Changing Demand Health Services PDF

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HEALTH SECTOR REVIEW
CHANGING DEMAND FOR HEALTH SERVICES
JULY 2014
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AUTHORS:
SOEWARTA KOSEN
TATI SURYATI
ENDANG INDRIASIH
NUGROHO ABIKUSNO
THOMAS WAI-CHUN LUNG
PHILIP CLARKE
3
Acknowledgements
The Report was prepared by a Study Team under the coordination ofNina Sardjunani
(Deputy for Human Resources and Culture, Bappenas) and Arum Atmawikarta (Coordinator,
Health Sector Review Secretariat).
The Study was conducted using various data frombaseline health research in 2007, 2010
and 2013; from the National Institute of Health Research & Development at the Ministry of
Health, Republic of Indonesia; with financial support provided by the Department of Foreign
Affairs and Trade (DFAT), Australia, through the Australia-Indonesia Partnership for Health
Systems Strengthening (AIPHSS).
In addition, we would also like to acknowledge the valuable data used from the National
Socioeconomic Survey 2011 and the Village Potential Survey 2011 from the Indonesia
Bureau of Statistics (BPS).
This study could not have been conducted without the administrative and technical support
from Agus Suprapto, D.D.S., M.Kes., Director of Community Empowerment, Health Policy
and Humanities, at the National Institute of Health Research and Development.
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Table of Contents
Acknowledgements ........................................................................................................... 3
Table of Contents .............................................................................................................. 4
List of Tables ..................................................................................................................... 6
List of Figures ................................................................................................................... 7
Glossary And Abbreviations .............................................................................................. 8
Executive Summary .......................................................................................................... 9
1. Introduction ............................................................................................................. 11
Methods ...................................................................................................................... 13
Sources of Data .......................................................................................................... 14
Strategic Issues ........................................................................................................... 14
2. Situational Analysis.................................................................................................. 16
Communicable Diseases ............................................................................................. 16
Non-Communicable Diseases ..................................................................................... 17
Injuries ........................................................................................................................ 18
Neglected Tropical Diseases ....................................................................................... 18
Frambusia/Yaws .......................................................................................................... 20
Schistosomiasis .......................................................................................................... 20
Risk Factors ................................................................................................................ 22
Access To Health Care Facilities ................................................................................. 25
Utilization Of In-Patient And Out-Patient Services, Indonesia 2013 ............................. 25
3. Challenges .............................................................................................................. 30
Demographic Transition............................................................................................... 30
Epidemiological Transition ........................................................................................... 30
Unequal Progress Of Health Development In Different Regions .................................. 30
Obstacles To Access ................................................................................................... 30
4. Strategy To Respond To These Challenges ............................................................. 31
Health Inequity ............................................................................................................ 31
Implications Of Universal Health Coverage ................................................................. 31
Quality Of Care ........................................................................................................... 31
The Need To Implement Multi-Tier Framework For Service Delivery ......................... 32
5. Projection And Modelling ......................................................................................... 33
6. Policy Direction And Strategies ................................................................................ 44
7. Program And Main Activities .................................................................................... 46
8. Conclusions ............................................................................................................. 48
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References...................................................................................................................... 49
Annex A. ......................................................................................................................... 51
Annex B. ......................................................................................................................... 57
Annex C. ......................................................................................................................... 58
Annex D. ......................................................................................................................... 82
Annex E. ......................................................................................................................... 83
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List of Tables
Table 1. Basic calculations for prediction of total medical costs .................................................39

Table 2. Estimated health care costs for leading causes of disease in 2015 (out-patient)..........40
Table 3. Estimated health care costs for leading causes of disease in 2015 (in-patient) ............40
Table 4. Estimated health care costs for leading causes of disease in 2019 (out-patient)..........41
Table 5. Estimated health care costs for leading causes of disease in 2019 (in-patient) ............42
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List of Figures
Figure 1. Population pyramid, Indonesia, 2015 and 2019.......................................................... 11

Figure 2. Relationships among demographic, epidemiological and health transition .................12
Figure 3. Burden of disease by cause in Indonesia, 1990-2010 ................................................13
Figure 4. CDR, IMR and life expectancy for 2010-2019 ............................................................14
Figure 6. Trends for filariasis cases in 2008-12 .........................................................................20
Figure 7. Number of leptospirosis cases in 2005-12 ..................................................................21
Figure 8. Situation of rabies in Indonesia in 2008-12 .................................................................22
Figure 9. Trends in Risk Factor of diseases, 2007 and 2013 .....................................................23
Figure 10. Prediction of DALYsloss in Indonesia, 2015 and 2019..............................................25
Figure 11. Projected proportion burden of disease by age group in 2015 and 2019 ..................26
Figure 12. Predicted DALYs loss, Indonesia 2010, 2015 and 2019 ...........................................27
Figure 13. Proportion of DALYsloss in 2015 by age group ........................................................28
Figure 14. Proportion of DALYs loss in 2019 by age group .......................................................29
Figure 15. Predicted impact of reduction DALYs lose with 3% joint PAF risk factors
intervention, Indonesia 2019 .......................................................................................34
Figure 16. The difference of DALYs loss with and without risk factors intervention, Indonesia
2019 ............................................................................................................................35
Figure 17. Predicted impact of reduction mortality with 3% joint PAF risk factors
intervention,Indonesia 2019 ........................................................................................36
Figure 18. The difference in mortality cases, with and without reduction of 3% of the joint
PAF risk factors, Indonesia 2019 .................................................................................36
Figure 19. Three model intervention in joint PAF attr to DALYs loss for strokes, IHD, DM,TB
and LRI .......................................................................................................................37
Figure 20. Three Model intervention of Joint PAF attributable to Mortality stroke,IHD,DM,TB
& LRI cases .................................................................................................................38
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Glossary and Abbreviations
BoD : Burden of Disease

CD : Communicable Disease
CDR : Crude Death Rate
COPD : Chronic Obstructive Pulmonary Disease (COPD)
DALY : Disability Adjusted Life Year
DM : Diabetes Mellitus
IHD : Ischaemic Heart Disease
LBW : Low Birth Weight
LF : Lymphatic Filariasis
LRI : Lower Respiratory Infection
MDA : Mass Drug Administration
NCD : Non-Communicable Disease
NTD : Neglected Tropical Disease
URI : Upper Respiratory Infection
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Executive Summary
Indonesia has been undergoing a rapid demographic and epidemiological change over the
past decade, including significant declines in fertility and mortality, as well as dramatic
increasesin life expectancy at birth. Population growth and changesin population structure
are the primary driversbehind increasing demand for health services. Currently
(2013),Indonesias total population is about 249 million, and this is expected to rise to over
255 million by 2015 and then 268 million by 2019. Average life expectancy at birth in 2015
will reach 70.1 years and by 2019 will likely be 70.9 years. In terms of the size of its elderly
population, Indonesia will soon have the fourth-largest elderly population in the world, with
about 21.7 million elderly in 2015, rising to 25.9 million in 2019.
Indonesias transition in health has been influenced by changes in its demographic and
epidemiological character, seen in the changes in urbanization, industrialization, rising
incomes, the expansion of education, and advances in medical and public health technology.
Indonesia has demonstrated solid progress in reducing mortality from communicable
diseases, with the result that the burden of disease attributable to non-communicable
diseases (NCDs) andinjuries resulting in disabilitieshas steadily risen. In 2015, the ten
largest disease burdens were due to cerebrovascular disease, road traffic accidents,
ischaemic heart disease, cancers, diabetes mellitus, tuberculosis, pneumonia, major
depressive disorders, birth asphyxia andbirth trauma, and chronic obstructive pulmonary
disease.
Thus, demand for quality health services, disability management and long-term care,
combined with the increase in GDP per capita (US$3,509.00; IMF 2013), is expected to
increase significantly going forward. The evolution in the demand for quality health services
will drive increasing complexity in the provision of health care services (personnel,
specialization, sophisticated medical equipment and technology) and increasing expenditure
on health care (primary, secondary and tertiary services). With the introduction of
Indonesias national health insurance scheme in January 2014, utilization rates of health
services (in-patient and out-patient) will increase markedly and affect the burden on health
care facilities, as well as the health system as a whole.
The response of the health care system and public policies in view of the demographic and
epidemiological transition will affect the incidence, the characteristics, the distribution, and
the burden of future diseases. Unequal developmental progress across the various regions
and islands of Indonesia, difficult geographic conditions, poor transport infrastructure,
obstacles to access (culture, finance, level of education, availability and distribution of health
care facilities), the availability of health resources (health personnel, drugs, medical
equipment, budget, etc.) will all need to be addressed.
The Government of Indonesia (GoI) at its various levels needs to increase the allocation of
budget for the management of NCDsand injuries, curb the related risk factors, promote
healthy life styles, and strengthen the promotingand preventative roles of primary health care
programs. Curbing key risk factors includes improved tobacco control efforts, salt reduction,
the promotion of healthy diets and physical activity, and the reduction in the harmful use of
alcohol.
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In addition, controlling major risk factors for NCDs, and controlling the existing but neglected
tropical diseases (for example,filariasis, yaws, leprosy and schistosomiasis) and
communicable diseases with a large burden (for example, tuberculosis, diarrheal diseases,
pneumonia, malaria and HIV and AIDS) also need to be prioritized. Also of growing
importance, special preventive efforts by the health sector and other related sectors should
be focused to reduce road traffic injuries.
In order to support the recently launched national health insurance scheme, the results of
the burden of disease analysis in terms of incidence and prevalence of diseases,together
with information on the likely costs per case treated, should be used to forecast the financial
burdens that will be created by the epidemiological transition. Instituting disease expenditure
tracking and linkages to ongoing updates of the burden of disease, and theinstitutionalization
of a health technology assessment program, should also be implemented.
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1. Introduction
The demand for health services in Indonesia is expected to increase significantly in the
coming years. Population growth and changesin population structure in Indonesia are the
primary drivers of increasing demand for health services. Population growth in Indonesia as
reflected by the countrys demographic pyramidmirrors most other developing lower middle-
income countries in the Asia-Pacific region, where the population of 60 year olds and above
is roughly equal to the population of 14 year olds and below. The current (2013) total
population of almost 249 million will rise to about 255 million by 2015 and then to 268 million
by 2019 if the total fertility rate continues to stagnant at the current level.
Population pyramid
Population 2015 Population 2019

70-74 70-74
60-64 60-64
50-54 50-54
40-44 40-44
30-34 30-34
20-24 20-24
10-14 10-14
0-4 0-4
-15.000,00-10.000,00 -5.000,00 0,00 5.000,00 10.000,00 15.000,00 -15.000,00-10.000,00 -5.000,00 0,00 5.000,00 10.000,00 15.000,00
female male female male
Figure 1. Population pyramid, Indonesia, 2015 and 2019
The demographic transition is naturally affected by the overall balance of births and deaths.
Average life expectancy at birth (eo) is also one of the indicators of peoples welfare, and in
2015 this will reach 70.1 years,while in 2019 it should rise to 70.9 years (Indonesian
Population Projection 2010-35).1The demographic transition is also influenced by the
increasing number of elderly people (60 years and older) in the population. Indonesia is
believed to have entered its demographic window of opportunity, but within less than 15
years the population of productive age able to support the elderly population will start to
decreasein otherwords the dependency ratiowithin the population will start to rise. Data
from the Ministry of Social Affairs also show that in 2012 there were 3 million elderly people
who lived alone, or were poor or displaced (Ministry of Social Affairs, 2012). Furthermore,
estimates of the number of elderly with dementia were 960,000 in 2013, and this number is
expected to increase to 1.89 million by 2030 and 3.98 million by 2050.2In the case of the
health sector, this is an opportune moment to invest in human resources qualified in
1
BPS, Bappenas, UFPAN. Indonesia Population Projection 2010-35, Jakarta 2013.
2
Alzheimers Diseases International. World Alzheimer Report 2012: Overcoming the stigma of
dementia. London: Alzheimers Disease International, 2012.
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gerontology and geriatrics, especially at the primary health care level and the referral
system.
Source: W. Henry Mosley, J.L. Bobadilla, and D.T. Jamison. The Health Transition: Implications for Health Policy in Developing
Countries, 1993.
Figure 2. Relationships among demographic, epidemiological and health transition
The health transition is influenced by demographic and epidemiologicalchanges. The

demographic transition is characterized by urbanization, industrialization, rising incomes, the
expansion of education, and advances in medical and public health technology. Along with
the demographictransition and growing industrialization in Indonesia, the epidemiological
transition is characterized by declines in infectious diseases, lower mortality and fertility
rates, and a shift in the structure of the population from the young to the elderly. The
demographic transition causes a more gradual change in the epidemiological transition with
a slow increase in chronic and non-communicable diseases. However, several infectious
diseases still remain highly prevalent, and there is also a surge in the number of injuries from
road traffic accidents due tothe rapid increase in the number of motor vehicles both in urban
and rural areas. Thesediseases and injuries create a double burden on the health sector,
which is exacerbated by the existence of neglected tropical diseases, namelyleprosy, yaws,
filariasis, fasciolopsis, schistosomiasis and intestinal helminths.These burdensare
compoundedby the unfinished agenda of maternal and child health problems. In response to
the changing nature of the burden of disease, the WorldHealth Organization(WHO) and the
World Bankestablishedthe Disability AdjustedLifeYears (DALYs)3Loss method as ameans of
3
The disability-adjusted life year (DALY) is a measure of overall disease burden, expressed as the
number of years lost due to ill-health, disability or early death.
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measuringthe disease burden at regional, nationaland local levels.
Burden of disease by cause in Indonesia, 1990-2010

