Indonesia, 2018).

References:

Ministry of Health Republic of Indonesia. (2018). Riset Kesehatan Dasar 2018. Jakarta: Lembaga Penerbit Badan Penelitian dan Pengembangan Kesehatan. Available at: http://labdata.litbang.kemkes.go.id/images/download/laporan/RKD/2018/Laporan_Nasional_RKD2018_FINAL.pdf

According to a WHO report from 2000, the estimated prevalence of ‘adult onset hearing loss for adults aged 15 years and’ older was 7.1 for adults aged 41 and older, 1.4 for people aged 61 and older and 0.1 for people aged 81 and older (Mathers et al., 2000, p.8).

References:

Mathers, C., Smith, A. & Concha, M. (2000). Global burden of hearing loss in the year 2000, Geneva: World Health Organization. https://www.who.int/healthinfo/statistics/bod_hearingloss.pdf

The Basic Health Survey 2018 reported that 33.8% of the population over 15 years old consumed tobacco (smoked or chewed). This report did not state the overall proportion of tobacco smokers. However, another source suggests that approximately 9.1% of persons aged 10-18 years old are active smokers (Ministry of Health Republic of Indonesia, 2018).

References:

Ministry of Health Republic of Indonesia. (2018). Riset Kesehatan Dasar 2018. Jakarta: Lembaga Penerbit Badan Penelitian dan Pengembangan Kesehatan. Available at: http://labdata.litbang.kemkes.go.id/images/download/laporan/RKD/2018/Laporan_Nasional_RKD2018_FINAL.pdf

The Basic Health Survey 2018 reported that 6.1% of the population live with depression. This prevalence estimate is based on an assessment with the Mini International Neuropsychiatric Interview. No information was found on the number of people getting an official diagnosis among this group. However, only 9% of them get medical treatment (Ministry of Health Republic of Indonesia, 2018).

References:

Ministry of Health Republic of Indonesia. (2018). Riset Kesehatan Dasar 2018. Jakarta: Lembaga Penerbit Badan Penelitian dan Pengembangan Kesehatan. Available at: http://labdata.litbang.kemkes.go.id/images/download/laporan/RKD/2018/Laporan_Nasional_RKD2018_FINAL.pdf

It is estimated that 33.5% of the national population were categorised as physically inactive (defined as a cumulative physical activities less than 150 minutes per week) (Ministry of Health Republic of Indonesia, 2018).

References:

Ministry of Health Republic of Indonesia. (2018). Riset Kesehatan Dasar 2018. Jakarta: Lembaga Penerbit Badan Penelitian dan Pengembangan Kesehatan. Available at: http://labdata.litbang.kemkes.go.id/images/download/laporan/RKD/2018/Laporan_Nasional_RKD2018_FINAL.pdf

 

According to the Riset Kesehatan Dasar (Basic Health Survey) 2018 the prevalence of diabetes in people older than 15 years in Indonesia is 2%. This estimated prevalence is based on the existence of clinical diagnosis. However, a blood test-based diagnosis suggested a higher proportion (10.9%) (Ministry of Health Republic of Indonesia, 2018).

References:

Ministry of Health Republic of Indonesia. (2018). Riset Kesehatan Dasar 2018. Jakarta: Lembaga Penerbit Badan Penelitian dan Pengembangan Kesehatan. Available at: http://labdata.litbang.kemkes.go.id/images/download/laporan/RKD/2018/Laporan_Nasional_RKD2018_FINAL.pdf

No data was found regarding the amount of alcohol consumed per capita.

An estimated 3.3% of the population aged 10 and over were reported to consume alcoholic drinks, although only 0.8% were reported to be heavy drinkers (Ministry of Health Republic of Indonesia, 2018).

References:

Ministry of Health Republic of Indonesia. (2018). Riset Kesehatan Dasar 2018. Jakarta: Lembaga Penerbit Badan Penelitian dan Pengembangan Kesehatan. Available at: http://labdata.litbang.kemkes.go.id/images/download/laporan/RKD/2018/Laporan_Nasional_RKD2018_FINAL.pdf

The most recent data on cholesterol levels in the national population aged 15 and over is available from the Riskesdas 2018. High total cholesterol (> 240 mg/dL) was found in 7.6% of the population and borderline results (200-239 mg/dL) were found in 21.2% (Ministry of Health Republic of Indonesia, 2018).

References:

Ministry of Health Republic of Indonesia. (2018). Riset Kesehatan Dasar 2018. Jakarta: Lembaga Penerbit Badan Penelitian dan Pengembangan Kesehatan. Available at: http://labdata.litbang.kemkes.go.id/images/download/laporan/RKD/2018/Laporan_Nasional_RKD2018_FINAL.pdf

In 2015, the Indonesian Neurologist Association/Perhimpunan Dokter Spesialis Saraf Indonesia (PERDOSSI) issued a clinical practice guideline on dementia diagnosis and management. The document outlined diagnostic paths in the different levels of healthcare services (PERDOSSI, 2015).

In primary care, patients coming with subjective complaints, change of activities of daily living (ADL), or brought to the clinic due to the family/carer’s concern on their cognitive changes will be considered for assessment. The physician should interview the patient and/or the carer about the history of the complaint and then perform physical examination of the patient, especially of the cardiovascular and neurological system. The patient’s cognitive function will then be assessed using the Mini Mental State Examination (MMSE). The physician should also document changes on the patient’s activities and cognitive function using the AD8 instrument based on the carer’s report. Patients with abnormalities in clinical or neurological examinations, MMSE score of less than 24, or AD8 score of 2 or more should be referred to a neurologist (in the second level of healthcare services) or to a memory clinic (in the third level of healthcare services). If these criteria are not met, the patient is advised to return for a check-up in 6 months (PERDOSSI, 2015).

In hospital (secondary level of healthcare), patients presenting with complaints suggestive of dementia or referred by the primary care will undergo a similar process to that of primary care. In an addition the Geriatric Depression Scale should be performed to exclude depression as well as a clock-drawing test (CDT), and the Montreal Cognitive Assessment (MoCA). Blood sample should be taken to check the patient’s lipid profile, renal and liver function, glucose level, and electrolytes. A CT-scan should be done to aid diagnosis. Patients with abnormalities in physical examination, AD8 > 2/MMSE < 24/CDT < 24/MoCA < 24 are advised to be referred to a memory clinic (PERDOSSI, 2015).

In the memory clinic (tertiary healthcare level), additional exams performed include other neuropsychological tests, the Neuropsychiatric Inventory (NPI), other blood tests (fasting blood glucose, folic acid, and vitamin B12 levels, thyroid function) and an electrocardiogram. Other specific tests according to indication can also be ordered, such as VDRL for syphilis or a HIV test. An MRI (preferable) or CT should be performed, followed by electroencephalogram or lumbar puncture if indicated. These additional exams are expected to aid diagnosis of dementia and its causes (PERDOSSI, 2015).

During our interview for WP3 with a general practitioner managing a geriatric clinic of a primary care centre, we learnt that dementia screening practice is not routine practice. The physician informed us that most of the dementia cases documented in that centre already received a diagnosis in the hospital and then reported back to the centre for documentation and administrative requirements (Source: WP3 FGD info from GP). However, this is contradictory to another statement by the physician. The GP explained that based on the new Ministry of Health’s regulation no. 4/2019 on the Minimum Standard of Service, the centre has now routinely started to screen older people with several tools that include a cognitive instrument (Abbreviated Mental Test) (Ministry of Health Regulation No. 4/2019 on Technical Standard to Fulfill Quality of Basic Service in Minimum Standard of Healthcare Service (Permenkes No. 4/2019 Tentang Standar Teknis Pemenuhan Mutu Pelayanan Dasar Pada Standar Pelayanan Minimal Bidang), 2019). More about this regulation will be discussed in this document in Part 7, Dementia Care System Organisation, Community-based Services for Dementia, and Diagnostic services (in primary care)).

The stratified screening and diagnosis pathway outlined above seems to be typical of patients using the National Health Insurance. However, the pathways of patients with self-funded access to healthcare vary greatly depending on the patient’s economic status and geographical area. Some patients decide to go directly to the secondary or tertiary healthcare providers, or even undertake tests abroad. Some secondary health centres have sufficient resources to perform the examinations outlined for tertiary health care providers and thus can provide the level of diagnosis at secondary level. It is also important to note that a lot of patients receive their diagnosis of dementia whilst being treated for other issues (WP3 FGD info from neurologist and GP).

References:

Ministry of Health Regulation no. 4/2019 on Technical Standard to Fulfill Quality of Basic Service in Minimum Standard of Healthcare Service (Permenkes no. 4/2019 tentang Standar Teknis Pemenuhan Mutu Pelayanan Dasar pada Standar Pelayanan Minimal Bidang , (2019) (testimony of Ministry of Health Republic of Indonesia).

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

There has been no research conducted to detect the percentage of people with dementia that have received a diagnostic assessment in Indonesia.

To date, we found no guidelines specifying any difference in diagnostic assessment according to geographical areas. However, the practice might differ according to availability of healthcare facilities.

The national strategy document states that the stakeholders responsible for the achievement indicators of the fourth action step (cognitive screening, diagnosis, and management of dementia) are the ‘Ministry of Health, the Ministry of Home Affairs, and the Ministry of Social Affairs (according to the ability at each level) (Ministry of Health Republic of Indonesia, 2015a, p.29). We assume that this would also include the care coordination. However, this document does not provide further details on the management or care coordination pathway.

