Makalah Prof Pradana Challenges in Diabetes Management in Indonesia (BioMed 2013)

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Soewondo et al. Globalization and Health 2013, 9:63

http://www.globalizationandhealth.com/content/9/1/63
REVIEW
Open Access
Challenges in diabetes management in Indonesia:

a literature review
564
Pradana Soewondo1*, Alessandra Ferrario2 and Dicky Levenus Tahapary1
Abstract
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Background and objectives: The expanding diabetes epidemic worldwide could have potentially devastating
effects on the development of healthcare systems and economies in emerging countries, both in terms of direct
health care costs and loss of working time and disability. This study aims to review evidence on the burden,
expenditure, complications, treatment, and outcomes of diabetes in Indonesia and its implications on the current
health system developments.
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Methods: We conducted a comprehensive literature review together with a review of unpublished data from the
Ministry of Health and a public health insurer (Askes). Studies presenting evidence on prevalence, incidence,
mortality, costs, complications and cost of complications, treatment, and outcomes were included in the analysis.
Results: A limited number of international, national and local studies on the burden and cost of diabetes in
Indonesia were identified. National survey data suggests that in 2007 the prevalence of diabetes was 5.7%, of
which more than 70% of cases were undiagnosed. This estimate hides large intracountry variation. There was very
limited data available on direct costs and no data on indirect costs. The most commonly-identified complication
was diabetic neuropathy.
Discussion: There were a number of limitations in the data retrieved including the paucity of data representative at
the national level, lack of a clear reference date, lack of data from primary care, and lack of data from certain
regions of the country.
Conclusions: If left unaddressed, the growing prevalence of diabetes in the country will pose a tremendous
challenge to the Indonesian healthcare system, particularly in view of the Governments 2010 mandate to achieve
universal health coverage by 2014. Essential steps to address this issue would include: placing diabetes and noncommunicable diseases high on the Government agenda and creating a national plan; identifying disparities and
priority areas for Indonesia; developing a framework for coordinated actions between all relevant stakeholders.
Keywords: Diabetes mellitus, Diabetes costs, Diabetes complications, Indonesia
Background
With a population of 237.6 million people in 2010 [1],
Indonesia is the worlds fourth most populated country.
It also has the seventh largest number of diabetic patients (7.6 million), despite relatively low prevalence
(4.8% including both diabetes type 1 and 2 in individuals
aged 2079 years) in 2012 [2].
The country is in the middle of a demographic and epidemiological transition. In 2009, life expectancy at birth
* Correspondence: soewondops@yahoo.com
1
Division of Metabolism and Endocrinology, Department of Internal
Medicine, Faculty of Medicine University of Indonesia, Dr. Cipto
Mangunkusumo Hospital, Jakarta, Indonesia
Full list of author information is available at the end of the article
was 68 years, which is slightly higher than the Southeast

Asian regional average of 65 years [3]. The fertility rate decreased from 3.1 in 1990 to 2.5 in 2000, reaching 2.1 in
2009 [3]. Both adult mortality and under-five mortality are
below regional averages (190 deaths in Indonesia vs. 209
deaths in the region among adults 1559 years old per
1000; 39 vs. 59 deaths among children under five per 1000
live births) [3]. The Indonesian epidemiological transition is
proceeding rapidly in comparison to the regional average.
In 2008, 41% (49% regional average) of the total years of life
lost (YLL) was due to communicable diseases while 45%
(36% regional average) were due to non-communicable
diseases [3].
2013 Soewondo et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
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However, marked geographical variations exist. While

infectious diseases and child mortality are still very
prevalent in the eastern provinces of Indonesia, Java and
Bali are starting to experience a higher burden of noncommunicable diseases (NCDs) [4].
The rising prevalence of diabetes has become a major
problem worldwide and affects more than 132.2 million
in the Western Pacific region (more people than in any
other region) [2]. Non-communicable diseases are estimated to account for 63% of all deaths in Indonesia [5].
Cardiovascular disease contributed to 30% of the total
number of deaths followed by cancers (13%), and diabetes (3%) [5]. The epidemiological and nutritional transitions play a major part in these trends [6].
Indonesias struggle to develop a responsive healthcare
system is exacerbated by an environment where health
insurance coverage is incomplete. The Government aims
to achieve universal health coverage by 2014 by progressively covering the remaining 139.9 million uninsured
citizens through Askeskin/Jamkesmas [7].
The main government health insurance programmes are
Askeskin/Jamkesmas, which is the national health insurance
scheme for the poor or nearly poor (76.4 million beneficiaries representing 32% of the population in 2010). Askes provides health insurance for civil servants and retired army
forces (16.5 million beneficiaries representing 7% of the
population in 2010). Jamsostek provides coverage for formal
sector workers (5.0 million beneficiaries representing 2% of
the population in 2010) [8]. Meanwhile, about 3% of the
population is covered by private health insurance [4].
Due to the potentially devastating effects of the diabetes epidemic to the development of the Indonesian
health system and economy (both in terms of direct
health care costs and loss of working time and disability), this study aims to review evidence on the burden,
expenditure, complications, treatment, and outcomes of
diabetes in Indonesia and its implications on the current
health system developments.
To our knowledge, no such study had been published at
the time of writing. Reviewing available evidence at regular
intervals is crucial to assess the situation and to inform
policies and programme implementation. This is particularly relevant at this point in time, as the Government of
Indonesia is preparing its national plan for diabetes. This
literature review thus aims to address this important literature gap by reviewing and critically assessing available
evidence, and making recommendations on areas of diabetes management which need to be strengthened.
Methods
We reviewed available evidence and summarised available data sources on: the prevalence of type 1 and type 2
diabetes and gestational diabetes; the incidence, direct
and indirect costs of diabetes; prevalence of complications
Page 2 of 17
(diabetes retinopathy, neuropathy, nephropathy, chronic

