A COMMUNITY

INTERVENTION MODEL

ON PREVENTION AND

CONTROL OF NCDs

IN INDONESIA

2017

PANDUPTM

Source : Indonesia Health Profile, MOH 2016 Central Agency on Statistic (BPS) 2015

17,504Islands1,904,569

square kilometres wide

Life Years

Expectancy

70.1

34 Provinces

416 Districtand 98 City with Decentralization

government system

The world ‘s fourth most populous

country

More than 258 million people

INDONESIA’SBACKGROUND

PHC Ratio per 30,000 people

is 1.13

9,767 Public Health Care

(PHC) 341,536Health

Workers

289,465Medical

professional

including

Population density reaches

135.2 person/ square

kilometres

1,618PHC

with health promotors workers

The population density is 135.2 people per square kilometer with population growth rate approximately 1.38% and life expectancy 70.1 years.

The Indonesian health system has a mixture of public and private providers and financing. The public system is administered in line with the decentralized government system in Indonesia, with central, provincial and district government responsibilities. The central Ministry of Health is responsible for management of some tertiary and specialist hospitals, provision of strategic direction, setting of standards, regulation, and ensuring availability of financial and human resources.

Provincial governments are responsible for management of provincial-level hospitals, provide technical oversight and monitoring of district health services, and coordinate cross-district health issues within the province. District/ municipal governments are responsible for management of district/city hospitals and the district public health network of community health centres (puskesmas) and associated subdistrict facilities. There are 9,767 primary health center (PHC) with PHC ratio per 30,000 people is 1.13 but only 1,618 PHC have health promotors.

Total health workers in Indonesia is 341,536 and 289,465 medical professionals. Indonesia has recently introduced a National health insurance (JKN) in Januari 2014 as a part of national social security system which have covered 171 million people (66.46%).

National Health Insurrance coverage

171 Million people (66.46%)per December

31 2016

Population growth rate is approximately

1.38%

Indonesia is the largest archipelago in the world which consists of 17,504 islands and total land mass 1,904,569 square kilometer. Divided into 34 provinces, 416 district and 98 city with decentralization goverment system. The country is ranked fourth globally in terms of population, with a population of more than 258 million people.

Sample Registration Survey, 2014:From 41,590 death in Indonesia :- 8,775 people die because of stroke,- 5,365 people die because of CVD- 2,786 people die because of DM and it’s complication- 2,204 people die because of hypertension and it’s complication

NCDs

Man and Woman

Source : SRS 2014 (National Institute of Health, Research and Development MOH)

12.9 %

6.7 %

Diarrhea and gastrointestinal infection

Pneumonia

Road injury

Liver

Lower respiratory tract infection

Hypertension and complication

Tuberculosa

Diabetes melitus and it’s complication

Cardiovascular disease

Stroke

1.9 %

2.1 %

2.6 %

2.7 %

4.9 %

5.3 %

5.7 %

21.1 %

10 CAUSE OF DEATH IN INDONESIA

CURRENT SITUATIONIN INDONESIA

Source : National Health Survey 2013

Indonesia has also emerged as a middle-income economy, economically strong and politically stable. The political and social landscapes have also been evolving through transition from authoritarianism to democracy and decentralization reforms. These macro-transitions have concurrently influenced an epidemiologic transition in which noncommunicable diseases (NCDs) are increasingly important, while infectious diseases remain a significant part of the disease burden.

Based on Sample registration survey (SRS) 2014, the third highest cause of death in Indonesia is NCDs : stroke as the highest cause of death followed by cardiovascular and diabetes with complication.

The increasing burden of noncommunicable diseases highlights the need to develop capacity to deliver care for chronic conditions, which require continuous long-term interactions between health providers and patients. According to the National health research (NHS) 2013, the highest prevalence of NCDs is hypertension 25.8 percent, followed by Injury 8.2 percent and Diabetes melitus 6.9 percent.