The Alzheimer association in Indonesia has taken its steps to support care coordination. We have learnt informally that ALZI is testing a new program called ‘care navigator’, which provides online support to family carers by referring them to relevant services, connecting them to experts who can help them address problems they are facing at home, such as behavioural and psychological symptoms of dementia (BPSD), combined with education sessions on dementia care skills.

References:

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

No, there are no dedicated services supporting people with dementia after a diagnostic assessment. However, first steps to develop these kinds of services have been made locally. The PERDOSSI guideline provides scientific recommendation regarding a variety of nonpharmacological approaches to dementia (PERDOSSI, 2015), but it does not advise where these dementia-specific services could be accessed in Indonesia.

In addition, there are several institutions offering dedicated services for people with dementia in Indonesia. These include the Adiyuswa Senior Day Care in Radjiman Wediodiningrat Psychiatric Hospital, Lawang, East Java (RSJ Dr. Radjiman Wediodiningrat, 2016), and RUKUN Senior offers a Dementia Day Care Programme in RUKUN Dementia Support Centre Cipete, Jakarta and RUKUN Senior Care, Sentul, West Java (RUKUN Senior Living, n.d.-a). General geriatric support services not specific for dementia are more widely available.

Furthermore, the private hospital chain Siloam has established a Memory and Aging Centre in April 2016 (Siloam Hospitals, n.d.). MAC claims to not only serve patients with dementia, but also as a place of development, medical services, research, which aims to be integrated with patient care in the long run (Handayani, 2016).

References:

Handayani, I. (2016). Siloam Hadirkan Pusat Layanan Pasien Demensia.

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

RSJ Dr. Radjiman Wediodiningrat. (2016). Psikogeriatri – Klinik Daycare ADIYUSWA. http://rsjlawang.com/main/fasilitas/psikogeriatri

RUKUN Senior Living. (n.d.-a). Dementia Day Program. Retrieved September 7, 2019, from https://rukunseniorliving.com/dementia-day-program/

Siloam Hospitals. (n.d.). Memory Clinic.

The referral system is regulated through the Ministry of Health’s Regulation no. 1/2012 and no. 4/2018 as well as through the regulation Health Insurance Administration Body of Indonesia (Badan Penyelenggara Jaminan Sosial-Kesehatan (BPJS-Kesehatan)) which establish links between different levels of healthcare services. The referral system also regulates the type of services that can be provided in primary care and how patients can be referred to specialist care services, including dementia cases (there are 14 public hospitals with geriatric integrated care teams).

The links are regulated through the Ministry of Health’s Regulation no. 1/2012 and no. 4/2018 as well as through the regulation Health Insurance Administration Body of Indonesia (Badan Penyelenggara Jaminan Sosial-Kesehatan (BPJS-Kesehatan)).

The Ministry of Health’s regulation no. 74/2014 regulates the type of services, facilities, and resources an integrated geriatric unit should have. It also regulates that such services should be managed by an Integrated Geriatric Team, formed by the hospital director. The geriatric service is classified into sederhana, lengkap, sempurna, and paripurna types, ranging from very simple services to very comprehensive, respectively. The regulation stated that the team should be led by a geriatric specialist in the paripurna (highest) types, or an internal medicine specialist in the lower types (Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 Tentang Pelayanan Geriatri Di RS), 2014).

References:

Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 tentang Pelayanan Geriatri di RS). (2014). (Testimony of Ministry of Health Republic of Indonesia).

There is no information available. We searched via Medline, PubMed, GoogleScholar, Factiva, news, and Neurona.

We were unable to identify relevant information. We searched via Medline, PubMed, GoogleScholar, Factiva, news, and Neurona.

ADI estimated that, in Indonesia, dementia costs US$1,777 million in 2015 (Alzheimer’s Disease International, 2019, p.4). There has been no official data on dementia cost according to the Indonesian government or research institutions. However, in 2015, the Executive Director of Alzheimer’s Indonesia DY Suharya estimated that the annual cost associated with dementia in Indonesia has increased from US$1.7 billion to US$2 billion. Unpublished data from Alzheimer Indonesia’s database of caregivers provides information on the approximate dementia-related cost of care that families incur on a monthly basis. Out of 193 respondents, 10.9% reported spending less than IDR 1 million, 38.3% between IDR 1-3 million, 26.4% between IDR 3-5 million, 18.7% between IDR 5-10 million, and 5.7% spend more than IDR 10 million per month (Alzheimer’s Indonesia database, October 2019, unpublished).

References:

Alzheimer’s Disease International. (2019). World Alzheimer Report 2019: Attitudes to Dementia. Alzheimer’s Disease International.

PERDOSSI has developed a diagnostic protocol for primary care. In addition, from 2019 onwards primary care centres have to adopt a screening approach by the Ministry of Health’s regulation no. 4/2019 on Minimum Standard of Service. The document states that all people aged 60 years old or above should receive an annual check of blood glucose and cholesterol level, Geriatric Depression Scale, Abbreviated Mental Test, Instrumental Activities of Daily Living (Ministry of Health Regulation No. 4/2019 on Technical Standard to Fulfill Quality of Basic Service in Minimum Standard of Healthcare Service (Permenkes No. 4/2019 Tentang Standar Teknis Pemenuhan Mutu Pelayanan Dasar Pada Standar Pelayanan Minimal Bidang, 2019).

References:

Ministry of Health Regulation no. 4/2019 on Technical Standard to Fulfill Quality of Basic Service in Minimum Standard of Healthcare Service (Permenkes no. 4/2019 tentang Standar Teknis Pemenuhan Mutu Pelayanan Dasar pada Standar Pelayanan Minimal Bidang). (2019). (Testimony of Ministry of Health Republic of Indonesia).

An assessment for behavioural and psychological symptoms of dementia (BPSD) is not routinely performed among older people or people who have been diagnosed with dementia. The Ministry of Health is currently planning a guideline for primary care, and this might include the Neuropsychiatric Inventory (NPI) to assess BPSD. The NPI, however, is commonly used for assessment in memory clinics.

Puskesmas santun lansia (geriatric friendly Puskesmas) provide promotive, preventive, curative, and rehabilitative services including psychosocial therapy services in rehabilitative sectors (Zakiah, 2017). The services consist of psychological health services and cognitive activities for older people, which aim to support older people in preserving their functional abilities and independency (Aistyawati, 2016).

References:

Aistyawati, I. (2016). Analisis Implementasi Kebijakan Program Puskesmas Santun Lanjut Usia di Puskesmas Mijen Kota Semarang. Administrasi Publik.

Zakiah. (2017). Puskesmas Santun Lansia. https://www.slideshare.net/dr_Qiqi/puskesmas-santun-lansia-76504165

Palliative care was first established in Indonesia in 1992. Expansion of programmes has been slow as services are concentrated in big cities (Putranto et al., 2017), leading to a lack of palliative care services in community-based and primary healthcare facilities. An example of palliative care in community-based service can be found in the Puskesmas Balongsari in Surabaya, East Java. A team of medical doctors, psychologists, nurses, and volunteers provides Palliative care services in the outpatient setting on Mondays and Wednesdays (Saleh et al., 2008). However, this is not dementia specific. Palliative care in Indonesia is mostly linked to cancer (Putranto et al., 2017) and in general is regulated by the Ministry of Health (Kementerian Kesehatan Republik Indonesia, 2007). There continues to be a lack of research evidence and initiative towards developing palliative care for people with dementia in Indonesia.

References:

Kementerian Kesehatan Republik Indonesia. (2007). Minister of Health Decree 812/2007 on Palliative Care Policy (Keputusan Menteri Kesehatan Republik Indonesia No. 812/2007 tentang Kebijakan Perawatan Paliatif).

Putranto, R., Mudjaddid, E., Shatro, H., Adli, M., & Martina, D. (2017). Development and challenges of palliative care in Indonesia: role of psychosomatic medicine. BioPsychoSocial Medicine.

Saleh, M. S., Danantosa, T., & Kusumawardhani, C. (2008). Perawatan Paliatif di Puskesmas Balongsari Surabaya: Upaya Mendekatkan Layanan Rawat Jalan Kepada Pasien Kanker Stadium Lanjut.

The Ministry of Health recognises the need of a public financial insurance system specific for dementia and LTC services through the national dementia plan. Although this has not been implemented, financial aid for older people (regardless of a dementia diagnosis) in healthcare services cost has been regulated by Government Regulations (Pemerintah Pusat Republik Indonesia, 2004) and data shows that Puskesmas Santun Lansia provide lower cost geriatric services than those provided in standard Puskesmas (Indriati et al., 2013).

Furthermore, according to the 2019 older people services programme, several people in Indonesia were to benefit from social and financial protection schemes in 2019. These schemes were not specifically for people with dementia.