kidney disease, and vascular complications including diabetic foot); cost of complications; treatment regimens and
use of renal transplantation and impact outcomes such as
HbA1c levels; frequency of checks for complications and
glucose monitoring. Further, we reviewed available national
guidelines for diabetes, available policies and national programmes, and searched for any available evidence on the
impact of smoking, tuberculosis (TB), HIV, and fasting during Ramadan on health outcomes for diabetic patients.
Where such information was available, we distinguished
between diabetes type 1 and 2.
A comprehensive literature review on diabetes care
management was conducted in February 2012. The following key words were used ((diabetes[Title/Abstract] OR
"chronic kidney" OR "renal disease") AND Indonesia
[Title/Abstract]) OR (("Diabetes Mellitus"[Mesh] OR "Diabetes Mellitus, Type 2"[Mesh] OR "Diabetes Mellitus,
Type 1"[Mesh]) AND "Indonesia"[Mesh]) in PubMed.
Diabetes, prevalence, treatment, complications, chronic
kidney, renal disease, direct cost, indirect cost, health insurance, health system, Indonesia were used in Google
and local journals. We did not put any time limits or language restrictions on our search and all articles identified
up to February 2012 were included.
Additional articles were identified from the references
in the retrieved literature.
We also retrieved unpublished data from the Ministry of
Health Republic of Indonesia and Askes. In addition, we
also included presentations from symposia on diabetes.
Studies presenting evidence (whether primary or secondary) on prevalence, incidence, mortality, costs, complications and cost of complications, treatment, outcomes
(e.g. blood glucose control) were included in the analysis.
If data on costs were only reported in Indonesian
Rupee (IDR), we converted the amounts into USD$
using the corresponding historical conversion rate from
the OANDA website (http://www.oanda.com/currency/
historical-rates/).
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Results
We retrieved 93 studies in PubMed: 69 were excluded
through title screening, one was excluded through abstract screening because they did not meet inclusion criteria. A total number of 23 peer-reviewed papers were
included in the analysis (Table 1). Four additional peerreviewed papers were identified through Google search.
Another 11 articles were identified through reference
searching in other articles. This was complemented by
grey literature such as reports and presentations.
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Data sources
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A limited number of data sources on the burden and 155

management of diabetes in Indonesia were identified. 156

Page 3 of 17
Area of diabetes Number of

management
references
retrieved
References
samples were collected from 24,417 urban residents aged 192

15 and over [16]. The next round of data collection as 193
part of Riskesdas is planned for 2013.
194
t1:4
Prevalence
[9-16]
A1CHIEVE
195
t1:5
Incidence
196
t1:6
Mortality
[17]
t1:7
Costs
[18-20]
t1:8
Complications
14
[18,21-32] and unpublished

observations from Yunir 2008i
t1:9 Costs of
t1:10 complications
[20,22,33-35]
t1:11 Treatment
[21,26,35-38]
t1:12 Outcomes
[18,21,26,36,39-41]
These included international studies, national surveys,

158 and studies.
A1chieve was a large multicountry observational study

on the use of insulin in DMT2 patients in real-life. The
aim was to evaluate the safety and effectiveness in routine clinical practice between 2009 and 2010 of three insulin analogues manufactured by Novo Nordisk. The
study recruited 66,726 people across 3,166 centres in 28
countries covering the four continents (Asia, Africa,
South America, and Europe). The primary aim of the
study was to assess the adverse event profile of the three
insulins in routine clinical practice, including rates of
hypoglycaemia. In addition, effectiveness (HbA1c, fasting
plasma glucose, and postprandial plasma glucose) and
patient quality of life outcomes were measured [42].
159 Diab care
Askes
209
t1:1
t1:2
t1:3
Table 1 Literature
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160
161
162
163
164
165
DiabCare Asia is an international collaboration between

Novo Nordisk Asia Pacific, Singapore, BioRad Pacific,
Hong Kong and diabetes associations in participating
Asian countries. The aim of this partnership is to collect
evidence on disease pattern, management, control status,
and complications of diabetes in the Asian diabetes
population.
DiabCare in Indonesia was conducted in 1997, 1998,
2001, 2003, and 2008 to estimate the prevalence of diabetes and its complications and to investigate treatment
outcomes [26]. In addition, DiabCare 2003 and 2008 also
evaluated the quality of life of patients with diabetes.
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199
200
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202
203
204
205
206
207
208
Most direct cost information available is unpublished 210

data from the health insurer Askes.
211
Jakarta primary non-communicable disease risk factors sur- 212
veillance (Jakarta NCD-S)
213
The Jakarta NCD-S study is the result of a collaboration

between the Ministry of Health and the University of
Indonesia started in 2006 [43]. Data collected include
the prevalence of diabetes and its risk factors and complications [43-45].
214
Indonesian renal registry
219
220
174
A national registry for end stage renal disease has been

established by the Indonesian Society of Nephrology
(PERNEFRI) to collect information on the prevalence
and incidence of end stage renal disease [22,34,46].
175
176
Studies
224
A few local cross-sectional studies on the prevalence of

diabetes and its complications were identified. These
studies investigated the prevalence and risk factors in a
remote island in the eastern part of the country [12];
prevalence in population sub-groups [9]; prevalence and
risk-factors for diabetes in northern Jakarta [15]; childhood diabetes cases in a hospital [13]; prevalence of decreased renal function among diabetes type 2 patients
[25]; prevalence of diabetes foot [24]; and the incidence
and prevalence of end-stage renal disease [22,34].
Evidence from secondary sources identified in this study
and the authors own knowledge suggest that an unknown
number of local studies on the prevalence of diabetes in
Indonesia remain unpublished. We could identify some of
these studies from secondary sources; however, information
on the study methodology and other important parameters
225
166
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168
169
170
171
172 International diabetes management practices study (IDMPS)

173 The IDMPS is one of the largest population-based stud-
ies of diabetes patients in developing countries. This

cross-sectional study aimed to estimate resource use for
diabetes type 2 and risk factors for hospitalisation, in177 patient days, emergency visits, and absenteeism in 24
178 countries in Africa, Asia, Latin America and the Middle
179 East [18].
180 National basic health research (Riskesdas)
181 The Riskesdas survey was commissioned
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186
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190
191
by the National
Institute of Health and Research (NIHRD) to provide
evidence for policy-makers on key health areas such as
health status, nutrition status, health environment,
health attitude, and various health service utilisation aspects. Evidence collected includes nationally representative indicators together with some district/city level
indicators based on a sample of 258,284 households
comprising 972,989 individuals. In 2007, for the first
time blood glucose was measured allowing for the estimation of diabetes prevalence. For this purpose, blood
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such as time and location were often missing from secondary sources limiting the use and comparability of such data.
Local studies are complemented by international efforts such as the PAD-SEARCH, an international study
on the prevalence of peripheral arterial disease in Asian
type 2 diabetes patients [23] and multi-country studies
on the prevalence of complications and outcomes of diabetes type 1 in children [21] and type 2 [36] in youth.
Other articles presented findings from secondary data
sources: Riskedas 2007 [10,11], diabetes complications
and outcomes from DiabaCare 2008 survey [26], and a
review reported results from unpublished epidemiological studies [14].
In addition to data from Askes, a few local studies addressing direct cost of diabetes were also identified
[19,20,33,47].
257 Diabetes prevalence