1990 2000 2010
Non-communicable Non-communicable
Non-communicable
Injuries
Injuries Injuries
7% 9% 9%
37%
49% 33%
43% 58%
56%
Communicable
Communicable
Communicable
Source: IHME
Figure 3. Burden of disease by cause in Indonesia, 1990-2010
An overview ofthe burden of diseaseinIndonesiashows some major changes. In 1990,the

highestdisease burdenwasfor cases ofinfectiousdisease(56 percent) andinjuries (7 percent).
The epidemiological transitionhas resulted inchanges inthe proportion ofthe burden of non-
communicablediseases. In 1990,the proportion ofthe burden ofNCDs was37 percent. Over
thecourse of the decade (to 2000)this proportion rose to49 percent in 2000,and 58 percentin
2010 fromthe totalburden ofdisease.The results of the analysis of the burden of disease
calculations in Indonesias DALYs show a significant increase of several NCD diseases,
namely cerebrovascular disease/stroke, ischaemec heart disease, cancers, diabetes
mellitus, major depressive disorders and chronic obstructive pulmonary disease.
Methods
The methods of the analysis were as follow:
Review of achievement of RPJMN 2010 - 2014. program performance and issues.
Analysis of the demographic and epidemiological transitions.
Analysis of trends, current demand and actual utilization of health care services.
Estimation of the national burden of disease for 2015 and 2019.
Projection and modeling risk factors attributable to DALYs lossand deathsin 2015 and
2019.
Estimation of the need and demand for comprehensive and sophisticated health care
services (promotive,preventive, curative and rehabilitative) in 2015 and 2019, due to
demographic and epidemical transitions, as well as the implementation of National
Health Insurance (JKN) and universal health coverage.
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Analysis of current and projected health service utilization (ambulatory and in-patient
services) and suggested policy options.
Predictiveanalysis ofthe economicimpact, models

ofsimultaneouslyreducingmulticausalriskfactorsand diseases with the highest burden by
2019.
Sources of data
Sources of data for the analysiswere obtained from:
Population census of Indonesia for 2010 and its projections.
RISKESDAS/ Baseline Health Research 2007, 2010, 2013.
RIFASKES/ Health Facility Survey 2011.
National Socioeconomic Survey 2007, 2011.
Seminar on Indonesias BoD (NIHRD & IHME), Ministry of Health,30 April 2013.
Other relevant studies, reports and documentsfrom national and local levels.
35 71,3 71,5
71,2
71,1
30 70,9
70,8 71
life expectancy (e0)

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CDR & IMR
20 70,5
15 69,829,3 70
26 25,5 25,1 24,6 24,2
10
6,4 6,4 6,4 6,4 6,5 6,5
69,5
5
0 69
2010 2015 2016 2017 2018 2019
CDR IMR e0
Source: Indonesia Population Projection 2010-2035, BPS, 2013
Figure 4. CDR, IMR and life expectancy for 2010-19
Figure 4showsthetrends of increasedlifeexpectancyand theCDRfrom2010 to2019;

whileIMRdeclinedfrom29.3per 1,000 population in 2010 to 24.2in 2019. Thesedataserve as a
basisfor predicting thew number ofcases, whileconsidering thenumberof
newcases(incidence) and therate ofexposurefor eachdiseasein thepopulation.
Strategic issues
The strategic issues to be discussed, analyzed and interpreted in this report include:
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Demographic and epidemiological transitions in Indonesia.
Different pace of transition indifferent areas in Indonesia.
Changing epidemiological profile, as shown by the increasing prevalence of non-

communicable diseases and injuries.
Controlling risk factors forNCDs,whichis essentially theimpactofadverse

healthbehaviours.
The unfinished agenda of neglected tropical diseases, existing communicable diseases,

and maternal neonatal and child health issues (the latter to be reported in a separate
report).
Fulfilling the demand for health and health services.

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2. Situational Analysis
Communicable Diseases
Communicable diseases are spread from one person to another or from an animal to a
person. Spreading often occurs via airborne viruses or bacteria, but can also occur through
blood or other bodily fluids.People of all ages can get diarrhea. The symptoms of diarrhea
are loose, watery stools, and passing loose stools three or more times a day. The incidence
of diarrheal disease among under-five children on average was 6.7 percent in 2013. The
province with the lowest incidence of diarrhea was East Kalimantan (3.3 percent) and the
highest incidence was in Aceh (10.2 percent).
The incidence and prevalence of malaria were 1.9 and 6.0 per 1,000 population,
respectively, in 2013. The province with the lowest prevalence was Riau (0.2 per 1,000
population) and the highest prevalence was Papua (27.0 per 1,000 population). The national
Annual Parasite Incidence (API) decreased from 4.68 per 1,000 population in 1990 to 3.62 in
2000, 1.96 in 2010 and 1.69 in 2012, while the API target in the RPJMN is to acheieve 1.00
per 1,000 population by 2014. The province with the lowest incidence of API is Central Java
(0.3 per 1,000 population) and the highest prevalence is West Papua (39.5 per 1,000
population).
Theprevalence of pneumonia in the last four weeks (diagnosed by health personnel) for all
ages in 2007 and 2013 were on average 6,3 and 2,0 per 1,000 population, respectively.In
2013, the prevalenceof pneumonia in the last four weeks was high forunder-five children,
with an average of2.4 per 1,000 population.The highest prevalence for under fives in the last
four weeks found in Aceh Province(6,1 per 1,000).It is predicted that the increasing number
of the elderly will have an impact on the increased incidence of pneumonia cases.
Until recently,cases of tuberculosisinIndonesiawere still high. Prevalence of tuberculosis in

all ages (diagnosed by health personnel) in thepast 12 months was 0.4 % in 2013.The
province with the lowest prevalence was Bali (0.1 percent) and the highest prevalence was
West Java (0.7 percent). The case detection rate of tuberculosis has increased and the
success rate (SR) has remained almost the same between 2004 and 2014. The case
detection rate was 89.5 percent in 2004 and 90.8 percent in 2014, while the SR remained
similar at 89.5 percent in 2004 and 90.8 percent in 2014. The proportion of the population
covered by the national tuberculosis program was 56.2 percent on average in 2013. The
coverage of the tuberculosis program was the lowest in Riau (30.0 percent) and the highest
in West Java (65.0 percent).
The prevalence of hepatitis for all ages, diagnosed by health providerin the past 12 months,
on average increased from 0.6 percent in 2007 to 1.2 percent in 2013. The province with the
lowest prevalence was East Kalimantan (0.3 percent) and the highest prevalence was East
Nusa Tenggara (4.4 percent).The proportionof the various strains of hepatitisbased onthe
surveyshowedhepatitisA at 19.3 percent, hepatitisBat 21.8 percent, hepatitisCat 2.5
percent,andothertypes ofhepatitis at 1.8 percent.
The number of HIV and AIDS cases increased between 2005and 2012. In 2005,there were
859 HIV cases, while AIDS cases stood at 4,973. The communicable disease program
datain 2010 show a sharp increase inthe number ofHIV casesto 21,591cases. In 2012,the
numberof HIV casesdecreased slightly to 21,511cases,while the number ofAIDS casesrose
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to 5,686. The proportionof AIDS patientsin 2012showed51.5percentmale, and the

percentage of cumulative AIDS cases in 2012 was highest in the age group 20-29 years
(35.2 percent), the age of 30-39 years (28.1 percent)and 40-59 years (10
percent).Riskfactorsassociatedwith HIV casesinIndonesia,based on 2010-12data, were as
many as 50 percentdue toheterosexual transmissions, 11percentdue to thesharing of
needles,and7percentdue tohomosexual relations.
Non-Communicable Diseases
Chronic and non-communicable diseases (NCDs) are the number one cause of death and
disability in many countries. The major NCDs, which are responsible for almost two-thirds of
deaths annually, are: cardiovascular diseases, cancers, chronic respiratory disease and
diabetes.4 In addition to information about NCD-related deaths, morbidity data are important
for the management of health-care systems and for planning and evaluation of health
service delivery system.5
The prevalence of strokesin 2007 and 2013 was on average 8.3 and 12.1 per 1,000
population, respectively, with male strokepatients higherthan females.The province with the
lowest prevalence was Riau (5.0 per 1,000 population) and the province with the highest
prevalence was South Sulawesi (18.0 per1,000 population). Within the age group45-
54years, theprevalenceof strokecases(based on diagnosis and
symptoms)reached16.7per1,000 population, and with increasingagethe prevalence could
rise until67.0per 1,000 population.
Prevalence of diabetes mellitus in 2007 and 2013 was on average 1.1 and 2.1 percent,
respectively. The province with the lowest prevalence was Lampung (0.8 percent) and the
highest prevalence was Central Sulawesi (3.8 percent).Diabetes mellitusprevalenceis
higherin women than in men. Inold ageprevalence starts to rise, with the highestprevalencein
the 55-64yearage group, when it reaches5.5percent.
The prevalence of musculoskeletal disease in the population (above age 15) based on a
diagnosis by a health provider,decreased in 2013 compared with 2007, with rates of 24.7
and 30.3percent, respectively. Musculoskeletal diseaseprevalenceis higherin
womenthanmen.The province with the lowest prevalence was Riau (12.0 percent) andthe
highest prevalence was East Nusa Tenggara (32.0 percent).
The prevalence of cancersper 1,000 for all ages based ondiagnosis by a doctor in 2013 was
on average 1.4 per 1,000 population. The province with the lowest prevalence was
Gorontalo (0.1 per 1,000 population) and the highest prevalence was Yogyakarta (4.2 per
1,000 population). The typesof cancerbasedon respondentsinformation (all ages) and
diagnosedby adoctor were asfollows: 8 per 1,000cervicalcancer, 5 per 1,000breast cancer, 2
per 1,000prostate cancer, 0.6 per 1,000lymphatic cancer, 0.5per 1,000colo-rectal cancer, 0.4
per 1,000nasopharingeal cancer,0.4 per 1,000pulmonaryandbroncial cancer, and 0.2 per
1,000leukaemia.The proportion of women with cancerswas threetimes higher than for men.
4
Global Health. Non-Communicable Diseases Website. http://www.globalhealth.gov/global-health-
topics/non-communicable-diseases/index.html. Accessed May 19, 2014.
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The prevalence of mental disease in the population (aged 15 years and above) in 2013 on
average was 6.0 percent. The province with the lowest prevalence was Lampung (1.2
percent) and the highest prevalence was Central Sulawesi (11.6 percent). The prevalence of
severe psychosis for all ages in 2013 was 1.7 percent on average. The province with the
lowest prevalence was West Kalimantan (0.7 percent) and the highest prevalence
wasYogyakarta (2.7 percent).
The prevalence of chronic renal failure in the populationaged 15 years and above in 2013
was 0.2 percent on average. The province with the lowest prevalence was Jakarta (0.05
percent) and the highest prevalence was Central Sulawesi (0.45 percent).
The prevalence of coronary heart disease in the population aged 15 years and above in
2013 was0.5 percent (with women higher than men).At the age group of 65 to 74 years,the
prevalence increasedto 2,0 percent.The province with the lowest prevalence was Riau (0.2
percent) and the highest prevalence was Central Sulawesi (0,8 percent).
The prevalence of chronic obstructive pulmonary disease (COPD) in the population aged
above 30 years in 2013 was 3.7 percent. The prevalence among males was 4.2 percent, and
for 75 yearsand above the prevalence increased to 9.4 percent. The province with the lowest
prevalence was Lampung (1.8 percent) and the highest prevalence was East Nusa Tenggara
(9.6 percent).
Injuries
According to the Global Burden of Disease study 2010, road traffic injuries (RTIs) were
responsible for over one-third of the worldsentire injury burden. If no significant action is
taken to curb RTIs, this burden is predicted to rise.6 In Indonesia, the prevalence of injuriesis
also rising, and increased from 7.5 percent in 2007 to 8.2 percent in 2013. The province with
the lowest prevalence was Jambi (4.4 percent) and the highest prevalence was South
Sulawesi (12.4 percent)(Balitbangkes, 2013).
In terms of external causes of injury, most injuries were the result of falls (40.9 percent) and
motorcycle accidents (40.6 percent), followed by exposure to sharp objects (7.3 percent).
Places where injuries occurred in 2013 in descending order were: highways, at 42.8 percent;
the home, at 36.5 percent; agricultural areas, at 6.9 percent; schools, at 5.4 percent; sports
areas, at 3.5 percent; public areas, at 2.3 percent; industrial areas, at 1.8 percent; and
others at 0.8 percent.Survey datashowthat 43percentof motorcyclistswere not wearing
helmets at the time of their accident, while 5.6percentwere wearing helmetsbutthese were
notstrapped, while 1.2percentwere usinginferior quality helmets.
Neglected Tropical Diseases

