On 19 April 2016, the President of Indonesia, Joko Widodo, delivered an address to the UK Parliament following his meeting with David Cameron. As an Indonesian, I sensed the irony of having the Palace of Westminister as the venue of my first live encounter with the man affectionately known as Jokowi [pictured]. Eloquently, and in English, he spoke about democracy and Islam.
In her book, Indonesia, Etc., British author Elizabeth Pisani quoted one of her sources: “Indonesia is probably the most invisible country in the world.” In similar vein, Jokowi remarked to the Members of Parliament present: “We know more about you than you do about us,” before naming British football teams, music bands and clothing stores popular in Indonesia.
Indeed, when Indonesia does get in the press it has mainly been about radicalism, terrorism, the death penalty, human rights abuses, corruption and natural disasters. Jokowi spoke instead about humanity, pluralism and tolerance, highlighting freedom of speech, press freedom and soft power approaches to radicalism.
Just a month before, there had been a surge of international news articles related to Indonesia. This coincided with a report published by the Human Rights Watch (HRW), based on the hellish experiences of 72 Indonesians who had been shackled, chained, or caged in a local practice called pasung. The HRW estimated 18,000 Indonesians are being placed in restraint due to psychosocial disabilities. In an interview with Vice.com, author of the HRW report, Kriti Sharma witnessed the recovery of a 29-year-old woman following mental health care, and noted that pasung tend to occur in areas where access to services is limited.
Although the practice of pasung has been documented as far back as the colonial period, and banned by the government in 1977, concerted effort to eradicate pasung first began in Aceh in 2010. Recent awareness of modern mental health care developed from implementing disaster relief programmes post Boxing Day tsunami, which included the development of a community mental health system. Soon, the Ministry of Health adopted the effort as a national programme called Indonesia Free From Pasung. The goal was to eradicate pasung by 2014, but this was later amended to 2017.
The reasons for pasung are manifold. Firstly, the country’s health budget is around 5% of GDP, while mental healthcare spending is a mere 1% of this budget. There are limited funds for mental health promotion and training of professionals. Much in line with this, there are only 773 psychiatrists in 2015 serving a population of 250 million. Moreover, the geography of Indonesia and the unequal distribution of population result in large patches of extremely low population density, negating the feasibility of building and managing secondary and tertiary mental health care facilities in these areas. To make matters worse, the stigma of mental illness is very strong and mental illness is often seen as demon possession or a curse. The list goes on, but as a result, the treatment gap is above 90%.
Jokowi inherited the administrative challenges of a complex archipelago, with over 17,000 islands, 300 ethnic groups, and 500 languages. His optimism in sharing Indonesia’s list of achievements to the world, remains strong even after 18 months at the helm. Jokowi’s speech on 19th April, acknowledged by the Parliament as the only address delivered by a head of state who is a fan of Led Zeppelin, made me want to share Indonesia’s achievements strengthening its mental health system. Indeed, Indonesia has embarked on efforts to improve access to mental health services, especially through its vast network of 9,729 state-owned community health centres.
Community mental healthcare
In his 2009 World Mental Health Day speech, Ban Ki-Moon emphasised that community mental health care reduces stigma, prevents unnecessary hospitalisation and human rights violations, makes good economic sense, and beyond that, is a pro-poor strategy. Since 2005, the Ministry of Health has provided upskill training for clinicians from community health centres across the country so they could provide basic mental health care. By end 2014, 47% of almost 10,000 community health centres across the country have at least one member of staff trained in mental health care. In 2015, the training curriculum was aligned with the World Health Organization Mental Health Gap Action Programme.
Relatively unknown to the outside world is a homegrown framework of specialist primary mental healthcare. The Centre for Public Mental Health, based on Gadjah Mada University’s Faculty of Psychology, manages masters-level clinical psychologists employed by 43 community health centres in two districts. This project, which also began 11 years ago, is about to be rolled out to a third district in January 2017. While the evaluation of clinical and cost effectiveness of both efforts is underway in Indonesia, consider the amount of people already helped over the past 11 years.
Like Ban Ki-Moon, I believe that community mental healthcare is the most immediate solution to the treatment gap problem in Indonesia. Currently, evaluation of the clinical and cost effectiveness of the above frameworks is underway to see whether encounters with health services result in recovery from psychosocial disabilities. Evaluation results should enable the government to confidently invest its precious 1% of the health budget in a mental healthcare framework that has been proven to be effective.
With increased international awareness on the matter already, let me take a page out of Jokowi’s book and focus on potential solutions rather than harping on about the problems.
*Sabrina Anjara  is doing a PhD in Public Health and Primary Care focused on mental health in Indonesia. She is currently crowdfunding her research project at https://crowdfunding.justgiving.com/JIWAtrial. Picture credit: Wikipedia.
Sabrina Gabrielle Anjara
- 2014 PhD Public Health and Primary Care
- Queens' College
Sabrina recently completed her PhD as the first Gates Cambridge Scholar from Indonesia. Her thesis focused on the implementation and outcome evaluation of mental health care policies in Indonesia, specifically in adapting service delivery models to local contexts. She is currently a Postdoctoral Research Fellow at University College Dublin, working on the implementation of Collective Leadership in the Ireland East Hospital Group.
Sabrina holds a BA in Psychology and Asian Studies from the University of Melbourne, and an MSc in Organisational Psychiatry and Psychology from King’s College London. Prior to Cambridge, Sabrina worked at the Yong Loo Lin School of Medicine, National University of Singapore and at the Ministry of Social and Family Development, Singapore. She’s a World Economic Forum Global Shaper.