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T2 270
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According to the International Diabetes Federation (IDF),

the national prevalence of diabetes in Indonesia was 4.8%
in 2012 (the international comparative prevalence was
5.1% in 2012) [2]. More than half of all diabetes cases
(58.8%) were underdiagnosed in 2012 [2]. The proportion
of urban and rural cases was almost the same, although
slightly higher in urban areas (1.1 urban : rural ratio in
2012) and it is expected to increase to an estimated 1.6
urban : rural ratio by 2030 [2].
Data from the 2007 Indonesian National Basic Health
Research (Riskesdas), found a prevalence of diabetes of
5.7%, with more than 70% undiagnosed diabetes cases
[16] (Table 2). However, this estimate hides large variation within the country with the lowest prevalence in
the province of East Nusa Tenggara (1.8%) and the highest in the provinces of West Kalimantan and North
Malaku (11.1%) [16].
A very high prevalence of diabetes mellitus (19.6%) was
found in the suburban population of Ternate, a small remote island in Eastern Indonesia in 2008 [12]. This finding
supports results from Riskesdas 2007 which identified the
North Moluccas province (to which the city of Ternate belongs), jointly together with West Kalimantan, to be the
provinces with the highest rates of diabetes prevalence
[16]. Marriage between close relatives is common in this
area and can lead to diabetes inheritance; indeed multivariate analysis showed that a family history of diabetes
was a risk factor for diabetes in the study [12].
Epidemiological studies in urban areas of Indonesia
showed a marked increase of diabetes prevalence in the
last 30 years. Diabetes prevalence in Jakarta rose from
1.7% in 1982 to 5.7% in 1993, and then more than doubled to 12.8% in 2001 [48]. A study in Ujung Pandang
also showed similar results [48]. In contrast, a study in
the rural area of Ende found a much lower prevalence of
1.56% (Soebardi 2011, unpublished observations).
Page 4 of 17
This urban vs. rural divide concerning the burden of

diabetes is supported by a study on the causes of death
in an urban (Surakarta) and rural city (Pekalongan) in
Indonesia. In this study, diabetes was identified as the second main cause of death in the urban municipality (representing 8.5% of all deaths) but was not one of the main
causes of death in the rural municipality [17]. At the national level, diabetes was identified as the third main cause
of death after stroke and hypertension, ahead of cancer
and chronic obstructive pulmonary disease [11,16,49].
In terms of risk factors, studies identified age, central
obesity, hypertension and smoking habits as risk factors
for undiagnosed diabetes [10] and dyslipidaemia as a risk
factor in newly diagnosed patients in comparison to nondiabetic patients [43]. Although no formal statistical testing was conducted, prevalence of diabetes increased with
age, was higher in women, people with no primary education, housewives, jobseekers, followed by employees and
entrepreneurs according to Riskesdas 2007 [16]. This finding seems to indicate that diabetes affects the less affluent
and the affluent alike. However, in the same study, diabetes prevalence was found to rise with increasing levels
of household expenditure per capita [16].
There is very little evidence on the prevalence of gestational diabetes mellitus in the country. One study using
WHO criteria estimated a prevalence of 9.8% in 1998
(unpublished study, findings reported in [50], gestational
week was not specified) and a previous study using Sullivan and Mahan criteria reported a prevalence of 1.93.5% (unpublished study, findings reported in [50,51], no
information on reference year or gestational week).
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295
Diabetes costs
325
At the time of writing there was no published evidence on

the national direct costs of diabetes. However, there are a
few local studies (mostly from individual hospitals) on diabetes costs and also unpublished national data from Askes.
In addition to that, the IDMPS study offers some insights
into diabetes-related resources use. There is no published
evidence on the indirect costs of diabetes.
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327
Local studies
333
A study on the costs of diabetes of 100 diabetic patients at

Kodya hospital Yogyakarta (secondary health care facility)
was conducted in 2004. Monthly mean direct costs of type
2 diabetes was estimated at USD$ 19.97 [19]. Most of the
direct medical costs identified were spent on drugs (96.4%).
The use of triple drug combinations was found in 36%
of cases and among those, the combination of glikuidone, metformin and acarbose was the most expensive
regimen (USD$ 39.44)[19].
A similar study was conducted at the Dr. Sardjito hospital in Yogyakarta (tertiary health care facility) in 2005.
The average direct cost per month for diabetes treatment
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Page 5 of 17
t2:1
t2:2
t2:3
Prevalence of DM
Table 2 Prevalence of diabetes mellitus in Indonesia

Estimate
Study year Sampling frame and sample
Study design
Diagnostic test
and diagnostic
criteria
Reference
t2:4
t2:5
19.6%, men 21.9%, women

18.2%, n = 97, N = 495
2008
Cross-sectional survey
Diagnostic test:
FPG
[12]
t2:6
t2:7
t2:8
t2:9
Peak age group was

5059 years old, followed
by 4049 years old, and
6069 years old
Sample: 495 individuals, 187

(37.8%) men and 308 (62.2%)
women, 2084 years old
Riskesdas
t2:10 5.7%, 1.5% diagnosed, 4.2%
t2:11 undiagnosed 6.4% women, 4.9% 2007
t2:12 men
t2:13
t2:14
t2:15
t2:16
t2:17
t2:18
t2:22
t2:19
t2:20
t2:21
1.7% (1982),5.7% (1993), 12.8%

(2001) in Jakarta1.5% (NA), 5.4%
(NA) in Ujung Pandang, 6.1% in
Mandado (1980s), 1.5% Bali (NA)
East Java rural and urban areas,
1.47% (NA)
Sampling frame: Suburban

population of Ternate, a small
remote island in Eastern
Indonesia
Criteria: ADA 1997

FBG (>126 mg/dl)
Sampling frame: 33 provinces,

urban areas
Diagnostic test:
FPG and OGTT
Criteria: WHO
1999 and ADA
2003
(> = 200 mg/dl)
Sample: 24,417 urban

residents, >15 years old and
not pregnant
1980s,
Sampling frame: Various urban
1982, 1983, and rural areas
1995, 2001
Sample: NA
NA
Diagnostic test:
NA
Criteria: NA
t2:23 Rural area of Ende, found a

t2:24 much lower prevalence of 1.56%
t2:25 (NA)
t2:26 Asymptomatic cases of diabetes 1997
t2:27 Population screening: 5.42%,
t2:28 n = 51 both sexes 7.42%, n = 21
t2:29 women 4.6%, n = 30 men
t2:34
t2:30
t2:31
t2:35
t2:32
t2:36
t2:33
t2:37
Clinical screening: 17.08%,

n = 155 both sexes, 16.14%,
n = 78 women, 18.16%,
n = 77 men
t2:38
t2:39
t2:40
t2:44
t2:41
t2:45
t2:46
t2:42
t2:43
1.63%, n = 44, N = 2,704, 18

