Similar to the current state in Brazil, Project HOPE does not have any current diabetes or chronic-related programs in Indonesia. Dr. Nasar, Project HOPE’s country lead, was immediately supportive in identifying local and regional leaders to speak with about the current priorities in diabetes from government, corporate, and the health services perspective. I knew that a number of national efforts related to diabetes were still nascent, but blown away by our first day of interviews with the country’s leading experts in the field.
Current Leaders in Diabetes
Dr. Rudijanto, President of the Indonesian Diabetes Association, and Dr. Aris Wibudi, President of the Indonesian Diabetes Educator Association, both met with Dr. Nasar and I to discuss their experiences and insights on the need for new programs in country. We met in the Rumah Sakit Pantai Indah Kapuk hospital which they are using as a pilot for some fairly innovative diabetes programs (focused on both community-level and healthcare worker-level interventions. In addition to the Society of Endocrinology in Indonesia – these two know probably more than anyone in the country about the needs and opportunities, and importantly, how Project HOPE can help.
Left to right: Me, Dr. Nasar, Dr. Rudijanto, and Dr. Aris Wibudi
One of the first pieces of information we discussed was by far the most shocking: there are only 54 endocrinologists in the entire country of Indonesia. Since there are an estimated 7 million people in Indonesia with diabetes, this would make each endocrinologist responsible for 130,000 patients! I asked a lot of questions around why this is the case. It seems as though a lot of it has to do with the medical education system – everyone is first trained as a General Practitioner (GP), then if they would like to become a specialist, pays out of pocket for the additional years of training (followed by residencies which I imagine would be limited in volume considering there are few established specialists to practice under).
What happens as a result is that the majority of diabetes care is delivered by GPs in the primary setting. This is very fascinating and changes the strategy for new diabetes programs quite a bit. For the Indonesian Diabetes Association, the current priorities are awareness – educating patients, families, and communities affected by diabetes. For the Diabetes Educator Association, the current programs are focused on a “train the trainer” model where GPs and nurses receive formal education (conducted once annually). Dr. Rudijanto is also in the process of developing a formal “diabetes nurse” role that would involve an extra 3 months of exclusive diabetes training provided in addition to the standard nursing curriculum.
As the Dr. Rudijanto and Dr. Aris Wibudi described the current state and opportunities it was impossible to overlook the passion and dedication these two have devoted to the field over the years. As more attention has been brought to diabetes over the past few years, they have committed themselves to aiding the Ministry of Health and others in helping patients with diabetes across Indonesia.
“Fun” and Diabetes with Dr. Roy
One of the most exciting parts of my visit to Indonesia was meeting Dr. Roy at the Rumah Sakit Pantai Indah Kapuk hospital. Probably the most enthusiastic and forward-thinking individuals in this space – I immediately fell in love with his vision for community-level efforts for diabetes in Indonesia. I was first escorted to their new pilot – the diabetes education center – a free space for education and screening including facilitated and self-study resources about diabetes risks, treatment, complications. As I sat down, the diabetes center honestly felt like I was in a coffee shop, not a hospital. What a great concept? Large windows, big chairs, neatly arranged materials made it an inviting space for anyone young or old. One of the stigmas around diabetes is that people don’t want to feel like a “patient” all the time – this center definitely did a great job at providing the technical capabilities without turning the space into a “medical” clinic.
Dr. Nasar, Me, Dr. Rudijanto, and Dr. Roy in the diabetes education center
A patient starts out with a free assessment and video on diabetes to give them background on the disease, risk factors, and progression over time. Patients can then sit for custom educational sessions on nutrition, exercise or diabetes management. Or, over coffee or tea, read through a number of materials provided for self-study. The staff that runs the center also does “roadshows” to elementary schools and once a year seminars to do patient education in a lively format. See the "diabetes kiosk" below for automatic risk assessments for visitors!
Dr. Roy’s goal is to “make diabetes education as fun as possible.” He sees diabetes education as the most essential part of diabetes promotion AND treatment. People in Indonesia are constrained from a resources standpoint, “everyone can’t afford to be put on insulin.” Lifestyle interventions are a must and he is determined to figure out how to make them work – and I wholeheartedly support his ambitious efforts to do so! Dr. Roy also believes that you have to go out and find people at risk vs. waiting for them to come to the hospital with signs of diabetes or worse, complications. He uses channels such as Agoyang Jakarta (meaning “shake Jakarta”) an exercise / dancing group in the city to do sessions on diabetes awareness. Similar to Dr. Roglic from WHO, Dr. Roy believes that access to healthy choices (e.g. walkways in public spaces) are critical to facilitating healthy lifestyles.
Tuesday exercise course - it turned into a potluck lunch celebration for Dr. Roy's recent birthday!
Every Tuesday and Thursday, Dr. Roy also holds exercise courses in the hospital (they have an open room with nurses who lead the program) followed by a 30min presentation on an aspect of diabetes and group Q&A. I really enjoyed watching the exercise course itself and was later excited to see Dr. Roy in action presenting on complications related to diabetes.