These include:

  • ASLU: to reach 30,000 people with the value of assistance is Rp 200,000 × 12 months per older person.
  • Home care: to reach 20,000 older people with assistance valued to IDR 2,000,000 per person.
  • Family support: to reach 7,000 people.
  • Social Assistance through Social Welfare Institutions Seniors/Asistensi Sosial Melalui Lembaga Kesejahteraan Lanjut Usia (LKS-LU), targeting 2,655 people.
  • Older people who received social services through Case Response Target in 2019: 8,390 people.
  • Other supporting activities including development of age-friendly neighbourhood and day care services.
  • Progres LU (Program Rehabilitasi Sosial Lanjut Usia) aimed to help older people to rehabilitate and develop their social functioning ability. Progres LU consists of:
    • non-cash assistance worth Rp. 200,000 per person per month,
    • social care within families/community halls, in the form of social assistance of Rp. 1,200,000 per person per year through LKS-LU,
    • support for relatives who are taking care of older people, in the form of non-cash social assistance of Rp. 3,000,000 per person per year,
    • therapy, in the form of social assistance Rp. 1,350,000 per person per year through LKS LU,
    • Social Professional Assistant for Seniors: for community social workers who coordinate and assist in older people social rehabilitation programs at all levels (national, provincial, district/city-level, rehabilitation centres). For paid Social Assistant for older people, the payment is Rp. 2,500,000 per person per month.
  • Other technical support related to main activities in the program.
  • Support for Accessibility for older people through Pemenuhan Hak Hidup Layak (Fulfillment of the Right to Decent Living), in the form of social assistance for older people in emergency situation with a value of Rp 750,000 per person, and Bimbingan dan Dukungan Aksesibilitas (Guidance and Accessibility Support), in the form of social assistance for older people experiencing barriers to mobility and accessibility with value in the amount of Rp. 750,000 per person (Badan Pusat Statistik, 2019b).
References:

Badan Pusat Statistik. (2019b). Statistik Penduduk Lanjut Usia di Indonesia 2019. xxvi + 258 halaman.

Indriati, S., Oktarina, D., Santoso, K., Sikoki, B. S., & Sine, J. J. (2013). Forum Nasional IV Jaringan Kebijakan Kesehatan Penilaian Kepatuhan terhadap Standar Kebijakan Nasional untuk Pelayanan Kesehatan Lansia di Yogyakarta: Pelayanan kesehatan vs lanjut usia.

Pemerintah Pusat Republik Indonesia. (2004). Undang-Undang No. 43 Tahun 2004. https://peraturan.bpk.go.id/Home/Details/66188

Community-based services, such as Pos Layanan Terpadu (Posyandu) Lansia (Integrated Service Post for Older People) are available not only in capital and main cities but also in rural areas. However, there’s still unequal distribution. For example, there are 52.450 Posyandu Lansia in East Java province, while 10 provinces in Indonesia (Aceh, Bengkulu, Gorontalo, Riau Islands, Lampung, South Kalimantan, Southeast Sulawesi, West Nusa Tenggara, Papua, West Sulawesi, and West Sumatera) still had no Posyandu Lansia in 2015 (Ministry of Health Republic of Indonesia, 2017). This suggests that services generally are more readily available in urban areas.

Since the annual cognitive screening for older people in primary care has been regulated in the new Ministry of Health bill (Ministry of Health Regulation No. 4/2019 on Technical Standard to Fulfill Quality of Basic Service in Minimum Standard of Healthcare Service, 2019), it should be available in all Puskemas (government-owned primary care centres) across country. However, considering that there are remote areas which are difficult to access by the Puskesmas staff, we have to see if this regulation is widely implemented across the country. So far, we were unable to identify data to confirm that community-based services are available in all areas.

References:

Ministry of Health Regulation no. 4/2019 on Technical Standard to Fulfill Quality of Basic Service in Minimum Standard of Healthcare Service (Permenkes no. 4/2019 tentang Standar Teknis Pemenuhan Mutu Pelayanan Dasar pada Standar Pelayanan Minimal Bidang. (2019). (Testimony of Ministry of Health Republic of Indonesia).

Ministry of Health Republic of Indonesia. Profil Kesehatan Indonesia 2017. Jakarta: Ministry of Health Republic of Indonesia [Internet]; 2018. Available at: https://pusdatin.kemkes.go.id/resources/download/pusdatin/profil-kesehatan-indonesia/Profil-Kesehatan-Indonesia-tahun-2017.pdf

Services provided via the public sector have been covered above. We were unable to find relevant information for the private sector.

There is no specific data on people living with dementia who received these community-based care. However, we know that 27.84% of total older people in Indonesia received community-based care in Puskesmas in 2017 (Badan Pusat Statistik, 2017). In 2019, this figure grew up to 28.39% for men and 31.17% for women receiving community-based care from Puskesmas/Pustu. In addition, there were 3.19% of older men and 4.13% of older women who accessed UKBM (Upaya Kesehatan Berbasis Masyarakat), which covers Posyandu, Poskesdes, and POD/WOD. Posyandu, Poskesdes POD/WOD are services provided in villages or rural areas with the goal to support health services. Warung Obat Desa or Pos Obat Desa (WOD/POD) provides basic pharmacy services (Badan Pusat Statistik, 2019b).

References:

Badan Pusat Statistik. (2017). Statistik Penduduk Lanjut Usia 2017. xxvii + 258 halaman.

Badan Pusat Statistik. (2019b). Statistik Penduduk Lanjut Usia di Indonesia 2019. xxvi + 258 halaman.

There is not yet a regulation or mechanism from the government for this. We have learnt informally that ALZI is testing a new program called ‘Care Navigator’ which provides online support to family carers by referring them to relevant services, connecting them to experts who can help them address problems they are facing at home, such as behavioural and psychological symptoms of dementia (BPSD), combined with education sessions on dementia care skills.

PERDOSSI’s national clinical guideline takes into account the family members’ description of symptoms of the person suspected with dementia (PERDOSSI, 2015). The clinical guideline also considers family history of dementia in screening and diagnosing possible people with dementia. However, in the current national action plan for dementia, caregivers are not recognised at diagnosis stage (Ministry of Health Republic of Indonesia, 2015b). We could not identify any further information.

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

Some interventions were done in the context of research experiments. For instance, a senam poco poco (a type of dance) program was implemented among members of a community gymnasium to evaluate the dance program’s effectiveness in memory capacity (Nastiti et al., 2015). However, this program included only people aged 30 to 50 years old. Moreover, a study was conducted on the effects of poco-poco dance on the executive functions of type 2 Diabetes Mellitus patients with Mild Cognitive Impairment which showed that by doing biweekly poco-poco dance for 30 minutes is able to improve the executive functions (Theresa et al., 2019).

Group Cognitive Stimulation Therapy (CST), a form of nonpharmacological treatment which has been shown effective for dementia in different countries, has also been available in Indonesia, albeit in research settings. Most of this research took place in senior home settings (Sanchia & Halim, 2019; Triestuning & Sipollo, 2019; Yuliana, 2017), but it has also been studied in community-dwelling older people in Indonesia (Komalasari, 2014), and the adaptation of this intervention into the Indonesian context generally has shown promising results.

Music therapy has existed in research settings and as part of Alzheimer’s Indonesia service – although this is not a routine activity yet (Alzheimer’s Indonesia, 2019b). There seem to be considerable interest in this type of therapy. Research on music therapy in Indonesia has been conducted to examine the effect not only on cognitive function but also on the benefit for stress-coping mechanisms (Oktaviani, 2018), sleep problems (Mitayani, 2018), and loneliness in dementia (Arlis & Bate’e, 2019).

Other types of interventions could also be found in Indonesia, mostly in research settings. An experimental study using puzzle therapy was conducted among older people with dementia in one of the social service centres for older people in Yogyakarta Special Region, which showed that puzzle therapy was effective in improving the cognitive function of the elderly with dementia (Erwanto & Kurniasih, 2020). Other studies used traditional games as the intervention, such as halma (Andiny et al., 2016) or dakon (Yulianti, 2018).

Although some of the studies do not directly examine the effect on these interventions on behaviour, these interventions promote meaningful activities for the persons with dementia, which helps reducing BPSD. There is a potential for these interventions to exist outside research settings in Indonesia and future research delving into the feasibility is needed.

References:

Alzheimer’s Indonesia. (2019b). Tentang Alzheimer Indonesia.

Andiny, F., Haryanto, J., & Hadisuyatmana, S. (2016). Permainan halma mencegah progresiftas kerusakan kognitif pada lansia demensia. Jurnal Keperawatan, IX(2), 71–75.

Arlis, & Bate’e, W. V. (2019). Pengaruh Terapi Musik Tradisional Cina terhadap Kesepian pada Lansia di Panti Jompo Yayasan Guna Budi Bakti Kelurahan Martubung Kecamatan Medan Labuhan Kota Medan Tahun 2019. Jurnal Keperawatan Priority, 2(2), 1–14. https://media.neliti.com/media/publications/290559-pengaruh-terapi-musik-tradisional-cina-t-d87767cf.pdf

Erwanto, R., & Kurniasih, D. E. (2020). The effectiveness of puzzle therapy on cognitive functions among elderly with dementia at Balai Pelayanan Sosial Tresna Werdha ( BPSTW ) Yogyakarta , Indonesia. Bali Med J, 9(1), 86–90. https://doi.org/10.15562/bmj.v9i1.1628

Komalasari, R. (2014). Domain Fungsi Kognitif Setelah Terapi Stimulasi Kognitif. Jurnal Keperawatan Indonesia, 17(1), 11–17.