(40%) had previously been
diagnosed but only 50% of
them were on treatment, 1.8%,
n = 23 men, 1.5%, n = 21
women
population
screening,
2000
clinical
screening
Sampling frame: A group of

government employees and
retired military officers
Population screening
and clinical screening
Sampling frame: Koja Utara

subdistrict, Tanjungpriok,
Northern Jakarta
Diagnostic test:
Population
screening with
OGTT. Clinical
screening with
FBG and OGTT
Data from local

unpublished studies,
results reported in
[14,48] and
unpublished
observations from
Soebardi 2011
[9]
Criteria: WHO
1999 criteria
Sample: Population screening:

941 (290 women, 651 men),
clinical screening: 907 (483
women, 424 men)
Study year:
December
1981-June
1982
[11,16]
NA
Diagnostic test:
OGTT
[15]
Criteria: WHO
1980 criteria
Sample: 2,704, > = 15
t2:47 Peak age was 5564 for both

t2:48 men and women
t2:49 0.2% (Semarang), 0.26%
t2:50 (Surabaya)
Study year: Sampling frames: Cities of

1974, 1977, Semarang (1974), Surabaya
1973-1977 (1977), one clinic (19731977)
t2:51 28 patients with

t2:52 insulin-dependent DM
t2:53
Sample: 620 years old
t2:54
(Semarang, Surubaya), all
t2:55
children who attended the
t2:56
clinic between 19731988
t2:57
aged between 115 years old
t2:58
(clinic)
t2:59 Notes: OGTT: Oral-glucose tolerance test; FPG: Fasting plasma glucose.
was IDR 208,500 (USD$ 21) of which 59.5% was spent on

drugs, followed by 31% which was spent on diabetes348 related complications [20].
346
347
NA
Diagnostic test:
NA Criteria: NA
Review of previous
study plus data from
the authors clinic [13]
The combination of biguanid, alpha glucosidase inhibi- 349

tor and insulin was the most expensive drug combin- 350
ation at IDR 571,000 (USD$ 57) per month [20].
351

352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
These two studies suggest that in tertiary care facilities

costs of diabetes were high for most of the Indonesian
population (average GDP per capita is USD$ 245.5 per
month in 2010 [52]), particularly in a context of incomplete insurance coverage. Of course these higher costs
are likely to be caused by the more complex nature of
cases (e.g. presence of co-morbidities and complications)
in a tertiary level hospital.
An ongoing study is trying to estimate diabetes-related
costs in Cipto Mangunkusumo National Public Hospital
(RSCM), a national referral hospital located in Jakarta.
Preliminary results indicate that diagnostic costs for
comprehensive evaluation (consultation fee and further
examinations) are about USD$ 150 (Tahapary 2011, unpublished data).
367 Askes data

368
369
370
371
372
373
374
375
376
In 2010, Askes covered around 16.5 million people in

Indonesia (7% of the population). In the same year, diabetes
was the second most common diagnosis made (420,743
people) after hypertension. It was reported that Askes covered diabetes treatment costs of more than USD$ 22.4
million in 2010. The yearly treatment cost for diabetics
without chronic kidney disease was estimated around USD
$ 40, while in patients with complications, the cost can be
as high as USD$ 800 (Askes 2011, unpublished data).
377 International diabetes management practices study

378 This study reports the annual quantities of diabetes-
related resource use in different countries from 2006

07. In Indonesia, the annual number of specialist visits
was higher (10.2, SD 7.5) than GP visits (6.2, SD 7.8),
382 while the annual number of diabetes educator visits was
383 1.4 (SD 2.8) [18].
379
380
381
384 Diabetes complications

385
386
387
388
389
390
391
T3 392
T4 393
394
395
396
397
398
399
400
401
402
Published studies on the prevalence of complications in

diabetic patients show that the most frequent diabetic
complications were: neuropathy (78-13%), albuminuria
(77.7-33%), microvascular complications (5327.6%), decreased glomeral filtration rate (43.7-7.5% varying also
depending on the method used), retinopathy (42.617.2%), nephropathy (267.3%), macrovascular complications (20-16%), and diabetic foot (247.3%) (Table 3
and Table 4).
We found a similar number of studies at the hospital
level [24,25,27,28,30,31] and at multiple hospital or diabetes
centre locations [18,21-23,26,29,32]. However, only one
study was considered to be nationally representative [26].
A study on end-stage renal disease (ESRD) in Indonesia
showed increasing incidence (measured as the total number of ESRD patients undergoing renal replacement therapy per million people) and prevalence rates (measured as
the total number of ESRD patients alive on December 31
Page 6 of 17
of the current year per million people) of ESRD between

2002 and 2004 in East and Central Java, in Jakarta, and in
Bali [34]. The exception is West Java where incidence and
prevalence decreased between 2002 and 2004 [34]. Furthermore, Bali stands out with a very high increase in incidence and prevalence between 2000 and 2003 [34].
403
404
Cost of complications
409
A study of type 2 diabetes patients who failed (the study

does not provide a definition of failure) with oral antidiabetic medications measured the cost of patients with
and without complications. In patients with both microvascular and macrovascular complications, the total cost
of management increased up to 130% compared to those
without complications [33]. Between 2007 and 2008, the
6-month direct medical cost among type 2 diabetic patients with no complications, one complication and two
or more complications were USD$ 339.14, USD$ 433.44
and USD$ 478.8 respectively [33].
Data from a hospital-based study in 2005 showed that
the highest cost for monthly treatment was recorded for
patients with complications including hypertension and
retinopathy of IDR 754,500 (USD$ 75) [20].
Haemodialysis (HD) imposes a high cost of treatment
on most ESRD patients with limited or no insurance, who
are mostly from low socioeconomic groups. The annual
costs of HD twice a week was about USD$ 4,900-6,500
[34] (the year to which this estimate refers is not clear
from the source but is likely to be 20002003) while the
GDP per capita at constant USD$ (2000) was USD$ 816
in 2002 and USD$ 876 in 2004 [52]. These costs refer to
the public sector and are subject to variation within the
country.
The cost for renal-replacement therapy is paid as part of
government health insurance and came to USD$
5,776,565 in 2002 and to USD$ 7,691,046 in 2006 [22].
The health insurance (Askes, Jamkesmas) covers the renal
replacement therapy (RRT) but with some limitations;
notably, the coverage of haemodialysis is limited to two
sessions a week. In addition, there are geographical barriers affecting availability of RRT units.
However, due to limited insurance coverage, a large proportion of patients have to pay out-of-pocket for HD
[34,35]. Continuous ambulatory peritoneal dialysis (CAPD),
an alternative treatment to HD, is offered in a limited number of centres but its costs (CAPD catheter insertion: USD
$ 1,150, annual costs of four fluid exchanges: USD$ 4,8006,400) are not fully covered by insurance, not even for Government officials [34]. The use of renal transplantation as
an alternative to dialysis is still limited mainly because of
religious issues regarding the use of cadaveric donors, limited number of doctors able to perform this intervention,
and the financial barriers. The cost for pre-transplantation
and transplantation varied between USD$ 12,000 15,650,
410
405
406
407
408
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
426
427
428
429
430
431
432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
447
448
449
450
451
452
453
454
455

t3:1
t3:2
Estimate
t3:3
Diabetic retinopathy
t3:4
42.6%, n = 760, N = 1785
Table 3 Complications of the vascular system

