The Intersectional Approach to Diabetes in Primary Care: Does It Exist? A Comparative Rapid Literature Review and Policy Analysis from Indonesia and India

Background

Diabetes mellitus (DM) type 2 is a type of noncommunicable diseases (NCDs) - hallmarked by high blood glucose level due to either the lack of the insulin hormone (type 1) or the body’s insensitivity to it (type 2) - that can have multiorgan impacts. It can lead to various complications, including disabilities and death, if it is not diagnosed timely and treated properly. DM is connected to many other noncommunicable and chronic diseases such as cardiovascular, neurological, and ophthalmic diseases (Hoogwerf et al., 2006). DM is also a complex disease contributed by multifactorial factors and determinants which include genetics, maternal, behavioural, environmental, and social aspects (Chan et al., 2009; Richards et al., 2022). Once seen as a disease of the rich, research has actually found that people living in poverty are more at risk for diabetes. Gender and biological sex also play their roles, with females more at risk especially amongst poorer communities (Hsu et al., 2012). Furthermore, household food insecurity plays a role in worsening the quality of diabetes management (Gaskin et al., 2014).

Low- and Middle-Income Countries (LMICs) around the world have been faced with increasing burden due to DM, in contrast to the decline observed in High Income Countries (HIC) (Liu et al., 2022). Asia particularly has been called “the diabetes epicenter of the world”. Indonesia and India are amongst the top 10 countries worldwide predicted to have the most number of people living with DM in 2030 (Chan et al., 2009). As LMICs who are climbing up the ladder of economic growth with a significant number of population, the burden of DM is indeed especially significant for India and Indonesia. In 2018, 10.9% of Indonesian adults suffered from diabetes - an increase from 6.9% in 2013 (Badan Penelitian dan Pengembangan Kesehatan RI, 2013, 2018). In India, the estimated prevalence for diabetes in 2020 was 11.4%, significantly higher than previous estimates (Anjana et al., 2023).

On the other hand, both countries still struggle with the provision of diabetes management. The costs of hospital-based care for diabetes care in Indonesia were significantly burdensome for the national health insurance scheme (Hidayat et al., 2022). Meanwhile, it was estimated in 2019 that almost 8 million Indonesians lived with undiagnosed diabetes (Harbuwono et al., 2021). In India, there is a continuous lack of access to quality care for diabetes and diabetes also remains undiagnosed for a significant portion of the population. Funding for diabetes and awareness of the diseases are also low in India (Das et al., 2022). The health priorities in Indonesia and India are indeed in transition. Both countries experience a double burden of disease - an epidemiological and demographic transition leads to the rise of burden from noncommunicable diseases, while communicable diseases (while decreasing) still represent significant burden.

Amongst Indonesians, older age (>55) is generally correlated with increased prevalence of DM especially for type 2 (Idris et al., 2018; Indrahadi et al., 2021). However, the prevalence of undiagnosed cases are estimated to be higher amongst the younger age groups (Tanoey & Becher, 2021). Data also shows that females are more at risk for developing DM than males, and that this pattern becomes more prominent with increased age (Idris et al., 2018; Mihardja et al., 2014; Tanoey & Becher, 2021). Some studies found that married Indonesians are more at risk for DM compared to unmarried or never married ones, although another concluded that marriage can be protective among urban dwellers (Dany et al., 2020; Idris et al., 2018; Indrahadi et al., 2021) - prompting an inquiry on what roles socially-imposed gender roles or other determinants might play in marriage institutions in different contexts in Indonesia.

Studies have found that Indonesians from a resource-deficit economic background (at times also measured using proxies like low education level or unemployment) were increasingly at higher risk for DM - a sign of epidemiological shift. Similar shift can also be observed regarding rural versus urban Indonesians, with rural being increasingly at risk (Dany et al., 2020; Idris et al., 2018; Indrahadi et al., 2021). Although detailed data is limited, it was estimated that there is a large in-country variation regarding prevalence of DM in Indonesia - something that might be connected to large variations observed for other related components of metabolic syndrome between regions and ethnicities (Ayuningtyas et al., 2022; Herningtyas & Ng, 2019; Soewondo et al., 2013). Furthermore, studies found that stigma related to DM amongst Indonesians is related to other identity markers such as age, other comorbidities, socioeconomic status, and gender; as well as with perceived individual behaviour and lifestyle choices (Rai, Irwanto, et al., 2020; Rai, Peters, et al., 2020). Policy responses to address commercial determinants of health in Indonesia also tend to be weak, as is shown in the case of the tobacco and palm oil industry (Kadandale et al., 2019; Kramer et al., 2023).

Meanwhile in India, the prevalence of DM also increases with age (Maiti et al., 2023; Mathur et al., 2022). However, Indian adolescents also face increasingly higher prevalence of pre-DM and DM, with adolescent boys having it higher than girls (Kumar et al., 2021). Overall prevalence of DM and its complications is indeed higher amongst males than females in India, but females with DM tend to face more challenges in achieving optimal control of their blood sugar level which is exacerbated with increased age. However, females in urban settings have higher prevalence of DM compared to their male counterparts (Pradeepa et al., 2023; Sujata & Thakur, 2021). Currently married Indians are also more at risk for DM compared to unmarried ones. In terms of religion, Indian Muslims are more at risk for DM compared to their Hindu counterparts - for the females, but not for the males - and the Sikhs have even less risk then the Hindus for both sexes (Sujata & Thakur, 2021).

While different studies have linked higher prevalence of DM with more affluent socioeconomic classes in Indian settings - such as higher prevalence in more economically developed states or amongst those who are from oppressor castes, more highly educated, or from wealthier households (Corsi & Subramanian, 2019; Krishnamoorthy et al., 2023) - more recent analysis shows the India has started to experience epidemiological shift as well. For example, prevalence amongst Indian urban poor is on the rise (Oruganti et al., 2019). The rise of DM prevalence over the years is faster amongst India’s socioeconomically disadvantaged groups such as the poorest weight quintiles and the uneducated (Wetzel et al., 2023). The rural-urban gap is also getting narrow (Ranasinghe et al., 2021). Regarding stigma, DM is still stigmatized within Indian society, for example stigma related to insulin injection equating it with drug addiction. Stigma towards DM is also often gendered, especially towards women, who for example can be seen as undesirable concerning marital prospect and also as an economic burden (Chittem et al., 2022; S. Sharma & Jayanta Mishra, 2021). Additionally, evidence-informed policy response towards commercial determinants of health in India still needs strengthening as in the case of the tobacco industry - although interestingly, in this case civil society plays an important role in both pushing for and technically supporting the creation of more effective policy (Kashiwabara et al., 2011; Rao Seshadri et al., 2021).

Indonesia and India, while each has their own unique context and challenges, indeed share similarities not only in the patterns of their health burdens related to DM but also in being vastly diverse nations. Both countries have vast numbers of ethnicities, languages, religions, and rich cultural heritage. Society in both countries also tends to be both communal and hierarchical, resulting in complex social structures. These mean there are a myriad of intersecting social determinants for DM in each country, interacting in intricate manners as illustrated briefly above. Therefore, having a comparative look on how each country deals with a disease as complex as DM can potentially bring opportunity for collective learning, reflections, and potential innovative solutions.

Review Objectives

We attempted to conduct a comparative rapid review and analysis of the approach used by Indonesia and India to address their DM-related health burdens - especially at primary healthcare level, including promotive and preventive efforts - using the lens of intersectionality. Specifically, our objectives are:

• To examine the extent to which national/union policies addressing primary, community, or first level of care for people living with diabetes/at risk of diabetes in India and Indonesia are (if at all) intersectional
• To identify existing evidence on the intersectionality of interventions at primary, community, or first level of care for people living with diabetes/at risk of diabetes in India and Indonesia; and the extent to which studies examining/looking for evidence regarding these interventions consider intersectionality
• To identify lessons learned and recommendations from comparing insights from the above mentioned objectives between India and Indonesia

Methodology

Intersectionality as Our Framework

Intersectionality has been defined as “the ways in which systems of inequality based on gender, race, ethnicity, sexual orientation, gender identity, disability, class and other forms of discrimination ‘intersect’ to create unique dynamics and effects”. In another word, it is a critical way to look at how different aspects of one’s identity intersect with each other in their life to create a unique situation for them - such as their social standing, power to advocate and negotiate for themselves, and/or access to resources and opportunity. A central concept of intersectionality is power dynamics, emphasizing that social identities are not neutral - they are conceptualized and operationalized through a system of power.

While intersectionality theory has been around for a long time across disciplines, it has only recently joined the chat on public health. The theory stands to contribute generously towards illuminating the understanding of human health by departing from the bio – medical model and individual level determinants to critically ascertaining the health effects ensuing from the intersection of hegemonic power dynamics such as systemic sexism and racism (Alvidrez et al., 2021). It can be argued that intersectionality fits the social determinant frameworks of public health, with an added value of offering critical power analysis into why health inequities happen. Public health’s commitment to social justice also makes it a natural fit with intersectionality’s focus on multiple historically oppressed populations (National Collaborating Centre for Determinants of Health, 2016).

