Since the commencement of the Millennium Development Goals in 2000, Indonesia has made great strides towards improving the health of its people, particularly in reducing cases of infectious diseases such as malaria. As we move into the era of the Sustainable Development Goals, Indonesia faces yet another challenge, with lifestyle changes in both urban and rural communities creating dramatic increases in the prevalence of chronic diseases. According to Indonesia’s Ministry of Health, a quarter of Indonesians are physically inactive, and a third of the adult population are active smokers, while less than 10% consume sufficient fruits and vegetables. It is unsurprising then, that the prevalence of chronic diseases such as hypertension and diabetes in Indonesia continues to increase. Indeed, data from the 2013 Riskesdas and Indonesia Family Life Survey, indicates that prevalence of diabetes in rural and urban area are 7% and 6.9% respectively while hypertension are 46% and 49% respectively. Despite being highly preventable, these chronic diseases are of huge concern to Indonesian society, not just because of this increasing prevalence, but because of their connection to other non-communicable diseases (NCDs), especially Chronic Kidney Disease (CKD).
In many low and middle income countries, especially in Asia Pacific, CKD is a major health problem. Predominantly affecting men, and with a higher prevalence in rural areas, the majority of affected individuals are also still in their most productive years. These findings are consistent with the Indonesian context, and effectively mean that the majority of suffers are those who can least afford a debilitating illness; the breadwinners of families from lower income rural areas. According to Indonesia’s Nephrology Association, 25 million Indonesians have developed CKD, with 200,000 suffering from end-stage renal disease. Of this figure, only small proportion have access to kidney replacement therapy, with the majority having to undergo high-cost haemodialysis.
Beyond the debilitating health impacts of CKD, poor management of the disease is creating a huge economic burden for the country. Delays in treatment or noncompliance in the treatment of diabetes, is a major risk factor for the development of renal failure. Unfortunately, many Indonesians, especially those in rural areas, have a poor understanding of the symptoms and risk factors for CKD, or lack access to high quality healthcare, which makes delays in treatment and noncompliance commonplace. As the result, it is a common pattern for patients arrive at healthcare facilities already in an emergency state, with no other treatment options except haemodialysis. This is creating a massive strain on the National health insurance budget and as a result, it is now the second largest claim covered by the Indonesia Health Insurance Agency (BPJS), having already costed the BPJS’s Rp 2.68 trillion or 7% of total spending. In order to reduce this burden, the health care system needs to strengthen preventive measures and improve the identification and management of CKD at the community level.
Fortunately, the government is already taking steps to strengthen the prevention of NCDs. The nationwide health campaign, Healthy Living Community Movement (GERMAS) provides information on the benefits of a healthy diet, regular exercise and regular medical check-ups to prevent NCDs. Within GERMAS, there are also two health-specific programs, the Healthy Indonesia Program with Family Approach (PIS PK) and Posbindu (Integrated Service Post for NCDs). While these are vital first steps to tackling NCDs at the community level, common issues such as lack of funding and consistent, high quality implementation across the country mean that these programs are yet to maximise their full potential for creating healthier communities.
These issues, such as lack of high quality health care services and inconsistent implementation of programs, are core barriers to reducing the burden of CKD, especially in rural areas where the need is greatest. While national policies dictate that government health care expenditure cover chronic disease management, including CKD, there are shortfalls in the implementation of high quality management. At the community level, there is a lack of overall awareness about the symptoms and risk factors for CKD, and prevention and screening programs are lagging. A key step to reducing the incidence and prevalence of CKD at the community level would be through strengthening the management of hypertension and diabetes in the Prolanis and Posbindu programs. Specifically, there is an urgent need to develop CKD detection and prevention programs in the primary health care setting, as despite being mandated by Health Minister regulation number 37, too many health care centers fail to meet the need due to procurement and human resourcing issues.
Further investigation is required to understand the unique etiologic factors of CKD in different geographic regions, so that prevention programs can be targeted appropriately. Activating Prolanis with already existing health workers might be done seamlessly by primary health care centers under strong district health office leadership. Strengthening Posbindu however, might need support from specific stakeholders such as the families of patients, the community, and organizations who have a strong understanding of the needs and attitudes of patients toward the disease. To drive effective and sustainable change in these programs, government authorities must engage with a range of stakeholders. Discussion with representatives from relevant health industries such as haemodialysis centers, medical device producers and insurance companies could create a dialogue for potential cost-cutting strategies to make renal replacement therapy more accessible to the general population, while collaboration with stakeholders who have a strong interest in the management of CKD and related diseases could strengthen prevention, management and treatment practices at the primary health care level. Indonesian think-tanks, academics or consultancy agencies with vast experience in the health system, especially in regards to program implementation and stakeholder management understanding at the local level would be well placed to act as implementation partners to ensure acceptable and sustainable solutions for both health care providers and the community.
A study by Gindo Tampubolon from University of Manchester on economic burden of non-communicable disease suggests that if the government does nothing until 2035, the total burden is estimated to reach US $ 5.4 trillion, approximately Rp 70,200 trillion. Conversely, if the prevalence of non-communicable diseases, such as heart disease, stroke, and diabetes could be reduced, this in turn would lower the economic burden to US $ 1.3 trillion, around Rp 16,900 trillion. Targeting CKD as a prioritized issue in tackling the NCD burden in Indonesia is a strategic step, not only because it addresses CKD case reduction itself, but also provides a holistic approach to simultaneously addressing a number of related chronic diseases, while relieving the massive economic burden and strain on the health system that is caused by these. Health information, education and communication alone however, are not enough to lead people towards healthier behaviour. Without strategic actions to prevent and reduce CKD in the population, the economic burden will be greater, not only from health costs, but also from loss of productivity due to premature death and hospitalization. If the economic burden can be reduced, Indonesia will be far more competitive than neighbouring countries, a mission that must be met within the scope of the ASEAN Economic Community that has come into force.
This articles has been published on The Jakarta Post, March 22, 2018
Fadjar Wibowo who graduated as Master in Global Health from Karolinska Institute’s is a medical doctor and Madelaine Randell is a public health advisor graduated from University of Sydney. Both work for the Center for Indonesia’s Strategic Development Initiatives (CISDI).