Mitayani, T. (2018). Penerapan Terapi Musik pada Asuhan Keperawatan Lansia dengan Gangguan Tidur di BPSTW Unit Budi Luhur Kasongan Bantul. http://eprints.poltekkesjogja.ac.id/1384/

Nastiti, D. A., Khamdiniyati, N., Latisi, M. P., Aprilia, L., & Nessya, I. A. (2015). Pengaruh Senam Poco-Poco Untuk Melawan Dimensia. Psikostudia, 4(1). http://e-journals.unmul.ac.id/index.php/PSIKO/article/view/2268

Oktaviani, P. (2018). Terapi Musik untuk Meningkatkan Kemampuan Coping Stress Pada Penderita Demensia. http://digilib.uinsby.ac.id/28776/1/Prilia Oktaviani_J91214121.pdf

Sanchia, N., & Halim, M. S. (2019). Terapi Stimulasi Kognitif untuk Lansia dengan Mild Cognitive Impairment: Studi Eksperimental di Panti Wreda. Neurona, 36(4), 258–264. http://www.neurona.web.id/paper-detail.do?id=1123

Theresa, R. M., Nasrun, M. W., Soejono, C. H., & Trihandini, I. (2019). The effects of poco-poco dance on the executive functions of type 2 diabetes mellitus patients with mild cognitive impairment achieved through improvements in neuronal functions and plasticity. International Journal of Pharmaceutical Research, 11(2), 595–601. https://doi.org/10.31838/ijpr/2019.11.02.097

Triestuning, E., & Sipollo, B. V. (2019). Cognitive Stimulation Therapy on Elderly with Dementia in Panti Werdha Pandaan, Pasuruan. International Conference of Kerta Cendekia Nursing Academy, 1, 139–144.

Yuliana, W. (2017). Pengaruh Stimulasi Otak terhadap Tingkat Kognitif Lansia di Panti Werdha Bhakti Luhur. Penelitian Kesehatan, 5(1), 1–5.

Yulianti. (2018). Dampak Program Elderly Day Care Service terhadap Kesejahteraan Lansia Studi kasus di Panti Sosial Tresna Werdha Budi Dharma Bekasi.

There are several social intervention initiatives for elderly people in general within their communities; however, not specifically for dementia or coordinated at central level. For instance, an initiative for prevention of dementia called “Omah Cegah Demensia” or “Grandma Preventing Dementia” was established in the village of Dusun Gulon Desa Pengkol Kecamatan Lendah, Kabupaten Kulon Progo. In addition, a service called “ojek lansia” was established in the village of Desa Penagan, Kabupaten Bangka. Ojek is typically a motorcycle-taxi service. Ojek lansia is specialised for elderly people to commute between their house, and the posyandu had successfully increased posyandu visits from 65% to 84% from 2017 to 2018 (Kencana, 2019).

References:

Kencana, M. R. B. (2019). Ojek Lansia, Inovasi Antar Jemput Orang Tua ke Posyandu.

Regional and city-level differences can be seen in the amount of posyandu lansia available. The facilities are concentrated in Java provinces, with more than 30,000 alone only in Jawa Tengah and Jawa Timur out of the total 72,510 posyandu lansia. Papua Barat and Sulawesi Barat each only have fewer than 200 facilities (Kementerian Kesehatan Republik Indonesia, 2019a).

References:

Kementerian Kesehatan Republik Indonesia. (2019a). Data Dasar Puskesmas.

PUSAKA (Pusat Santunan dalam Keluarga, or “home-based care centre”) programs have been available since 2002 (Do-Le & Raharjo, 2002). PUSAKA is a community-based scheme that provides assistance and services for disadvantaged and/or poor older people within a neighbourhood. Each PUSAKA served approximately 45-60 older people. Services include home visits for older people who are too frail to visit PUSAKA centres, provision of meals, distribution of medicine and vitamins, and improvements in residences of older people including the provision of clean water, ventilation, and repair works. Most recently in 2020, there is a forum for PUSAKA staff in Jakarta for 2020-2025, indicating the program’s ongoing operation (Media Purna Polri, 2020).

In addition, unrelated to PUSAKA, The Ministry of Social Affairs’ programmes provide home care services for neglected and/or poor older people. As of 2014 there were 1,100 older people in 18 locations across Indonesia benefitting from the home care services (Media Purna Polri, 2020). (Please note that there is no information regarding the locations where this service is provided). Home improvement projects were done for 514 older people in 2013 and 644 people in 2014.

On the other hand, private home care services have grown immensely over the past few years to accommodate the increasing demand of the public. One of the private home care providers is Rukun Senior Living which has been providing an array of services for older people since 2011, including home care. RUKUN Home Care provided services such as daily living assistance, wound management, medical management, and so on, to improve the health condition and maximise the quality of life and wellness of the elderly. As of now, the services are available in certain areas of Jakarta, Bogor, Depok, Tangerang and Bekasi (Alzheimer’s Indonesia, 2019a).

References:

Alzheimer’s Indonesia. (2019a). 10 Gejala Awal Demensia Alzheimer. https://alzi.or.id/10-gejala-awal-demensia-alzheimer/

Do-Le, K. D., & Raharjo, Y. (2002). Community-Based Support for the Elderly in Indonesia: The Case of PUSAKA. “Southeast Asia’s Population In A Changing Asian Context,” June, 10–14.

Media Purna Polri. (2020). Kukuhkan Kepengurusan FK-Pusaka 2020-20215, Kadis Sosial DKI: Siapkan Program Bermanfaat Bagi Lansia.

The criteria to be eligible for PUSAKA support are:

  • Aged 60 and over,
  • Widowed and from a poor family,
  • Holding a residence card (KTP/national ID) and a letter of recommendation from the Head of Neighbourhood Association (RT/RW) and the Head of the Village (Lurah),
  • Living within walking distance from the caregiver’s home.

However, in practice the programme was also open to the elderly who do not fulfil all the criteria (Do-Le & Raharjo, 2002).

References:

Do-Le, K. D., & Raharjo, Y. (2002). Community-Based Support for the Elderly in Indonesia: The Case of PUSAKA. “Southeast Asia’s Population In A Changing Asian Context,” June, 10–14.

There is a national NGO dementia association, Alzheimer’s Indonesia, which is also a member of ADI. It was first founded as Asosiasi Alzheimer Indonesia in 2000, and in 2013 it evolved into the Alzheimer’s Indonesia Foundation. It has been recognised as an ADI member since 2009 (Alzheimer’s Indonesia, 2019b).

References:

Alzheimer’s Indonesia. (2019b). Tentang Alzheimer Indonesia.

Alzheimer’s Indonesia national office is located in Jakarta. It currently has regional chapters in 18 cities/towns in Indonesia and 3 in other countries (Groningen, Netherlands; San Francisco, USA; Geneva, Switzerland) to serve the Indonesian diaspora there (Alzheimer’s Indonesia, 2019b).

References:

Alzheimer’s Indonesia. (2019b). Tentang Alzheimer Indonesia.

The association provides:

  • Caregivers meetings (monthly in Jakarta, less often in the regional chapters),
  • Education sessions,
  • Workshops on Dementia Care Skills.

The government does not fund any of ALZI activities. However, according to ALZI internal reports, in some collaboration with government institutions, they provide in-kind support such as venue and meals.

The organisation has worked closely with the government on accelerating the launch of the National Dementia Policy in 2016. It has also been involved in the development of a national guideline on dementia diagnosis and management in the primary care which is currently being drafted by the Ministry of Health since 2016.

Plenty of dementia-related services are provided through Alzheimer’s Indonesia. For instance, caregivers’ meetings, knowledge upskilling on Alzheimer’s for the Purple Troop cadres, early detection and screening of dementia, and awareness-raising campaigns about dementia involving youth (Alzheimer’s Indonesia, n.d.). In general, the activities are categorised into four main groups: caregiver meetings, education and training, seminars, and World’s Alzheimer Month. Alzheimer’s Indonesia has eighteen chapters across major cities in Indonesia (Jakarta, Bali, Bandung, Bekasi, Bengkalis, Bogor, Depok, Jakarta, Kupang, Malang, Manado, Medan, Salatiga, Semarang, Solo, Surabaya, Tangsel, and Yogyakarta).

References:

Alzheimer’s Indonesia. (n.d.). Kegiatan.

There is no information on payment for accessing services for people with dementia or their carers. However, Alzheimer’s Indonesia sells various merchandise such as books and stationeries to raise funds for the operational costs of the provided services (https://store.alzi.or.id/product). We have learnt informally that ALZI is testing a new program called ‘care navigator’ which provides online support to family carers by connecting them to experts who can help them address problems they are facing at home, such as behavioural and psychological symptoms of dementia (BPSD), combined with education sessions on dementia care skills. One session costs about IDR 500,000 (approximately USD 30, rate as of July 2020), which is put towards the operational costs of the programme.

According to information posted on Alzheimer’s Indonesia’s website and social media, as of 2018 they have held 169 caregiver meetings and 225 events of awareness raising and risk reduction activities. This has reached 2,500 people with dementia and 5,000 carers across Indonesia over the whole year (Alzheimer’s Indonesia, 2019b). Although no specific information could be found about the characteristics of people with dementia and their caregivers who access the organisation’s services, in general, the organisation chapters are based in urban areas (Alzheimer’s Indonesia, 2019b).

References:

Alzheimer’s Indonesia. (2019b). Tentang Alzheimer Indonesia.

Across all provinces, there are 2,473 neurologists and 609 neurosurgeons (Badan PPSDM Kesehatan Kementerian Kesehatan Republik Indonesia, n.d.).

References:

Badan PPSDM Kesehatan Kementerian Kesehatan Republik Indonesia. (n.d.). Data SDM Kesehatan yang didayagunakan di Fasilitas Pelayanan Kesehatan (Fasyankes) di Indonesia. http://bppsdmk.kemkes.go.id/info_sdmk/info/

There are a total of 63 geriatric nurses across provinces (Badan PPSDM Kesehatan Kementerian Kesehatan Republik Indonesia, n.d.).