0 5 10 15 20 25 30

Hypertension (%)

Injury (%)

Diabetes Melitus (%)

COPD (%)

Coronary Heart Disease (%)

Stroke (‰)

Renal Failure (‰)

Cancer (‰)

25.88.2

6.93.7

1.512.1

21.4

NCDs PREVALENCE IN INDONESIA

Source: NHS, 2013

NCDsRISK FACTOR IN INDONESIA

0 20 40 60 80 100

Eat less vegetable and fruits

Eat Flavouring Food

Eat Sweet Food

Eat Fatty Food

Smoking

Eat Salty Food

Insufficient Physical Activity

Mental Emotional Disorder

93.6

77.3

53.140.7

36.3

26.226.1

6

In other hand NCDs behavioural risk factor also contributes for increasing morbidity. NHS 2013 reported that Indonesian behavioural risk factor of NCDs consists of unhealthy diet, smoking, physical inactivity and mental emotional disorder. The highest prevalence of NCDs risk factor is eating less vegetable and fruit 93.6%.

Indonesia faces the challenge of increasing health expenditures, as nominal health spending has been steadily increasing for example the most spending health expenditure on catastrophic disease are heart disease, renal failure, cancer and stroke. According to social insurance administration (BPJS), there has been increase of heath expenditure since 2014 from 4.4 trillion to 7.4 trillion in 2016 and those spending mostly alocated for by pass surgery, stenting and medication.

4.4

1.6

2.7 2.5

1.5

2.4 2.2

0.741.1 1.2

6.97.4

2014 2015 2016

Heart Disease

Source: Social Insurance Administration Organization(BPJS)

Renal Failure Cancer Stroke

CATASTROPHIC DISEASE BURDEN IN INDONESIA

NCDsPREVENTIONAND CONTROL POLICY

Hypertension prevalence

IndicatorNoNo

01

0202

03

Halt Obesity prevalence

Smoking prevalence ≤ 18 years old

NATIONAL MID-TERM DEVELOPMENT PLAN INDICATOR OF NCDS PROGRAM 2015-2019

PRESIDENTIAL DECREE NO. 2, 2015

NCDs

Global Target

Healthy Indonesian

Program with Family

Approach

MinimumStandardfor HealthServices

Community Empowerment

(GERMAS)

National Action Plan

for NCDs

MOHStrategicPlan for

NCDs

National mid-term

development plan

Addressing NCDs issues, the goverment needs to develop a comprehensive strategy which take consideration the growing interregional disparities in terms of resources, services and health outcomes. With a large, widespread area and population, and with the commencement of a universal health coverage system, the need for a reliable and integrated health system to support planning and decision-making is becoming even more urgent.

The goverment is commited to preventing and controling NCDs by setting up indicator of achievement in National mid-term development plan, National action plan 2015-2019 and MOH strategic plan 2015-2016. The president of Indonesia officialy instructed community empowerment to promote and prevent NCDs risk factor by GERMAS (Gerakan Masyarakat Hidup Sehat) or community movement for healthy life such as: 1. Stop smoking, 2. Physical activity and 3. Eat more vegetable and fruit.

Smoking percentage for ≤ 18 years old

IndicatorNoNo

01

0202

03

04

05

PHC percentage implementing PANDU PTM

Village/gampoong percentage with Posbindu PTM(community based intervention)Women age 30-50 years old percentage who hadbreast and cervical cancer screeningDistrict/city with No smoking area policy inminimum 50% state school

Morbidity and mortality

IndicatorNoNo

01

0202

03

04

Biologic Risk Factor

Behavioural Risk Factor

Health System Services Response PHC percentage for implementing PANDU PTM

STRATEGIC PLAN INDICATOR FOR NCDs PREVENTION AND CONTROL PROGRAM

2015-2016

NATIONAL ACTION PLAN INDICATOR FOR NCDs PREVENTION AND CONTROL 2015-2019

( MOH DECREE NO.5/2017 )

GOVERNMENT COMMITMENT ON PREVENTION AND CONTROL OF NCDs

NCDsPREVENTION AND CONTROLING STRATEGYIN INDONESIA

STRATEGY

Advocacy,partnership,

leadership andmanagement

Health systemStrengthening infrastructure,

Enchancing primary care delivery system to detect NCD risk factors,

diagnoses and HT (Providing PEN)

NCD Health Promotion through lifecourse

and NCD risk Reduction

PREVENTIONAND CONTROL

OF NCD

HEALTHY INDONESIA PROGRAM

Enchanching Research,Data base collection,

Web-based surveillance system, strong management

information system and data reporting mechanism

NCDs PREVENTION AND CONTROL STRATEGYTHROUGH THE HEALTHY INDONESIAN PROGRAM :

01

02

03

04

Advocacy and partnership inter program and inter sector

Strengthening of health services capacityfor risk factor early detection, diagnosisand integrated prompt treatment of NCDs cases.