The Government of Indonesia has demonstrated its awareness of the important burden of
neglected tropical diseases (NTDs). National plans and policies have been developed to
6
Hyder. A. A, Prasanthi P & Allen AK. WISH Road Traffic Injury Report 2013, Road Traffic Injury and
Trauma Care: Innovations For Policy (Road Trip),Website. http://www.wish-qatar.org/app/media/388.
Accessed March 20, 2014
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fight leprosy, lymphatic filariasis (LF), schistosomiasis, soil-transmitted helminths (STH) and
yaws.7 The neglected tropical diseases (NTDs) are a group of infectious diseases that
primarily affect the poorest sections of society, especially the rural poor and the most
disadvantaged urban population. Over the past five years three of these diesases,namely
leprosy, lymphaticfilariasis, and yaws, havebeen targeted for elimination.These diseases not
only affect large numbers of the population,but also give rise to high mortality and morbidity;
they also affect peoples productivity and social lives. Moreover, most of them are strongly
feared in the population and are the source of social stigma and prejudice and, as a result,
are often hidden, and therefore poorly documented.
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9,5 9,4 9,6 9,6
10 9,1
per 100.000 population
8,4
8 8,3
7,8 7,6 7,5
6 7,2
6,6
4
0
2007 2008 2009 2010 2011 2012
Incidens Prevalence
Source: DG of Control Diseases & Environmental Health, MoH 2013
Figure 5. Trends for leprosy per 100,000 (2007-12)
Figure 5 shows the trends in leprosy from 2007 to 2012. The data monitoring program
showsthat the number ofcases ofleprosyinfive provinces(Jakarta, WestJava, CentralJava,
Yogyakarta, and EastJava)in 2007 was 566. This level declineduntil 2009(when the number
of cases wasjust 335), but increasedagainthrough 2011 withthe number ofcases
reaching855.8
7
MoH &WHO, Neglected Tropical Disease in Indonesia: An Integrated Plan of Action Ministry of Helth
Indonesia 2011-2015.
8
MoH, Ditjen PPPL, 2013.
20
12.100 12.066
11.969
12.000
11.914 11.903
11.900
cases
11.800
11.699
11.700
11.600
11.500
2008 2009 2010 2011 2012
Number of cases
Source: DG of Control Diseases & Environmental Health, MoH 2013
Figure 6. Trends for filariasis cases in 2008-12
The GoI has decreed that the elimination oflymphatic filariasis is one of its priorities in
fighting communicable diseasesunder Presidential Decree No.7/2005, and has agreed to
participate in the international goal launched by WHO to eliminate lymphatic filariasis as a
public health problem by 2020. The filariasis programs objectives are to reduce and
eliminate the transmission oflymphatic filariasis bymass drug administration (MDA), and to
reduce and prevent morbidity in those affected. In 2009, MDA with diethylcarbamazine
(DEC)+albendazole covered more than19 million people in 30 percent oftheendemic
districts, with an average rate of program drug coverage at 66.5 percentinthe population
atrisk withindistricts. Figure6 shows thatthe number of lympatic filariasis cases increased in
2008-11 but has declined from 2012 onwards.
Frambusia/Yaws
Yaws, also known as frambusia, is transmitted primarily through skin contact with an infected
person. A single skin lesion develops at the point of entry of the bacterium after 2-4 weeks. If
left untreated, multiple lesions appear all over the body. Although fatal casesare rare, yaws
can lead to chronic disfigurement and disability.9 Yaws is the most common of these tropical
infections, occurring mainly in poor communities in warm, humid forested areas. While the
prevalence rate was less than 1 per 100,000 population and the disease does not cause
death, the GoI has agreed to eradicate yaws by 2020.
Schistosomiasis
Schistosomiasis is a disease common amongst the poor that leads to chronic ill-health.
Infection is acquired when people come into contact with fresh water infested with the larval
9
WHO, Yaws and other endemic treponematoses. Website http://www.who.int/yaws/en/ accessed
May 2, 2014
21
forms (cercariae) of parasitic blood flukes, known as schistosomes.10The diseaseis endemic

in the Lindu Valley (Sigi district), Napu and Bada Valleys (Poso district), all of them in Central
Sulawesi, with populationsatrisk of 25,000 to 50,000.In the area, schistosomiasis occurs not
only in humans, but also in mice and snails. Schistosomiasis prevalence in humans in 2008-
12increased, with over 1 percent of the populationinfected in 2012. The prevalence is still
rising due to the behaviour of people in not wearing footwear.
900 857 16
13,91
800 14
12,13
700 664
10,51 12
number of cases
600 9,59 9,57

8,58 10
500 426 6,87 409 8
400 335
5,16
6
300 239
200 145 4
115
57 82 2
100 16 22 23 43 29
14
0 0
2005 2006 2007 2008 2009 2010 2011 2012
No of cases No of mortality cases CFR %
Source: DG of Control Diseases & Environmental Health, MoH RI, 2013
Figure 7. Number of leptospirosis cases in 2005-12
Data from the CDC program show that number of leptospirosis cases increased from 2005
(115 cases) until 2012(239 cases). Overthisperiod, there were two pointsin time (2007 and
2011) when the numbers of cases surged to 664 and 857, respectively. The fatality rate has
remained high, albeit declining from 13.9 percent in 205 to 12.1 percent in 2012.
10
WHO, Schistosomiasis: A major public health problem. Website:
http://www.who.int/schistosomiasis/en/ accessed May 2, 2014
22
90000 84010 84750 250

78574
80000 195 74331
206 184 71843 200
70000
Number of Lyssa cases

63658
Cases GHPR & PET
60000
137
122 150
50000 45466
40000 35316
100
30000
21245
20000 14683 50
10000
0 0
2008 2009 2010 2011 2012
GHPR PET Lyssa Casus
Source: DG of Control Diseases & Environtmental Health, MoH RI, 2013
Figure 8. Situation of rabies in Indonesia in 2008-12
Based on CDC data, cases of rabies infections increased due to to animal bites. In 2008,
21,245 cases were reported, with this rising in 2012 to 84,750 cases. Post-exposure
treatment in 2008 totalled 14,683 cases, rising to 74,331 cases in 2012.
Risk factors
The increasingprevalence of NCDsinIndonesia is partly caused by the shift from an
agriculturalsocietytowards a more industrial/urban era. This gradual shift has affected
peoples behaviour and has a generally negative impacton health. Although some risk
factors in NCDs are caused by modifiable risk factors, intervention is generally not
straightforward when this is only administered by health personnel. What is also needed is
inter-sectoralsupportfrom outside the Ministry of Health, including the private sector and local
community support.
Baseline Health Research data from 2007 and 2013 show an overview of risk factors in the
population. Blood pressure steadily increases with age, except in people with relatively lower
salt intake, higher levels of exercise, normal body weight and non-consumers of alcohol.
Consistently high blood pressure produces structural changes in the blood flow of the brain,
heart, kidneys and other organs. Prevalence of hypertension (above 140/90 mm Hg) was
found 31.7 percent of the population in 2007 and 25.8 percent in 2013. Further validation
exercise showed that the difference is due to differences of the blood pressure equipment
used.
23
Figure 9.. Trends

Trend inrisk factors of diseases, 2007 and 2013
Cholesterol levels are influenced bydiets

by highin saturated animal fats, heredity factors, and
various metabolic disorders such as diabetes. Cholesterol rises steadily with age, more so in
women than in men,, and stabilizes in middle age. Cholesterol increases the risk of suffering
from ischaemic
emic heart disease, strokes,, and other vascular diseases. Globally, high
cholesterol causes 18 percent of cerebrovascular disease mostly of a non-fatal
non type and 56
percent of ischemic heart disease.
Being overweight orsuffering from obesity causes hypertension, high cholesterol and
triglycerides and insulin resistance. It brings high risks of coronary heart disease, ischemic
type strokes and diabetes. It also increases the risk of cancers of the breast, prostate,
endometrium, kidney and gall bladder. It also increases
increases the risk of osteoarthritis, a major
cause of disability.
Fruit and vegetables are important components of a healthy diet. Data suggest that they
prevent major diseases, such as cardiovascular disease and cancers,
cancer mainly of the digestive
type. Fruit and vegetables contain many micronutrients and antioxidants, such as flavonoids,
carotenoids, Vitamin
itamin C, folic acid and fiber.
Global estimates of physical

hysical inactivity for adults average at about 17 percent,
percent ranging from
11 to 24 percent across subgroups. Physical activity reduces the risk of cardiovascular
disease, cancers (especially
especially colon and breast) and diabetes. Physical activity can improve
musculoskeletal health, body weight, while also reducing the incidence of depression,
anxiety and stress. The prevalence
revalence among theIndonesian population (10 years and above)
who were lack of physical activity was 26.1 percent in 2013. The prevalence p in the
population(above
(above 10 years of age) wholackphysical activity based on demographic de
characteristics was26.3
26.3 percent among men and slightly fewer women, at 25.8 percent.
Educational status was an important factor: those with no schooling were the most likely not
to do any physical activity, at 32.9 percent,while
,while the lowest level of inactivity was seen in
primary school graduates, at 23.2 percent. Those living in urban areas were more likely to be
inactive, at 28.2 percent,, while those in rural areas were less likely to be inactive, at 23.9
percent. Those who were unemployed registered no physical activity, at35.9 at percent, far
24
higher than laborers, only 13.4 percent of whom were physically inactive. Those in the
highest social economic level registered inactivity at 30.8 percent, significantly higher than
those in the lowest economic level, at 23.8 percent.
The prevalence in the population (above 15 years of age) who smoke or chew tobacco on
average increased from 34.2 percent in 2007 to 36.3 percent in 2013. The province with the
lowest prevalence of smoking and tobacco chewing was Bali (15 percent) and the highest
prevalence was East Nusa Tenggara (50.0 percent).
The prevalence in the population (above 10 years of age) whodo not consume sufficient
quantites of fruit and vegetables on average was 93.5 percent in 2013. The province with the
lowest prevalence wasYogyakarta (84.0 percent) and the highest prevalence was South
Kalimantan (98.0 percent).
The proportion of households following healthy lifestyles (PHBS) on average was 32.3
percent. The province with the lowest prevalence of PHBS was Papua (20.0 percent) and
the highest prevalence was Jakarta (58.0 percent). The proportion of households
implementing the 10 indicators fora healthy lifestyle were (in descending order):
Birth delivery by a health provider: 87.6 percent
Good clean water source: 82.2 percent
Toilet facilities 81.9 percent
No in-door smoking: 78.8 percent
Use of water in container for washing: 77.4 percent
Weighing of under-five children: 68.0 percent
Daily physical activity: 52.8 percent
Regular hand washing: 47.2 percent
Exclusive breast-feeding: 38.0 percent
Daily vegetable and fruit consumption: 10.7 percent
The proportion of households with access to improved toilet facilities increased from 40.3
percent in 2007 to 59.8 percent in 2013. Access to improved toilet facilities increased by
around 50 percent over the same period.
Indicators of exclusive breastfeeding and daily vegetable and fruit consumption were very
poor and showed the quality of continuum of care services from infancy to adulthood based
on the lifecycle approach. Access of households to improved drinking water increased from
62.0 percent in 2007 to 66.8 percent in 2013. The province with the lowest prevalence was
Riau islands (25.0 percent) and the highest prevalenceswere Bali and Yogyakarta (at around
80.0 percent, respectively).
25
Access to Health Care Facilities

Villages access tohealth-care facilities was very difficult according to respondentsfor3.6
percent to access a sub-health centre; 4.4 percent to access a health centre; 8.9 percent to
access a mid-wife practice; 11.6 percent to access a hospital; and 14 percent to access a
village clinic. Meanwhile, respondents said it was difficultfor 10.2 percent to access a sub-
health centre; 12.8 percent to access a mid-wife practice; 13.1 percent to access a health
centre; 16.6 percent to access a village clinic; and 21.8 percent to access a hospital;
Most communities inrural areas(34.6percent) could reachthe nearest governmenthospitalin

30-60minutes, 33.4percent of people could reach onein more than60minutes, while
25.6percent of people could reach onewithinjust 15-30minutes. In thelowesteconomic
group(quintile 1), the majority ofpeople(40.6percent) could only reach a public hospitalin
over60minutes. Most peoplein urban areas(41percent) could reach a government
hospitalwithin16-30minutes.
Most of the population(65.6percent) could reach a community health centrein

lessthan15minutes. However,10.1percent of the population inquintile1(the lowest income)
could only reach acommunity health centrein over 60minutes.The majority of the
populationspent moneyfor transportationto governmenthospitalorhealth centre of the order of
up to Rp10,000.
Utilisation of In-patient and Out-patient Services, Indonesia 2013

On average, the utilization of in-patient services of hospitals in 2013 was 2.3 percent of the
total population per year and for out-patient services was 10.4percent of the total population
per month. The province with the highest utilization was Yogyakarta with in-patient service of
4.5percent and out-patient service of 17percent. The province with the lowest utilization was
Bengkulu with in-patient service of 4percent andout-patient service of 1percent.
Indonesias burden of disease (BoD)
2015 2019
Injuries; Injuries;
12,6% 12,3%
Communicabl
e Diseases;
30,3%
Communicabl
e Diseases;
28,3%
Non
Non
Communicabl
Communicabl
e Diseases;
e Diseases;
59,3%
57,1%
Figure 10. Prediction of DALYslossin Indonesia, 2015 and 2019
The results of the burden-of-disease analysis show that the highest proportion of DALYs
lossis from NCDs, and that this increased from 57.1 percent (DALYs loss of 38.6 million) in
2015 to 59.3 percent (DALYs loss of 42.6 million) in 2019. The burden of communicable
26
disease is expected to decrease from 30.3 percent in 2015 to 28.3 percent in 2019. Injuries
are also expected to decreasemarginallyfrom 12.6 percent in 2015 to 12.3 percent in 2019.
The burden of injuries will alsoincrease from 8.50 million in 2015 to 9.30 million DALYs lossin
2019.
Proportion burden of disease by causes Proportion burden of disease by

and age group, Indonesia, 2015 causes and age group, Indonesia, 2019
2% 1%
2%
100% 4% 1% 100% 4%
1% 1%
90% 21% 90% 21%
80% 41% 80% 41%
70% 70%
60% 60%
14% 51% 84% 94% 14% 51% 85% 94%
50% 97% 50% 97%
40% 40%
30% 30%
20% 45% 20% 44%
28% 28%
10% 10%
12% 11%
0% 5% 0% 5%
0-4 5-14 15-44 45-59 60+ 0-4 5-14 15-44 45-59 60+
CDs NCDs Injuries CDs NCDs Injuries
Figure 11. Projected proportion burden of disease by age group in 2015 and 2019
Figure 11showsthatchildren aged under fivewill be 97percentdominated

bycommunicablediseases,while the proportion of CDs will tend to decline with increasing
age. Conversely, NCDs are dominated by the older age group, declining in the younger
agegroup. Injurieshave the highestproportionin the group aged5-14 years and declines with
increasingage.
27
Figure 12. Predicted DALYs loss, Indonesia, 2010, 2015 and 2019
The burdenof disease (DALYs loss) in2010showed that6out of 10 diseases causing a

highburden of disease were NCDs. In 2015, 7out of 10 diseases with a high burden of
disease were NCDs, and these levelsare expected to continue until 2019.Cerebrovascular
disease or strokeshad the highest burden of disease in Indonesia in 2010 and are predicted
to remainat the same level through to 2019.
Tuberculosis showed the second-highest burden of disease in 2010, and is projected to

further decline to the sixth rank in 2015 and then seventh rankby 2019.Road traffic accidents
will becomethe second-highestranking burden of diseasein 2015 and thethird-
highestrankingin 2019.
28
Hearing loss, adult onset