References:

Badan PPSDM Kesehatan Kementerian Kesehatan Republik Indonesia. (n.d.). Data SDM Kesehatan yang didayagunakan di Fasilitas Pelayanan Kesehatan (Fasyankes) di Indonesia. http://bppsdmk.kemkes.go.id/info_sdmk/info/

In 2016, DKI Jakarta Provincial Government (Pemprov) in collaboration with ALZI inaugurated the Purple Troops to realise a dementia-friendly and age friendly city of Jakarta. For the first phase, 200 members of the Purple Troop consisted of doctors, nurses, cadres from the DKI Health Service, Social Service, Supervision and Control (P3S) officers from the Jakarta Social Service, and ALZI volunteers. The creation of the Purple Troops (Pasukan Ungu) is hoped to help make Jakarta a dementia-friendly and age-friendly capital. According to the Assistant Secretary for the People’s Welfare Fatahillah, there were 481 doctors under the DKI Health Service attending a workshop on dementia screening in the Purple Troops training in 2016 (Jakarta Resmikan Pasukan Ungu Bantu Penderita Demensia, 2016).

The Purple Troops are trained to check signs of dementia, promote awareness, engage in preventive efforts and public education among the citizens of Jakarta citizens to educate about dementia-friendly environments. The DKI Jakarta Health Office has mobilized the Knock of the Door with Heart Service (KPLDH) consisting of teams of doctors, midwives, and nurses to deal with issues around dementia. KPLDH team together with community cadres such as PKK or Jumantik, go from house to house to collect information on people affected by dementia. Currently the team is focusing on slums, densely populated, flats, and lower middle-class areas. The KPLDH team received training from Indonesian Alzheimer’s Foundation on methods for screening dementia symptoms (Priherdityo, 2016). However, since the responsible Governor for this program lost his position, it is unclear if the program is still ongoing.

References:

Jakarta Resmikan Pasukan Ungu Bantu Penderita Demensia. (2016). BeritaSatu. https://www.beritasatu.com/kesehatan/387342/jakarta-resmikan-pasukan-ungu-bantu-penderita-demensia

Priherdityo, E. (2016). Perawat Demensia Rentan Jadi “Pasien Kedua.”

There is a Standar Kompetensi Lulusan (Competency Standard) for Course & Training of Health Care Workers based on the Indonesian Qualification Framework detailing the competency expected of care workers (Direktorat Jenderal Pendidikan Anak Usia Dini Non-Formal dan Informal Kementerian Pendidikan dan Kebudayaan Republik Indonesia, 2014).

Education and training programmes are often provided by the institutions. For example, some LTC service providers that collaborate with ALZI seek training for their future employers (Alzheimer’s Indonesia, 2019a). The Radjiman Wediodiningrat Lawang Psychiatric Hospital also provides caregivers training (Hukormas Rumah Sakit Jiwa Dr. Radjiman Wediodiningrat, 2017). There is no information on how training assessments are done.

Mutiara Kasih is an example of a training institution for care workers. They provide training and conduct assessments afterwards, in which the participants will receive a certificate from Lembaga Sertifikasi Kompetensi Pekarya Kesehatan (Health Workers Competency Certification Institute) (Mutiara Kasih, n.d.).

References:

Alzheimer’s Indonesia. (2019a). 10 Gejala Awal Demensia Alzheimer. https://alzi.or.id/10-gejala-awal-demensia-alzheimer/

Direktorat Jenderal Pendidikan Anak Usia Dini Non-Formal dan Informal Kementerian Pendidikan dan Kebudayaan Republik Indonesia. (2014). SKL Kursus dan Pelatihan Pekarja Kesehatan Jejang II Berbasis Kerangka Kualifikasi Nasional Indonesia.

Hukormas Rumah Sakit Jiwa Dr. Radjiman Wediodiningrat. (2017). RSJRW Segera Buka Layanan Baru “Elder Caregiver Training Center.”

Mutiara Kasih. (n.d.). Uji Kompetensi Pekarja Kesehatan. 2020.

Yayasan Emong Lansia (YEL), an NGO, has established a Jakarta-based training program at local and national level based on the needs of people involved in the care of older persons. The training program is called the Indonesia Training Center on Ageing (ITCOA, n.d.) . It is an initiative built together with the Indonesia Alzheimer Association and aims to improve knowledge, skills, and understanding of individuals and groups that work across all levels of care for older people in Indonesia.

References:

ITCOA. (n.d.). Indonesia Training Center on Aging (ITCOA).

The training efforts for the health workforce do not seem coordinated at national level. On the website of the Directorate General for Health Services, workshops and training on relevant skills for dementia care, such as screening and management of condition are mentioned. However, these training sessions are based on a single hospital and are initiated by specific doctors/hospitals or NGOs.

The numbers of “panti jompo” or “panti werdha” or homes for older people in Indonesia are minimal (Redaksi KOPI Pewarta Indonesia, 2019). There are only about 250 panti jompo (capacity 200,000 older people) and 20 panti werdha (capacity 2,000 older people) in the whole nation. The number is unlikely to increase significantly, as the Minister of Social Affairs had emphasised more on family-based caring model for older people instead of through the pantis (Tempo.co, 2016).

References:

Redaksi KOPI Pewarta Indonesia. (2019). Hasil Survey YPI, Jababeka Senior Living Merupakan Panti Werdha Terbaik di Indonesia.

Tempo.co. (2016). Menteri Sosial Imbau Lansia Tak Dirawat di Panti Jompo.

We are aware of examples of private day care provision; however, this may only be offered to small groups of the population. (RSJ Dr. Radjiman Wediodiningrat, 2016; RUKUN Senior Living, n.d.-a).

References:

RSJ Dr. Radjiman Wediodiningrat. (2016). Psikogeriatri – Klinik Daycare ADIYUSWA. http://rsjlawang.com/main/fasilitas/psikogeriatri

RUKUN Senior Living. (n.d.-a). Dementia Day Program. Retrieved September 7, 2019, from https://rukunseniorliving.com/dementia-day-program/

Some Posyandu Lansia offer social activities, however, these activities may depend on the availability of volunteers (Pratono & Maharani, 2018).

References:

Pratono, A. H., & Maharani, A. (2018). Long-Term Care in Indonesia: The Role of Integrated Service Post for Elderly. Journal of Aging and Health, 30(10), 1556–1573. https://doi.org/10.1177/0898264318794732

 

We are unable to find information also after checking privately owned long-term facilities such as Rukun Senior Living and Jababeka Senior Living (RUKUN Senior Living, n.d.-b).

References:

RUKUN Senior Living. (n.d.-b). RUKUN Senior Living.

There is no indication of hospitals allocating their beds specifically for dementia patients. For instance, even in Rumah Sakit Pusat Otak Nasional (National Brain Hospital), the way the beds are allocated are based on level of amenities and whether it is for emergency or normal wards (Rumah Sakit Pusat Otak Nasional Prof. Dr. dr. Mahar Mardjono Jakarta, n.d.).

References:

Rumah Sakit Pusat Otak Nasional Prof. Dr. dr. Mahar Mardjono Jakarta. (n.d.). Rumah Sakit Pusat Otak Nasional Prof. Dr. dr. Mahar Mardjono Jakarta. https://www.rspon.co.id/bed.php

There is no data about number of geriatric-specific beds from Indonesian Health Profile 2018, which details statistics of hospitals and their beds in the country (Kementerian Kesehatan Republik Indonesia, 2019b). Ministry of Health’s Rule No. 79/2014 specifies what a geriatric service in hospitals needs in terms of types of beds and other specifications, but there is no guideline on how many geriatric beds are needed or must be provided in the hospitals’ geriatric wards (Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 Tentang Pelayanan Geriatri Di RS), 2014; International Association for Hospice & Palliative Care, n.d.).

References:

International Association for Hospice & Palliative Care. (n.d.). Global Directory of Palliative Care Institutions and Organizations.

Kementerian Kesehatan Republik Indonesia. (2019b). Profil Kesehatan Indonesia 2018 [Indonesia Health Profile 2018]. http://www.depkes.go.id/resources/download/pusdatin/profil-kesehatan-indonesia/Data-dan-Informasi_Profil-Kesehatan-Indonesia-2018.pdf

Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 tentang Pelayanan Geriatri di RS), (2014) (testimony of Ministry of Health Republic of Indonesia).

 

We are unable to find information based on academic publications, as well as from several largest Indonesian hospitals’ annual reports and media releases.

The Global Directory of Palliative Care Services and Organizations lists 12 hospice organisations or associations in Indonesia (Abikusno, 2007). Some hospices are specialised for children and others for cancer. These are spread across Surabaya, Jakarta, Yogyakarta, Talangsari, Bali, and Makassar. In addition, there are about 250 panti jompos and 20 panti wredha nationally, as discussed above.

References:

Abikusno, N. (2007). Long term care support and services for older persons : Case study of Indonesia. ESID/SPAG/4. http://libprint.trisakti.ac.id/145/1/2007%287%29-Abikusno.pdf

There are dementia patients in mental hospitals in Indonesia (PERDOSSI, 2015), although mental hospitals are not explicitly stated to be in the care pathway for dementia in the national clinical guideline (Wijayanto, 2019). For instance, in 2018 an older person was not allowed to embark on a pilgrimage trip to Mecca because of their dementia symptoms and was referred to a mental hospital (BPJS Kesehatan, n.d.).