Rapid Review of Policy Documents

We undertook a rapid review of national/union level policy documents addressing the burden of DM in Indonesia and India. Policy documents and policy-related grey literature in Indonesian and English were identified through Google search engine using search strategies and strings developed both decisively and based on the review objectives. We examined policy documents between the years 2014-2023, as in this period both countries have their current incumbent executive leaders and both will hold new elections by 2024. 

Relevant data has been extracted from the aforementioned repository of documents and qualitatively analyzed through Delve Tool by employing inductive and deductive coding. Finally, the report has been written by interpreting the relevant coded extracts through the lens of intersectionality, using both intersectional analysis of social determinants of health and intersectionality-based policy analysis (IBPA) (Humphries et al., 2023). 

Limitations

In the process of implementing an intersectionality-based policy analysis (IBPA) approach, even if the IBPA is deliberately adapted and rigorously applied while simultaneously new ways of thinking about a policy problem or issue is explored and examined, policy is inherently complex. Our choice of only examining policy documents cannot claim to be able to reveal this complexity, as we were not able to examine other elements of policy in-depth such as the actors, process, context, and power dynamics. This study also looked at policy at national/union level, hence we could not examine the policy at state, provincial, or any other regional levels.

Time constraint is also a limitation of this study. We were not able to conduct primary data collection, for example in the forms of key informant interviews, hence data triangulation is limited. We did, however, look at studies evaluating the policy in question to be able to take into account some nuances and context surrounding the policy and its development and implementation. A rapid review approach was also chosen due to time limitation, and our search might have missed some policy documents.

Finally, as feminist researchers we believe that there is no study that is perfectly unbiased regardless of the methodology. While there are systematic methods to try to minimize bias, the researcher’s own positionality and experience will always influence how they design the study and interpret the results. As nondiabetic persons with certain educational and socioeconomic advantages, we have attempted to be aware of our own power and positionality and how they might influence our work and views in this study. However, we cannot claim full understanding of the lived experience and aspirations of people who live with DM in Indonesia and India with all their diversity, and this study does not intend to provide such a claim.

Results

Framing DM in Policy: Personal vs Structural

Indonesian policy documents do recognize DM as an increasingly concerning public health problem. DM is acknowledged as one of the prioritized health issues to be addressed in the Medium Term National Development Plan 2020-2024, although its prevalence or incidence rate is not directly included as part of development indicators (however the prevalence of adult obesity is included). As a public health issue, the policy acknowledges that - if not managed properly through effective and efficient prevention, control, and management efforts - DM can lead to significant numbers of death and disability. These efforts are recognized to be a joined contribution of national government, local government, and the community. The need to have intersectoral work, for example in ensuring that Indonesian people can have healthy diets, is also recognized. Furthermore, the policy documents also recognize diabetes as a complex condition correlated with various risk factors - genetics, maternal, individual biology such as age and hormonal, behavioral, environmental, and the existence of other comorbidities.

That being said, most Indonesian policy documents that we analyzed characterize DM - and other health conditions related to DM and metabolic syndromes, such as obesity - as arising from the change of lifestyle towards unhealthy habits and behaviors. This emphasis on lifestyle changes also has more focus on individual poor lifestyle choices and unhealthy behaviors. While policy documents acknowledge structural factors such as poverty, unsupportive/unsafe environment for physical activities, and availability of fast food commerce as contributing to noncommunicable diseases, we found those much less often mentioned and less emphasized compared to individual behaviors, lifestyle, choices, and so-called ‘ignorance’.

Indian policy documents acknowledge the epidemiological change resulting in double burden of disease in the country as well as the alarming rise in mortality rates of individuals due to NCDs including DM. NCDs are viewed as a cluster of health concerns (as opposed to framing each NCD as a separate subject of concern) largely owing to behavioral factors like tobacco use, physical inactivity, unhealthy diet, harmful use of alcohol, but also environmental risk factors such as stress and household air pollution. Most of the policy texts put emphasis on individual behavior and lifestyle choices which are regarded as “risky behaviors” (particularly alcohol consumption and tobacco dependency). 

Yet, there are some cursory attempts to mention larger environmental factors such as globalization, urbanization, aging population, stress, and the need for improved safety at the workplace. The policy documents also acknowledge that vulnerable and socially disadvantaged populations face disproportionate risk and poor health outcomes for NCDs. However, it doesn’t explore how social determinants of health interplay in the process of marginalization. There are some general mentions on ‘health-in-all-policy’, primarily through the 2017 National Health Policy (NHP).

Policy Response

Scope of Response

The Indonesian policy documents define management of NCDs, including DM, as covering promotive, preventive, curative, and rehabilitative aspects. The aim of management of NCDs is stated as to protect the people and communities from NCDs, to increase quality of life, and to reduce the social, economic, and cultural impacts of NCDs on individuals, families, and communities. There are mentions of both individual and community-level health efforts. The policy documents also emphasize that prevention efforts shall focus on “early detection and control of modifiable risk factors for DM such as smoking, minimal physical activity, unhealthy diet, consumption of alcoholic beverages, and unhealthy environment”. 

It is interesting to see that compared to how the policy documents frame DM above, the way they frame policy response towards broader NCDs seem to be more holistic. For example, they mention broader efforts beyond individuals such as health-oriented development plans; how to address commercial determinants of health such as the food and tobacco industry; how to innovatively promote healthy lifestyle and make it a culture; widening access to nutritious and healthy food; community strengthening; and multisectoral collaboration. It seems like when it comes down to more specific regulations and guides around DM, especially at the level of service delivery, this broader framing on social determinants of health becomes more diluted.

The Indian policy documents covers management of NCDs through promotive, preventive, curative, rehabilitative, and also palliative care. Additionally, the policy documents have laid much emphasis on the importance of preventing and controlling NCDs mainly through health education to change individual behaviors and also by screening for NCDs. 

The Indian policy documents strive for the advancement of investments in healthcare, the organization of health services, disease prevention, and the promotion of well-being through cross-sectoral initiatives. This involves enhancing access to technologies, cultivating human resources, advocating for medical pluralism, fostering a knowledge base, formulating improved financial protection strategies, reinforcing regulation, and ensuring health assurance.

Dedicated Programs for DM and NCDs

Within the mechanism of the Indonesian national health insurance scheme (Jaminan Kesehatan Nasional or JKN), there is a dedicated program for chronic diseases in which diabetes is included. The program is called “Prolanis” (Program Pengendalian Penyakit Kronis or Chronic Disease Management Program). In this program, the primary health care facilities (Fasilitas Kesehatan Tingkat Pertama or FKTP) which are part of the JKN scheme - be it public or private FKTP - play significant roles in screening, early detection, long-term management of, and prevention of complications from diabetes with both pharmacological and non pharmacological approaches. Prolanis-related indicators, such as the ratio of Prolanis clients who routinely have control visits, is even linked to capitation-based payment for FKTP in the JKN scheme. It needs to be noted, however, that Prolanis only includes patients who are already diagnosed with diabetes and who are members of JKN.

In Prolanis, primary healthcare is essentially positioned as the main patient’s manager. Regular activities within Prolanis include medical consultations and health evaluations, laboratory check-ups, group-based education and physical activities catered to diabetes and other chronic diseases like hypertension, home visits, medication dispensing, referrals to higher-level care as needed, and visit reminders. An important element of Prolanis is the obligation for secondary/tertiary care facilities to refer the patient’s back to their primary care provider once they are clinically stable enough. This can help diabetic patients as they do not always have to go to hospitals to get regular care. All activities within Prolanis are covered by JKN.

The Indian National Diabetes Control Program was launched in 1987 and was the first pilot scheme that was developed and carried out by the Indian federal government to control and reduce the prevalence of diabetes. It was introduced in the districts of Kashmir, Tamil Nadu, and Karnataka, and was tasked with raising awareness of the disease through health education, identifying high-risk individuals, reducing mortality in high-risk individuals, and rehabilitating people that are disabled by diabetes. However, in spite of the merits of the program, it was not extended to other Indian states on account of lack of funding. 

It was not until 2008 that the federal government launched another program for the prevention of DM under Ministry of Health: the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS). The objectives of this broad program include the prevention and control of NCDs, health education, detection of people at risk, and monitoring of people with various conditions including DM. The program is still in operation in India and is the only one that has been implemented in all Indian states. NPCDCS aims to support the Indian health system with respect to health promotion, early diagnosis, management, and redressal of NCDs. However, in spite of the aspiration to achieve effective DM prevention in India, the federal programs have experienced a number of limitations - most prominently, financial resources.

Health Service Delivery

Primary healthcare providers, especially the public ones or Puskesmas (Pusat Kesehatan Masyarakat or Community Health Center), are given a certain emphasis in the policy documents for management of DM and other NCDs. Apart from their roles in the Prolanis program, Puskesmas is generally tasked with mainstreaming and supervising all community-level health efforts. Alongside the role of primary care, the role of general practitioners, nurses, nutritionists, and other cadres as primary care providers is also strongly emphasized. 