Study year
Sample frame and sample
Study design
Diagnostic test and

diagnostic criteria
Reference
Nov 2008 Feb 2009
Sample frame: 18 diabetes centres,

nationally representative
Cross-sectional
study
Blood samples
[26]
Sample: 1785 DM T2 patients, 15

years old
t3:5
t3:6
t3:7
Page 7 of 17
17.2%, n = 52, N = 302
Year: NA
t3:8
t3:9
t3:10
t3:11 28%
Sample frame: Diabetes clinic in

Surabaya
Sample: 302 T2DM patients, 132 males
and 170 female, mean age of
55.9 21.1 years
2002
t3:12
Sample frame: Primary health care,

Jakarta (Urban Area)
Retrospective
review of
medical
records over
one year
[28]
Cross sectional
study
[27]
Sample: NA, 3060 years old
t3:13 Diabetic neuropathy

t3:14 63.5%, n = 1133, N = 1785
Nov 2008 Feb 2009
t3:15
t3:16
t3:17 58.6%, n = 177, N = 302
Cross-sectional
study
Blood samples
[26]
Sample: 1785 DM T2 patients, > = 15

years old
Year: NA
t3:18
t3:19
t3:20
t3:21 70% in malnutrition-related
t3:22 diabetes, n = 7, n = 10

Sample frame: Diabetes clinic in

Surabaya
and 170 female, mean age of
55.9 21.1 years
Study period:
NA
t3:25 78% in non-insulint3:23

t3:24 dependent diabetes, n = 7,
t3:26
Sample frame: Dr. Sutomo Hospital,

Surabaya
Retrospective
review of
medical
records over
one year
[28]
Cross-sectional
[31]
Sample: 27 diabetic patients between 22

and 55 years old
t3:27 N = 9 13% in
t3:28 insulin-dependent diabetes,
t3:29 n = 1, N = 8
t3:30 Vascular complications
t3:31 Macrovascular 16%, n = 285; Nov 2008 t3:32 microvascular 27.6%, n = 493; Feb 2009
t3:33 N = 1785
t3:34
t3:35

t3:36 Macrovascular 20%

t3:37 microvascular 53%
Sample frame: Patients with type 2

diabetes
2006 - 2007
t3:38
t3:39
t3:40
t3:41
Cross-sectional
study
Blood samples
[26]
Multi-centre,
cross-sectional,
observational
study.
Prevalence-based
approach to estimate
resource use occurred
during a 1-year period.
[18]
Sample: 1785 DM T2 patients, > = 15

years old
Sample: N = 674, mean age 55.2

(SD = 10.2), 55% females,
mean duration for diabetes 6.1
(SD = 6.4) years.
t3:42 Diabetic foot 7.3%, n = 22,

t3:43 N = 302
t3:44
t3:45
t3:46
Year: NA
Sample frame: Diabetes clinic in Surabaya Retrospective

review of
medical
and 170 female, mean age of 55.9
records over
21.1 years
one year
t3:47 Peripheral arterial disease

t3:48 (PAD) DM type 2 patients
Year: NA
Sample frame: 14 hospitals in Indonesia

DM type 2 diabetes patients, aged 50
and older with one or more of the
following risk factors: on smoking or with
history of smoking, hypertension,
dyslipidaemia
t3:49 13,807 PAD patients per

t3:50 100,00 DM patients
[28]
Blood pressure
[23]
measurement at upper
arms and ankles to
obtain the ankle-brachial
index (ABI)

Page 8 of 17
Table 3 Complications of the vascular system (Continued)

t3:51 PAD was defined as an ABI
t3:52 value lower than 0.9.
t3:53 Prevalence of diabetic foot
t3:54 according to Wagners
t3:55 classification
Sample: 464 males and 521 females

1999 - 2004
t3:56 Degree 0 (high risk-foot with

t3:57 no ulcer) 71.6% (n = 202)
ZSample frame: Koja Regional General

Hospital Jakarta
Sample: Diabetic patients, inpatient and
outpatient, with diabetic foot
Retrospective
analysis of
medical
records.
[24]
Retrospective
study
(unpublished
observationsi)
t3:58 Degree 1 (superficial ulcer)

t3:59 1.8% (n = 5)
t3:60 Degree 2 (deep ulcer with no
t3:61 bone involvement or abscess
t3:62 formation) 2.5% (n = 7)
t3:63 Degree 3 (deep ulcer with
t3:64 cellulitis or abscess formation)
t3:65 3.9% (n = 11)
t3:66 Degree 4 (localised gangrene)
t3:67 6.7% (n = 19)
t3:68 Degree 5 (extended
t3:69 gangrene involving the
t3:70 whole foot) 13.5% (n = 38)
t3:71
t3:72
t3:75
t3:73
t3:76
t3:74
t3:77
t3:78
456
457
2007
As many as 15% of diabetic
patients will suffer from ulcer
in their lifetime, and will
12-24% undergo amputation.
Sample frame: Tertiary Care Hospital