References:

BPJS Kesehatan. (n.d.). Panduan Praktis Pelayanan Alat Kesehatan. 2938.

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

Wijayanto. (2019). Mengidap Demensia Berat, JCH Asal Gagal Berangkat.

 

There is coverage for dementia medications according to the National Formulary 2015 (there are amendments in 2017, 2018 but not affecting Alzheimer’s drugs). Covering is only available for donepezil (classified as anticholinesterase). It can only be obtained at health facilities at level 3 (tertiary hospitals/type A hospitals according to BPJS) and can only be prescribed for mild to moderate Alzheimer’s. Coverage is 30 tablets per month for both film-coated tablets 5mg and for dispersible tablets 10mg.

According to the e-catalogue of the Government Procurement Policy Agency/Lembaga Kebijakan Pengadaan Barang/Jasa Pemerintah (LKPP), Donepezil is available in generic form (Lembaga Kebijakan Pengadaan Barang / Jasa Pemerintah, n.d.). The Ministry of Health stated that the prices of drugs available through the National Health Insurance system are made available in the e-catalogue website to eliminate bidding process (Kementerian Kesehatan Republik Indonesia, 2017).

References:

Kementerian Kesehatan Republik Indonesia. (2017). Upaya Kemenkes Antisipasi Ketimpangan Harga Obat. https://www.kemkes.go.id/article/view/17021300003/upaya-kemenkes-antisipasi-ketimpangan-harga-obat.html

Lembaga Kebijakan Pengadaan Barang / Jasa Pemerintah. (n.d.). Katalog Elektronik.

 

Under the national health insurance JKN scheme, assistive technology for elderly people such as spectacles, wheelchairs, false teeth, walking frames, neck brace, and hearing aids are available free of charge for those who need them. A cut-off value of each item and an annual limit of device purchase apply for each type of medical device or assistive technology. For instance, for hearing aid, JKN will cover only up until IDR 5 million and can only be given once every five years per claimant (Sanchia & Halim, 2019).

References:

Sanchia, N., & Halim, M. S. (2019). Terapi Stimulasi Kognitif untuk Lansia dengan Mild Cognitive Impairment: Studi Eksperimental di Panti Wreda. Neurona, 36(4), 258–264. http://www.neurona.web.id/paper-detail.do?id=1123

So far, Cognitive Stimulation Therapy has been implemented in Indonesia only in research/academic settings. The 2019 study that was conducted in nursing homes shows a significant difference in the cognitive function within attention domain and memory domain measured after participation in the CST intervention (Triestuning & Sipollo, 2019).  Another study published in 2019 also finds significant differences in cognitive functions between the CST group compared to the control group (Komalasari, 2014). However, a pre-post study published in 2014 with a small sample showed no significant impact of CST in improving cognition (Jakarta Smart City, 2015).

References:

Jakarta Smart City. (2015). Laporkan Kinerja Pemerintah Melalui Qlue.

Komalasari, R. (2014). Domain Fungsi Kognitif Setelah Terapi Stimulasi Kognitif. Jurnal Keperawatan Indonesia, 17(1), 11–17.

Triestuning, E., & Sipollo, B. V. (2019). Cognitive Stimulation Therapy on Elderly with Dementia in Panti Werdha Pandaan, Pasuruan. International Conference of Kerta Cendekia Nursing Academy, 1, 139–144.

In 2016, the DKI Jakarta Provincial Government has launched the “Missing Older People” feature in the Qlue online application (Jakarta Resmikan Pasukan Ungu Bantu Penderita Demensia, 2016). The application can be accessed via smart phones by the public to facilitate and accelerate the handling of lost older people in the DKI Jakarta area. Through these features, the community can play an active role in reporting when they find older people who got lost. The report is then forwarded to the “lurah” through the Qlue application and can be followed up by the closest Purple Troops members (BPOM RI, n.d.; Shopee, n.d.).

References:

BPOM RI. (n.d.). Statistik Produk yang Mendapatkan Persetujuan Izin Edar.

Jakarta Resmikan Pasukan Ungu Bantu Penderita Demensia. (2016). BeritaSatu. https://www.beritasatu.com/kesehatan/387342/jakarta-resmikan-pasukan-ungu-bantu-penderita-demensia

Shopee. (n.d.). Hasil Pencarian Untuk “Pegagan”.

Only donepezil is approved on the national formulary for dementia and Alzheimer’s. For donepezil film-coated tablet 5mg, the price varies according to province with higher prices seen in eastern regions of Indonesia, but the price range is around Rp. 1,700 to Rp. 2,200. There are other products registered at BPOM (Badan Pengawas Obat dan Makanan) as traditional supplements without specific dementia indication but can be found on locally popular e-commerce websites advertised as dementia medication at a much higher price. For example, Kapsul Esktrak Pegagan priced at Rp 250,000, citicoline 500mg (Rp 165,000), and Lycozein Softgel (Rp 450,000) (Wu, 2014).

References:

Wu, T. (2014). The Asian Family, the State and Care for Urban Older Adults: A Comparison of Singapore, China, and Indonesia. July.

There is no clear information for dementia-specific care, however, older people have been estimated to receive 4.56 hours of unpaid care per day from their primary caregiver. Primary caregivers are typically the spouse or the biological child of the older person. Older people living in bigger households receive more care time and assistance (Hidayati, 2014).

References:

Hidayati, N. (2014). Perlindungan terhadap Pembantu Rumah Tangga (PRT) Menurut Permenaker No. 2 Tahun 2015. Ragam Jurnal Pengembangan Humaniora, 14(3), 213–217. https://jurnal.polines.ac.id/index.php/ragam/article/view/512

There is no specific information related to employment condition and safeguarding concerns of informal workers for dementia-specific care in Indonesia. However, there are several protective measures for informal care workers in Indonesia, especially for domestic helpers. By rule of Ministry of Labour No. 2/2015, referring to International Labour Organisation Convention No.189, domestic workers are stated to have the rights for a safe working condition (Wu, 2014). The rule details sanctions against agencies that provide domestic worker services and exploited this relationship. However, domestic workers are considered by law as “entrepreneur” and, thus, they are not given the same protection that other types of lower-paid employments receive (e.g., factory workers). There is no regulation on rights related to minimum wage, working hours and rest times, leave allowances, communication rights, and written employment contracts.

References:

Wu, T. (2014). The Asian Family, the State and Care for Urban Older Adults: A Comparison of Singapore, China, and Indonesia. July.

In Indonesia, the main primary caregivers for older women are their biological children, while for Indonesian older men, their primary carers are their wives (Magnani & Rammohan, 2006). Data from Indonesian Family Life Survey 2000 shows that unpaid Indonesian caregivers are predominantly women (54.3%), Moslem (88.5%) – of these, 49.6% are married and 41.4% are educated until senior high school or college level (Hoang et al., 2012). Alzheimer’s Indonesia survey found that 74% of family caregiver are the children of the person with dementia, while spouse makes up 10% (Turana et al., n.d.).

References:

Hoang, L. A., Yeoh, B. S., & Wattie, A. marie. (2012). Transnational labour migration and the politics of care in the Southeast Asian family. Geoforum https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437558/

Magnani, E., & Rammohan, A. (2006). The effect of elderly care and female labour supply in Indonesia. May, 1–33.

Turana, Y., Sani, T. P., & Konny, L. (n.d.). Economic Costs of Dementia in Indonesia.

Middle Eastern countries and Malaysia are major destinations for Indonesian migrants although Hong Kong, Singapore, and Taiwan are becoming increasingly important. The Middle East-bound flow is dominated by female domestic workers migrating on short-term fixed contracts leaving families behind (Tatisina & Sari, 2017). In 2004, women accounted for 94% of registered Indonesian workers in Saudi Arabia. In 2005, more than a million Indonesian female migrants were employed as domestic workers in the Middle East and Asia. There is indication of a “care drain” when women in families are leaving the households to take up caregiving or domestic helper roles in other families.

References:

Tatisina, C. M., & Sari, M. (2017). The Correlation Between Family Burden And Giving Care for Dementia Elderly at Leihitu Sub-District, Central Maluku, Indonesia. 2(3), 41–46.

In a 2017 study conducted in Maluku, 74.5% of all family caregivers of people with dementia were women, 49% had high school as the last education attainment, 50.6% with monthly income of more than Rp1,2 million, and all were Muslim. The most common occupation was farmer (43,7%) (International Labour Organization (ILO), n.d.-b). According to ILO, the majority of Indonesian domestic workers work for 6 or 7 days in a week. 71% of adult domestic helpers and 61% of young domestic helpers (aged 10-17 years old) work this number of days. There are more female domestic helpers than men. In 2008, there were 320 female domestic workers for every 100 males. In 2015, there were 292 women to 100 men (International Labour Organization (ILO), n.d.-b). We are unable to provide further information regarding the socio-economic status of domestic or other informal care workers.

References:

International Labour Organization (ILO). (n.d.-b). Pekerja Rumah Tangga Di Indonesia.

According to ILO, 46% of the adult domestic workers and 29% of the young domestic helpers (aged 10-17 years old) earn IDR 1 million per month (Badan Pusat Statistik, 2019b).

References:

Badan Pusat Statistik. (2019b). Statistik Penduduk Lanjut Usia di Indonesia 2019. xxvi + 258 halaman.

