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Printed in India Addressing mental health in Indonesia Prepared for the Ministerial Roundtable of the 75th Session of the WHO Regional Committee for South-East Asia 6th September 2022 Addressing mental health in Indonesia2 Sources: World Bank (https://data.worldbank.org/, accessed 25 June 2022); Mental health atlas, 2020 data Gross national income per capita, Atlas method (current US$) UHC service coverage index Hospital beds per 100 000 population Mental health expenditure as a % of total government health expenditure Per capita spending on mental health (US$) Doctors per 100,000 Nurses and midwives per 100 000 3,870 (2020) 59 (2019) 104 (2017) 2% (2019) 0.34 (2019) 46 (2019) 380 (2019) Population 273.5 million (2020) Life-expectancy in years 72 (2020) World Health Organization 3 • The prevalence of depression was 6.1%. Only 9% of them had access to medicines. • The prevalence of psychosis was 7 per million households • No data are available on anxiety and bipolar disorders. • 1.5 million people in Indonesia are estimated to be suffering from epilepsy with a prevalence of 0.5–0.6% of the total population (1). • It is estimated that there were 1.2 million people with dementia in 2016, and it is predicted to increase up to 2 million people in 2030 and up to 4 million people in 2050 (2). • No data are available on neurodevelopmental disorders and suicide. • Based on the Basic Health Research Study of 2018, the prevalence of alcohol use in those over 10 years old was 3% . • Based on the National Narcotic Agency data, there were 951 drug users in 2018 nationwide, decreasing from 1039 cases found in 2018. The most consumed drug is marijuana (3). • The treatment gaps for mental health conditions are not known. The burden of mental health problems Based on the basic health research report in 2018: 1 Muttaqin Z. Epilepsy surgery in Indonesia: achieving a better result with limited resources. Bali Med J. 2012;1(2):57–63. Available from: http://ojs.unud.ac.id/index.php/bmj/article/view/4545 2 Statistics on dementia. In: Alzheimer’s Indonesia [website] (https://alzi.or.id/statistik-tentang-demensia/, accessed 21 August 2022). 3 National Narcotics Board. Statistics of narcotics case uncovered. In: Radan Narkotica Nazional [website] (https://puslitdatin.bnn.go.id/ portfolio/data-statistik-kasus-narkoba/, accessed 21 August 2022). Addressing mental health in Indonesia4 Mental health policies, programmes and laws Prevention and promotion activities: organization and coverage • There is no mental health policy at present. • The Mental Health Law that was approved in 2016 drives the the provision of mental health programme and services in Indonesia. It strongly focuses on the provision of mental health in the medical services system, and is co-referenced with the Disability Law No 8, 2018. • The government is using the Disability Law which is in line with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) to promote inclusion of people with psychosocial disabilities in productive work and social support. • There are ministerial decrees that address immediate national issues, such as the COVID-19 pandemic which include components related to mental health. Early childhood and good parenting The current programmes focus on parenting and mental health, based on the milestone of development. Preventing bullying The focus is on awareness raising, case detection (screening) and reporting on bullying at school levels. World Health Organization 5 Alcohol, tobacco, drug use prevention WHO is supporting the No-Tobacco programme. The drug prevention programme is managed by the Ministry of Health and the National Narcotic Agency (BNN). Both have different roles where the Ministry of Health focuses on disease control and health services while BNN focuses on law enforcement. Regulation and distribution of alcohol is managed through the Ministry of Industry and Trade. The ministries of Health and Finance regulate the tariffs and taxations. Mental health literacy With the vast use of social media, mental health literacy is improving for the last 5 years in Indonesia. The literacy level varies among different age groups. Young people are more open to share their experience living with mental health problems and focus on productivity rather than the disease, while the older adults would focus more on disease prevention. Yet, the stigma related to mental illness are considered similar in all age-groups and geographical areas. Stigma reduction Most mental health awareness programme address stigma reduction. Stigma results in exclusion from the community, reduced job opportunities and low salaries. Suicide prevention Indonesia has not developed a national suicide prevention strategy. However, the media often portrays suicide negatively. Cases related to suicide and attempted suicide are not yet included in the national insurance scheme. Epilepsy, dementia, neurodevelopmental disorders These three programmes are managed by different directorates at the Ministry of Health. They are not considered as mental illnesses in general and thus, the stigma is less. Access to services and treatment for these conditions are still limited, and are often provided by private sectors and are costly. Although such services are available free-of-charge in government health facilities, it requires specialized doctors who work in bigger hospitals. Caregiver programmes Caregiver support and capacity-building are provided by the mental hospitals as a part of the medication service. The mental health nurses also recruit caregivers to be trained in mental health and provide support to other families. Social support programmes Social support programmes are managed by the Ministry of Social Affairs. Those with severe mental illness are categorised as a vulnerable groups and are eligible to receive this support. However, they must have an identity number and an address as the main requirements. With the vast use of social media, mental health literacy is improving for the past 5 years in Indonesia. The literacy level varies among different age groups. Young people are more open to share their experience living with mental health problems and focus on productivity rather than the disease. Mental health services: organization and coverage Health Workers per 100,000 population • The Ministry of Health (MoH) and its subnational offices manages the community mental health programme at the primary level where they train health providers, stakeholders, and community volunteers on community mental health. The required support to maintain service quality includes increasing programme budgets, continuous training in mental health and data management for evidence- based programme development • Mental health services are available from the primary level (primary health centres) and secondary level (district and provincial general hospitals). The type of services are subjected to the investment of the subnational governments. • Mental hospital remains the highest referral in the structure. 