Sample: Sequential sampling of all
diabetic patients hospitalised in Cipto
Mangunkusumo Hospital
while the annual cost for immunosuppressive drugs ranged

between USD$ 6,250 10,000 [34,35].
458 Treatment
459
460
461
462
463
464
465
466
467
468
469
470
471
472
473
474
475
476
477
478
479
480
481
482
483
A few studies have looked at the type of treatment used by

patients attending diabetes centres and the use of renal replacement therapy. For diabetes type 2, one study among
patients aged on average 59 years reported that most patients (61.9%, n = 1133) received oral antidiabetic drugs
monotherapy, followed by insulin and oral antidiabetic
drugs (OAD) (19.4%, n = 356), insulin monotherapy
(17.3%, n = 317), no treatment (1.1%, n = 20), and herbal
treatment (0.3%, n = 5) [26]. For insulin therapy the most
common mean number of injections per day (mean units
per day 37.8) was two (55.7%, n = 371) followed by more
than two (25.1%, n = 167) and one (18.9%, n = 126) [26].
A previous study in 2003 among young diabetes type 2
patients (<18 years old) found that 42.9% of patients did
not receive any medication, 28.6% received insulin and
OAD combination therapy, and 14.3% received insulin
monotherapy and another 14.3% received OAD monotherapy [36]. These data need to be compared with caution as the first study is nationally representative while
the second study was part of a larger Western Pacific
study on diabetes and the sample size for Indonesia was
only seven patients.
A third study looked at the treatment regimen of diabetes type 1 patients and found that most patients received one to two injections per day (87.8%) while 10.2%
received three injections per day (mean dose across all

countries included in the study was 1.0 + 0.4U/kg) [21].
It is not clear what type of treatment the remaining 2%
received.
The use of renal transplantation is very limited for a
number of reasons which include: the costs of kidney
transplantation are unaffordable for the majority of the
population; cultural and religious beliefs; perception of the
law; lack of information about organ donation; and lack of
infrastructure and skilled health personnel [38]. Between
1997 and 2001, only 247 transplantations from living donors were performed in Indonesia in comparison to 757 in
Thailand and 1246 in the Philippines both from living and
cadaveric donors [37]. The use of continuous ambulatory
peritoneal dialysis (CAPD) has been increasing from 23
patients in 2002, to 152 in 2004, 592 in 2006, and 774 in
2007 [35]. However, the rate of dropout, mainly due to
death, infection, or catheter failure, was also reported to
be high [35].
484
Outcomes and control of diabetes
503
504
Evidence on the outcomes and control of diabetes was

scarce. We identified two main studies in the area, DiabCare 2008 which assessed outcomes, control and complications of diabetes as well as quality of life of patients, and
the IDMPS in 200607 [18,26] (Table 5). The quality of
life data collected as part of DiabCare 2008 found that
most responses from patients fell in the positive impact
territory of WHO-5-wellbeing index [26]. We identified a
485
486
487
488
489
490
491
492
493
494
495
496
497
498
499
500
501
502
505
506
507
508 T5
509
510
511

t4:1
t4:2
Estimate
t4:3
Diabetic nephropathy
t4:4
7.3%, n = 131, N = 1785
Table 4 Complications of the renal system

Study year Sample frame and sample
Study design
Nov 2008 - Sample frame: 18 diabetes centres, nationally Cross-sectional

Feb 2009
representative
study
t4:5
t4:6
t4:7
Page 9 of 17
Diagnostic
test and
diagnostic
criteria
Reference
Blood
samples
[26]
Sample: 1785 DM T2 patients, > = 15 years

old
19.2%, n = 58, N = 302
Year: NA
t4:8
t4:9
Sample frame: Diabetes clinic in Surabaya

Sample: 302 T2DM patients, 132 males and
170 female, mean age of 55.9 21.1 years
t4:10 Overt nephropathy 11%

t4:11 Incipient nephropathy 26%
2003
t4:12
t4:13
t4:14
Sample frame: Tertiary care hospital,

Outpatient Endocrinology Clinic
Retrospective
review of
medical records
over one year
[28]
Cross sectional
study
[30]
Cross sectional
study
[27]
Retrospective
study
[25]
Cross sectional
study
[27]
Cross-sectional
survey
[32]
Sample: 100 consecutive sampling, mean

age 54 (SD 9.6) years old, 42% male 58%
female
t4:15 Overt nephropathy 8% Incipient

t4:16 nephropathy 25%
2002
t4:17
Sample frame: Primary health care, Jakarta

(Urban Area)
t4:18 Chronic kidney disease

t4:19
t4:20
t4:21
t4:22
t4:23
t4:24
t4:25
Prevalence of decreased glomeral filtration

rate (GFR < 60 ml/min) in newly diagnosed
patients with type-2 DM:
Jan 2003Dec 2006
Sample frame: Outpatient Endocrinology

clinic, Cipto Mangunkusumo hospital
Sample: 1283 new diagnosed DM type 2
patients
Cockroft-Gault (CG) All ages:

36.1% 60 years old: 54.1%
t4:26 Modification of diet in renal disease (MDRD)

t4:27 All ages: 13.2% 60 years old: 19.3%
t4:28 CG-adjusted to body surface (BSA)All ages:
t4:29 43.7% 60 years old: 63%
t4:30 Chinese adapted MDRD (C-MDRD)
t4:31 All ages: 22.8%
t4:32 Creatinine > 2 mg/ml (abnormal level in
t4:33 Indonesia) All ages: 5.8% 60 years old:
t4:34 7.5%
t4:35
t4:36
t4:37
t4:38
t4:39
Prevalence of decreased glomeral filtration

rate (GFR < 60 ml/min) patients with
type-2 DM:
Sample frame: Primary health care, Jakarta

(Urban Area)
30.7% (n = 16, N = 52) Albuminuria: 33%
t4:40 Prevalence of decreased glomeral filtration

t4:41 rate
t4:44
t4:42
t4:43
t4:45
t4:46
t4:48
t4:47
t4:49
2002
Year: NA
Cockroft-Gault: GFR 60 ml/min 87.5%

(n = 1310) GFR < 60 ml/min 12.5% (n = 187)
Sample frame: Four urban and semi-urban

areas: Yogyakarta, Jakarta, Surabaya and Bali
Sample: 9412 (64.1% females). Note: From
Prodjosudjadi et al. 2009 it is not clear which
sub-sample was used to estimate the
glomeral filtration rate.
MDRDGFR 60 ml/min 91.4% (n = 1370)

GFR < 60 ml/min 8.6% (n = 129)
t4:50 C-MDRD GFR 60 ml/min 92.5% (n = 1386)

t4:51 GFR < 60 ml/min 7.5% (n = 133)
t4:52 Prevalence of:
t4:53 -albuminuria: 77.7%
MayOctober
2002
Sample frame: three medical centres

(outpatient)
t4:54 -macro-albuminuria: 44.7% (41.2-48.1,

t4:55 95% CI)
t4:56 -micro-albuminuria: 33% (29.7-36.3, 95% CI)
Sample: 207 patients aged 18 years and

older, with hypertension and DMT2
[29]