Now I understand what he means by fun! He used examples, images, and analogies that were catchy and related to “hot” topics that people were talking about in the community already – there was even a picture of Angelina Jolie in the presentation! What was fascinating to me is that this is a technique I’ve heard is used often in religious organizations through sermons – often relating to current events or topics that will help the message “stick” over time. Why not adopt similar techniques with diabetes education?
Dr. Roy and I also discussed the needs in Indonesia comparatively to the rest of Asia. The hereditary propensity is extremely high with prevalence rates are very similar to India in Jakarta (12%), but resembling China in other cities (7% urban, 5% rural). These numbers are growing and patients are getting younger. Still, Dr. Roy’s determination to bring diabetes to the lives of people in Indonesia is inspiring. As he joked relating to diabetic foot care, “why do people in the rural areas know more about Cristiano Ronaldo then they know about their own foot?” It’s a problem, but not one that can’t be tackled.
Indonesia’s Ministry of Health
Later in the week Dr. Nasar and I were able to meet with Dr. Tjandra Yoga Aditama, the Director General of the Ministry of Health of Indonesia (via introductions from Dr. Aris Wibudi). This was quite an honor and he brought in some of his leads for diabetes and noncommunicable diseases to make it an especially productive discussion.
Dr. Nasar, me, Dr. Aditama (Dir Gen MOH), and diabetes leads
What was very interesting to me off the bat, was how new the recognized need for noncommunicable programs is in Indonesia. Only four years ago the office was 100% focused on infectious diseases. The change has required them to create new positions, restructure governance, and reallocate funding completely. Dr. Aditama and I discussed this evolution some and then his challenges with the fact that the majority of funding is still heavily on the infectious disease and environmental health sides (e.g. where USAID and the UN priorities are still focused). This has limited some of their efforts to institute new promotion and prevention programs associated with CVD or diabetes, for example. “The data shows that the need is there” (CVD is now the #1 killer in Indonesia like most Western countries) he pushed, but their priorities are still on communicable disease.
I also spent some time after our meeting with the diabetes lead directly, Hj. Titi Renawati. She and I had a “heart to heart” about her efforts building up the programs from scratch over the past few years. This was a significant undertaking! After our discussion it was apparent that few external resources had been available to her to help develop the strategic plan and actionable materials for implementation. She gave me books they'd developed on diabetes education for GPs (community centers / primary care) and showed me examples of very nice campaign materials (posters / pamphlets) that they were piloting in a few cities.
It is very clear that providing access to global best practices could be one of the best ways to help countries like Indonesia. Local leaders often know what is best for the country and how to best implement programs – what they need is a “menu” of things that have worked in other places so they can pick and choose what they think could help them best. For both developing countries and countries where the health policies / programs are still developing – this could be very powerful. Although Hj. Renawati’s funding may limit her from attending international conferences where such ideas are discussed – a mechanism must be put into place to help her access these resources.
Tertiary Care in Indonesia
Dr. Nasar and I also visited Rsud Kota Bekasi hospital in West Java to understand the current state of diabetes and chronic disease care in the hospital setting. Similar to India or China, there is no outpatient appointment system in Indonesia. Patients are referred from primary care centers to hospitals where they sit in a department-specific waiting area for their turn to see the physician (also about 5-8min visits per patient). For the poorest patient population, nearly 100% of care is covered by government insurance and 25-50% is covered for the second poorest patient group (all within their district). Traditional medicine is also very prevalent in Indonesia, but managed by “traditional healers” and separated entirely from the formal hospital-based healthcare system (unlike China where they have traditional hospitals and India where they have integrated East-West facilitates).
Wait times are fairly long in these outpatient centers – maybe 3-5 hours to be seen within one day (not unlike other countries in the region). Something that fascinated me though – was how this hospital in particular started to use these wait times for their advantage. The hospital gives some nurses part-time education roles and have them stand with a microphone (not kidding) to do sessions on prevention and awareness in the facility. Some of these are already focused on diabetes! I asked to speak with one of these nurses and learned more about how they selected topics and who the messages were directed towards and what I was really dying to know – have they seen any changes? More patients? I started brainstorming the potential for a non-healthcare worker screening advocate who would go to OP centers for women’s health, cardiology, pulmonology, and other specialties relating to chronic disease. Could they fill out a risk assessment card that they would take to their GPs for further assessment and referral?
Despite some coverage and improvements in screening, affordability is a major huge concern in Indonesia. I’m not really sure how to address this as it’s more of a systemic issue that would need to be addressed by policies in the MOH or laws regarding standards of care. Few qualify for government insurance and therefore all or most spending in health is by the patient – out of pocket. This means that many people don’t go to the doctor unless they are really sick, and well at that point, their expenses in the health facility are likely also high.