What is arguably missing, however, is the role that the private sector - especially FKTP within JKN and private entities working at the intersection of health, development, and social justice, and who come bottom-up from the community themselves - can play more holistically and how they should be regulated and supervised. It is clear that the private sector is already a significant primary care service provider in the JKN scheme. However, the heavy emphasis on Puskesmas on both individual and community health can, if not already, have consequences on the workload they have to bear. The public health sector in Indonesia - and in many other LMICs - often struggles with limited financial, human, and administrative resources. There is a potential for the private sector to be more involved with the right regulation mechanism.

India is currently trying to strengthen its public primary health care network through the AB-HWCs program, which per June 2023 comprises over 160,000 centers and has registered a footfall of over INR 1.8 billion. It is currently in the process of going through the biggest expansion of services. The mandate of AB-HWCs program comprises early detection of health disorders and identification of their risk factors; prompt initiation of effective care at home or near home; connecting with specialized care when required through telehealth or referrals to secondary or tertiary care facilities; and ensuring continuity of care. A wide range of promotive and preventive services - including health and nutrition literacy and tobacco and alcohol control - are listed as parts of AB-HWCs mandate. However, we could not identify any linkages between AB-HWC and the previously mentioned NPCDCS - possibly indicating duplication of efforts or a fragmented policy response.

It is important to note that these relatively recent efforts by the Indian government come in the context of a health system that is already predominated for a long time by the private sector - which has gained a considerable amount of power. Interestingly, Indian NHP 2017 itself looks at [health] problems and solutions holistically with the private sector as a “strategic partner”. Alongside the AB-HWCs program and still within the Ayushman Bharat Program as a whole, there is also the element of the Public-Funded Health Insurance (PHFI) scheme - which mainly covers inpatient services at secondary and tertiary levels. Critics towards PFHI have highlighted that it can potentially adversely influence the ongoing process of health system strengthening at all levels - primary, secondary, and tertiary. The PFHI scheme might have a much faster uptake as compared to AB-HWCs and eats away funding for AB-HWCs - resulting in the prioritization of secondary/tertiary levels and not primary care (Bajpai, 2018). 

Community Involvement

We found a consistent and significant number of emphasis on community involvement in the policy documents. This involvement ranges from activities that have long been part of Puskesmas’ activities in the Indonesian health system - such as community-based integrated service posts - to more NCD-specific activities. The importance of community involvement and support are often mentioned in policy texts about all aspects in the management of diabetes and other NCDs, including in clinical guidelines. We also found emphasis on community involvement in policy documents related to social determinants of health beyond the health sector such as those about developing healthy cities, regencies, and special areas.

Interestingly, we found that one policy document mentions the government's willingness - or at least intention - to “open itself and give more space for the community [...] and to directly understand the community's aspirations”, including by reducing “top-down and instructional approaches”. While these documents have certainly assigned many and various roles within diabetes and NCDs’ management efforts to the communities, what remains to be seen and critically examined - especially in policy implementation and practice - is whether this means merely shifting the roles and responsibilities from the state to the communities or an actual power and resource sharing between those two entities.

Community health workers (CHW) - or, in Indonesian term, kader - are given the forefront roles by the policy documents in addressing the burden of DM and other NCDs. Their assigned roles include both prevention and control efforts, especially through community health programs overseen by Puskesmas. These further include awareness raising, community education, acting as “agents of change”, and screening activities. There are government-published guidelines dedicated for kader around DM and its related conditions such as obesity and prediabetes, using common nontechnical languages. However, despite their wide responsibilities, in Indonesia the policy for kader’s wellbeing - especially regarding proper financial compensation - has been criticised as not clear or equitable enough (Koalisi Kesejahteraan Kader Kesehatan, 2023).

Another interesting element of community resource and involvement mentioned in the policy documents is the role of what is commonly phrased as ‘traditional medicine’. In this paper, we are referring to the same concept with an alternative, more decolonized phrasing of ‘indigenous medicine’. TOGA (Tanaman Obat Keluarga or Family’s Medicinal Herbs) is a concept used by the Indonesian government to encompass various home-grown herbs and plants that have been indigenously used by Indonesian communities as medicines, often for generations. The Buku Pintar Kader Posbindu (Smart Book for Posbindu’s Kader), for example, mentions various TOGA that can be used to “help manage DM and other NCDs” along with their recommended dosages and preparation instructions. However, the same information is not available in other policy documents - especially not in any guidelines meant for the formal health care service providers. 

This incorporation of TOGA can be a way to appreciate the indigenous health knowledge systems and to increase cultural acceptability of DM management strategy. Traditional indigenous medicine plays important roles in the lives of Indonesian people. In 2018, 31.4% of Indonesians had utilized traditional medicine in the last year with 79.8% of those utilization involved consumption of traditional concoctions (Kemenkes RI, 2019). For DM itself, there are various local or indigenous and empirically used plants and herbs in Indonesia that have been researched in order to identify possible antidiabetic mechanisms or any active ingredients with antidiabetic properties (for example see Fu’adah et al., 2022; Rehman et al., 2016; Setyani et al., 2023; Аrbаin et al., 2021). However, as far as we were able to search, none of these studied plants went into clinical trials for drug development yet. 

The discrepancies between the mentioning of TOGA in the guidelines for kader - who are tasked with community health efforts - and its nonexistence in guidelines for formal health care providers can potentially lead to further tension or distrust between patients and their families or communities - who may use TOGA as part of their indigenous health practices - and formal healthcare providers, who are mostly trained in and practice Western medicine. On one hand, community engagement to increase utilization of TOGA - including through the involvement of kader - seems to be increasingly promoted (Minanga & Kristamuliana, 2022; Rahman & Yudha, 2022; Uly et al., 2021). On the other hand, there is no information provided on how Western medications and TOGA can potentially have drug interactions and how to prevent them. This can raise safety concerns, at least from a pharmaceutical point of view. These discrepancies seem to show disjointed policy efforts between strengthening formal healthcare systems and promoting indigenous health practices in Indonesia.

Across the Indian policy documents, the role of the “community” is typically four-pronged, with the inclusion of the cadre of various types of community health care workers or frontline health workers (typically female), the network of women’s self help groups (SHGs), community based organizations (CBOs), and community platforms that are embedded in the bodies of local self government. The role of the “community” is generally viewed as supplementary to the work undertaken by the network of formal actors (public and private). The basket of work undertaken by the community typically centers around health promotion activities and early diagnosis and treatment of common NCDs. 

There are many categories of community health workers in India. There are the Accredited Social Health Activist (ASHA), Auxillary Nurse Midwife (ANM), Anganwadi Workers (AWW), and Multipurpose Health Workers (MPHW) among others. Furthermore, all of the aforementioned workers are typically already assigned a number of different responsibilities in various national health programs and schemes. Evidence also suggests that there is a palpable gap between the knowledge and skills of the CHWs regarding NCDs (Jeet et al, 2018). 

There are also mandated community participation platforms such as the Village Health, Sanitation, Nutrition Committees (VHSNCs), Mahila Arogya Samitis (Women’s Health Committees), Rogi Kalyan Samitis (Sick Person’s Health Committees) and Jan Arogya Samitis (People’s Health Committees), as stakeholders of community health in the Indian context. They typically comprise CHWs, representatives of local self government, and members of the community. They are ideally meant to be leveraged by the State apparatus to facilitate intersectoral convergence and local planning and action to address issues related to access and quality of care. Among a number of duties, they are also tasked with the responsibility of conducting surveillance and addressing risk modification for common NCDs. However, evidence informs us that community groups such as VHSNCs and MAS play a limited role in NCD care. The members of these platforms are also not well-versed with the NCD program and lack adequate training to focus on the integration of NCDs into existing community monitoring mechanisms. Additionally, the MAS cadre needs a good deal of strengthening in urban areas (Garg et al, 2024). 

Within the larger view of community involvement, there is a discernible push for recognizing and developing “pluralistic” medical systems, such as AYUSH (Ayurveda, Yoga, Unani, Naturopathy, Siddha and Homeopathy) - especially as an alternative to allopathic or Western medicine systems. While AYUSH has been recognized as an indigenous form of medicine as unique to the Indian context, it needs to be differentiated from indigenous knowledge systems and practices which is particular to multifarious indigenous tribal communities of India (Albert, 2015). 

In the case of AYUSH, the policy documents tend to mainstream its potential by ascertaining the importance of recognizing the need to standardize and validate Ayurvedic medicines and establish a sound and efficacious quality control mechanism for AYUSH drugs. However, it is critical to mention that the Department of AYUSH - which used to be a department under the Ministry of Health but made into a separate ministry in 2014 - has garnered some bad press for itself by prescribing puritanical (and irrational) remedies (Samal, 2016). Additionally, the Indian Medical Association (IMA) which comprises over 250,000 practitioners of allopathic medicine have shared their sharp criticism and ire with the government as well as the public regarding the use of “placebos” and other alternative forms of medicine that lacks scientific rigor and sound evidence, especially during the COVID-19 pandemic.