Progres LU provides family members who care for older people with non-cash assistance worth Rp. 3,000,000 per person per year (Lukihardianti & Amanda, 2019). We could not find a clear breakdown on what non-cash assistance entails. Since 2018, low-income families that are enrolled in Program Keluarga Harapan (Family Hope Program) receive additional assistance if they take care of older family members in their homes (TNP2K, 2018b).

References:

Lukihardianti, A., & Amanda, G. (2019). Kemensos akan Beri Tambahan Dana untuk PKH yang Punya Lansia.

TNP2K. (2018b). The future of the social protection system in indonesia: social protection for all (pp. 1–15). http://tnp2k.go.id/download/24864181129 SP Exe Summary ENG-web.pdf

The Keluarga Harapan Program (PKH) is a conditional cash transfer programme which is put in place for the very poor families. The programme was not specifically for unpaid caregivers of people with dementia as it focuses on reducing inter-generational poverty in the long-term by investing in children’s health and education, with a “top-up” feature if the family has an older member living with them. The program was also designed to absorb the scheme for older people (Asistensi Sosial Lanjut Usia/ASLUT) in 2017 (Kartika et al., 2019).

References:

Kartika, A. W., Choiriyah, M., Kristianingrum, N. D., Noviyanti, L. W., & Fatma, E. P. L. (2019). Pelatihan Tugas Perawatan Kesehatan Keluarga Caregiver Lansia dalam Pogram RURAL (Rumah Ramah Lansia). Jurnal Pengabdian Kepada Masyarakat (Indonesian Journal of Community Engagement), 5(3), 448. https://doi.org/10.22146/jpkm.45139

In 2019, the Ministry of Health released a practical guideline for caregivers in taking care of the elderly, consisting of information on long-term care for the elderly, categorisation of elderly based on their level of dependence, general caring tips such as skincare, bathing, communication, praying, and recreation for the elderly in care (Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat, 2018). Also in 2019, a study in Malang, East Java, provided training for family caregivers to ensure that home environment is optimal for the elderly’s well-being. The study finds that providing training for carers of home-bound elderly with chronic pain is effective to enhance the ability of caregivers in improving the health status of the elderly (Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 Tentang Pelayanan Geriatri Di RS), 2014).

References:

Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat. (2018). Pedoman untuk Puskesmas dalam Perawatan Jangka Panjang bagi Lanjut Usia. Kementerian Kesehatan RI.

Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 tentang Pelayanan Geriatri di RS). (2014). (Testimony of Ministry of Health Republic of Indonesia).

There is no systematic psychosocial support from the government for unpaid or family caregivers in Indonesia. However, it is worth noting that there is a non-governmental organisation working to support dementia caregivers in Indonesia such as Alzheimer Indonesia and Perkumpulan Asuhan Demensia Indonesia (PADI), which conducts events such as talks and seminars focusing on educating and improving capabilities of caregivers of people with dementia (Alzheimer’s Indonesia, 2019b; Perkumpulan Asuhan Demensia Indonesia, n.d.).

References:

Alzheimer’s Indonesia. (2019b). Tentang Alzheimer Indonesia.

Perkumpulan Asuhan Demensia Indonesia. (n.d.). Facebook Page: Perkumpulan Asuhan Demensia Indonesia. Retrieved December 6, 2020, from https://www.facebook.com/916681961846086/posts/perkumpulan-asuhan-demensia-indonesia-padi-or-indonesian-society-of-dementia-car/1054667844714163/

 

Respite care is defined in the Regulation of Ministry of Health of the Republic of Indonesia No. 79/2014 (Ministry of Health Republic of Indonesia, n.d.). It is described to be within hospital or health facility settings, containing rooms dedicated for individual geriatric patients to stay, with communal areas like libraries, socialising areas, gardens, and reception rooms for families. In practice, there are various publicly and privately-owned day-care centres for older people (not specific to those with dementia). Rehabilitasi Sosial Lanjut Usia (RSLU) are government-owned social rehabilitation centres for older people. One of the services offered is day care. There are pre-set eligibility criteria for the day-care assistance recipients, regulations for day care workers, and indicators to measure the success of day-care centres (Kristanti et al., 2018a).

References:

Kristanti, M. S., Engels, Y., Effendy, C., Astuti, Utarini, A., & Vernooij-Dassen, M. (2018a). Comparison of the lived experiences of family caregivers of patients with dementia and of patients with cancer in Indonesia. International Psychogeriatrics, 30(6), 903–914. https://doi.org/10.1017/S1041610217001508

Ministry of Health Republic of Indonesia. (n.d.). Day Care (Pelayanan Harian Lanjut Usia).

No information on legal rights of family providing unpaid care for older persons was found.

Indonesia’s culture is characterized by strong family bonds and familial piety and, thus, caregiving for people with dementia is perceived as obligatory for family members (Hunger et al., 2019). In addition, the lack of available long-term care services leaves some families no other option but to take up the caregiving responsibilities. Kristanti and colleagues (2019) qualitatively compared the experience of family members caring for relatives with dementia and cancer in Yogyakarta. The main differences identified was that carers of people with dementia missed the loss of their previous relationship with the person they cared for and experienced difficulties in communicating with their relatives. In addition, carers of people with dementia blamed themselves as they believed they contributed to their relatives’ illness. They also found that in Indonesia, family carers invoke words such as “obligation” and “calling” to express reasons to be a caregiver for people with dementia (Kristanti et al., 2019).

Religion also plays a role in shaping the notion of obligation to give care, as some carers believe that good deeds on earth will be rewarded in the afterlife. For adult children, caring for their ailing parents is also a form of showing gratitude or reciprocity (Tatisina & Sari, 2017). Gender plays a significant role in caring for older people and people with dementia, with more women than men taking the role of carers (Tatisina & Sari, 2017).

References:

Hunger, C., Kuru, S. S., & Kristanti, S. (2019). Psychosocial burden, approach versus avoidance coping, social support and quality of life (QOL) in caregivers of persons with dementia in Java, Indonesia: A cross-sectional study. https://doi.org/10.21203/rs.2.16801/v1

Kristanti, M. S., Effendy, C., Utarini, A., Vernooij-Dassen, M., & Engels, Y. (2019). The experience of family caregivers of patients with cancer in an Asian country: A grounded theory approach. Palliative Medicine, 33(6), 676–684. https://doi.org/10.1177/0269216319833260

Tatisina, C. M., & Sari, M. (2017). The Correlation Between Family Burden And Giving Care for Dementia Elderly at Leihitu Sub-District , Central Maluku , Indonesia. 2(3), 41–46.

Tatisina and Sari (2017) report that where family members cannot adapt to the caregiver role, they experience stress, which can be expressed through fatigue that does not go away despite resting, alcohol or drug use, social isolation, lack of attention  of  carers’ own needs, inability and unwillingness to accept help from other people, feeling unappreciated, anger, depression, anxiety, and feeling guilty because he/she did not live up to their own expectations of the carer role (Yuniati, 2017). The complaints which were expressed by families included feeling tired, experience back pain, pain in the limbs, sleep disruption, headache, muscle strain, and dizzyness. The families also reported feelings of anger, impatience, stress, sadness, worry, and guilt because sometimes they mistreated the older person with dementia.

References:

Tatisina, C. M., & Sari, M. (2017). The Correlation Between Family Burden And Giving Care for Dementia Elderly at Leihitu Sub-District , Central Maluku , Indonesia. 2(3), 41–46.

Yuniati, F. (2017). Pengalaman Caregiver dalam Merawat Lanjut Usia dengan Penurunan Daya Ingat. Jurnal Bahana Kesehatan Masarakat, 1(1), 27–42.

There is information about the physical and mental health impact that caregivers experience due to caring for people with dementia, but very little about the impact of caring on the caregivers’ other life aspects. Yuniati (2017) finds that caregivers of older people with declining cognitive function had to change and adjust their working hours or work-related travels and to reduce social activities (Hammad et al., 2019).

References:

Hammad, R., Kurniasih, J., Hasan, N. F., Dengen, C. N., & Kusrini, K. (2019). Prototipe Machine Learning Untuk Prognosis Penyakit Demensia (The Prototype of Machine Learning for The Prognosis of Dementia). JURNAL IPTEKKOM : Jurnal Ilmu Pengetahuan & Teknologi Informasi, 21(1), 17. https://doi.org/10.33164/iptekkom.21.1.2019.17-29

Yuniati, F. (2017). Pengalaman Caregiver dalam Merawat Lanjut Usia dengan Penurunan Daya Ingat. Jurnal Bahana Kesehatan Masarakat, 1(1), 27–42.

We are unable to find information about impact of social protection on the caregivers that have been caring for people with dementia.

We are unable to find information for employment policies for unpaid/family carers from sources.

Currently, the government’s support through social assistance programmes is the most common type of services available for family/unpaid carers. However, NGOs also play a role in providing support for family/unpaid carers, for instance, Alzheimer’s Indonesia and PADI (Alzheimer’s Indonesia, 2019b; Perkumpulan Asuhan Demensia Indonesia, n.d.).

References:

Alzheimer’s Indonesia. (2019b). Tentang Alzheimer Indonesia.