Pertussis
Violence
Dengue
Cirrhosis of the Liver
Appendicitis
Abortion
Obsessive-compulsive disorder
Vision disorders, age related
STD excluding HIV
Asthma
Migraine
Upper Respiratory Infections
Drowning
Measles
COPD
Cerebrovascular disease
Protein-energy malnutrition
Major Depressive Disorders
Diabetes Mellitus
Cancer
Diarrhoeal Diseases
Tuberculosis
Ischaemic heart disease
Low birth weight
Birth asphyxia and birth trauma
Lower Respiratory Infections
Road traffic accidents
0% 10% 20% 30% 40% 50%
0-4 5-14 15-44 45-59 60+
Figure 13. Proportion of DALYsloss in 2015 by age group
Figure 13showsthe estimated proportion ofthe burden of diseasein2015by age group. In

children aged up to 4 years, the highestproportion ofDALYsloss is due to birth asphyxia and
birth trauma (25 percent), followed by lowbirthweight(24percent), protein-energy malnutrition
(12percent), diarrhoeal disease (7percent),upperrespiratory infection(6percent) and
lowerrespiratoryinfection(5percent).There are alsocases ofmeasles,
tuberculosisandviolence, at about 3percent. The burden ofdiseasein the 60 year old and
above age groupis dominatedbycasesof strokes, COPD, ischaemicheart disease, cancers,
migraines, visiondisorders, diabetes, tuberculosis, lower respiratory
infectionandmajordepressive disorders.
29
Meningitis
Hearing loss, adult onset
Vision disorders, age related
Abortion
Obsessive-compulsive disorder
STD excluding HIV
Pertussis
Asthma
Cirrhosis of the Liver
Violence
Dengue
Appendicitis
Upper Respiratory Infections
Drownings
Measles
COPD
Protein-energy malnutrition
Major Depressive Disorders
Diabetes Mellitus
Cancer
Tuberculosis
Diarrhoeal Diseases
Ischaemic heart disease
Low birth weight
Birth asphyxia and birth trauma
Lower Respiratory Infections
Road traffic accidents
0 0,1 0,2 0,3 0,4 0,5

0-4 5-14 15-44 45-59 60+
Figure 14. Proportion of DALYs loss in 2019 by age group
Figure 14 shows the estimated proportion ofDALYslossby age groupin 2019, with almost
similar results to 2015. The burdenof disease in the age group of60years and aboveis due to
strokes (30percent), ischaemic heartdisease (8percent), COPD (8 percent), cancers
(5percent), diabetes mellitus (4 percent),majordepressivedisorders (3 percent) and lower
respiratory infection (2percent).
30
3. Challenges
Demographic Transition
Predicted life expectancy at birth in 2015 will be 70.1 years and in 2019 will rise to 70.9
years (Indonesian Population Projection 2010-35). The number is being pushed steadily
higher by the increasing number of elderly people (60 years and older), who will total 21.7
million in 2015 and 25.9million in 2019.
Ministry of Social Affairs data show that in 2012 there were 3 million elderly people who live
alone, or who are poor or displaced (Ministry of Social Affairs, 2012). Estimates of the elderly
with dementia totalled 960,000 in 2013, and this number is expected to increase to 1.89
million by 2030 and 3.98 million by 2050 (World Alzheimer's Report, 2012).
Epidemiological Transition
The growing number of NCDs and injuries needs more sophisticated services and better
trained health personnel. Projected numbers of NCDsand injuries in 2015 will be about 112
million and 2.7 million, respectively, rising to about 121 million and 2.8 million, respectively,
in 2019. This will add a major burden to the Indonesian health care system, and there is
therefore an urgent need to control major risk factors for these diseases/conditions in order
to lower the disease burden.
Unequal progress of health development in different regions

Some areas of Indonesia are located in isolated, remote or border areas with poor transport
facilities. These areasneed to be managed differently, as the pace of the demographic and
epidemiological transition will not necessarily be the same as in more developed area.
Obstacles to access
In addition, factors such as culture, economic conditions, levels of education, the availability
and distribution of health care facilities, and the availability of quality health resources (health
personnel, drugs, medical equipment, laboratory facilities, and standard procedures) may all
influence access. In this case, the private sector should be encouraged to become a more
important plater in meeting the increasing demand for health services.
Overall health spending (both private and public) is still low by international standards, and
much of current public sector health spending is more devoted to curative care
Law No.36/2009 on Health provides guidance to central and local governments on allocating
sufficient budgetsto the health sector (5 percentat the central level and 10 percent atthe local
level). A revised government regulation on the division of authority between central,
provincial and district/city governments regulates the obligatory public health functions and
minimum service standards, includingpublic goods and private goods activities.
31
4. Strategy to Respond to These Challenges
Several approaches are recommended to respond to the current situation:
There is a need to estimate future demand for health services, including renovation and
construction of new health facilities at the primary and secondary levels, raising the
staffing levels of health personnel, medical and laboratory equipment, drugs, transport
facilities for outreach activities, a referral system and operational costs.
It is necessary to improve the role of the private sector in providing health care and
formulatinga cooperation mechanism between public sector and private sector health
care facilities.
Better planningof the health care financing systemis required, as well as anticipating the
financial implications of the implementation of the universal coverage of National Health
Insurance.
Equity in accessing health care needs more attention and should be closely monitored
and improved.
Health care system efficiency is required at various levels of the system.
Health Inequity
Significant health inequity exists in Indonesia due to differences between urban and rural
areas, geographic locations, physical infrastructure, socio-economic conditions, education
levels, and levels of development. Those who are better off show a higher health status and
are found mostly in urban areas. In order to prioritize public goods interventions, the Ministry
of Health needs to ensure the full implementation of obligations forpublic health functions
and minimum service standards.A policy that pursues the universal availability of high-quality
primary health care needs to be developed by improving primary and secondary care
facilities based on evidence.
Implications of Universal Health Coverage

The need for beds and skilled manpower will Increase significantly with the implementation
of Universa Health Coverage.
The forces at work include:
Increase in demand for treatment, especially hospitalization.
Shift in demand to expensive chronic diseasesand NCDss, e.g., cancers, heart disease,
strokes.
Increase in demand for high-quality in-patient and out-patient care, including referral
services.
Quality of Care
Quality of care can be assessed using the Institute of Medicines Six Elements of Quality
(2001), consisting of:
32
Patient safety. Are the risks of injury minimal for patients in the health system?
Effectiveness. Is the care provided scientifically sound and neither under-used nor over-
used?
Patient centeredness. Is patient care being provided in a way that is respectful and
responsive topatients preferences, needs, and values? Are patients values guiding
clinical decisions?
Timeliness. Are delays and waiting times minimized?
Efficiency. Is waste of equipment, supplies, ideas, and energy minimized?
Equity. Is care consistent across gender, ethnic, geography, and socioeconomic

conditions?
The need to implement Multi-Tier Framework for Service Delivery

This framework comprises effective coverage, and equity and efficiency of service delivery.
Effective coverage consists of accessibility and quality.
Accessibility consists of physical characteristics, waiting times and affordability.
Quality consists of safety, effectiveness, appropriateness, and adequacy.
Efficiency consists of technical efficiency (efficiency of infrastructure, productivity of human

resources, use of pharmaceuticals).
33
5. Projection and Modelling
About 45percent of the causes of globalmortalityandthe burden of diseasesinthe worldare

causedby a combination of19risk factorsthatcanbe modifiedorare non-modifiable.11The
cohortstudieson the relationshipof eight individualriskfactorswith the incidenceof ischaemic
heart disease have proven the previous observations.12
Predictivemodelingeffortsundertaken toimplement multiplerisk-

factorinterventionssimultaneously have been developed. The modelselectsriskfactorsthat
have an impact on the diseases that include the 10highestburdens (DALYsloss) in
Indonesiain 2019, namely strokes, ischaemic heart disease, road traffic accidents, cancers,
diabetes mellitus, lower respiratory infections, tuberculosis, and major depressive disorders.
Efforts to reduce the burden of disease by 2019 should be focused on NCDs and selected
infectious diseases by intervening in the risk factors associatedwith the incidenceof these
disease,andthat could potentiallylead todeath. These include: hypertension, lack of physical
activity, tobacco use, low dietof fruit and vegetables, high cholesterol, high fasting plasma
glucose, and household air pollution. Modelling is conducted with five intervention scenarios
(a combination of seven risk factors)in order to decrease the number of productive years lost
(DALYs loss), as well as decreasingthe number of deaths by 2019. Efforts to lower the
percentage of the five risk factors associated with the incidence of the diseases are made by
a 3 percent, 5 percent and 10 percent scenario of Joint PAF (Population Attributable
Fraction) to decrease attributable risk to DALYs lossand mortality in 2019. Modeling results
are then compared with the predictions of DALYs loss and deaths in 2015 and 2019 with no
interventions.
Risk factor intervention models are as follows :
Combined 7 variables:
Hypertension, tobacco consumption, low diet of fruit and vegetables, household air
pollution, low physical activity, high cholesterol, and high fasting plasma glucose.
Combined 5A variables:
Hypertension, low diet of fruit and vegetables, low physical activity,

tobaccoconsumption, and high fasting plasma glucose.
Combined 5B variables:
Hypertension, low diet of fruit and vegetables, tobacco consumption, household air
pollution,and low physical activity.
Combined 4A variables:
11
Lopez Alan, murray CJ , 2006Global and Reagional burden disease and risk factors, 2001:
systematic analysis of population health data, Lancet ;vol 367: May 2006.p. 1747-57
12
Majid Ezzati, Alan D.Lopez, Anthony Rogers, C.Murray (2004), Comparative quantification of
Health Risks GBD attributable to selected Major Risk Factors, WHO vol-2, 2004, p.1-2248,
Switzerland.
34
Hypertension, low diet of fruit and vegetables, tobacco consumption, and household air
pollution.
Combined 4B variables:
Low diet of fruit and vegetables, tobacco consumption, householdair pollution, and
low physical activity.
Results of modelling the intervention of risk factors attributable to BoD (DALYs loss),
Indonesia 2019
600
500
400
300
200
100
-
thousand stroke IHD DM TB LRI total
7 var 200 126 116 9 27 479 7 var
4A var 208 122 116 5 27 478 4A var
4B var 180 119 116 9 8 432 4B var
5A var 206 123 116 9 8 462 5A var
5B var 209 208 116 5 8 547 5B var
Figure 15. Predicted the impact of the reduction DALYs loss with 3% Joint PAF risk factors
intervention, Indonesia 2019
Figure 15 shows theresults ofmodelinga 3 percentreductionin theriskfactorsthatcan be

modifiedsimultaneously. Modeling 5Bshowsthe results ofthe mostsignificantimpactof
interventionsandis predicted todecrease the DALYs loss (thelossof productiveyears) by as
many as547,000years.If theinterventioniscarried outbased on Model4A,there are
combinedrisk factorsof hypertension, low diet of fruit and vegetables,tobaccoconsumption,
and household air pollution, thepredicted impact ofthe resultsare fewer declinesthan Model
5B (478,000productive yearslost).
Interventionswithallseven types ofrisk factor variables willgreatlyimpact on

theDALYslosstostrokes, ischaemic heart disease anddiabetes. The impact
ontuberculosisand lower respiratory infections (LRI) is low due to the effective
concomitantriskfactorsincludingonlytwovariables: namely tobaccoconsumptionandhousehold
air pollution. However, for tuberculosisthese variables aretobaccoconsumptionand high
fasting plasma glucose.
35
LRI
no intervention 2019
TB DALYs 2015
DM 5B variabel
5A variabel
IHD
4B variabel
stroke 4A variabel
7 variabel
- 1.000 2.000 3.000 4.000 5.000 6.000 7.000 8.000
stroke IHD DM TB LRI

no intervention 2019 7.173 4.261 3.899 3.290 3.422
DALYs 2015 6.402 3.749 3.580 3.505 3.269
5B variabel 6.825 4.052 3.706 3.281 3.377
5A variabel 6.830 4.056 3.706 3.274 3.377
4B variabel 6.872 4.063 3.706 3.274 3.408
4A variabel 6.826 4.057 3.816 3.281 3.377
7 variabel 6.840 4.051 3.706 3.274 3.377
Figure 16. The difference of DALYs losswith and without risk factors intervention, Indonesia
2019
Figure16shows theresults of a reduction inDALYslossby3 percentJoint PAF with

combinedinterventions in riskfactorsthathavean impact onfive diseases. The prediction of
DALYsloss fortuberculosis casesandLRIdecreasesfrom2015to2019, butfor strokes,
IHDandDMit increases. Without any interventions, a prediction ofthe burdenof
strokesin2019would be 7,173,000years lost. Withinterventionusing Model5B, the burden of
strokeswould decrease to6,825,000years lost. If theinterventionisperformedusing Model
4Athen the impact onstrokeswould decrease the number of years lost to6,826,000.
36
40.000 37.804 37.769
35.000
30.000
25.000 21.505 21.581
20.000
15.000 11.741
11.888
10.000
4.028 4.029
5.000 183 183 347 89
-
7 var 20.474 11.984 4.029 344 347 37.179 7 var
4A var 21.505 11.741 4.028 183 347 37.804 4A var
4B var 4B var
18.340 11.203 1.536 344 89 31.512
5A var
5A var 21.272 11.794 4.029 344 89 37.529
5B var
5B var 21.581 11.888 4.029 183 89 37.769
Figure 17. Predicted impact of reduction mortality with 3% Joint PAF risk factors
intervention,Indonesia 2019
Figure17shows themortality figures for the five diseases that couldbe reduced with a 3
percentJoint PAF interventionof the riskfactorssimultaneously.In Figure15,using Model 5B
with the most significant impacton reducing DALYsloss, the totally deaths can be reduced to
37,769in 2019.The largest impactinterventionsgreatly affect thereduction in fatalities in
strokes, IHDandDM. Inthe case oftuberculosisandLRI,the risk factorsthatcan be targeted for
intervention are onlytwo, namely tobaccoconsumptionandhousehold air pollution.
800.000 746.044
724.463
700.000
600.000 7 variabels
4A variables
500.000 4B variables
406.487
394.599 5A variables
400.000
5B variables
300.000 Mortality 2015
no intervention 2019
170.077
200.000 134.430
130.401 169.987
105.682105.864
100.000
-
7 variabels 725.569 394.503 130.401 105.520 169.729
4A variables 724.539 394.746 130.402 105.682 169.729
4B variables 727.704 395.284 132.894 105.520 169.987
5A variables 724.772 394.692 130.401 105.520 169.987
5B variables 724.463 394.599 130.401 105.682 169.987
Mortality 2015 647.397 347.403 118.315 119.257 154.887
no intervention 2019 746.044 406.487 134.430 105.864 170.077
Figure 18. The difference inmortality cases, with and without reduction of 3% of the Joint PAF
risk factors, Indonesia 2019
Conclusions from themodelinterventionof 3 percentreduction