Intersectionality in Policy: Does It Exist?

From our analysis of the policy documents, we attempted to identify elements of intersecting social determinants of health related to DM that are or are not addressed in the texts of the policy documents and how (if at all) they are addressed. We focused mainly on determinants that have been discussed in the background section.

Age

In the Indonesian policy documents, there are both specific texts acknowledging age as an important determinant for DM. There are dedicated programs or approaches to address (risk of) DM and NCDs amongst elderly populations mandated to Puskesmas for implementation. While some dedicated approaches for the elderly exist, the state of the current framing of DM in policy documents and the capacity of the public health sector lead us to question how holistic and sustainable it might be.

There also seems to be more emphasis on individual elderly’s illness rather than elderly’s health as a whole concept. Focus is often placed on screening illnesses amongst elderly rather than approaches to enable elderly’s good life and wellbeing. This might contribute rather than decrease stigma around the relationship between aging and illnesses. Additionally, the epidemic transition of diabetes shows that it is no longer the disease of the elderly. We could not find any specific policy reference on protecting children and young people from the risk of developing diabetes and other NCDs. A prominent focus on elderly population may also persuade the public to think that DM is only relevant for this age group - which can also further stigma and risk deprioritizing other groups who are also at risk.

Indian policy documents envision that citizens of all ages must be free of all preventable NCDs. However, the documents look at targeting populations above 30 years old (or between 30 - 69 years of age,according to some of the documents) for population-based screening & service provision. There is a lack of comment in the policy documents for ages below 30. This is despite evidence showing that the country has witnessed an upward tick in the prevalence of DM and prediabetes among children, adolescents, and young adults. 

The NHP 2017 mentions dedication to implementing culturally appropriate community-centered solutions to address the health requirements of the aging population, while also ensuring compliance with the constitutional obligations outlined in the Maintenance and Welfare of Parents and Senior Citizens Act 2007. This policy acknowledges the increasing demand for palliative and rehabilitative care for diverse geriatric illnesses, emphasizing the importance of maintaining a continuum of care across all levels. There is also a comment on providing user - friendly health services to the elderly.

Gender

The only reference in the Indonesian policy documents on gender is about gestational diabetes, which relates more to biological sex rather than gender as a social construct. It seems like the Indonesian policy response regarding DM is still gender-blind, even though data shows gender plays significant roles in the issue. There is no policy acknowledgement, for example, on how gender dynamics and rigid gender roles can influence women’s access to health care, balanced and healthy diet, or safe space to exercise. Policy on elderly’s health care or healthy cities also does not have recognition on how people of different genders can experience aging differently or have unique needs in terms of development of healthy living spaces.

The Indian policy documents acknowledge the role of certain non-modifiable (biological) risk factors such as age, sex, and genetics with NCDs. However, the policy documents are gender blind in their approach with the health of women being particularly taken into consideration only during the course of their pregnancy. Additionally, the documents talk about the role of the State NCD cell by involving the participation of “women’s self help groups” in the community. This is despite the challenges of ‘triple burden’ generally experienced by women who are active members of society (paid work, unpaid care work, and community work) (Nichols, 2021). 

Geography, Location, and Indigeneity

There is a strong focus in the Indonesian policy documents on improving health care in rural and geographically isolated areas. However, none of the policy documents we analyzed contains or refers to any geographically disaggregated data on prevalence of DM - while at the same time (disaggregated) data from the Basic Health Research remains the only official source of data. Although decentralization approach and synergy between central and regional governments are emphasized in the overall health sector policy, it is crucial to critically question how the absence of disaggregated data might introduce the risk of using a blanketed policy approach for DM. Other common public health indicators in Indonesia, such as maternal mortality rate, clearly show the existence of regional discrepancies. A study evaluating the utilization and cost of Prolanis in Indonesia found that the program’s acceptance rate in regions outside of Java Island was lower than in Java (Khoe et al., 2020), indicating that a more contextualized approach to the regional needs might be paramount. The framing of DM in the policy documents - which focuses on individual lifestyle and behavior - also arguably gives the impression that DM is an urban disease. This framing does not fit the evidence development any longer. 

Policy documents related to food security issues in Indonesia do pay attention to the importance of a locally contextualized approach. For example, regional governments can determine which type of food should be prioritized for food security depending on their regional characteristics. The diversity of Indonesian people also means that food sources can be very diverse between regions. Food diversity is indeed one of the protective factors from DM. However, in an effort to maintain food sovereignty, the Indonesian government has been promoting ‘food estate’ projects that are mainly monocultural (focusing on a single food source, like rice) in nature and located in various regions out of Java. This project has been criticized as threatening indigenous food local system and food diversity, which can introduce greater risk for both undernutrition and NCDs like DM for indigenous peoples (Jong, 2020; Tuasikal, 2023). Indonesia’s long-standing food security policy has also been criticized as politically biased towards rice (Alta et al., 2023).

It is critical to highlight that while there is a significant gap on access to quality health care between the rural and urban geographies of India, with the latter outperforming the former on a number of indicators, the current efforts for primary health care (AB-HCWs) is (largely) significant in the rural hemisphere of the country as opposed to their urban counterparts.Urban Indians largely depend on secondary and tertiary forms of care or exclusive forms of treatment via private players; introducing a big financial barrier especially for the urban poor, such as the rural-to-urban migrants. The current infrastructure and delivery of primary health care services in urban India indeed remain unorganized with a high level of induced out-of-pocket payment. However, the policy documents also recognize that the interventions available in the urban hemisphere of India are generally tokenistic and there is an urgent requirement to scale-up assured interventions, with special emphasis on the urban poor including particularly vulnerable populations such as homeless people, rag-pickers, street children, rickshaw pullers, construction workers, sex workers, and temporary migrants. 

Indian policy documents are also cognizant of the prevalence of NCDs such DM as predominantly urban. While DM is no longer an issue exclusively impacting the urban - and while the policy documents seek to DM management efforts through planned early detection and better secondary prevention like the mandates of the AB-HWCs - the fact that such efforts to strengthen the primary health care system in the urban settings are currently highly fragmented might risk leaving the urban poor behind.

The food security act in India has been criticized as ‘subsidizing DM’ as it provides mainly rice and wheat to resource deficit citizens at low prices through the public distribution system (PDS). Furthermore, critics have questioned whether the food security act is delivering the promise of nutrition rich grains and cereals. There is adequate evidence that suggests that (over consumption of) white polished rice is unhealthy and linked to diabetes. In fact, rice was only eaten during festivals in India and traditionally it was not the white polished rice. There has been a change in food habits ever since the subsidization of the cereal through the PDS system. Additionally, the wheat that is consumed today is also unhealthy due to the multi-layered hybridization of the crop (Vyasulu, 2013). 

It is then worth asking if food security policy in India merely aims to fill the stomachs or if it is meant to provide appropriate and balanced nutritional sources. There is a need, for example, to encourage the consumption of what is referred to as “coarse grains” or so-called “inferior cereals” such as millets, which has been traditionally consumed by the people of the country. This might be achieved partly by gaining a deeper understanding of the nomenclature of “coarse” and “inferior” used for this type of food source in the context of India - which might have colonial, industrial, class, or caste biases (Bhat et al., 2018; Nadkarni, 1986) - especially when evidence suggests that they are more nutritious and better for health. 

Poverty

Similar to the issue of urban-rural gap, the policy framing of DM as a disease of the more affluent no longer fits current evidence of epidemiological shift in Indonesia. Embedding the policy response on the current framing can risk deprioritization of the more socioeconomically disadvantaged population groups, who already face more barriers in accessing care. Another important issue pertaining to these groups is the issue of exposure to commercial determinants of health. Indonesia’s experience with the tobacco industry - for which exposure poor people are more at risk (Amalia et al., 2019) - should be used as a lesson learned to critically examine whether and how socioeconomically disadvantaged communities are exposed to certain food and beverage industries. 

In the policy, there is indeed a regulation that makes nutritional labeling for food products in Indonesia mandatory. However, this comes in the form of quantitative amounts of salt, sugar, and fat in a certain product - a type of information that might not be easily understood and linked to DM or other NCDs by all population segments (e.g., those with low education). Additionally, Indonesia has a challenge related to affordability of food items that can enable a healthy and balanced diet (Purwanti, 2021). While food security policy has focus on food affordability and food diversity, its implementation has been criticized as having the consequences of reducing rather than increasing food diversity while at the same time is disconnected from policies in the agricultural and trading sector (Alta et al., 2023).