Page 10 of 17
Table 4 Complications of the renal system (Continued)

t4:57
t4:58
t4:59
t4:62
t4:60
t4:63
t4:61
t4:64
t4:65
t4:66
t4:67
t4:68
t4:69
Incidence of renal replacement therapy for

end-stage renal disease in Indonesia was
14.5 (n = 2149) and 30.7 (n = 4656) per
million population in 2002 and 2006
respectively.
Prevalence of renal replacement therapy for
end-stage renal disease in Indonesia was
10.2 (n = 1517) and 23.4 (n = 3549) in 2002
and 2006 respectively.
t4:70 Complications in children with DM type 1

t4:71 Hypoglycaemia (Events per 100
t4:72 patient-years, rate (95% CI)): 76.2
t4:73 (3.4 to 149)
2002-2006
Sample frame: 13 nephrology centres in

public and private hospitals
Retrospective
study
[22]
Cross-sectional
clinic-based
survey
[21]
Sample: Total number of patients on renal

replacement therapy (either haemodyalisis,
continuous ambulatory peritoneal dialysis or
renal transplant)
Nov 2001 - Sample frame: Seven diabetes centres

April 2002
Sample: 64 DM type 1 patients
(45% boys, 55%, girls), mean age 11
t4:74 Diabetic ketoacidosis: 20.3 (9.5 to 31.2)

t4:75 Microalbuminuria (n,%): 3 (4.7)
t4:76 Hypertension (%) 31.7
t4:77 Notes: Modification of diet in renal disease (MDRD), Cockroft-Gault (CG).
512
513
514
515
516
517
518
519
520
521
522
523
524
525
526
527
528
529
530
531
532
533
534
535
536
537
538
539
540
541
542
543
544
545
546
547
few other multi-country studies, but they did not present

all their results at the national level.
There seems to be general agreement between studies
that more than 60% of diabetes type 2 patients had HbA1c
levels greater than 7%. HbA1c levels were suboptimal also
for diabetes type 1 patients according to two surveys conducted at clinic level; one study showed an average HbA1c
level of 10.5 [21] and the other showed that more than
half of the assessed patients had levels above 10 [41]. Information on the frequency of annual checks for complications and glucose monitoring is limited and only covers
patients attending clinics. Available information suggests
that among patients attending clinics, about half were
tested for micro- and macrovascular complications (56%
and 46% respectively) [18] and that more than half of the
patients performed home glucose monitoring and had
four or more clinic visits in the past year [36]. For patients
with type 1 diabetes (though the sample size is very small),
37% did not have any HbA1c testing in the previous year,
while 21% had three or more tests [21].
A study on the frequency of annual eye checks among
diabetes patients in urban Jakarta found that only 15.3% of
them had undergone eye examinations. Screening was
found to be correlated with knowledge about diabetic retinopathy along with the number of years since diagnosis
was made, and not to be correlated with education, income, health insurance status, or diagnosis of diabetic retinopathy. Respondents who did not go for annual checks
mentioned lack of knowledge (60.6%) and financial barriers (13.8%) as reasons for not getting screened [40].
Askes in collaboration with Perkeni developed a training module (PROLANIS) for general practitioners and
monitored their diabetes treatment. Data from PROLANIS on blood glucose control between 2010 and 2011,
show that the percentage of diabetic patients reaching
target levels of fasting plasma glucose (FPG) and post
prandial blood glucose (PPBG) increased significantly 548

(FBG 15% to 51%; PPBG 18% to 48%) (Askes 2011, un- 549
published observations).
550
National guidelines for diabetes treatment and prevention
551
The Indonesian Society of Endocrinology (Perkeni) is responsible for developing diabetes treatment guidelines in
Indonesia. Guidelines for diabetes mellitus type 2 are periodically reviewed and the latest version was last published
in 2011. Screening is recommended for high risk groups
such as individuals with a sedentary lifestyle, a lack of physical activity, an unhealthy diet, a family history of diabetes,
obesity, hypertension, dyslipidemia, coronary artery disease,
polycystic ovary syndrome, a history of gestational diabetes,
and/or have given birth to a baby weighing more than 4 kg.
[48]. The guidelines recommend FPG or random blood
glucose only if the classic symptoms of diabetes mellitus
such as polynuria, polyphagia, polydipsia and weight loss
without etiology are present [48]. If classic symptoms are
not present, the oral glucose tolerance test (OGTT) is recommended to be performed according to WHO recommendations [48]. For high risk individuals with a negative
result, it is recommended that the test should be repeated
on an annual basis, while for people aged over 45 and without other risk factors, screening is recommended every
three years [48]. The guidelines also address issues related
to diabetes management in relation to smoking, tuberculosis, and fasting but not in relation to HIV.
Treatment guidelines for type 1 diabetes were developed
in 2000 and have been revised in the frame of a project in
collaboration with the World Diabetes Foundation (2008
2011) [53]. However, at the time of writing, we could not
find any publicly available version on the internet.
Additional guidelines for insulin therapy [54] and dyslipidaemia were recently published [55]. It is difficult to assess
implementation of these guidelines but the Indonesian
552
553
554
555
556
557
558
559
560
561
562
563
564
565
566
567
568
569
570
571
572
573
574
575
576
577
578
579
580
581
582

t5:1
t5:2
t5:3
Estimate
t5:4
t5:5
HbA1c 68% patients >7% 81%

patients >6.5%
t5:6
t5:7
FPG 47% patients >7.2 mmol/l 69%

patients >6.1 mmol/l
Page 11 of 17
Table 5 Outcomes
Study year
Sample frame and sample size
Study design
Reference
Nov 2008 Feb 2009
Sample frame: 18 diabetes centres
Cross-sectional study,
blood samples
DiabCare
2008 [26]
Multi-centre, cross-sectional,
observational study.
IDMPS
[18]
DMT2
Sample size: 1832 participants (1785 DM T2,

17 DM T1)
t5:8 47-69% of the surveyed patients

t5:9 depending on the criteria applied
t5:10 (IDF/ADA or APDPG)
t5:11 HbA1c: 69% patients >7%
2006 - 2007
t5:12
t5:13
t5:15
t5:14
t5:16
t5:17
t5:18 Mean SD HbA1c 8.1 2 (N = 1932)
t5:19 Categories by central HbA1c values
t5:20 (%)
Sample frame: Patients with type 2 diabetes

Sample size: N = 674, mean age 55.2 (SD =
10.2), 55% females, mean duration for diabetes
6.1 (SD = 6.4) years.
Mar - Dec
1998
t5:21 <7: 34%
Sample frame: several diabetes centres with

more than 100 diabetic patients a month
Prevalence-based approach to
estimate resource use occurred
DiabCare
1998 [39]
Cross-sectional clinic-based
survey
[21]
Sample size: N = 1932
t5:22 7-8: 25%

t5:23 >8: 41%
t5:24 Local mean SD HbA1c 7.7 2.6
t5:25 (N = 144)
t5:26 DMT1
t5:27 HbA1c: 10.5+/2.7 (mean +/ SD)
t5:28
t5:29
t5:30 HbA1c:
t5:31 46% patients 10
Nov 2001 Apr 2002
Sample frame: Seven diabetes centres
Apr - Jun
1999
Sample frame: Children with type 1 diabetes at Cross-sectional survey

the Paediatric Endocrinology Clinic of the
University of Indonesia.
t5:32
t5:33 54% patients 10
t5:34
Sample size: 64 DM type 1 patients (45% boys,

