The dynamic of non-communicable disease control policy in Indonesia

Political economy analysis of health taxes (tobacco, alcohol drink and sugar-sweteened beverage): qualitative study of three provinces in Indonesia

OBJECTIVE

Efforts to implement health tax policies to control the consumption of harmful commodities and enhance public health outcomes have garnered substantial recognition globally. However, their successful adoption remains a complex endeavour. This investigates the challenges and opportunities surrounding health tax implementation, with a particular focus on subnational government in Indonesia, where the decentralisation context of health tax remains understudied.

DESIGN

Employing a qualitative methodology using a problem-driven political economy analysis approach.

SETTING

We are collecting data from a total of 12 focus group discussions (FGDs) conducted between July and September 2022 in three provinces-Lampung, Special Region of/Daerah Istimewa Yogyakarta and Bali, each chosen to represent a specific commodity: tobacco, sugar-sweetened beverages (SSBs) and alcoholic beverages-we explore the multifaceted dynamics of health tax policies.

PARTICIPANT

These FGDs involved a mean of 10 participants in each FGD, representing governmental institutions, non-governmental organisations and consumers.

RESULTS

Our findings reveal that health tax policies have the potential to contribute significantly to public health. Consumers understand tobacco's health risks, and cultural factors influence both tobacco and alcohol consumption. For SSBs, the consumers lack awareness of long-term health risks is concerning. Finally, bureaucratic complexiting and decentralised government hinder implementation for all three commodities.

CONCLUSION

Furthermore, this study underscores the importance of effective policy communication. It highlights the importance of earmarking health tax revenues for public health initiatives. It also reinforces the need to see health taxes as one intervention as part of a comprehensive public health approach including complementary non-fiscal measures like advertising restrictions and standardised packaging. Addressing these challenges is critical for realising the full potential of health tax policies.

Socioeconomic disparities in the burden of hypertension among Indonesian adults - a multilevel analysis

Background

Hypertension remains a problem of public health across various socioeconomic groups, despite its high prevalence. However, few studies account for geographical variation in examining socioeconomic inequalities and hypertension in Indonesia.

Objective

To investigate the burden of hypertension in Indonesia based on prevalence, awareness, treatment, and control of hypertension among adults; and assess whether or not the burdens vary according to geographical variation and socioeconomic status

Methods

In Wave 5 of the Indonesian Family Life Survey in 2015, 32,034 individuals aged 15 and over participated in the study. Concentration Curves (CC) and Concentration Indexes (CI) were used to analyse socioeconomic inequality. We used multilevel logistic regression to assess biological, geographical variation, and socioeconomic factors associated with the burden of hypertension, adjusting for potential covariates.

Results

The prevalence of hypertension in Indonesia was 26.1%, and only 26.9% of those with hypertension were aware of their condition. Approximately 22.5% of hypertensive patients received treatment, but only 28.2% had controlled blood pressure and reached the therapeutic goal. Low socioeconomic groups were more prone to hypertension (CI = −0.047 in urban and CI = −0.075 in rural). In contrast, awareness, treatment, and control of hypertension were more concentrated in higher socioeconomic groups.

Conclusions

The high prevalence of hypertension, low awareness of the condition, poor compliance with treatment, and poor control of the condition, as well as the existing socioeconomic inequality, make this a significant determinant of public health issue in Indonesia. There is a need for effective programs for the prevention of hypertension and better management of hypertensive patients.

Primary health care policy and vision for community pharmacy and pharmacists in Indonesia

The practice of community pharmacy in low and middle-income countries, including in Indonesia, is often described as in the state of infancy with several intractable barriers that have been substantially and continuously hampering the practice. Such description might be valid in highlighting how pharmacy is practiced and the conditions within and beyond community pharmacy organizations. Therefore, it is not surprising that the concept of integrating community pharmacy into the primary care system may not be considered in the contemporary discourse despite the fact that community pharmacy has been operating within communities for years. However, in the case of Indonesia, we argue that changes in the health care system within the past decade particularly with the introduction of the universal health coverage (UHC) in 2014, may have significantly amplified the role of pharmacists. There is good evidence which highlights the contribution of pharmacist as a substantial health care element in primary care practice. The initiative for employing pharmacist, identified in this article as primary care pharmacist, in the setting of community health center [puskesmas] and the introduction of affiliated or contracted community pharmacy under the UHC have enabled pharmacist to work together with other primary care providers. Moreover, government agenda under the “Smart Use of Medicines” program [Gema Cermat] recognizes pharmacists as the agent of change for improving the rational use of medicines in the community. Community pharmacy is developing, albeit slowly, and is able to grasp a novel position to deliver pharmacy-related primary care services to the general public through new services, for example drug monitoring and home care. Nevertheless, integrating community pharmacy into primary care is relatively a new notion in the Indonesian setting, and is a challenging process given the presence of barriers in the macro, meso- and micro-level of practice.

Behavioral Risk Factors Of Non-Communicable Diseases Among A Nationally Representative Sample Of School-Going Adolescents In Indonesia

Background

The aim of this study was to investigate the prevalence and correlates of behavioral non-communicable diseases (NCD) risk factors among adolescents in Indonesia.

