Mrs B and her family, current experience | Indonesia

Mrs B and her family, current experience | Indonesia

17 Oct 2022

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Mrs. B is in her 70s and lives in mid-size town. When her son got married, she moved in with her son and his wife. For the last few years, she helped the family by looking after the grandchildren and doing housework and cooking while her children were working in the business they own. About two years ago, Mrs. B’s family became worried about her behaviour and memory. Now Mrs. B mostly stays at home. She does not go out unless someone of the family accompanies her. Mrs. B also stopped cooking, which she always enjoyed. Her daughter-in-law reminds her to take medication she needs for other health issues and helps with dressing. Mrs. B does not like being left alone in the house. Mrs. B’s daughter-in-law is worried about her hygiene, but having to look after the business, taking over the cooking and shopping for the family as well as making sure that Mrs. B is safe and well during the day takes a lot of her energy and so she postpones thinking about this aspect. Once a week Mrs. B’s son takes his mother to [church].

In this case, Mrs. Bunga relocated from her old home to her son’s family home in a mid-size town (such as Salatiga or Malang).

In the JKN scheme, one has to go to a designated local Puskesmas/primary care clinic, which is based on the address in one’s National ID card. This means Mrs. Bunga’s family has to first apply to change Mrs. Bunga’s ID card or request a letter from local authorities stating her current domicile. This letter will then be used to apply to move her primary care clinic to one that is local to her son’s house. It will be approved as long as they have all the required documents, but the process might take some time (from 1 week – 1 month).

If they do not have all the required documents, the family might have to pay out-of pocket for Mrs. Bunga’s healthcare services. In this case, Mrs. Bunga’s family

When this has taken place, she can then be seen in the Puskesmas for a screening under the JKN scheme. The GP in Puskesmas will perform a screening, and if they find anything concerning, will provide a referral letter to take with them to the next healthcare facility (hospital).

Being in a mid-size town might give an advantage to Mrs. Bunga, as her family might be more aware about dementia through local Alzheimer association activities in that town or a neighbouring town or from the media. The healthcare practitioners there might have undergo training provided by the government or organisations about geriatric problems or even dementia. Moreover, the size of the healthcare workforce might be greater, and thus Mrs. Bunga can immediately be seen.

After being screened in the Puskesmas, if Mrs. Bunga is suspected to have cognitive impairment or other serious health conditions, she will be referred to a 2nd level referral hospital. If she has other serious conditions, such as a heart problem, she will be quickly referred. As the family might have heard about dementia or Alzheimer, they might bring this up when seeing the GP, and thus the GP will be aware of the possibility and put this in the referral letter.

As it is a mid-size town, it most likely has a 2nd level referral hospital. Transportation will have to be paid OOP, but since it is in the same town, the cost might not be too high.

In the hospital, Mrs. Bunga will be seen by a specialist. Depending on the GP’s referral, she might be referred to an internist/geriatrician/neurologist/psychiatrist. The specialist will order tests to exclude possible reversible causes of her cognitive decline. If there are no reversible causes, Mrs. Bunga will be referred to a neurologist/psychiatrist/geriatrician (if not yet) in the same or another 2nd level referral hospital – or if not available, referred to the 3rd level.

Neurologists, psychiatrists, and geriatricians will have been trained in dementia during their training, regardless of where their training took place in the country. Mrs. Bunga would undergo tests and if found to have dementia, they might prescribe her dementia medication. The medication have to be paid OOP if it is prescribed in the 2nd level of referral hospital.

If the family choose to get the medication under JKN coverage, they need to seek a referral to the 3rd level, which will be in the provincial capital (might take 1-2 hours trip covered OOP for the transportation cost). They need to come back every month to refill the prescription, which means spending more time and money on transportation.

If they choose to shoulder the OOP costs, it is more likely that Mrs. Bunga will get all the diagnostic and treatment at the 2nd level referral. This means less time travelling to get the prescription refill, but bigger cost on the medication.

If Mrs. Bunga’s family is from a middle-upper socioeconomic class, they might bypass the long referral process by bringing her directly to a neurologist/psychiatrist/geriatrician at a nearby 2nd level referral hospital and pay OOP. They would also probably hire a lived-in paid carer to assist with her daily activities. This is a quite common choice in the middle-upper socioeconomic class. This paid carer most likely has not had a formal training about dementia, but if they already have much experience working with older people, they are usually quite patient and resourceful.

In Indonesia, the caring role is usually taken by a female member among the person’s family or friends. Mrs. Bunga initially helped with caring for her grandchildren. When her condition deteriorates, her neighbour or her pengajian friends might come in to help assist with domestic tasks (caring for the grandchildren, cooking, etc). However, when she can no longer perform her daily activities independently, she will gradually need a 24/7 assistance. Most likely it would be her daughter-in-law who will take the role of the primary carer. This means she will gradually have to leave her role in their business, and it means the husband have to shoulder more responsibility at work. This might also threaten their business stability and thus their family’s financial stability, if they are not yet in a position to hire a staff.

The family might be able to seek post-diagnostic support/information from a local dementia association, or if there is none in their town, in the nearest town. With the current pandemic, it is more likely that they will seek information and support through online means.