Perkumpulan Asuhan Demensia Indonesia. (n.d.). Facebook Page: Perkumpulan Asuhan Demensia Indonesia. Retrieved December 6, 2020, from https://www.facebook.com/916681961846086/posts/perkumpulan-asuhan-demensia-indonesia-padi-or-indonesian-society-of-dementia-car/1054667844714163/

Technologies, such as the mobile application Qlue in Jakarta may play a role in supporting people with dementia and their carers, but there is no evidence regarding its success so far. A 2019 study authored by Yogyakarta students and published by the Ministry of Communication and Information focused on prototype machine learning with forward-chaining method to support the diagnosis of dementia (Badan Litbangkes Kementerian Kesehatan Republik Indonesia, n.d.; Kementerian Riset dan Teknologi/Badan Riset dan Inovasi Nasional, n.d.; Lembaga Ilmu Pengetahuan Indonesia, n.d.).

References:

Badan Litbangkes Kementerian Kesehatan Republik Indonesia. (n.d.). Badan Litbangkes Kementerian Kesehatan Republik Indonesia.

Kementerian Riset dan Teknologi/Badan Riset dan Inovasi Nasional. (n.d.). Kementerian Riset dan Teknologi / Badan Riset dan Inovasi Nasional. https://www.ristekbrin.go.id/

Lembaga Ilmu Pengetahuan Indonesia. (n.d.). Lembaga Ilmu Pengetahuan Indonesia.

The Rules of the Ministry of Social Affairs No 19/2012 on Guidelines for Social Services for Older People dictates the social programs in the country, but there is no specific commitment for people with dementia. Programs include provisions of basic needs, home care services for 20,000 older people in 2019, family support (caregivers’ benefits) for 7,000 families in 2019, formal caregivers assigned from the Ministry of Social Affairs, and social rehabilitations at local centres.

  • Progres LU (Program Rehabilitasi Sosial Lanjut Usia) aims to help older people to rehabilitate and develop their social functioning ability. Progres LU consists of:
    • non-cash assistance worth Rp. 200,000 per person per month,
    • social care within families/community halls, in the form of social assistance of Rp. 1,200,000 per person per year through LKS-LU,
    • support for relatives who are taking care of older people, in the form of non-cash social assistance of Rp. 3,000,000 per person per year.
    • therapy, in the form of social assistance Rp. 1,350,000 per person per year through LKS LU.

Social Professional Assistant for Seniors: for community social workers who coordinate and assist in older people social rehabilitation programs at all levels (national, provincial, district/city-level, rehabilitation centres). For paid Social Assistant for older people, the payment is Rp. 2,500,000 per person per month (Komalasari, 2014).

References:

Komalasari, R. (2014). Domain Fungsi Kognitif Setelah Terapi Stimulasi Kognitif. Jurnal Keperawatan Indonesia, 17(1), 11–17.

Ministry of Social Affairs Republic of Indonesia. (2012). Ministry of Social Affairs Regulation No.19/2012 on Guideline on Social Service for Older People (Permensos No. 19/2012 tentang Pedoman Pelayanan Sosial Lanjut Usia).

Yes, the National Strategy for Dementia, published in 2015 by the Department of Health includes 7 main planned actions, one of which is on dementia research implementation and the application of findings at national level (basic, clinical, epidemiological, and social research). The document names Badan Penelitian dan Pengembangan Kesehatan / Litbangkes (Institute for Research and Development in Health), Lembaga Ilmu Pengetahuan Indonesia / LIPI, Akademi Ilmu Pengetahuan Indonesia / AIPI, DIKTI (Ministry of Research, Technology and Higher Education of the Republic of Indonesia), and other research centres as responsible institutions for the research programs.

Research activities planned in the strategy document include:

  • Research on nutrition for older people with cognitive dysfunction, and people with dementia;
  • Evaluation on national level of the impact of physical activities on dementia and of dementia risk factors;
  • The inclusion of questions in national surveys, such as Riskerdas (Riset Kesehatan Dasar/Basic Health Research), to obtain prevalence data on dementia and other cognitive problems;
  • Analysis of the socioeconomic impact of Alzheimer’s and other dementia conditions.
References:

Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI. (2013). Riset Kesehatan Dasar 2013 (Vol. 6). (https://doi.org/1 Desember 2013) https://pusdatin.kemkes.go.id/resources/download/general/Hasil%20Riskesdas%202013.pdf

Indonesia, A. I. P. (n.d.). Akademi Ilmu Pengetahuan Indonesia.

Lembaga Ilmu Pengetahuan Indonesia. (n.d.). Lembaga Ilmu Pengetahuan Indonesia.

No, research on dementia or Alzheimer’s or cognitive dysfunction could be identified after going through the publication lists, digital archives, research repositories, and future research agendas of 4 research institutions (Litbangkes, LIPI, AIPI, and DIKTI) (Alzheimer’s Disease International, 2019). In Riskesdas from Litbangkes, there is a category for non-communicable diseases, but it still does not include information on dementia and other cognitive decline conditions. The National Report 2018 from Litbangkes has a chapter on mental health but no specific subsection on dementia. In 2013, DIKTI (Ministry of Research, Technology and Higher Education of the Republic of Indonesia) sponsored a trial on cognitive stimulation therapy in Indonesia through a scheme dedicated for early-career university lecturers (Komalasari, 2014; Nastiti et al., 2015; Triestuning & Sipollo, 2019).

References:

Alzheimer’s Disease International. (2019). World Alzheimer Report 2019: Attitudes to Dementia. Alzheimer’s Disease International.

Komalasari, R. (2014). Domain Fungsi Kognitif Setelah Terapi Stimulasi Kognitif. Jurnal Keperawatan Indonesia, 17(1), 11–17.

Nastiti, D. A., Khamdiniyati, N., Latisi, M. P., Aprilia, L., & Nessya, I. A. (2015). Pengaruh Senam Poco-Poco Untuk Melawan Dimensia. Psikostudia, 4(1). http://e-journals.unmul.ac.id/index.php/PSIKO/article/view/2268

Triestuning, E., & Sipollo, B. V. (2019). Cognitive Stimulation Therapy on Elderly with Dementia in Panti Werdha Pandaan, Pasuruan. International Conference of Kerta Cendekia Nursing Academy, 1, 139–144.

There has been no document regulating this. Involvement of people with dementia are mostly as research respondents. Indonesia-specific data on the stigma survey conducted by ADI for the World Alzheimer Report 2019 indicated that there is a higher proportion of healthcare practitioners (65.7%) and general public (44.1%) agreeing that people with dementia are perceived as dangerous. The general public’s perception that people living with dementia are impulsive and unpredictable is also widely spread (74.2% respondents from Indonesia, compared to 63.6% overall global). These might be some of the barriers preventing persons with dementia being involved in research development process (STRiDE, n.d.; Alzheimer’s Disease International, 2019). Based on research published so far on interventions for dementia (e.g., CST, dance therapy), the people with dementia were not involved in the development or design process, but as research participants (Astuti, 2019).

References:

Alzheimer’s Disease International. (2019). World Alzheimer Report 2019: Attitudes to Dementia. Alzheimer’s Disease International.

Astuti, R. D. (2019). Can Bali Become a Paradise For Ageing?

STRiDE. (n.d.). Strengthening responses to dementia in developing countries.

Some dementia research undertaken in Indonesia is funded from other countries:

– STRiDE-Dementia (funded by the UKRI GCRF) (Biro Kerjasama dan Komunikasi Publik Kemenristek/BRIN, 2019)

– Surveymeter’s research on cognitive impairment prevalence in Yogyakarta and Bali (funded by the Knowledge Sector Initiative) (Prakarsa, n.d.)

– Research on benefit of tempeh (fermented soybean) on cognitive function (Funded by Newton Fund) (Jauhary & Wardyah, 2019; Lembaga Penelitian dan Pengabdian Kepada Masyarakat, 2018).

There is also funding for research related to older people (not specifically dementia):

– Prakarsa, a Jakarta-based NGO think tank performs research, analysis and capacity building on a wide range of topics related to welfare issues including in older people and receive funding from various donors listed on their website (including Oxfam NOVIB, The Ford Foundation, The Asia Foundation, Australian National University, Hivos, University of Illinois at Chicago, Institute of Development Studies – University of Sussex, etc). However, there are no details on which donor provides funding for which programme (Jauhary & Wardyah, 2019; Lembaga Penelitian dan Pengabdian Kepada Masyarakat, 2018).

Many research projects run by academics in Indonesia are supported by internal funding of each of the universities (Jauhary & Wardyah, 2019; Lembaga Penelitian dan Pengabdian Kepada Masyarakat, 2018).

References:

Biro Kerjasama dan Komunikasi Publik Kemenristek/BRIN. (2019). Newton Prize 2019: Kolaborasi Peneliti Indonesia-Inggris untuk Mempersiapkan Komunitas Pesisir Menghadapi Dampak Perubahan Iklim, Menangkan Kategori Newton Country Prize 2019.

Jauhary, A., & Wardyah, N. S. (2019). Untuk penelitian dosen Unhas gelontorkan dana Rp70 miliar.

Lembaga Penelitian dan Pengabdian Kepada Masyarakat. (2018). Laporan Tahunan LPPM Unika Atma Jaya 2017.

Prakarsa. (n.d.). The Prakarsa – NGO Think Tank Based In Jakarta, Indonesia. http://theprakarsa.org/donor-mitra-kerja/

We are unable to find any scoping review after checking several Indonesian universities’ internal publications, DIKTI, Neurona, Indonesian Journal of Medicine, and Perpustakaan Nasional Republik Indonesia (The National Library of Indonesia via e-library access for citizens).