Methods

Cross-sectional national data were analyzed from 11,124 in-school adolescents (mean age 14.0 years) of the Indonesia Global School-Based Student Health Survey (GSHS) in 2015. Seven behavioral NCD risk factors (substance use, dietary behavior, overweight or obesity, low physical activity, and sedentary behavior) were assessed by questionnaire in a classroom setting.

Results

The prevalence of low physical activity was 87.8%, insufficient fruit and vegetable intake 76.8%, having soft drinks daily 27.9%, leisure-time sedentary behavior 27.3%, overweight or obesity 15.8%, current tobacco use 12.8%, and alcohol use 4.4%. From the seven behavioral NCD risk factors, the mean was 2.5 (SD=1.0), and almost half (46.5%) had at least three risk factors. In adjusted linear regression analysis, being a boy, increasing age and psychological distress increased the odds and hunger or food insecurity and parental support decreased the odds for having behavioral risk factors.

Conclusion

A high co-occurrence of behavioral risk factors was identified. Several risk factors (older age, boys, distress, and poor parental support) were identified that can be targeted in intervention programs.

Non-communicable disease prevention policy process in five African countries

BACKGROUND

The increasing burden of non-communicable diseases (NCDs) in sub-Saharan Africa is causing further burden to the health care systems that are least equipped to deal with the challenge. Countries are developing policies to address major NCD risk factors including tobacco use, unhealthy diets, harmful alcohol consumption and physical inactivity. This paper describes NCD prevention policy development process in five African countries (Kenya, South Africa, Cameroon, Nigeria, Malawi), including the extent to which WHO "best buy" interventions for NCD prevention have been implemented.

METHODS

The study applied a multiple case study design, with each country as a separate case study. Data were collected through document reviews and key informant interviews with national-level decision-makers in various sectors. Data were coded and analyzed thematically, guided by Walt and Gilson policy analysis framework that examines the context, content, processes and actors in policy development.

RESULTS

Country-level policy process has been relatively slow and uneven. Policy process for tobacco has moved faster, especially in South Africa but was delayed in others. Alcohol policy process has been slow in Nigeria and Malawi. Existing tobacco and alcohol policies address the WHO "best buy" interventions to some extent. Food-security and nutrition policies exist in almost all the countries, but the "best buy" interventions for unhealthy diet have not received adequate attention in all countries except South Africa. Physical activity policies are not well developed in any study countries. All have recently developed NCD strategic plans consistent with WHO global NCD Action Plan but these policies have not been adequately implemented due to inadequate political commitment, inadequate resources and technical capacity as well as industry influence.

CONCLUSION

NCD prevention policy process in many African countries has been influenced both by global and local factors. Countries have the will to develop NCD prevention policies but they face implementation gaps and need enhanced country-level commitment to support policy NCD prevention policy development for all risk factors and establish mechanisms to attain better policy outcomes while considering other local contextual factors that may influence policy implementation such as political support, resource allocation and availability of local data for monitoring impacts.

How is Indonesia coping with its epidemic of chronic noncommunicable diseases? A systematic review with meta-analysis

BACKGROUND

Chronic noncommunicable diseases (NCDs) have emerged as a huge global health problem in low- and middle-income countries. The magnitude of the rise of NCDs is particularly visible in Southeast Asia where limited resources have been used to address this rising epidemic, as in the case of Indonesia. Robust evidence to measure growing NCD-related burdens at national and local levels and to aid national discussion on social determinants of health and intra-country inequalities is needed. The aim of this review is (i) to illustrate the burden of risk factors, morbidity, disability, and mortality related to NCDs; (ii) to identify existing policy and community interventions, including disease prevention and management strategies; and (iii) to investigate how and why an inequitable distribution of this burden can be explained in terms of the social determinants of health.

METHODS

Our review followed the PRISMA guidelines for identifying, screening, and checking the eligibility and quality of relevant literature. We systematically searched electronic databases and gray literature for English- and Indonesian-language studies published between Jan 1, 2000 and October 1, 2015. We synthesized included studies in the form of a narrative synthesis and where possible meta-analyzed their data.

RESULTS

On the basis of deductive qualitative content analysis, 130 included citations were grouped into seven topic areas: risk factors; morbidity; disability; mortality; disease management; interventions and prevention; and social determinants of health. A quantitative synthesis meta-analyzed a subset of studies related to the risk factors smoking, obesity, and hypertension.

CONCLUSIONS

Our findings echo the urgent need to expand routine risk factor surveillance and outcome monitoring and to integrate these into one national health information system. There is a stringent necessity to reorient and enhance health system responses to offer effective, realistic, and affordable ways to prevent and control NCDs through cost-effective interventions and a more structured approach to the delivery of high-quality primary care and equitable prevention and treatment strategies. Research on social determinants of health and policy-relevant research need to be expanded and strengthened to the extent that a reduction of the total NCD burden and inequalities therein should be treated as related and mutually reinforcing priorities.