Community empowerment with health promotion,prevention and reducing NCDs risk factors)

Strengtening surveillance, monitoring and NCDsresearches.

MOH has made Healthy Indonesia Program which include blood pressure measurement for all citizens above 15 years old and suggesting all family member to stop smoking and not to smoke. This programme has to be implemented all over Indonesia in 2019.

SCOPE OF NCDsINTEGRATED HEALTH SERVICES (PANDU PTM)

NCDs risk factor Early detection, monitoring, counseling and doing

healthy activity

NCDs risk factor Early detection, monitoring, counseling and doing

healthy activity

Physical and laboratory examination, diagnosis and prompt treatment based on Pandu PTM are being done by the medical profesional.

Reffer NCDs cases with complication or target organ damage to the

hospital

Limited rehabilitation and paliative care for

NCDs cases

Reffering NCDs cases to PHC

REVERSE REFFERAL

CBI PHC Hospital

The Ministry of Health also organizes and directs health promotion activities, which are delivered through the network of facilities at district and community levels. Preventive efforts also focus on NCDs, including health promotion to raise public awareness, and community-based health awareness groups, early screening and early detection in form of community based health services (UKBM).

For example, the Posbindu is a community engagement programme that addresses almost all NCD risk factors, and is integrated into other settings within the community to detect and monitor NCDs risk factor. If the health cadres detect NCDs risk factor in community they are able to reffer the person to the PHC.

In PHC , health workers do early detection risk factor of NCD , monitor, Communicate, Inform, Educate and do physical actvity together with community. The medical professional do physical and laboratory examination, diagnosed and case management of NCDs by Pandu PTM. They also do case refferal if target organ damage occurs and provide limited case rehabilitation and paliative treat-ment.

The National Health Insurance covered for promotive, preventive, curative and rehabilitative NCDs cases including the referral expenditure from hospital to the primary health care.

SCOPE OF NCDs INTEGRATED HEALTH SERVICES

INTEGRATED HEALTH SERVICES (PANDU PTM)

Adapted from WHO-PEN and adjusted to Indonesian Health program

Strengthening Health system and primary health care services

It’s a prioritized set of cost effective intervension for an acceptablequality care that affordable for the local goverment.

It is a minimum essential intervension in National Health Insurrance.

Focused on Hypertension and Diabetes management with additionalcore set of cancer, sight disorders, hearing disorders and community based rehabilitation.

Involving the development of community based intervention(Posbindu PTM) as apart of referral mechanisme to the primary health care.

DIFFERENCE BETWEEN CORE SET OF

WHO-PEN AND PANDU PTM

PANDU PTMCORE SET WHO-PEN

Primary prevention of heart attacks and strokes

Acute myocardial infarction

Secondary prevention(post myocardial infarction)

Secondary prevention(post stroke)

Secondary prevention(Rheumatic heart disease)

Type 1 Diabetes

Type 2 Diabetes

Prevention of foot complicationthrough exmination and monitoring

Prevention of onset and delayin progression of chronic kidney

Prevention of onset and delay ofprogression of diabetic retinopathy

Prevention of onset andprogression of neuropathy

Bronchial asthma

Prevent exacerbation ofCOPD and disease progression

Cancer

We adopted eleven core set of WHO-PEN, except secondary prevention of rheumatic heart disease, Type 1 Diabetes and Neuropathic management Additional core set in PANDU PTM are management of sight disorders, hearing disorder and comunity based rehabilitation.