37
inriskfactorssimultaneously:Model 5B(hypertension, low diet of vegetablesandfruit, cigarette

consumption, household air pollution, low level ofphysical activity)ispredicted to
reduceDALYsloss byas many as547,000productive years. Interventionwiththese risk factors
could decrease mortality by2019to 37,769deaths (21,581 stroke deaths, 11,888IHD
deaths,4,029DM deaths, 183TB deaths,and 89 deaths from LRI).
WHO targetsfor thecontrolof NCDriskfactorsinthe Southeast Asia region for 2013-20, among
others, a reduction of 10 percent in the prevalence ofpoor physical activityanda 25 percent
reduction in the prevalenceof hypertension. Interventionstoincreasephysical activityin the
main targetage groupof 18 yearsand above (moderatephysicalactivityfor at
least60minutesperweek) are predictedtoreducethe riskof heart diseaseand hypertention by
about 30 percent. Regular physicalactivity, even in oldage, significantly reduces the risk
ofheartdisease, diabetes, hypertensionandobesity. Improvedcompliance in
medicationconsumption amongst patients with hypertensionis predicted toreduce strokes by
more than40 percent (Mackay. J, Mensah, G,2004).13
1.800
1.600
1.400
1.200
1.000
800
600
400
200
-
3% 5% 10%
thousand
7 var 479 798 1.595
7 var
4A var 478 687 1.531 4A var
4B var 432 720 1.246 4B var
5A var 462 801 1.237 5A var
5B var 547 804 1.256 5B var
Figure 19. Three model intervention in joint PAF attr to DALYs lossforstrokes, IHD,DM,TB and
LRI
Figure19 shows theresults ofa simulationmodel reduction inDALYslossifthe

combinedinterventiononriskfactorsrelated tocasesof strokes, IHD, DM, TBandLRIis as much
as3 percent, 5percentand10percent. The simulation resultsin an interventionof 10percent of
the Joint PAF with Model 4Asimultaneously(hypertension, low diet of
vegetablesandfruit,tobaccoconsumption,and household air pollution) is predictedto
reducetotalDALYsloss by as much as1,531,000 deaths.The impact oftheinterventionof
10percentwith Model4A is predicted toreducemortality by as many as122,579deaths.
13
Mackay Judith, Mensah George,the atlas of hearth disease and stroke, WHO, CDC, Geneve, 2004
38
140.000
120.000
100.000
80.000
60.000
40.000
20.000
-
10% 5% 3%
7 var
7 var 123.932 61.966 37.179 4A var
4A var 122.579 62.577 37.804 4B var
4B var 119.887 52.681 31.512 5A var
5A var 122.439 62.979 37.529 5B var
5B var 123.071 63.649 37.769
Figure 20. Three model intervention of Joint PAF attributable to mortality due to
strokes,IHD,DM,TB and LRI
Figure20shows that thetotalmortality fromstrokes, IHD, DM, TBandLRIcan bereduced

bythreekinds ofmultiplerisk factorinterventionmodelssimultaneously.
WHO is targeting the control ofNCDsinSoutheast Asian countriesin2013-20, including

loweringby 25 percentthe number of deaths fromcardiovasculardisease, diabetes,
chronicrespiratory diseasesandcancer(WHO, SEA-NCD, 2013).
Moderate physical activity (60 minutes per week) is predictedto reduce the risk of death from
strokes by 20 percent. If somebody does vigorous physical activity more frequently then this
is predictedto reduce the risk of death from strokes by 27percent.
The impact of stopping smoking for three months will improve blood circulation in the body. If
someone stops smoking for 5 to 15 years, the impact on reducing the incidence of strokesis
the same as for people who have never smoked before. If stopping smoking for more than
15 years, the impact will reduce the risk of death from coronary heart disease.
The results ofmultiplerisk factorsimultaneous intervention studies(avoiding saturatedfats,

increasedconsumption of vegetablesandfruit, regular exerciseandstopping smoking)
bydoctors and paramedicsin primary health carehave been provento be notsignificant
enoughto reduce the riskof death fromcerebrovascularcases(Ebrahim.S, 2000).
These effortsmust be balancedwithefforts toreduce blood pressure as the key

factortriggeringcerebrovasculardisease. Effortsto controlbloodpressurewith
adequatemedicationwill be beneficial, since its effect canreduce the prevalence
ofstrokesbymore than70 percent.Efforts to reducehousehold air pollution, withthe target of
reducingthe use of solid fuels for cooking by 50 percent(wood,coal, etc.) are also strongly
recommended.
In order tocontrol thefasting plasma glucoselevelsandhypertension, screening ofthe

population aged18 years old and above should be organized. Regulations on manufactured
(packaged) food to limitsugarandsaltand to monitor sugar and salt consumption are
important. Reducing saltintakefrom12 to3gramsper day canlower the incidence of
strokesby30 percent (Mackay.J, Mensah, G, 2004).
39
Intensive health promotion inthe community is required toincrease theconsumption of

vegetablesandfruitto at leastfivebowlsa daywith emphasisonthe importance ofhealthy foods
thatcontain fibre(vegetablesandfruit), lowsugarand salt,and are low insaturatedfats.
Appropriate tobacco controlefforts based on Law No. 36/2009 on healthneeds to be
enforced.
Table 1. Basic calculations for prediction of total medical costs
Out-patient
Diseases cases Out- Utilization In-patient
patient In-patient Utilization
(x 1000) cases cases Peryear peryear
Cerebrovascular disease 1,595 1,990 85 11,941 110
Ishaemic HD 4,219 5,266 224 15,797 291
DM 2,097 2,617 111 13,087 28
TB 1,797 2,243 95 13,459 48
LRI 10,170 12,692 5,111 38,077 511
Cancer 551 688 29 2,063 22
COPD 810 1,011 43 12,135 4
Major depressive disorders 640 799 34 40 2
Birth asphyixia & birth

trauma 94 118 5 104 5
Road traffic accidents 1,170 1,460 62 1,460 31
Table 1 showsnumber of casesofdiseases forthe10highestburdens(DALYsloss)in 2019who

utilize out-patient and in-patient services.In order topredict thenumber of casestreated, and
the health care expenditure, the assumptions used are:
Utilization of out-patient: 10.4 percent per month from total population (Riskesdas 2013).
Utilization of in-patient: 2.3 percent per year from total population (Riskesdas 2013) and
will increase to 5.0 percent in 2015 and 9.0 percent in 2019; due to National Health
Insurance program (Riskesdas 2013).
Visit for out-patient is also calculated for one time.
Visit for in-patient is only calculated for one disease episode in one year.
Unit costs of health care costs are obtained from INA-CBG (Indonesian Case Based
Group) Tariff for National Health Insurance, for Class D Hospital in Region A (Sumatra
and Jawa).
The results will show the minimal health care expenditure for 10 leading causes of DALYs
loss in 2015 and 2019.
40
Measuring Health Care Costs
Table 2. Estimated health care costs for leading causes of disease in 2015 (out-patient)
Number of Cases (thousand) Unit Cost Expenses

out-
patient
Disease Total Males Females (Rp) Total (Rp) Males Females
160,474
Tuberculosis 705.79 378.89 326.90 113,260,965 60,801,468 52,459,497
Lower respiratory
201,031
infections 4,095.25 2,067.51 2,027.74 823,271,779 415,634,127 407,637,653
Birth asphyxia and

152,641
birth trauma 42.45 21.65 20.80 6,479,711 3,304,612 3,175,099
235,718
Cancer 215.94 65.70 150.24 50,900,437 15,486,936 35,413,500
160,474
Diabetes mellitus 815.74 404.15 411.58 130,904,468 64,856,032 66,048,436
Major depressives
304,299
disorders 261.49 130.85 130.65 79,571,468 39,816,032 39,755,436
Ischemic heart
196,308
disease 1,709.33 880.46 828.86 335,554,376 172,842,119 162,712,256
Cerebrovascular
136,735
disease 586.25 294.93 291.32 80,161,050 40,327,565 39,833,485
Chronic obstructive
246,328
pulmonary disease 315.12 189.86 125.27 77,623,384 46,766,762 30,856,622
Road traffic
183,428
accidents 492.39 287.18 205.21 90,318,772 52,677,290 37,641,482
Table 2 shows the lowest estimate of health care costs for out-patients in 2015, applying unit
costs of INA CBG used for National Health Insurance (JKN); based on new cases with out-
patient utilization rate of 44 %with one visit per year (National Socioeconomic Survey 2007)
41
Table 3. Estimated health care costs for leading causes of disease in 2015 (in-patient)
Number of Cases Unit cost Expenses

for in-
Disease
patient
Total Males Females Total Males Females
(Rp)
Tuberculosis 80.02 42.96 37.06 2,327,413 186,243,211 99,980,259 86,262,951
Lower respiratory
Infections 464.31 234.41 229.90 2,333,685 1,083,562,197 547,043,442 536,518,756
Birth asphyxia and

birth trauma 4.81 2.45 2.36 4,967,634 23,909,222 12,193,554 11,715,668
Cancer 24.48 7.45 17.03 1,555,150 38,074,347 11,584,478 26,489,869
Diabetes mellitus 92.49 45.82 46.66 1,942,893 179,692,558 89,027,873 90,664,685
Major depressive
disorders 29.65 14.84 14.81 2,541,024 75,335,041 37,696,205 37,638,835
Ischemic heart
disease 193.80 99.83 93.98 2,331,582 451,863,245 232,752,146 219,111,099
Cerebrovascular
disease 66.47 33.44 33.03 2,929,830 194,741,064 97,970,684 96,770,381
Chronic obstructive
pulmonary disease 35.73 21.53 14.20 2,374,006 84,818,780 51,101,864 33,716,915
Road traffic
accidents 55.83 32.56 23.27 4,782,834 267,010,977 155,730,802 111,280,176
Table 3 shows the lowest estimate of health care costs of new cases for in patient services
in 2015 with utilization rate of 5 % per year (one time hospitalization)
Table 4. Estimated health care costs for leading causes of disease in 2019 (out-patient)
Number of cases (thousand) Unit cost Expenses

for out-
patient
Disease 2019 Total Males Females (Rp) Total Males Females
Tuberculosis 1,258.17 632.42 625.75 160,474 201,903,755 101,487,169 100,416,586
Lower respiratory
201,031 1,431,162,936 719,260,130 711,902,806
infections 7,119.12 3,577.86 3,541.26
Birth asphyxia
152,641 10,088,227 5,147,543 4,940,684
and birth trauma 66.09 33.72 32.37
42
Cancer 385.80 119.51 266.29 235,718 90,939,225 28,170,387 62,768,838
Diabetes mellitus 1,468.08 722.95 745.13 160,474 235,589,235 116,015,046 119,574,190
Major depressive
304,299 136,305,993 68,060,976 68,245,017
disorders 447.93 223.66 224.27
Ischemic heart
196,308 579,809,572 297,016,729 282,792,843
disease 2,953.57 1,513.01 1,440.56
Cerebrovascular
136,735 152,639,272 76,011,658 76,627,614
disease 1,116.31 555.90 560.41
Chronic
obstructive
246,328 139,722,002 83,276,069 56,445,933
pulmonary
disease 567.22 338.07 229.15
Road traffic
183,428 150,165,135 87,373,719 62,791,416
accidents 818.66 476.34 342.32
Table 4 shows the lowest estimate of health care costs for out-patients in 2019, applying unit
costs of INA CBG used for National Health Insurance (JKN); based on new cases with out-
patient utilization rate of 44 % with one visit per year (National Socioeconomic Survey 2007)
Table 5. Estimated health care costs for leading causes of disease in 2019 (in-patient)
Number of cases
unit cost Expenses
(thousand)
for in-
Disease 2019 Total Males Females patient Total (Rp) Males Females
Tuberculosis 161.76 81.31 80.45 2,327,413 376,493,640 189,244,987 187,248,652
Lower respiratory
2,333,685 2,136,056,578 1,073,518,810 1,062,537,767
infections 915.31 460.01 455.30
Birth asphyxia and

4,967,634 42,212,172 21,538,866 20,673,306
birth trauma 8.50 4.34 4.16
Cancer 49.60 15.37 34.24 1,555,150 77,139,222 23,895,538 53,243,684
Diabetes mellitus 188.75 92.95 95.80 1,942,893 366,728,040 180,593,864 186,134,176
Major depressive
2,541,024 146,341,554 73,071,982 73,269,572
disorders 57.59 28.76 28.83
Ischemic heart
2,331,582 885,406,172 453,563,477 431,842,696
disease 379.74 194.53 185.21
Cerebrovascular
2,929,830 420,507,244 209,405,170 211,102,074
disease 143.53 71.47 72.05
72.93 43.47 29.46 2,374,006 173,131,982 103,188,836 69,943,145