Researchers have commented that the Indian government has been quick to assume that “rapid economic growth and changing lifestyles” is the critical reason for epidemiological transitions concerning NCDs, while not taking into account much more pressing yet invisibilized phenomena such as poverty. One of the policy documents makes a reference to “vulnerable and marginalized” populations. However, the vulnerable and marginalized populations in question have a certain social and political identity. It is uncertain whether recognition of these identities might reveal the systemic and systematic discriminatory practices prevalent in the broader social and policy environment against the concerned people (Bajpai, 2017). 

In Indian context, the epidemic of DM even among the poor or resource deficit cannot be adequately explained by lifestyle changes as much as it is perhaps by Barker’s hypothesis, which privileges generational impact of malnutrition as the triggering mechanism. In epidemiological discourse, the fetal origins hypothesis - championed by David J. Barker - suggests that enduring certain health conditions in adulthood such as DM may stem from circumstances experienced decades earlier, specifically during in utero nutrition. Economists have extended this hypothesis, exploring various fetal shocks and conditions and revealing significant repercussions later in life that affect outcomes like test scores, educational achievements, income, and overall health. The observed impacts tend to be substantial in magnitude (Almond et al, 2011). 

Stigma

The Indonesian policy documents contain some stigmatizing languages - especially related to obesity, one of the metabolic conditions related to DM. For example, the policy documents use words like ‘anti’ or ‘fight’ to refer to educational campaigns on obesity. This could introduce psychosocial barriers to care. Furthermore, individual-focused policy framing on DM can also strengthen the stigmatization of individuals with DM as ‘lazy’ or ‘ignorant’ - including by health care providers. Likewise, this can be a barrier to care. The gender-blind nature of the policy response can also exacerbate stigma related to DM experienced by certain gender like women. Additionally, the bias towards social affluence in the policy framing of DM can exacerbate public stigma and distress experienced by poor people who live with DM - a phenomenon that is already happening with poor people who smoke, who experience class-related stigma from part of Indonesian society. Finally, the approach on elderly’s illness rather than elderly’s health can similarly exacerbate stigma about the relationship between aging, multiple illness, and frailty.

Discussions

At the heart of intersectionality, there is power analysis. Looking at the various determinants of DM in Indonesia and India as identified by the literature and how they are addressed (or not addressed) by each country’s policy response, we have attempted to apply the lens of power dynamics to dissect further how these phenomena happen and how they are interconnected. Furthermore, we also compared our analysis of both countries and extracted similarities, differences, and lessons learned.

People of certain age groups, like the youth and elderly, can experience certain vulnerabilities in the health space - not necessarily because of their biological age, but contributed by ageism. The elderly can be seen as ‘normally’ sick and frail (including with multiple comorbidities), yet at the same time their life years are seen as less valuable compared to younger people. They can also be seen as less economically productive and a ‘burden’ (Harris et al., 2018; Langmann, 2023; Lloyd-Sherlock et al., 2015). 

In the case of DM in Indonesia’s policy response, we argue that the good intention of elderly (or rather, elderly’s illnesses)-specific programs can have the unintended consequences of reinforcing this stigma. It seems like India’s policy response is more balanced in its approach for elderly’s health, at least on paper. On the other hand, both countries’ policy responses tend to invisibilize the younger generation beside evidence of epidemiological shift. This invisibilization can reinforce the assumption that younger people cannot have DM - therefore missing the opportunity of having appropriate public health response for them and at the same time stigmatizing younger people who do have DM. This missed opportunity also leaves young people more vulnerable to being targeted by commercial actors promoting unhealthy life choices. Furthermore, both age groups can also experience exacerbated stigma contributed by ageism and the policy framing of individual responsibility.

Gender has also been extensively recognized as a significant determinant of health operating through power dynamics, including in NCDs (see for example: Mackay, 2022; S. R. Sharma et al., 2020). The gender-blind policy response of both countries to DM misses the opportunity to address the gendered dynamics that are at the roots of women’s risk for and experience of DM. This is despite the evidence showing various gender dynamics - such as that women with DM can experience gendered stigma through being seen as irresponsible (and therefore not ideal) women (Rai, Peters, et al., 2020). Men with DM can also be stigmatized as sexually impotent (and therefore not an ideal man), although both genders can experience DM-related sexual dysfunctions uniquely (Foster et al., 2022; Siddiqui et al., 2012). 

The gender-blind policy responses of both countries also misses addressing gendered and intersecting barriers to care for DM. For example, gendered dynamics in the family, community, or cultural values can burden women with domestic tasks, even when they struggle with their health. It can also introduce barriers to women to access healthy food because the family prioritizes the men and children (Akter, 2021). Women might not feel safe to exercise in public facilities due to sexual harassment issue (Adlakha & Parra, 2020).

From an intersectional lens, women of different identities can also have different experiences related to DM. Elderly and/or poor women who do not have an independent source of income, for example, may experience more financial challenges to independently access care (Jacobs et al., 2016). Women of indigenous communities, who are usually at the forefront of food-related work and have close relationships with land and natural resources, might lose access to their food systems and resources and become more vulnerable to poverty, marginalization, and risk of violence (Csevár, 2021). Women from certain cultures or religious communities may have mobility restrictions and cannot do outdoor activities as much, or struggle to implement diet changes due to cultural expectations (Basu & Garg, 2017). 

Next, it is critical to examine the pattern of both countries’ policy response regarding community involvement. In this case, it is perhaps helpful to think about primary health care not just as a static “come to me” model which is often the case with facility based models, but as a system wherein health services need to reach people where the are and where the “primary” in primary care also means promotive and (both primary and secondary) preventive work. While both countries have strong elements of community involvement, we argue that the issue regarding the existence of true power sharing and bottom up approach arise. India’s approach seems to be very fragmented with many duplications in this matter and risk burdening community stakeholders with various responsibilities without adequately resourcing them. 

While Indonesia’s approach seems to be less fragmented, it is unclear whether support and access to resources provided to the community - especially because community efforts are supposed to be supervised by Puskesmas which itself is typically overburdened - is sufficient. Kader, who are positioned and even celebrated as agents of change, are not yet properly compensated. This pattern in itself also prompts another critical question: is there an honest effort to address power imbalance between the state and communities, or is it a one-way delegation of tasks without a sufficient support in terms of power-sharing or resources? In the case of India, the highly feminized pattern of the CHWs also raises critical questions about the pattern of overburdening (and perhaps also underpaying) women through care works, especially in the light of gender-blind policy response.

Both countries’ policy responses also still fail to acknowledge the impact of systemic poverty on NCDs like DM in spite of the evidence. While on one hand this might be understandable due to the fact that both Indonesia and India are still facing challenges with undernutrition - which is directly contributed by poverty through lack of access to nutritious food - a missing comprehensive policy understanding of other adverse impacts of systemic poverty on nutritional status warrants a highlight. India’s health system strengthening efforts needs to be critically examined in this regard due to its current exclusion of the urban poor, its fragmented approach, and its high appetite for privatization. Poverty can worsen the burden of DM through more than one way - it can limit access to proper health care and to healthy life choices, while also expose people to the negative impact of commercial determinants of health. Living with untreated DM itself can also exacerbate poverty through catastrophic health expenses.

When comparing the two countries, Indonesia is in a way at an advantage due to the long-term existence of its public primary health care system when India practically has to work in the opposite direction. This might be one of the most important differences influencing the different challenges faced by each country in addressing DM. It does not mean, however, that both countries’ primary health care systems - regardless of how long they have been around - are currently adequately resourced to spearhead the efforts.

Private sector engagement can indeed be a debated issue in the health sector. This is not without good reasons. The Indian health system experience shows how privatization and private encroachment of the health system can lead to a weakened public health system and decreased public health funding. There are cases, however, where private sector engagement can be carefully explored. We argue that the in the case for Indonesia, for example, the overburdened Puskesmas can benefit to some extent from the expansion of the involvement of private actors in public education, campaign, and preventive and promotive efforts to tackle DM. Private actors do not always refer to for-profit private health care providers. They can also include entities such as social entrepreneurs, independent researchers and health advocates, private think-tanks, and community-based small and medium enterprises. The increased involvement of private FKTP can also be encouraged, although this will require careful incentivization and monitoring strategy. We acknowledge, however, that the power dynamics related to private sector engagement in health need to be threaded carefully.

It is also important to examine not only whether both countries’ policy responses on food security are in line with management of DM, but also whether they trigger unintended negative consequences for vulnerabilized communities such as the poor, the indigenous peoples, and the marginalized caste. This is a good example on how ‘health-in-all-policy’ and holistic intersectoral work to advance health without leaving anyone behind are still serious homeworks for both countries. As mentioned above, the epidemiological shift for both malnutrition (from under to overnutrition or both) and DM (from ‘disease of the rich’ to ‘disease of the disadvantaged’) needs to be a strong signal for both countries to rethink their policies and strategies as informed by evidence, alongside the obligation to identify and understand how the process of (multiple) marginalization(s) contributes to this shift.