√

√

√

√

-

-

-

-

√

√

√

√

√√ Focus on Breast and

cerviks cancer

Sight disorders

ADDITIONAL PACKAGE OF PANDU PTM

Hearing disorders

Community based rehabilitation

DIFFERENCE BETWEEN CORE SET IN WHO-PEN AND PANDU PTM

0102

0304

050607

080910

11121314

Workshop WHO-PENParticipant:MOH inter-program, medical professional organization, Representative of District health office

-Piloting Pandu PTM in 5 Province(Sumbar, Sumut, Lampung, Bali, Aceh)56 District/City92 PHC 124 medical workers

-Develop Guidelines Pandu PTM

Piloting Pandu PTM di 26 Province258 district/city,343 PHC, 561 medical workers

Assesment of readiness for implementing PANDU PTM

Assesment of readiness for implementing PANDU PTM

WHO-PEN was first introduced by Prof. Shanty Mendez in 2011 , some participants were invited such as inter programme in MOH, representative of Province and District Health Offices, PHCs and health professional. We adapted WHO- PEN as PANDU PTM ( Pelayanan Terpadu Penyakit Tidak Menular) as an Integrated health services for NCDs.  

DEVELOPMENT OF NCDs INTEGRATED HEALTH SERVICES

(PANDU PTM) IN INDONESIA

DEVELOPMENT OF NCDS INTEGRATED HEALTH SERVICES (PANDU PTM) IN INDONESIA

2012

2013

2014

2011 2015

Workshop WHO-PENParticipant:MOH inter-program, medical professional organization, Representative of District health office

-Piloting Pandu PTM in 5 Province(Sumbar, Sumut, Lampung, Bali, Aceh)56 District/City92 PHC 124 medical workers

-Develop Pandu PTM Guidelines

Piloting Pandu PTM in26 Province258 district/city,343 PHC, 561 medical workers

Assesment of readiness for implementing PANDU PTM in Cimahi and Palembang City

Assesment of readiness for implementing PANDU PTMin Cimahi and Palembang City

In 2012 we developed a guidelines Pandu PTM and piloted it in five province and we continued doing that in another 26 provinces in 2013 in the same year MOH set up the PANDU PTM as one of 2014 to 2015 strategic plan indicators.

In 2014 and 2015 MOH did assesment on readiness for implementing Pandu PTM in four district. In 2016 and 2017 we had national training three times on WHO-PEN which Prof. Shanty Mendez attended as an technical consultant and other participants from cross programme in MOH, representative of Province and District Health Offices, PHCs, health professional, University and State school.

We also executed Training for Trainer in 34 Provinces for province program manager of NCDs and MOH master of training. Beside that we conducted some training for primary health workers on PANDU PTM in 321 primary health care of 22 province.

In 2018 we are planning to have another training PANDU PTM for untrained primary health workers and evaluation of implementing PANDU PTM will follow. We are targetting that 50% PHC will have conducted PANDU PTM in 2019.  

2017

2018

2019

2016

3 National training for implementing WHO-PENTOT Pandu PTM for 13 ProvincePandu PTM training for 4 Province 18 District/City20 PHC, 60 medical workers

TOT Pandu PTM for 21 ProvincePandu PTM training for18 Province211 District/city,301 PHC, 501 medical workers

Pandu PTM training for34 Province34 District/city,68 PHC, 180 medical workersPandu PTM implementation evaluation in 14 Province

Targetting 50% PHC implements PANDU PTM

OBSTACLES CHALLENGES&

OBSTACLES

CHALLENGES

Limited budgeting

NCDs program is not priority yet in province and district

Frequent rotation among the trained health worker.

Making PANDU PTM as a minimum standard as achievement of health secvices in provinces and district

Recent advances in IT in operation of district offices

Developing PANDU PTM as a curriculum of medical and nursing faculty.

Written by :

dr. Lily S Sulistyowati, MMdr. Zamhir Setiawan, M.Epid

dr. Tristiyenny Pubianturi, M.Kesdr. Juzi Delianna, M.Epid

dr. Prihandriyo Sri Hijranti, M.EpidJamaludin SKM, M.Epid

Nengsih Hikmah Sensiawati, SKM, MKMRindu Rachmiaty, SKM, M.Epid

Ridho Ichsan Syaini, SKM, M.Epiddr. Elmi Suryani

Graphic Director :

drg Anitasari SMIra Carlina Pratiwi, S.Sn

Directorate of Non-communicable Disease,Directorate General of Disease Prevention and Control,

Ministry of Health of Indonesia

www.p2ptm.kemkes.go.id

@p2ptmkemenkesRI

@p2ptmkemenkesRI

@p2ptmkemenkesRI