Chronic obstructive
43
pulmonary disease
Road traffic
4,782,834 503,423,236 292,917,265 210,505,972
accidents 105.26 61.24 44.01
Table 5 shows the lowest estimate of health care costs of new cases for in patient services
in 2019 with utilization rate of 5 % per year (one time hospitalization)
44
6. Policy Direction and Strategies
Indonesia needs to accelerate efforts to improve the health status of its population. The
provision of health services at the local level should always consider the socio-cultural
context due to the fact that public health services are provided mostly to people who are
poor, and who have low education and low social status. The local media should be included
in health promotion campaigns focusing on improving food intake for a healthy diet,
refraining from smoking, and safe and responsible sexual behaviour. Furthermore, each
individual is influenced by their genetic make-up and their living environment, especially
access to clean water sources and sanitation.
Addressing communicable diseases such as diarrhea requires a combination of

environmental sanitation, micronutrient supplementation, treatment, and water disinfection.
HIV infection requires safer injection practices and antiviral medication. Combating
cardiovascular disease should be through lowering cholesterol, educating the population on
lowering salt intake, especially in processed foods. National and sub-regional health
institutions should prioritize tackling under-nutrition, poor water sanitation, lack of tobacco
free areas, and the surveillance of blood pressure and cholesterol levels in the general
population.
In order to reduce the burden of disease and injuries, special efforts should be prioritized,
planned and implemented, including:
Early detection and control of major risk factors for NCDs: unhealthy diet including
reduction of salt consumption and avoiding high cholesterol foods, regular consumption
of fruit and vegetables, routine physical activity, controlling for high blood pressure and
smoking behaviour.
Special preventive efforts by the health related sectors should be carried out to reduce
road traffic injuries.
Intensify coverage of quality health care for MNCH, including basic and comprehensive
neonatal and obstetric care.
Intensify control activities of communicable diseases with a large burden (tuberculosis,

pneumonia, malaria, HIV and AIDS, diarrheal diseases).
Escalation of the program for the integrated management of sick children.
Improvement of availability and distribution of health care facilities (Puskesmas,district

and city hospitals).
Development of quality services for NCDs and injuries, including promotive, preventive,
curative and rehabilitative activities at all levels.
Improvement of referral health services.
Development of age-friendly primary health care services and referral services. These
services include gerontology/geriatric health posts/Posbindu Lansia,and home- and day-
care services.
45
Revitalization of school health services for education on risk factors and a healthy life
style.
Eradication and control of neglected tropical diseases (filariasis, schistosomiasis, yaws,

etc)
Essential Public Health Functions should be implemented by district and city health
offices as part of a new initiatives in public health services, including:
Monitoring, evaluation and analysis of the local health situation.
Public health surveillance, research and control of risks.
Health promotion on healthy lifestyles and health maintenance.
Social participation in health such as community peer group support.
Policies and institutional capacity for planning and management.
Strengthening institutional capacity for regulation and enforcement.
Evaluation and promotion of equitable access to health services.
Human resource development and training.
Quality assurance in personal and population-based health services.
Research in public health.

46
7. Program and Main Activities
Revitalization of obligatory public health functions (UW SPM): promotive, preventive,

curative and rehabilitative activities, as well as other essential public health functions.
Control of major risk factors for NCDs: unhealthy diet including reduction of salt and
sugar consumption, avoiding high total cholesterol foods, controlling high blood pressure,
tobacco use, household air pollution.
Control of communicable diseases with a high burden, such as tuberculosis, diarrheal

diseases, malaria, HIV and AIDS and pneumonia.
Special preventive efforts by the health sector and other related sectors to reduce road
traffic injuries.
Acceleration and improvement of highly cost effective health efforts, such as

immunization, school health services, integrated management of sick children.
Priority health services are targeted at specific age groups (based on Continuum of
health care): age-friendly primary health services.
Ensuring universal health coverage of comprehensive health care (promotive,

preventive, curative and rehabilitative) for individuals and the community.
Eradication of neglected tropical diseases (leptospirosis, anthrax, filariasis,

schistosomiasis, etc)
Continuum of Health Careprogram activities consist of :
Pre-marriage and marriage advice and counseling on family planning and marriage
preparation, includingconflict mediation.
Antenatal care by increasing the coverage of pregnant mothers with complete prenatal
care visits. This package consists of health maintenance, birth delivery exercises, and
nutrition supplementation.
Normal birth weight delivery by qualified birth attendant in health care facilities.
Exclusive breast feeding for 6 months, followed by complementary feeding until 2 years
(toddler).
Complete basic immunization for all infants.
Monitoring the growth and development of young preschool children (under-fives).
Surveillance of first year school children for stunting and wasting.
Supplementary feeding for school children in elementary school.
Promotion of reproductive health activities for adolescents.
Health examinations/check-ups for people in middle age and pre-retirement age at

wellness clinics or NCD clinics.
47
Routine health examination for the elderly suffering from chronic diseases.
Universal health coverage
Universal health coverage is defined as ensuring that all people have access to needed
promotive, preventive, curative and rehabilitative health services of sufficient quality to be
effective, including community-based public goods activities and private goods activities
implemented through National Health Insurance.National Health Insurance also ensures that
people do not suffer financial catastrophic hardship when paying for these services
New program approach
Interventions at primary health centres focusing on major NCDs andCDs namely

strokes, ischemic heart disease, diabetes, and lower respiratory infections.
The new approach will include: registration of basic demographic and clinical data, early
identification of people with NCDs and CDs, application of evidence-based
interventions, management of NCD emergencies by trained staff to handle acute
myocardial infraction, strokes, unconscious patients, hypoglycemia, diabetes
ketoacidosis, severe asthma and COPD, monitoring of complications, as well as
capacity building for health system research and training (WHO, 2010).
Interventions at primary health centres focusing on major NCDs, namely strokes,

ischaemic heart disease, diabetes, as well as lower respiratory infections.
Capacity-building for health system research and training (WHO, 2010).
Strengthening of referral health facilities (secondary and tertiary hospitals).
Improvement standard operating procedures, including referral procedures and

mechanisms.
Improvement of the quality of health care, including patient safety.
Improvement of referral consultations, including the use of telemedicine between

medical centres and facilities in under-served area.
Establishment of National Medical Service Standard in all health care facilities

48
8. Conclusions
Results of the burden of disease in terms of incidence and prevalence of diseases,

along with information on likely costs per case treated, should be used to forecast the
health system burden that should be expected as a result of the ongoing demographic
and epidemiological transition, and the related changing characteristics of demand for
health services
Institutionalization of disease expenditure tracking and linkage to ongoing updates of the

burden of disease should be undertaken to anticipate high care cost areas and the need
for more sophisticated health services.
In order to achieve universal health coverage,the GoI should focus in ensuring that
effective depth of coverage exists, especially in rural and remote areas of the country,
and at the primary care level.
49
References
BPS, Bappenas, UNFPA. Indonesia Population Projection 2010-2035, Jakarta 2013
Alzheimers Diseases International. World Alzheimer Report 2012: Overcoming the stigma of
dementia. London: Alzheimers Disease International,2012
Global Health. Non-Communicable Diseases Website. http://www.globalhealth.gov/global-

health-topics/non-communicable-diseases/index.html. Accessed May 19, 2014
Hyder. A. A, Prasanthi P& Allen AK. WISH Road Traffic Injury Report 2013, Road Traffic
Injury and Trauma Care: Innovations for Policy (Road Trip),Website. http://www.wish-
qatar.org/app/media/388. Accessed March 20, 2014
Lopez Alan, murray CJ, 2006Global and Reagional burden disease and risk factors, 2001:
systematic analysis of population health data, Lancet ;vol 367: May 2006.p. 1747-57
Mackay Judith, Mensah George,the atlas of hearth disease and stroke, WHO, CDC,
Geneve, 2004
Majid Ezzati, Alan D.Lopez, Anthony Rogers, C.Murray (2004), Comparative quantification
of Health Risks GBD attributable to selected Major Risk Factors, WHO vol-2, 2004, p.1-
2248, Switzerland
MoH&WHO, Neglected Tropical Disease in Indonesia: An Integrated Plan of Action Ministry

of Helth Indonesia 2011-2015
Minister of Health Decree No.69/2013 on Standard Tariff of Social Health Insurance

Program
Stroke best Practices , Mark J.Albert, Donald Easton(2004), Stroke best practices; A Team
Approach Evidence-Based Care, Chicago,Illinois-Rhode Island, J NatlMedAssoc.vol.96,
no.4, April 2004
WHO, Yaws and other endemic treponematoses. Website http://www.who.int/yaws/en/

accessed May 2, 2014
WHO, Schistosomiasis: A major public health problem. Website:

http://www.who.int/schistosomiasis/en/ accessed May 2, 2014
Global Burden of Disease 2000: Version 2 method and results. Colin D. Mathers, Claudia
Stein, Doris Ma fat et al. WHO Global Program on Evidence for Health Policy, WHO,
Geneva, October 2002
Evaluasi indikator program PP dan PL Tahun 2010 s.d 2012. (Evaluation of indicators of
Communicable Disease and Environmental Sanitation program), Direktorat Jendral
Pengendalian Penyakit dan Penyehatan Lingkungan, Kementerian Kesehatan RI, 2013
National Burden of Disease Studies: A Practical Guide. Edition 2.0 October 2001. WHO
Global Program on Evidence for Health Policy, WHO, Geneva
50
Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health

Care in Low-Resource Settings. WHO, Geneva, 2010
World Health Report 2002, WHO, Geneva 2002
Global Burden of Disease 2010 Risk Factors: Population Attributable Fractions; GBD
Workshop. Institute for Health Metrics and Evaluation. University of Washington. Rhodes
Island Greece, May 2013.
Center for Community Empowerment, Health Policy and Humanities, NIHRD. Indonesian
Burden of Disease, 2015 and 2019, Jakarta 2014.
51
Annex A.
Risk Factors Attributed To DALYs Loss and Mortality
Risk factors of strokesattributable to DALYs loss
90
Risk Factors of Stroke Attributable to DALYs Loss
80
70
% attr DALYs male & female
Hypertensi
60
Dietary risk
50
inactivitas phisic
40
tobacco
30 HH air polution
20 cholesterol
10 HFPGlucose
0
2000 2005 2010 2015 2019
Risk factors of strokesattributable to mortality
100
90
80
% attr death male & female
70
Hypertensi
60
Dietary risk
50
inactivitas phisic
40 tobacco
30 HH air polution
20 cholesterol
10 HFPGlucose
0
2000 2005 2010 2015 2019
52
Risk factorsattributable to stroke mortality
100
90
80
70
60 Hypertensi
50 Dietary risk
inactivitas phisic
40
tobacco
30
HH air polution
20 cholesterol
10 HFPGlucose
0
2000 2005 2010 2015 2019
Risk factorsfor ischemic attributabe to DALYs loss
100
90
80
Hypertensi
70
% attr DALys male & female
Dietary risk
60
in-activitas physic
50
tobacco
40
HH air polution
30
high cholesterol
20
HFPGlucose
10
0
2000 2005 2010 2015 2019
53
Risk factors IHDattributable to mortality
100,0
90,0
80,0
70,0
Hypertensi
60,0 Dietary risk
50,0 in-activitas physic
40,0 tobacco
30,0 HH air polution

high cholesterol
20,0
HFPGlucose
10,0
0,0
2000 2005 2010 2015 2019
Risk factors DM attributable to DALYloss
120
100
Dietary risk
80
inactivitas phisic
tobacco
60
HFPGlucose
BMI
40
20
0
2000 2005 2010 2015 2019
54
Risk factors DM attributable mortality
120,0
100,0
% attr to death male & female
80,0
60,0
Dietary risk
40,0
inactivitas phisic
tobacco
20,0 HFPGlucose
BMI
-
2000 2005 2010 2015 2019
Risk factorstuberculosis attributable to DALYs loss
5
HFPGlucose
4
3 tobacco
1
0
2000 2005 2010 2015 2019
55
Risk factors TB attributable to mortality
5
% attr to mortality male & female
4 HFPGlucose
3
tobacco
2
0
2000 2005 2010 2015 2019
Risk factors LRI attributable to DALYs loss
45,0
40,0
35,0
30,0
% attr to DALY mal & female
25,0
tobacco
20,0
15,0
HH air polution
10,0
5,0
-
2000 2005 2010 2015 2019
56
Risk factors LRI attributable to mortality
45,0
40,0
35,0
tobacco
30,0
% attr to mortality male & femle
25,0
HH air polution
20,0
15,0
10,0
5,0
2000 2005 2010 2015 2019

57
AnnexB.
Table:Medical costs of selected diseases based on Indonesia Case Based Group/INA-CBG,

Minister of Health Decree No. 69/2013
Out-
Diseases In-patient patient
medical cost INA-CBG medical INA-CBG
(Rp) code cost (Rp) code
Cerebrovascular disease 2,929,830 G-4-14-I 136,735 Q-5-27-0
Ischaemicheart disease 2,331,582 A-4-16-I 196,308 Q-5-43-0
DM 1,942,893 E-4-10-I 160,474 Q-5-44-0
TB 2,327,413 G-4-18-I 160,474 Q-5-44-0
LRI 2,333,685 G-4-26-I 201,031 Q-5-38-0
Cancer 1,555,150 C-4-13-I 235,718 Z-3-17-0
COPD 2,374,006 C-4-12-I 246,328 J-3-13-0
Major depressive
disorders 2,541,024 F-4-11-I 304,299 F-5-10-0
Birth asphyxia and birth

trauma 4,967,634 J-1-10-I 152,641 J-3-17-0
Road traffic accidents 4,782,834 M-1-04-I 183,428 Z-3-27-0