To be able to push the governments of both countries to do as such, the role of civil society and academic community to evaluate and criticize governments’ policy responses is crucial. In Indonesian context, we were not able to identify many scholarly works that utilize critical approach based on power and intersectionality on evaluating the state’s policy response on DM. The evaluation studies on Prolanis at national level, for example, are still limited in number and we could not find any that utilized such lens in-depth. On the other hand, studies evaluating AB-HWC in India have at least utilized gender-aware approach, such as those that found gender-related barriers at the AB-HWC facilities such as an absence of gender specific toilets, the lack of water supply (water collection is a gendered task primarily born by women), and inequitable access to digital technology for female CHWs. However, we also found very limited impact evidence of the AB-HWCs program available in the public domain. Indian government’s publications on rural health statistics contain only structural indicators with an absence of data with respect to process and outcome indicators

Lessons Learned and Proposed Interventions

Through the findings of this study, we have identified several lessons learned and proposed interventions for both countries, alongside opportunities for co-learning between them. Both countries need to shift their policy framing towards DM from focusing on individual responsibility to acknowledging the significant roles of structural determinants of health. The latter would ideally involve awareness of how these roles are played out through power dynamics and marginalization. It is a high time as well for both countries to integrate gender and social inclusion-responsive approach into their policy response. For this, properly disaggregated data and in-depth contextualization of data are important.

Civil society and health advocates in both countries can pick up the opportunity to join power through cross-learning and experience sharing - including through utilizing available expertise on progressive social sciences - and push each of their governments towards the aforementioned goal. The governments on their part need to include expertise beyond the health and medicine field in their policy development and programming on health. The committee on management of DM formed by the government of Indonesia, for example, comprises predominantly specialized clinicians. We argue that this composition needs to be diversified because health is intextricably linked with social, economic, and political justice. There is a high need for the public health field to go beyond the technical approach in monitoring and evaluating state’s work, so that hidden root causes can be identified and tackled appropriately and pattern of marginalization can be eradicated.

Next, both countries still have unfinished homework in health system strengthening efforts - especially their primary health care - and align them with the goal of providing quality health services and continuum of care for people living with or at risk with DM. Although there are context differences, Indonesia’s experience in establishing a wide network of public primary health care system and integrating them in the national health insurance scheme alongside private providers (with a clear link of two-way referrals with higher levels of care) can perhaps be useful to inform India’s current efforts. 

Finally, while Indonesia and India seem eager to involve communities in several different ways to tackle the burden of DM, both countries as duty bearers have the outstanding homework to ensure that communities are not only tasked with responsibilities but also empowered and properly resourced. India needs to improve harmonization of its CHW initiatives, the equitability of their compensations, and their knowledge and skills. Indonesia, while seems to have more organized efforts than India, still needs to establish better policy to properly compensate the CHWs. 

Conclusion

Through this paper, we have attempted to examine national/union policy response towards addressing DM in Indonesia and India - two countries with some of the highest health burden of DM globally - using the lens of intersectionality including power analysis. We have found that most of the policy response in both countries are still blind about how patterns of marginalization and social injustice impact the health of people who live with or at risk for DM in various intersecting ways. At times, the policy response even exacerbates these patterns. Both Indonesia and India need to rethink and redirect their policy responses towards DM to ensure that those responses result in improvement in equity. We also proposed several interventions that can help mitigate this issue - such as expanding expertise utilized in public health design, programming, and monitoring and evaluation beyond the health and medicine field, with the critical and meaningful involvement of civil society and communities. This might be a long journey, but as we grow more and more awareness on how health is a social justice issue, we might see the significance of the efforts and how they may help bring the lasting change that we all hope for.

References

Adlakha, D., & Parra, D. C. (2020). Mind the gap: Gender differences in walkability, transportation and physical activity in urban India. Journal of Transport & Health, 18, 100875. https://doi.org/10.1016/j.jth.2020.100875

Akter, S. (2021). Gender Inequality and Food Insecurity in Asian Food System During the COVID-19 Pandemic.

Alta, A., Auliya, R., & Fauzi, A. N. (2023). Hambatan dalam Mewujudkan Konsumsi Pangan yang Lebih Sehat: Kasus Kebijakan Perdagangan dan Pertanian. Center for Indonesian Policy Studies. https://www.cips-indonesia.org/publications/hambatan-dalam-mewujudkan-konsumsi-pangan-yang-lebih-sehat-kasus-kebijakan-perdagangan-dan-pertanian

Alvidrez, J., Greenwood, G. L., Johnson, T. L., & Parker, K. L. (2021). Intersectionality in Public Health Research: A View From the National Institutes of Health. American Journal of Public Health, 111(1), 95–97. https://doi.org/10.2105/AJPH.2020.305986

Amalia, B., Cadogan, S. L., Prabandari, Y. S., & Filippidis, F. T. (2019). Socio-demographic inequalities in cigarette smoking in Indonesia, 2007 to 2014. Preventive Medicine, 123, 27–33. https://doi.org/10.1016/j.ypmed.2019.02.025

Anjana, R. M., Unnikrishnan, R., Deepa, M., Pradeepa, R., Tandon, N., Das, A. K., Joshi, S., Bajaj, S., Jabbar, P. K., Das, H. K., Kumar, A., Dhandhania, V. K., Bhansali, A., Rao, P. V., Desai, A., Kalra, S., Gupta, A., Lakshmy, R., Madhu, S. V., … Ghosh, S. (2023). Metabolic non-communicable disease health report of India: The ICMR-INDIAB national cross-sectional study (ICMR-INDIAB-17). The Lancet Diabetes & Endocrinology, 11(7), 474–489. https://doi.org/10.1016/S2213-8587(23)00119-5

Ayuningtyas, D., Kusuma, D., Amir, V., Tjandrarini, D. H., & Andarwati, P. (2022). Disparities in Obesity Rates among Adults: Analysis of 514 Districts in Indonesia. Nutrients, 14(16), Article 16. https://doi.org/10.3390/nu14163332

Badan Penelitian dan Pengembangan Kesehatan RI, -. (2018). Laporan Nasional Riskesdas 2018. Lembaga Penerbit Badan Penelitian dan Pengembangan Kesehatan. https://repository.badankebijakan.kemkes.go.id/id/eprint/3514/

Badan Penelitian dan Pengembangan Kesehatan RI. (2013). Laporan Riset Kesehatan Dasar (RISKESDAS) 2013. Badan Penelitian dan Pengembangan Kesehatan. https://repository.badankebijakan.kemkes.go.id/id/eprint/4428/

Bajpai, V.. (2018). National health policy, 2017 revealing public health chicanery. Economic and Political Weekly. 53. 31-35.

Basu, S., & Garg, S. (2017). The barriers and challenges toward addressing the social and cultural factors influencing diabetes self-management in Indian populations. Journal of Social Health and Diabetes, 5, 71–76. https://doi.org/10.4103/joshd.J_Soc_Health_Diabetes_3_17

Bhat, B. V., Rao, B. D., & Tonapi, V. A. (2018). The Story of Millets. Karnataka State Department of Agriculture, Bengaluru, India with ICAR-Indian Institute of Millets Research, Hyderabad, India. https://www.millets.res.in/pub/2018/The_Story_of_Millets.pdf

Chan, J. C. N., Malik, V., Jia, W., Kadowaki, T., Yajnik, C. S., Yoon, K.-H., & Hu, F. B. (2009). Diabetes in Asia: Epidemiology, Risk Factors, and Pathophysiology. JAMA, 301(20), 2129–2140. https://doi.org/10.1001/jama.2009.726

Chittem, M., Sridharan, S. G., Pongener, M., Maya, S., & Epton, T. (2022). Experiences of barriers to self-monitoring and medication-management among Indian patients with type 2 diabetes, their primary family-members and physicians. Chronic Illness, 18(3), 677–690. https://doi.org/10.1177/17423953211032251

Corsi, D. J., & Subramanian, S. V. (2019). Socioeconomic Gradients and Distribution of Diabetes, Hypertension, and Obesity in India. JAMA Network Open, 2(4), e190411. https://doi.org/10.1001/jamanetworkopen.2019.0411

Csevár, S. (2021). Voices in the Background: Environmental Degradation and Climate Change as Driving Forces of Violence Against Indigenous Women. Global Studies Quarterly, 1(3), ksab018. https://doi.org/10.1093/isagsq/ksab018

Dany, F., Dewi, R. M., Tjandrarini, D. H., Pradono, J., Delima, D., Sariadji, K., Handayani, S., & Kusumawardani, N. (2020). Urban-rural distinction of potential determinants for prediabetes in Indonesian population aged ≥15 years: A cross-sectional analysis of Indonesian Basic Health Research 2018 among normoglycemic and prediabetic individuals. BMC Public Health, 20(1), 1509. https://doi.org/10.1186/s12889-020-09592-7

Das, A. K., Saboo, B., Maheshwari, A., V, M. N., Banerjee, S., C, J., V, B. P., P, S. P., Mohan, A. R., Potty, V. S., & Kesavadev, J. (2022). Health care delivery model in India with relevance to diabetes care: Heliyon. https://www.cell.com/heliyon/fulltext/S2405-8440(22)02192-2 _returnURL=https%3A%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS2405844022021922%3Fshowall%3Dtrue

Ethiraj, G. (2023, August 1). “sedentary lifestyle responsible for diabetes surge.” Indiaspend. https://www.indiaspend.com/indiaspend-interviews/sedentary-lifestyle-responsible-for-diabetes-surge 871363#:~:text=Increasingly%20sedentary%20lifestyles%20and%20high,Dr%20Mohan’s%20Diabetes%20Specialties%20Centre.