Brief Illustrations: Coverage and Affordability
Dr. Nasar relayed two stories to me that have stuck with me and indicate aspects of the system that are failing:
First is about corruption. A district leader in Indonesia publicly revealed that the sub-district chief for that area was registered as poor to receive healthcare coverage (in addition to a number of other benefits). Although this may be common among government officials to benefit from their own policies, in this instance it was taking away from those who deservedly needed the health coverage.
Second is about access to care. Dr. Nasar had an incident where a taxi driver of his indicated he’d been driving for 3 days straight to make money for an operation. As it turned out, his wife was pregnant and had gone into labor but required a surgery costing about US$500 to deliver the child. What happened to my shock and horror, was that his pregnant wife (in labor) was sent home because their family couldn’t afford the surgery. Dr. Nasar gave him all the money he had in his wallet and indicated to the driver that he could lose both this wife and unborn child if the operation didn’t take place in a timely manner. In the US it’s illegal to refuse care to someone in need, regardless whether they can pay or not. This may be commonplace in a number of countries, but is a true tragedy and representative of an array of issues that need to be addressed at a larger level.
A healthcare system is undoubtedly failing if it is killing healthy, unborn children. While this is just one example and not related to chronic diseases in any way – it must have implications for them. For example, what happens if I’m diabetic and need my foot amputated but can’t afford it? Do I eventually lose my whole leg, or life?
Primary Care: Where it All Happens
My last site visit in Indonesia was with Dr. Saraswati in a primary care community clinic in West Java. The facility was staffed with 3 physicians, one nutritionist, several pharmacists, and one chief manager to oversee operations. Centers like these are the “first –line center of health” in Indonesia and largely focused on women and children’s health, vaccinations, and referral mechanisms for patients to larger facilities. Diabetes care is also offered here with limited prescriptions available for Type 2 patients (insulin is only provided by hospitals). However as I learned, diabetes medication can only be prescribed and distributed 5 days at a time (extended from the 3 days at a time for other conditions) which is a huge barrier to facilitating patient compliance with treatment.
The good news was that many patients that come here are entering with earlier symptoms for diabetes: sweating, urination, numbness vs. severe complications (they usually go directly to the hospital). Most patients when diagnosed initially are between 200-300 mg/dL which could be worse, but is a relatively optimistic starting point to have good glucose management long-term. Dr. Saraswati spends about 30min with each patient the first visit to go over the disease and recommended treatment.
Dr. Saraswati and the community center managing chief
The bad news is that the physicians see increases in the patients’ glucose levels as time goes on (400-500 mg/dL) as compliance to therapies and lifestyle change is very poor. Additionally, everything that Dr. Saraswati knows about diabetes she indicated that she learned online. Lack of resources for GPs in the primary care setting is clearly an issue – she’d like to have better training and educational resources for patients. I mentioned to her the fact that many diabetes centers use group-facilitated sessions (typically once a week) to maximize healthcare resources but also empower patients with the opportunity to learn from each other. She thought this was fascinating. “Where could I find these resources?” she asked me. Even if she just had a handful of sample “curricula” that she could use with her patients she feels it would be enough. I mentioned that these evening education sessions are also difficult because they encroach on personal time – but that didn’t seem to concern her one bit. It was clear that helping patients first was her priority.
What’s promising to me is that providing access to resources and contacts who have already made strides in developing diabetes programs could be a huge help for Indonesia. The quality of local leadership in Indonesia makes me feel confident that their ability to execute and impact lives of patients is very high. The attitude of physicians here is very open and collaborative (vs. more competitive / resentful in China or independent / entrepreneurial in India) and makes a strong platform for team-based approaches to diabetes and chronic disease care. After a wonderful week of research I’m looking forward to staying in touch with a number of contacts here to see how I can help going forward. In reflecting on my experiences in country, the personal connections and relationships here have really made me feel like a part of the process for finding solutions that work in Indonesia. I sincerely hope my professional travels bring be back soon and am eager to stay in touch to support their efforts in the meantime.
تعد من اهم شركات التنظيف في شمال الرياض فهى تقدم كافة خدمات النظافة لسكان شمال الرياض فان كنت عميلنا الكريم تحتاج الى افضل شركة مكافحة حشرات بالدمام فاتصل بنا الان فنحن في خدمتك في اى وقت وفي اى مكان شركة عزل خزانات بالرياض .
ReplyDeleteنصلك داخل الرياض وخارجها ونغطى جميع احياء الرياض ( حي النخيل الشرقي – حي النخيل الغربي – حي الريان – حي الخزامى – حي الروضة الغربي – حي المعذر الشمالي – حي الربيع – حي الغدير الغربي – حي الرائد الشرقي – حي المحمدية الغربي شركة غسيل خزانات بالرياض – حي العقيق الجنوبي – لبن الشيوخ- عفيف – المزاحمية – رماح – حريملاء – ثادق – الدرعية – الغاط – الدوادمى – الزلفي – القويعية – الأفلاج – شقراء – افضل شركة نقل الاثاث بالرياض حوطة بني تميم – الدواسر – – مرات – الخرج – المجمعة – الحريق – السليل – ضرما )
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