58
Annex C.
Indonesian Burden of Disease (DALYs Loss) and Estimated Number of Cases, 2015
and 2019
Indonesia Burden of Disease, 2015
Total DALYs loss by disease andsex (000)
Disease Total Male Female
1.Communicable, maternal, perinatal

and nutritional conditions 20,523.59 8,515.46 12,008.13
A. Infectious and parasitic diseases 8,460.72 4,271.25 4,189.46
1. Typhoid fever 94.43 46.79 47.64
2. Tuberculosis 3,505.02 1,772.10 1,732.93
3. STD excluding HIV 1,230.09 659.54 570.55
4. HIV 56.06 28.23 27.83
5. Diarrhoeal diseases 1,488.06 755.87 732.19
6. Childhood cluster diseases 0.00 0.00 0.00
a. Pertussis 158.18 81.94 76.24
b. Poliomyelitis 0.00 0.00 0.00
c. Diphtheria 3.61 2.10 1.51
d. Measles 569.71 285.20 284.50
e. Tetanus 205.00 103.45 101.56
7. Meningitis 140.82 63.52 77.30
8. Hepatitis B and C 152.25 69.37 82.88
9. Malaria 62.60 26.08 36.52
10. Lymphatic filariasis 588.42 291.70 296.72
11. Leprosy 1.59 0.80 0.79
12. Dengue 190.47 77.57 112.90
13. Japanese encephalitis 0.53 0.27 0.26
14. Trachoma 10.27 4.95 5.31
15. Intestinal nematode infections 3.63 1.79 1.84

59
B. Respiratory infections 3,938.80 1,995.83 1,942.97
1. Lower respiratory infections 3,269.43 1,643.22 1,626.21
2. Upper respiratory infections 606.13 309.28 296.85
3. Otitis media 63.23 43.32 19.91
C. Maternal conditions 2,874.19 0.00 2,874.19
1. Maternal haemorrhage 610.31 0.00 610.31
2. Maternal sepsis 157.51 0.00 157.51
3. Hypertensive disorders of pregnancy 543.83 0.00 543.83
4. Obstructed labour 170.11 0.00 170.11
5. Abortion 855.41 0.00 855.41
6. Other maternal conditions 537.02 0.00 537.02
D. Conditions arising during the perinatal

period 4,193.82 1,713.68 2,480.14
1. Low birth weight 2,074.60 640.09 1,434.51
2. Birth asphyxia and birth trauma 2,119.22 1,073.59 1,045.63
3. Other perinatal conditions 0.00 0.00 0.00
E. Nutritional Deficiencies 1,056.07 534.69 521.38
1. Protein-energy malnutrition 1,056.05 534.68 521.37
2. Iodine deficiency 43.00 23.00 20.00
3. Vitamin A deficiency 23.00 12.00 11.00
4. Iron deficiency 172.00 78.00 94.00
I. Non-Communicable Diseases 38,698.733 18,775.16 19,923.58
A. Malignant neoplasms 3,567.57 560.62 3,006.95
1. Mouth and oropharynx cancers 74.40 37.02 37.39
2. Oesophagus cancer 7.37 4.28 3.09

60
3. Stomach cancer 31.08 17.75 13.33
4. Colon and rectum cancers 105.94 56.63 49.31
5. Liver cancer 39.26 24.81 14.45
6. Pancreas cancer 28.38 17.74 10.64
7. Trachea, bronchus and lung cancers 348.78 251.60 97.18
8. Melanoma and other skin cancers 3.25 1.60 1.65
9. Breast cancer 1,764.87 0.00 1,764.87
10. Cervix uteri cancer 904.48 0.00 904.48
11. Corpus uteri cancer 63.22 0.00 63.22
12. Ovary cancer 13.94 0.00 13.94
13. Prostate cancer 77.95 77.95 0.00
14. Bladder cancer 8.16 6.80 1.36
15. Lymphomas and multiple myeloma 43.45 31.65 11.80
16. Leukaemia 53.04 32.80 20.25
17. Other malignant neoplasms 0.00 0.00 0.00
B. Other neoplasms 81.63 0.00 81.63
C. Diabetes mellitus 3,579.58 1,994.61 1,584.97
D. Endocrine and metabolic disorders 30.62 15.49 15.13
E. Neuro-psychiatric conditions 8,150.63 4,178.37 3,972.26
1. Unipolar depressive disorders 1,211.70 609.40 602.30
2. Bipolar disorder 1,679.64 823.50 856.14
3. Schizophrenia 684.68 349.35 335.34
4. Epilepsy 370.81 198.67 172.14
5. Alcohol use 341.09 302.25 38.85
6. Alzheimer and other dementias 356.00 160.94 195.06
7. Parkinson diseases 55.23 30.95 24.28

61
8. Multiple sclerosis 68.32 39.36 28.96
9. Drug use disorder 6.15 0.00 6.15
10. Post traumatic stress disorder 428.01 161.24 266.77
11. Obsessive-compulsive disorder 1,006.53 523.99 482.54
12. Panic disorder 0.00 0.00 0.00
13. Insomnia (primary) 735.76 370.10 365.66
14. Migraine 1,206.70 608.62 598.08
15. Mental retardation 0.00 0.00 0.00
16. Other neuropsychiatric disorders 0.00 0.00 0.00
F. Sensoryorgan diseases 5,125.65 2,303.55 2,822.10
1. Glaucoma 313.64 98.92 214.71
2. Cataracts 32.17 15.81 16.36
3. Vision disorders, age related 396.00 0.00 396.00
4. Hearing loss, adult onset 751.51 376.63 374.88
5. Other sense organ disorders 3,632.34 1,812.19 1,820.15
G. Cardiovascular diseases 11,815.57 5,942.84 5,872.73
1. Rheumatic heart disease 482.39 242.56 239.83
2. Ischaemic heart disease 3,748.85 1,872.56 1,876.29
3. Cerebrovascular disease 6,401.99 3,146.46 3,255.52
4. Inflammatory heart diseases 38.26 19.20 19.06
5. Hypertensive diseases 115.84 55.07 60.77
6. Other cardiovascular diseases 1,028.25 606.99 421.26
H. Respiratory diseases 3,304.67 1,977.43 1,327.24
1. Chronic obstructive pulmonary disease 2,097.79 1,298.83 798.96
2. Asthma 719.26 403.82 315.44
3. Other respiratory diseases 487.62 274.78 212.84
I. Digestive diseases 1,883.62 1,051.97 831.65

62
1. Peptic ulcer and dyspepsia 216.62 122.33 94.29
2. Cirrhosis of the liver 1,229.94 577.43 652.51
3. Appendicitis 395.20 330.03 65.17
4. Other digestive diseases 41.87 22.18 19.69
J. Genito-urinary diseases 170.27 150.04 20.23
1. Nephritis and nephrosis 42.45 22.22 20.23
2. Benign prostatic hypertrophy 127.82 127.82 0.00
3. Other genitourinary system 0.00 0.00 0.00
K. Skin diseases 445.04 216.20 228.84
L. Musculo-sceletal diseases 515.52 366.65 148.87
1. Rheumatoid arthritis 117.74 38.17 79.56
2. Osteoarthritis 397.79 328.48 69.31
3. Gout 0.00 0.00 0.00
4. Low back pain 0.00 0.00 0.00
5. Other musculoskeletal disorders 0.00 0.00 0.00
M. Congenital anomalies 9.65 7.80 1.85
N. Oral conditions 18.72 9.60 9.12
1. Dental caries 10.52 5.30 5.21
2. Periodental disease 8.20 4.30 3.90
3. Edentulism 0.00 0.00 0.00
4. Other oral diseases 0.00 0.00 0.00
III. Injuries 8,566.14 5,193.32 3,372.82
A. Unitentional injuries 6,673.55 4,043.06 2,630.50

63
1. Road traffic accidents 3,876.28 2,566.98 1,309.31
2. Poisonings 974.81 510.88 463.93
3. Falls 112.49 69.25 43.24
4. Fires 659.28 338.01 321.27
5. Drownings 1,050.69 557.95 492.75
6. Other unintentional injuries 0.00 0.00 0.00
B. Intentional injuries 1,892.59 1,150.27 742.32
1. Self-inflicted injuries 954.99 606.84 348.15
2. Violence 937.59 543.43 394.17
3. War 0.00 0.00 0.00
4. Other intentional injuries 0.00 0.00 0.00
AllCauses 67,788 32,484 35,305

64
Number of cases by disease and sex, Indonesia, 2015 (000)
Disease Total Males Females
I. Communicable, maternal, perinatal

andnutritional conditions 115,748 60,590.03 55,157.85
1. Typhoid fever 1,637.24 852.40 784.84
2. Tuberculosis 1,600.43 859.15 741.28
3. STD excluding HIV 1,966.70 1,055.36 911.34
4. HIV 14.78 7.50 7.28
5. Diarrhoeal diseases 23,297.50 11,825.78 11,471.72
6. Childhood cluster diseases 0.00 0.00
7. Pertussis 87.12 46.06 41.06
a. Poliomyelitis 0.00 0.00 0.00
b. Diphtheria 1.38 0.71 0.67
c. Measles 120.18 61.36 58.82
d. Tetanus 13.73 6.99 6.74
e. Meningitis 27.70 14.08 13.62
8. Hepatitis B and C 86.57 44.04 42.53
9. Malaria 122.84 47.41 75.43
11. Leprosy 1.52 0.76 0.75
12. Dengue 158.77 81.03 77.74
14. Trachoma 2.46 1.24 1.22
1. Lower respiratory Infections 9,286.28 4,688.24 4,598.04
2. Upper respiratory Infections 68,398.48 36,293.16 32,105.32

65
3. Otitis media 4,979.05 3,473.46 1,505.58
2. Maternal sepsis 162.88 0.00 162.88
5. Abortion 501.16 0.00 501.16
D. Conditions arising during the perinatal period 216.59 110.46 106.13
1. Low birth weight 120.33 61.37 58.96
2. Birth asphyxia and birth trauma 96.26 49.09 47.17
E. Nutritional deficiencies 1,536.69 792.44 744.25
1. Protein-energy malnutrition 660.62 339.35 321.27
4. Iron deficiency 6.48 3.35 3.12
II. Non-Communicable Diseases 111,895.44 56,171.38 55,724.05
A. Malignant neoplasms 399.82 104.22 295.61
3. Stomach cancer 9.06 2.15 6.91
5. Liver cancer 2.91 1.75 1.15
6. Pancreas cancer 6.14 3.88 2.26

66
9. Breast cancer 157.12 0.00 157.12
12. Ovary cancer 1.05 0.00 1.05
13. Prostate cancer 20.77 20.77 0.00
14. Bladder cancer 1.97 1.52 0.45
16. Leukaemia 16.08 9.53 6.55
C. Diabetes mellitus 1,849.74 916.45 933.30
1. Unipolar depressive disorders 415.43 208.96 206.47
2. Bipolar disorder 177.52 87.74 89.78
3. Schizophrenia 54.75 28.03 26.72
4. Epilepsy 458.18 286.45 171.73
5. Alcohol abuse 1,038.57 914.04 124.53
6. Alzheimers and other dementias 93.47 46.33 47.14
7. Parkinsons disease 18.58 10.58 8.00
9. Drug use disorder 1,234.30 621.96 612.34
11. Obsessive-compulsive disorder 165.22 83.31 81.91

67
12. Panic disorder 1,501.46 504.43 997.03
13. Insomnia (primary) 1,035.26 522.62 512.64
14. Migraine 6,696.65 3,375.04 3,321.61
F. Sensory organ diseases 2,046.94 1,020.67 1,026.27
1. Glaucoma 73.89 27.50 46.39
2. Cataracts 36.86 19.07 17.79
3. Vision disorders, age related 1,210.77 609.03 601.74
5. Other sense organ disorders 356.79 179.56 177.23
3. Cerebrovascular disease 1,329.37 668.78 660.59
5. Hypertensive diseases 1,217.54 581.09 636.45
6. Other cardiovascular diseases 0.00 0.00
H. Respiratory diseases 2,202.17 1,286.97 915.20
1. Chronic obstructive pulmonary disease 714.56 430.51 284.05
2. Asthma 640.15 361.71 278.43
I. Digestive diseases 515.14 271.25 243.89
2. Cirrhosis of the liver 197.09 71.41 125.69
3. Appendicitis 126.93 78.73 48.20

68
4. Other digestive diseases 0.00 0.00
3. Other genitourinary system 0.00 0.00
K. Skin diseases 21,746.35 10,150.75 11,595.60
L. Musculo-sceletal diseases 1,655.05 846.65 808.40
2. Osteoarthritis 482.50 235.54 246.97
3. Gout 497.16 262.91 234.26
4. Low back pain 550.96 303.16 247.80
N. Oral conditions 60,279.76 30,561.00 29,718.76
1. Dental caries 55,982.00 28,288.06 27,693.94
2. Periodental disease 3,026.13 1,632.40 1,393.73
3. Edentulism 1,271.63 640.54 631.09
III. Injuries 2,662.73 1,483.96 1,178.77
1. Road traffic accidents 1,116.54 651.21 465.33
2. Poisonings 429.25 224.88 204.37
3. Falls 212.13 119.00 93.13

69
4. Fires 249.28 130.23 119.05
5. Drownings 423.43 225.53 197.90
B. Intentional injuries 232.08 133.11 98.97
2. Violence 100.26 58.13 42.13
3. War 0.00 0.00 0.00
All Causes 230,306.04 118,245.37 112,060.67

70
Indonesia Burden of Disease, 2019
Total DALYs loss by disease andsex (000)
Disease Total Male Female

andnutritional conditions 20,382.89 8,414.80 11,968.09
1. Typhoid fever 97.74 48.41 49.33
2. Tuberculosis 3,289.77 1,654.26 1,635.50
3. STD excluding HIV 1,262.02 677.55 584.47
4. HIV 58.15 29.32 28.83
5. Diarrhoeal diseases 1,513.79 768.25 745.54
6. Childhood cluster diseases 0.00 0.00 0.00
7. Pertussis 155.38 80.54 74.84
b. Diphtheria 3.56 2.07 1.49
c. Measles 559.54 287.58 271.96
d. Tetanus 201.40 102.11 99.28
e. Meningitis 139.53 63.09 76.44
8. Hepatitis B and C 156.07 71.21 84.87
9. Malaria 63.94 26.57 37.37
11. Leprosy 1.66 0.84 0.83
12. Dengue 193.42 78.42 115.00
14. Trachoma 11.29 5.42 5.87
1. Lower respiratory infections 3,421.98 1,716.75 1,705.24