Foster, S., Pomerantz, A., Bell, K., Carvallo, M., Lee, J., & Lee, J. (2022). Victims of virility: Honor endorsement, stigma, and men’s use of erectile dysfunction medication. Psychology of Men & Masculinities, 23(1), 47–58. https://doi.org/10.1037/men0000369

Gaskin, D. J., Thorpe, R. J., McGinty, E. E., Bower, K., Rohde, C., Young, J. H., LaVeist, T. A., & Dubay, L. (2014). Disparities in Diabetes: The Nexus of Race, Poverty, and Place. American Journal of Public Health, 104(11), 2147–2155. https://doi.org/10.2105/AJPH.2013.301420

Hannah, E., Dumka, N., Bora, D., Roy, A. K., & Kotwal, A. (2023). Rapid assessment of NCD services rollout in Health and Wellness Centres in North-Eastern Indian state: A cross- sectional study. Journal of family medicine and primary care, 12(3), 466–471. https://doi.org/10.4103/jfmpc.jfmpc_1178_22

Harbuwono, D. S., Mokoagow, M. I., Magfira, N., & Helda, H. (2021). ADA Diabetes Risk Test Adaptation in Indonesian Adult Populations: Can It Replace Random Blood Glucose Screening Test? https://journals.sagepub.com/doi/10.1177/21501327211021015

Harris, K., Krygsman, S., Waschenko, J., & Laliberte Rudman, D. (2018). Ageism and the Older Worker: A Scoping Review. The Gerontologist, 58(2), e1–e14. https://doi.org/10.1093/geront/gnw194

Herningtyas, E. H., & Ng, T. S. (2019). Prevalence and distribution of metabolic syndrome and its components among provinces and ethnic groups in Indonesia. BMC Public Health, 19(1), 377. https://doi.org/10.1186/s12889-019-6711-7

Hidayat, B., Ramadani, R. V., Rudijanto, A., Soewondo, P., Suastika, K., & Ng, J. Y. S. (2022). Direct Medical Cost of Type 2 Diabetes Mellitus and Its Associated Complications in Indonesia. Value in Health Regional Issues, 28, 82–89. https://doi.org/10.1016/j.vhri.2021.04.006

Hoogwerf, B. J., Sferra, J., & Donley, B. G. (2006). Diabetes Mellitus—Overview. Foot and Ankle Clinics, 11(4), 703–715. https://doi.org/10.1016/j.fcl.2006.06.014

Hsu, C.-C., Lee, C.-H., Wahlqvist, M. L., Huang, H.-L., Chang, H.-Y., Chen, L., Shih, S.-F., Shin, S.-J., Tsai, W.-C., Chen, T., Huang, C.-T., & Cheng, J.-S. (2012). Poverty Increases Type 2 Diabetes Incidence and Inequality of Care Despite Universal Health Coverage. Diabetes Care, 35(11), 2286–2292. https://doi.org/10.2337/dc11-2052

Humphries, D. L., Sodipo, M., & Jackson, S. D. (2023). The intersectionality-based policy analysis framework: Demonstrating utility through application to the pre-vaccine U.S. COVID-19 policy response. Frontiers in Public Health, 11, 1040851. https://doi.org/10.3389/fpubh.2023.1040851

Idris, H., Hasyim, H., & Utama, F. (2018). Analysis of Diabetes Mellitus Determinants in Indonesia: A Study from the Indonesian Basic Health Research 2013. Acta Medica Indonesiana, 49(4), Article 4.

Indrahadi, D., Wardana, A., & Pierewan, A. C. (2021). The prevalence of diabetes mellitus and relationship with socioeconomic status in the Indonesian population. Jurnal Gizi Klinik Indonesia, 17(3), Article 3. https://doi.org/10.22146/ijcn.55003

Jacobs, B., de Groot, R., & Fernandes Antunes, A. (2016). Financial access to health care for older people in Cambodia: 10-year trends (2004-14) and determinants of catastrophic health expenses. International Journal for Equity in Health, 15, 94. https://doi.org/10.1186/s12939-016-0383-z

Jong, H. N. (2020, October 6). Indonesia’s food estate program eyes new plantations in forest frontiers. Mongabay Environmental News. https://news.mongabay.com/2020/10/indonesia-food-estate-program-papua-sumatra-expansion/

Kadandale, S., Marten, R., & Smith, R. (2019). The palm oil industry and noncommunicable diseases. Bulletin of the World Health Organization, 97(2), 118–128. https://doi.org/10.2471/BLT.18.220434

Kashiwabara, M., Arul, R., Goswami, H., Narain, J. P., & Armada, F. (2011). Local governments and civil society lead breakthrough for tobacco control: Lessons from Chandigarh and Chennai. Indian Journal of Public Health, 55(3), 234–239. https://doi.org/10.4103/0019-557X.89937

Khoe, L. C., Wangge, G., Soewondo, P., Tahapary, D. L., & Widyahening, I. S. (2020). The implementation of community-based diabetes and hypertension management care program in Indonesia. PLOS ONE, 15(1), e0227806. https://doi.org/10.1371/journal.pone.0227806

Kramer, E., Ahsan, A., & Rees, V. W. (2023). Policy incoherence and tobacco control in Indonesia: An analysis of the national tobacco-related policy mix. Tobacco Control, 32(4), 410–417. https://doi.org/10.1136/tobaccocontrol-2021-056633

Krishnamoorthy, Y., Rajaa, S., Verma, M., Kakkar, R., & Kalra, S. (2023). Spatial Patterns and Determinants of Diabetes Mellitus in Indian Adult Population: A Secondary Data Analysis from Nationally Representative Surveys. Diabetes Therapy, 14(1), 63–75. https://doi.org/10.1007/s13300-022-01329-6

Kumar, A., Goel, M. K., Jain, R. B., Khanna, P., & Chaudhary, V. (2013). India towards diabetes control: Key issues. The Australasian medical journal, 6(10), 524–531. https://doi.org/10.4066/AMJ.2013.1791

Kumar, P., Srivastava, S., Mishra, P. S., & Mooss, E. T. K. (2021). Prevalence of pre-diabetes/type 2 diabetes among adolescents (10–19 years) and its association with different measures of overweight/obesity in India: A gendered perspective. BMC Endocrine Disorders, 21(1), 146. https://doi.org/10.1186/s12902-021-00802-w

Lakiang, T., Daniel, S. A., C, K. K., Horo, M., Shumayla, S., & Mehra, S. (2021). Generating evidence on screening, diagnosis and management of non-communicable diseases during pregnancy; a scoping review of current gap and practice in India with a comparison of Asian context. PloS one, 16(2), e0244136. https://doi.org/10.1371/journal.pone.0244136

Langmann, E. (2023). Vulnerability, ageism, and health: Is it helpful to label older adults as a vulnerable group in health care? Medicine, Health Care, and Philosophy, 26(1), 133–142. https://doi.org/10.1007/s11019-022-10129-5

Liu, J., Bai, R., Chai, Z., Cooper, M. E., Zimmet, P. Z., & Zhang, L. (2022). Low- and middle-income countries demonstrate rapid growth of type 2 diabetes: An analysis based on Global Burden of Disease 1990–2019 data. Diabetologia, 65(8), 1339–1352. https://doi.org/10.1007/s00125-022-05713-6

Lloyd-Sherlock, P., Ebrahim, S., McKee, M., & Prince, M. (2015). A premature mortality target for the SDG for health is ageist. The Lancet, 385(9983), 2147–2148. https://doi.org/10.1016/S0140-6736(15)61016-9

Lognathan, V., Malhotra, S., Kumar, R., Krishnan, A., Gupta, S. K., & Nongkynrih, B. (2023). Coverage of a Population-Based Non-Communicable

Disease Screening Program Using Lot Quality Assurance Sampling in Rural North India: A Mixed Methods Study. Cureus, 15(2), e35330. https://doi.org/10.7759/cureus.35330

Mackay, H. (2022). Of fatness, fitness and finesse: Experiences and interpretations of non-communicable diseases in urban Uganda. Cities & Health, 6(1), 192–207. https://doi.org/10.1080/23748834.2020.1739189

Maiti, S., Akhtar, S., Upadhyay, A. K., & Mohanty, S. K. (2023). Socioeconomic inequality in awareness, treatment and control of diabetes among adults in India: Evidence from National Family Health Survey of India (NFHS), 2019–2021. Scientific Reports, 13(1), Article 1. https://doi.org/10.1038/s41598-023-29978-y

Mathur, P., Leburu, S., & Kulothungan, V. (2022). Prevalence, Awareness, Treatment and Control of Diabetes in India From the Countrywide National NCD Monitoring Survey. Frontiers in Public Health, 10, 748157. https://doi.org/10.3389/fpubh.2022.748157

Meena, S., Rathore, M., Gupta, A., Kumawat, P., & Singh, A. (2022). Assessment of National Program for Prevention and Control of Cancer, Diabetes, CVD and Stroke (NPCDCS): An observational study in rural Jaipur, Rajasthan. Journal of family medicine and primary care, 11(7), 3667–3672. https://doi.org/10.4103/jfmpc.jfmpc_2281_21

Mihardja, L., Soetrisno, U., & Soegondo, S. (2014). Prevalence and clinical profile of diabetes mellitus in productive aged urban Indonesians. Journal of Diabetes Investigation, 5(5), 507–512. https://doi.org/10.1111/jdi.12177

Modi, Bhavesh & Jadav, Pranay & Vasoya, Nikheeta. (2019). Evaluation of National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular disease and Stroke (NPCDCS) in Gandhinagar district, Gujarat 1 2 3. 10.