28 out of 34 provinces in Indonesia have at least 1 mental hospital. • The Ministry of Health does not implement programmes. It provides guidelines and necessary policies and regulations to support the subnational levels (provincial district and health offices) to implement programmes. The subnational health offices are responsible for capacity strengthening and service and programme development. Note: “Other” denotes private and nongovernment sectors. Source: Mental health atlas, 2020 data 0.4 (1120 - govt. 190, other 930) Psychiatrists 2.3 (6200 - govt 2700, other 3500) Mental health nurses 0.2 (415 - govt. 110, other 305) Psychologists 0.1 (250 - govt. 150, other100) Social workers 0.1 (150 – govt.50, 100 other) Occupational therapists Addressing mental health in Indonesia6 World Health Organization 7 • The Ministry can provide further support through capacity building for public mental health and increase collaborations with different sectors, community support organizations and universities. • At primary level, mental health services can be provided if at least one nurse and or doctor was trained in community mental health. The basic services are early detection, medicine provision, and referrals to bigger hospitals. The service can be expanded into a home visit services, village volunteer trainings with trained village volunteers supporting families and persons with lived experience, and development of support groups and for some provinces, provision of services of psychologists. • Oral antipsychotics are available in primary care. In some provinces where the community mental health programme and services are more developed, the primary health centres are allowed to administer injections prescribed by and under the supervision of the district psychiatrist. • Antipsychotic medicines are provided through a system of forecasting and procurement from the primary level to the national level developed by the Pharmacy Percentage of total expenditure on mental health Mental hospitals 11–20% General hospitals 6–10% Primary health care 20–40% Community services 6–10% Preventive programmes <5% Sources: Mental health atlas, 2020 data 49 Mental hospitals (11340 beds) 370 Psychiatric units in general hospitals (3820 beds) 150 Community residential facilities (2000 beds) 6.3 Number of mental health beds per (100,000) 609 Outpatient facilities for mental health Service facilities Source: Mental health atlas, 2020 data, Ministry of Health Addressing mental health in Indonesia8 • Within the Indonesian health system, mental health is often a specific section of the mental health department, mental health ward and mental hospital. Thus, the reports regarding mental health issues will be directed towards and followed up mainly by these structures. • Research in mental health is mainly conducted by the universities. However, this has not significantly contributed to the development of the mental health programme. There is potential for collaboration. Availability of data remains an issue, although the government is requested to develop an evidence-based programme by the planning agency. Mental health information system and research Directorate. Despite challenges, the list of the medicines is published in the national formulary. Procurement and audits are done by the pharmacy and mental health departments based on the national formulary which also regulate which antipsychotic medicines could be provided at each level of health facility. • Following the passing of the Disability Law in 2018, mental health has been associated with disability and rights as well. This has created more interest in mental health among the non-health sectors to mainstream mental health into their programme. • Currently, mental health is mainstreamed at different levels into various disability programmes, adolescent wellbeing programmes, geriatric health promotion programmes, school health, mother and child health, occupational health, universal health coverage and in population administration. • The involvement of stakeholders and non-health sector entities that include community groups is increasing. However, they are not working in collaboration with the government directly. The government works frequently with professional organizations in programme implementation. • There are halfway homes operated by private and non-profit institutions. The government is discussing the regulations regarding such facilities. There are only a few residential care facilities (panti) for people with psychosocial disabilities provided by the government. They are mainly available in big cities and are often full. Some provincial governments may provide day care centre services for people with psychosocial disabilities where they could participate in free classes and socialize. In Indonesia rehabilitation centres mainly serve drug users and the service is provided by the government and private institutions. World Health Organization 9 Issues requiring urgent attention Challenges and possible solutions What needs to be sustained, supported and invested on • Establishing and sustaining community mental health services, especially in relation to disasters is essential. • Data collection, reporting and knowledge management in relation to mental health need strengthening. • Specific financing for mental health is a priority requirement. • Advocacy for and mainstreaming rights- based mental health services is required. • Mental health is unlikely to become a high priority programme, even though the priority level is increasing due to the pandemic and global trends. Therefore, mainstreaming mental health through most health and social programmes will help to maintain fund allocation, people’s awareness, and government interest. • Developing an affordable mental health database system is also key to ensuring sustainability in financing and programme development, as the government would prioritize approval of a programme plan when it is evidence based. • Sustainable and mainstreamed mental health financing should be given high priority. • Development and maintenance of a database for mental health needs attention. • Continuous capacity building of primary level mental health providers and volunteers should be strengthened and sustained. • Mental health advocacy on issues such as rights-based services and suicide prevention should be further invested in. Analysis Addressing mental health in Indonesia10 There is a strong health services structure where the Ministry of Health prepares policies and guidelines and the provinces and districts implement these. Mental health literacy is improving. The government collaborates well with professional organizations for mental health programme implementation. The non-health sector is becoming increasingly involved in mental health. Programmes for the prevention of mental health issues and promotion of mental health are being conducted. Mental health services are available from the primary-, secondary- to the tertiary level in districts and provinces. The Mental Health Law can be used to strengthen social rehabilitation. Availability of a mental health law enables driving the agenda of mental health. The Disability Law ensures that mental health is included in the sphere of disability. SWOT Strengths Opportunities World Health Organization 11 There is a requirement for collaborations with different sectors, community support organization and universities. Although nongovernmental organizations are active in mental health issues, there are only a few formal collaborations with the government. Research capacity needs improvement. A mental health policy is required The non-availability of data on suicide and some mental health conditions impedes evidence-based policy development An established data collection system for mental health is required. Mental health is not seen as priority area yet, although the importance of mental health is increasing. A national strategy on suicide prevention is yet to be developed. Treatment gaps are not known but are possibly significantly high. Weaknesses Threats Addressing mental health in Indonesia12 Notes
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