71
2. Upper respiratory infections 598.95 305.73 293.21
3. Otitis media 62.62 42.91 19.70
2. Maternal sepsis 161.30 0.00 161.30
5. Abortion 874.52 0.00 874.52

period 4,014.25 1,618.89 2,395.36
1. Low birth weight 1,935.63 565.33 1,370.30
2. Birth asphyxia and birth trauma 2,078.62 1,053.56 1,025.05
1. Protein-energy malnutrition 1,035.82 524.71 511.11
4. Iron deficiency 172.00 78.00 94.00
A. Malignant neoplasms 3,872.41 637.25 3,235.16
3. Stomach cancer 33.81 19.40 14.41

72
5. Liver cancer 42.38 26.58 15.80
6. Pancreas cancer 33.44 20.74 12.71
9. Breast cancer 1,897.31 0.00 1,897.31
12. Ovary cancer 14.76 0.00 14.76
13. Prostate cancer 93.70 93.70 0.00
14. Bladder cancer 9.68 7.99 1.69
16. Leukaemia 55.56 34.21 21.34
1. Unipolar depressive disorders 1,298.12 651.68 646.44
2. Bipolar disorder 1,756.30 861.58 894.72
3. Schizophrenia 703.65 359.56 344.08
4. Epilepsy 388.60 208.45 180.16
5. Alcohol abuse 358.93 318.78 40.15
9. Drug use disorder 6.30 0.00 6.30

73
11. Obsessive-compulsive disorder 1,048.52 546.02 502.50
12. Panic disorder 0.00 0.00 0.00
13. Insomnia (primary) 775.52 389.85 385.68
14. Migraine 1,361.96 682.61 679.34
1. Glaucoma 358.31 113.00 245.31
2. Cataracts 37.90 18.46 19.44
3. Vision disorders, age related 396.00 0.00 396.00
5. Other sense organ disorders 4,136.85 2,047.58 2,089.27
3. Cerebrovascular disease 7,173.08 3,499.38 3,673.69
5. Hypertensive diseases 130.90 61.91 69.00
6. Other cardiovascular diseases 1,225.18 712.76 512.42
1. Chronic obstructive pulmonary disease 2,368.51 1,449.55 918.96
2. Asthma 749.28 418.02 331.26
I. Digestive diseases 2,041.68 1,121.28 920.41

74
2. Cirrhosis of the liver 1,351.27 626.09 725.18
3. Appendicitis 406.81 338.89 67.92
4. Other digestive diseases 46.78 24.67 22.11
3. Other genitourinary system 0.00 0.00 0.00
K. Skin diseases 467.36 225.57 241.79
L. Musculo-sceletal diseases 599.50 419.51 179.99
2. Osteoarthritis 461.05 374.41 86.64
3. Gout 0.00 0.00 0.00
4. Low back pain 0.00 0.00 0.00
N. Oral conditions 19.99 10.22 9.77
1. Dental caries 11.33 5.70 5.63
2. Periodental disease 8.66 4.53 4.13
3. Edentulism 0.00 0.00 0.00
0.00 0.00
III. Injuries 8,854.60 5,365.28 3,489.32
1. Road traffic accidents 3,993.30 2,643.05 1,350.26

75
2. Poisonings 1,013.82 532.07 481.76
3. Falls 116.01 71.16 44.85
4. Fires 679.13 348.61 330.51
5. Drownings 1,079.31 573.05 506.26
B. Intentional injuries 1,973.03 1,197.35 775.68
2. Violence 976.78 565.77 411.00
3. War 0.00 0.00 0.00
All Causes 71,918 34,422 37,496

76
Number of cases by disease andsex, Indonesia, 2019 (000)
Disease Total Males Females

andnutritional conditions 121,678 63,444.55 58,233.84
1. Typhoid fever 1,713.02 891.29 821.73
2. Tuberculosis 1,797.39 903.46 893.93
3. STD excluding HIV 2,022.28 1,086.87 935.41
4. HIV 15.49 7.87 7.62
5. Diarrhoeal diseases 24,066.36 12,198.53 11,867.83
6. Childhood cluster diseases
7. Pertussis 86.01 45.52 40.50
b. Diphtheria 1.39 0.71 0.67
c. Measles 120.93 61.70 59.23
d. Tetanus 14.06 7.15 6.92
e. Meningitis 28.51 14.46 14.05
8. Hepatitis B and C 89.71 45.63 44.09
9. Malaria 130.07 49.79 80.28
11. Leprosy 1.60 0.80 0.80
12. Dengue 161.54 82.35 79.20
14. Trachoma 2.75 1.38 1.37
1. Lower respiratory Infections 10,170.17 5,111.22 5,058.94
2. Upper respiratory Infections 72,229.80 38,197.50 34,032.30

77
3. Otitis media 5,022.19 3,502.23 1,519.96
2. Maternal sepsis 170.42 0.00 170.42
5. Abortion 517.77 0.00 517.77

period 200.63 102.37 98.26
1. Low birth weight 106.22 54.20 52.02
2. Birth asphyxia and birth trauma 94.42 48.18 46.24
1. Protein-energy malnutrition 648.19 333.17 315.02
4. Iron deficiency 6.35 3.29 3.06
0.00 0.00
A. Malignant neoplasms 451.94 121.48 330.46
3. Stomach cancer 9.64 2.47 7.18
5. Liver cancer 3.27 1.96 1.32

78
6. Pancreas cancer 7.33 4.59 2.74
9. Breast cancer 174.63 0.00 174.63
12. Ovary cancer 1.18 0.00 1.18
13. Prostate cancer 25.12 25.12 0.00
14. Bladder cancer 2.36 1.81 0.55
16. Leukaemia 17.84 10.47 7.37
1. Unipolar depressive disorders 447.50 224.59 222.91
2. Bipolar disorder 192.40 94.93 97.47
3. Schizophrenia 57.00 29.21 27.79
4. Epilepsy 486.05 305.09 180.96
5. Alcohol abuse 1,085.96 957.84 128.12
9. Drug use disorder 1,280.32 645.31 635.01

79
11. Obsessive-compulsive disorder 172.66 87.02 85.64
12. Panic disorder 1,572.77 526.77 1,046.01
13. Insomnia (primary) 1,096.71 552.59 544.13
14. Migraine 7,156.91 3,599.40 3,557.52
1. Glaucoma 87.03 32.31 54.72
2. Cataracts 44.08 22.58 21.50
3. Vision disorders, age related 1,347.56 674.69 672.87
5. Other sense organ disorders 408.86 204.36 204.50
3. Cerebrovascular disease 1,594.74 794.15 800.59
5. Hypertensive diseases 1,386.03 658.56 727.47
6. Other cardiovascular diseases 0.00 0.00
1. Chronic obstructive pulmonary disease 810.31 482.96 327.36
2. Asthma 668.06 376.44 291.62
3. Other respiratory diseases 1,001.59 581.35 420.24
I. Digestive diseases 561.05 294.38 266.67
2. Cirrhosis of the liver 218.25 79.52 138.74

80
3. Appendicitis 132.95 82.22 50.73
4. Other digestive diseases 0.00 0.00
3. Other genitourinary system 0.00 0.00
K. Skin diseases 23,239.57 10,679.84 12,559.73
L. Musculo-sceletal diseases 1,847.78 939.04 908.74
2. Osteoarthritis 554.72 270.39 284.33
3. Gout 543.96 286.35 257.61
4. Low back pain 598.99 328.33 270.66
N. Oral conditions 65,077.31 32,868.96 32,208.35
1. Dental caries 60,358.71 30,385.30 29,973.41
2. Periodental disease 3,220.23 1,735.68 1,484.55
3. Edentulism 1,498.37 747.98 750.39
0.00 0.00
III. Injuries 2,788.18 1,551.29 1,236.89
1. Road traffic accidents 1,169.51 680.48 489.03
2. Poisonings 443.28 232.32 210.96

81
3. Falls 220.50 123.46 97.03
4. Fires 259.84 135.61 124.23
5. Drownings 446.96 237.79 209.16
B. Intentional injuries 248.09 141.62 106.47
2. Violence 106.72 61.73 44.99
3. War 0.00 0.00 0.00
All Causes 245,413.04 125,376.69 120,036.35

82
Annex D.
Risk matrix: Changing demand for health and health services 2015-19
No. Policy or topic area Describe the problem What is the impact of this risk why List the porposed techncial
is risk is it important to respond - political solution and who sholuld take lead
risks,social or equity risks, in responding to the problem
techncial risks, economic risks
1. Demographic transition Growing number of the Risk of poor access to quality health Implement policies and program on
andepidemiologicaltransition elderly with growing services for the elderly and NCDs; low behaviour changes to control major
NCDs and injuries , quality of NCD services, higher cost of risk factors in the population, intensify
contributed by unhealthy curative care and related health health promotion and prevention as
behaviour as risk factors services, leading to potential well as nutrition education; improve
catastrophic health expenditures intersector coordination to reduce
especially for the poor and leading to tobacco smoking, regulate
greater inequality manufactured food and early
detection of NCDs
2. Road traffic injuries The incidence of road Rising health care costs due to Improve inter-sector promotive
traffic accidents morbidity and disability; increased andpreventive efforts led by the health
increases significantly catastrophic payment by the families; sector and include the National Police,
with increased morbidity, affect poverty alleviation program Ministry of Public Works, Ministry of
disability and death Transportation and local governments
3. Access to modern health Low utilization of in- Inadequate preventive services and Improvement of availability and
care services patient and out-patient increased undetected or advanced distribution of health care facilities
health care services stage of non communicable/chronic (Puskesmas, hospital), re-design
diseases, that require referral services better health referral services in
to more sophisticated and expensive various levels of government
health facilities
4. Communicable diseases Several communicable Increased morbidity, disability and Intensification of the disease control
with a large burden diseases with large premature death on population; with and eradication program of major
burden and neglected more impact on the poor segment of communicable and neglected tropical
tropical diseases are still population diseases, with priorities for the poor
exist and lead to double area
burden of disease
83
Annex E.
Target of major risk factors for diseases, Indonesia 2015-19
No Risk factors 2013 2015 2016 2017 2018 2019

1 Diet low fruitsand 93.5 93.5 80 70 60 60
vegetables
2 Low physical activity 26,1 26,1 25 24 23 23
3 Tobacco consumption 36,3 36,3 35 34 32 32
(aged > 15 years)
4 Household air pollution 28.9 28.9 27 25 23 23
(as result ofcooking fuel;
firewood, charcoal)
5 High fasting plasma 36.6 36.6 35 34 33 33
glucose
6 High cholesterol 10.1 10.1 9 8 7 7
7 Hypertension 25.8 25.8 24 23 22 22
8 IMT 27,0 (aged => 18 14,8 14,8 14 13 12 12
years)

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1

HEALTH SECTOR REVIEW

CHANGING DEMAND FOR HEALTH SERVICES

Table 1. Basic calculations for prediction of total medical costs .................................................39

Figure 1. Population pyramid, Indonesia, 2015 and 2019.......................................................... 11

Glossary and Abbreviations

BoD : Burden of Disease

Population 2015 Population 2019

female male female male

Figure 1. Population pyramid, Indonesia, 2015 and 2019

Figure 2. Relationships among demographic, epidemiological and health transition

The health transition is influenced by demographic and epidemiologicalchanges. The

measuringthe disease burden at regional, nationaland local levels.

Burden of disease by cause in Indonesia, 1990-2010

Figure 3. Burden of disease by cause in Indonesia, 1990-2010

An overview ofthe burden of diseaseinIndonesiashows some major changes. In 1990,the

Review of achievement of RPJMN 2010 - 2014. program performance and issues.

Analysis of the demographic and epidemiological transitions.

Estimation of the national burden of disease for 2015 and 2019.

Predictiveanalysis ofthe economicimpact, models

Population census of Indonesia for 2010 and its projections.

RISKESDAS/ Baseline Health Research 2007, 2010, 2013.

RIFASKES/ Health Facility Survey 2011.

National Socioeconomic Survey 2007, 2011.

life expectancy (e0)

Source: Indonesia Population Projection 2010-2035, BPS, 2013

Figure 4. CDR, IMR and life expectancy for 2010-19

Figure 4showsthetrends of increasedlifeexpectancyand theCDRfrom2010 to2019;

Demographic and epidemiological transitions in Indonesia.

Different pace of transition indifferent areas in Indonesia.

Changing epidemiological profile, as shown by the increasing prevalence of non-

Controlling risk factors forNCDs,whichis essentially theimpactofadverse

The unfinished agenda of neglected tropical diseases, existing communicable diseases,

Fulfilling the demand for health and health services.

Until recently,cases of tuberculosisinIndonesiawere still high. Prevalence of tuberculosis in

to 5,686. The proportionof AIDS patientsin 2012showed51.5percentmale, and the

Neglected Tropical Diseases

Source: DG of Control Diseases & Environmental Health, MoH 2013

Figure 5. Trends for leprosy per 100,000 (2007-12)

Source: DG of Control Diseases & Environmental Health, MoH 2013

Figure 6. Trends for filariasis cases in 2008-12

forms (cercariae) of parasitic blood flukes, known as schistosomes.10The diseaseis endemic

600 9,59 9,57

Source: DG of Control Diseases & Environmental Health, MoH RI, 2013

Figure 7. Number of leptospirosis cases in 2005-12

90000 84010 84750 250

Number of Lyssa cases

GHPR PET Lyssa Casus

Source: DG of Control Diseases & Environtmental Health, MoH RI, 2013

Figure 8. Situation of rabies in Indonesia in 2008-12

Figure 9.. Trends

Cholesterol levels are influenced bydiets

Global estimates of physical

Birth delivery by a health provider: 87.6 percent

Good clean water source: 82.2 percent

Toilet facilities 81.9 percent

No in-door smoking: 78.8 percent

Use of water in container for washing: 77.4 percent

Weighing of under-five children: 68.0 percent

Daily physical activity: 52.8 percent

Regular hand washing: 47.2 percent

Exclusive breast-feeding: 38.0 percent

Daily vegetable and fruit consumption: 10.7 percent