Nadkarni, M. V. (1986). ‘Backward’ Crops in Indian Agriculture: Economy of Coarse Cereals and Pulses. Economic and Political Weekly, 21(38/39), A113–A118.

Narayan, K. M. V., Varghese, J. S., Beyh, Y. S., Bhattacharyya, S., Khandelwal, S., Krishnan, G. S., Siegel, K. R., Thomas, T., & Kurpad, A. V. (2023). A Strategic Research Framework for Defeating Diabetes in India: A 21st-Century Agenda. Journal of the Indian Institute of Science, 1–22. Advance online publication. https://doi.org/10.1007/s41745-022-00354-5

National Collaborating Centre for Determinants of Health. (2016). Public Health Speaks: Intersectionality and health equity. https://nccdh.ca/resources/entry/public-health-speaks-intersectionality-and-health-equity

Oruganti, A., Kavi, A., & Walvekar, P. R. (2019). Risk of developing Diabetes Mellitus among urban poor South Indian population using Indian Diabetes Risk Score. Journal of Family Medicine and Primary Care, 8(2), 487–492. https://doi.org/10.4103/jfmpc.jfmpc_388_18

Pai, M. (2023, July 14). India cannot afford to ignore the epidemic of diabetes. Forbes. https://www.forbes.com/sites/madhukarpai/2023/07/13/india-cannot-afford-to-ignore-the-epidemic-of-diabetes/?sh=10793ec24442

Patnaik, Pranav Kumar & Jain, Kamlesh K & Chandra, P & Pathak, Jaya & Raman, K V & Shah, Asha. (2016). Diabetes in India: Measuring the dynamics of a public health catastrophe. Journal of Social Health and Diabetes. 4. 77. 10.4103/2321-0656.188000.

Perappadan, B. S. (2023, May 5). Government programme for non-communicable diseases renamed. The Hindu. https://www.thehindu.com/sci-tech/health/new-diseases-and-initiatives-prompt-health-ministry-to-widen-and-rename-ncd-programme/article66816673.ece#:~:text=The%20existing%20National%20Programme%20for,amid%20widening%20coverage%20and%20expansion

Pradeepa, R., Shreya, L., Anjana, R. M., Jebarani, S., Venkatesan, U., Kamal Raj, N., Swami, O. C., & Mohan, V. (2023). Sex-Based Differences in Clinical Profile and Complications among Individuals with Type 2 Diabetes Seen at a Private Tertiary Diabetes Care Centre in India. Healthcare, 11(11), 1634. https://doi.org/10.3390/healthcare11111634

Purwanti, T. (2021). RI Darurat Malnutrisi, Makanan Bergizi Belum Terjangkau. CNBC Indonesia. https://www.cnbcindonesia.com/news/20211201185938-4-295928/ri-darurat-malnutrisi-makanan-bergizi-belum-terjangkau

Rai, S. S., Irwanto, Peters, R. M. H., Syurina, E. V., Putri, A. I., Mikhakhanova, A., Naniche, D., & Zweekhorst, M. B. M. (2020). Qualitative exploration of experiences and consequences of health-related stigma among indonesians with HIV, leprosy, schizophrenia and diabetes. 

Kesmas, 15(1), 7–16. https://doi.org/10.21109/kesmas.v15i1.3306

Rai, S. S., Peters, R. M. H., Syurina, E. V., Irwanto, I., Naniche, D., & Zweekhorst, M. B. M. (2020). Intersectionality and health-related stigma: Insights from experiences of people living with stigmatized health conditions in Indonesia. International Journal for Equity in Health, 19(1), 206. https://doi.org/10.1186/s12939-020-01318-w

Ranasinghe, P., Jayawardena, R., Gamage, N., Sivanandam, N., & Misra, A. (2021). Prevalence and trends of the diabetes epidemic in urban and rural India: A pooled systematic review and meta-analysis of 1.7 million adults. Annals of Epidemiology, 58, 128–148. https://doi.org/10.1016/j.annepidem.2021.02.016

Rao Seshadri, S., Kaulgud, R., & Jha, P. (2021). ‘You cannot touch taxes easily’: Making the case for tobacco taxation in India. Health Policy and Planning, 36(3), 322–331. https://doi.org/10.1093/heapol/czaa171

Richards, S. E., Wijeweera, C., & Wijeweera, A. (2022). Lifestyle and socioeconomic determinants of diabetes: Evidence from country-level data. PLOS ONE, 17(7), e0270476. https://doi.org/10.1371/journal.pone.0270476

Shankar, D. S. (2023, July 19). Diabetes is a hidden Iceberg & India needs to review its policy to fight it. TheQuint. https://www.thequint.com/fit/diabetes-public-health-india-disparity-policy-initiatives#:~:text=can’t%20miss-,Diabetes%20has%20emerged%20as%20a%20major%20public%20health%20challenge%20in,of%20all%20the%20undiagnosed%20cases.

Sharma, S. R., Matheson, A., Lambrick, D., Faulkner, J., Lounsbury, D. W., Vaidya, A., & Page, R. (2020). The role of tobacco and alcohol use in the interaction of social determinants of non-communicable diseases in Nepal: A systems perspective. BMC Public Health, 20(1), 1368. https://doi.org/10.1186/s12889-020-09446-2

Sharma, S., & Jayanta Mishra, A. (2021). Social factors in understanding illness behaviour of women with Type 2 diabetes mellitus in Jammu, North India. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 15(4), 102178. https://doi.org/10.1016/j.dsx.2021.06.015

Siddiqui, M. A., Ahmed, Z., & Khan, A. A. (2012). Psychological Impact on Sexual Health among Diabetic Patients: A Review. International Journal of Diabetes Research, 1(2), 28–31.

Siegel, K., Narayan, K. M., & Kinra, S. (2008). Finding a policy solution to India's diabetes epidemic. Health affairs (Project Hope), 27(4), 1077–1090. https://doi.org/10.1377/hlthaff.27.4.1077

Soewondo, P., Ferrario, A., & Tahapary, D. L. (2013). Challenges in diabetes management in Indonesia: A literature review. Globalization and Health, 9(1), 63. https://doi.org/10.1186/1744-8603-9-63

Sujata, & Thakur, R. (2021). Unequal burden of equal risk factors of diabetes between different gender in India: A cross-sectional analysis. Scientific Reports, 11. https://doi.org/10.1038/s41598-021-02012-9

Tanoey, J., & Becher, H. (2021). Diabetes prevalence and risk factors of early-onset adult diabetes: Results from the Indonesian family life survey. Global Health Action, 14(1), 2001144. https://doi.org/10.1080/16549716.2021.2001144

Tuasikal, R. (2023). Environmental Reporting: Gastrocolonialism. Rainforest Journalism Fund. https://rainforestjournalismfund.org/environmental-reporting-gastrocolonialism

Verma, R., Khanna, P., & Mehta, B. (2012). National programme on prevention and control of diabetes in India: Need to focus. The Australasian medical journal, 5(6), 310–315. https://doi.org/10.4066/AMJ.2012.1340

Wetzel, S., Geldsetzer, P., Mani, S. S., Gupta, A., Singh, K., Ali, M. K., Prabhakaran, D., Tandon, N., & Sudharsanan, N. (2023). Changing socioeconomic and geographic gradients in cardiovascular disease risk factors among Indians aged 15–49 years – evidence from nationally representative household surveys. The Lancet Regional Health - Southeast Asia, 12. https://doi.org/10.1016/j.lansea.2023.100188

‘Arogyam Kendra’ - Health and Wellness Centres in Madhya Pradesh: An Assessment. (2021). Atal Bihari Vajpayee Institute of Good Governance and Policy Analysis, 1–80.