55%, girls), mean age 11
[41]
Sample size: N = 24 children mean age

13.6 years old 10 boys, 14 girls.
t5:35 Annual checks for complications and glucose monitoring

t5:36 DMT2
t5:37 Frequency of eye examination
t5:38 among known diabetic patients in
t5:39 the last year: 15.3%, n = 30, N = 196
t5:40
t5:41
Feb - Apr
2009
t5:42 Percentage screened for
2006 - 2007
t5:50 Four or more clinic visits in the

t5:51 previous year: 57.2%
t5:52 3 HbA1c test in the previous year:
t5:53 16.7%
[40]
Sample size: N = 196, mean age 58.4 years,

61.5% females.
t5:43 -Micro-vascular complications: 56%

t5:44
t5:47
t5:45 -Macro-vascular complications: 49%
t5:46
t5:48 Home blood glucose monitoring
t5:49 57.1%
Sample frame: One tertiary hospital and two

community clinics in Jakarta

Sample size: N = 674, > 18 years with average
age 55.2 (SD = 10.2), 55% females, mean
duration for diabetes 6.1 (SD = 6.4) years.
2003

Sample size: N = 7, 42.9% male, aged <18 years
Multi-centre, cross-sectional,
observational study
IDMPS
[18]
Prevalence-based approach to
estimate resource use occurred
Clinic-based survey
[36]

Page 12 of 17
Table 5 Outcomes (Continued)

t5:54 DMT1
t5:55 No HbA1c test in the previous year:
t5:56 37%
t5:57 More than three HbA1c test in the
t5:58 previous year: 21%
Nov 2001Apr 2002
Sample frame: Seven diabetes centres
Cross-sectional clinic-based
survey
[21]
Sample size: 64 DM type 1 patients (45% boys,

55%, girls), mean age 11
t5:59 Blood glucose self-monitoring was

t5:60 performed on average 32 times a
t5:61 month
t5:62 Notes: Fasting plasma glucose (FPG), standard deviation (SD).
583
584
585
Society of Endocrinology has adopted an intense dissemination strategy by promoting the use of the guidelines
through symposiums, workshops and training schemes.
586 Smoking, TB, HIV and fasting

587 Smoking is a major problem
588
589
590
591
592
593
594
595
596
597
598
599
600
601
602
603
604
605
606
607
608
609
610
611
612
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among men in Indonesia

(prevalence 61% and 5% among men and women respectively, aged 15 and older in 2009 [3]). Unfortunately, there
has been very little evidence on the impact of tobacco consumption on diabetes and its complications in Indonesia.
One study of 778 male diabetic patients in a clinic in
Yogyakarta between 200607 found that 65% patients
smoked before they were diagnosed [56]. The study
showed that most patients were unaware that smoking
could lead to serious complications; 34% thought that
smoking would not aggravate diabetes; 25% did not know;
and 41% thought smoking aggravated diabetes [56]. Yet
interestingly, despite minimal efforts by health doctors
and nurses to encourage smoking cessation, 74.4% of the
patients stopped smoking since diagnosis [56].
Uncontrolled diabetes can lead to various complications including increased susceptibility to infections [57]
such as TB and HIV. In turn, these infections can
worsen glycaemic control [58] and therefore impact
negatively on diabetes management. Additionally, there
are drug-to-drug interactions which may come into play.
Despite the high prevalence of TB (281 cases per 100
000 population in 2011 [3]), there was only one study on
the association between diabetes and tuberculosis in
Indonesia [59]. This casecontrol study found prevalence of diabetes mellitus among newly diagnosed TB
patients (median age 30 years, median body mass index
17.7 cases, 21.5 controls) was 13.2% and 3.2% in control
subjects (OR 4.7, 95% CI 2.7-8.1) [59]. There was no
study looking at the impact of these co-morbidities on
diabetes management (including drug-to-drug interactions), complications, or outcomes.
619 No study on diabetes mellitus and HIV/AIDS was found.
The majority of the Indonesian population is Muslim. A

small study (n = 24) evaluating the effects of fasting on
diabetes showed that Ramadan fasting can improve meta623 bolic control by reducing serum fructosamine and beta
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622
hydroxybutirate in patients with well controlled type 2 dia- 624

betes mellitus without causing a formation of beta hyroxy- 625
butirate (which is responsible for ketoacidosis) [60].
626
Programmes
The Indonesian Endocrinology Society (Perkeni), the

Indonesian Diabetes Association (PERSADIA), and
the Ministry of Health in collaboration with the World
Diabetes Fund (WDF) and other partners have implemented a series of programmes to address existing challenges in diabetes management.
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Ongoing
634
One ongoing project aims to address the human resource capacity gap by training master level staff, nurses,
educators, patients and their relatives in diabetes management between 2011 and 2014. Moreover, community
members will be reached by awareness raising and educational activities [61].
Another current project aims to reduce the prevalence
of NCDs and their risk factors by using a communitybased approach in the provinces of West Sumatra,
Bengkulu and Banten [62]. This project builds on a
successful pilot project in Depot in 2001 [63] and if successful, will be integrated into the national programme for
NCDs and extended to the remaining 30 provinces [62].
This project, implemented between 2010 and 2013, aims
to provide early detection, counselling and education for
people with or at risk of developing NCDs [62].
To date a number of results have been achieved including the development of a local policy on prevention
and control of diabetes and related NCDs; lay people
participation in community needs assessment; training
of nurses and health workers in integrated prevention
and control of NCDs; the training of teams of medical
professionals in clinical NCD control; the training of
cadres of health workers in risk factors; and the selection
and training of counsellors as dietary educators [62]. In
addition, 18 integrated community health posts (Posbindu PTM) and groups for people living with or at risk
of NCDs have been established and 1,800-3,600 people
have been screened, monitored and counselled on risk
factors at the community health posts [62].
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Another ongoing project (20092012) at the time of

writing is trying to improve the ability of the health care
system to deliver diabetes retinopathy care. The current
project outcomes include the renovation of a screening facility and the purchase of diagnostic equipment; training
of healthcare staff including specialists as well as educators; awareness raising activities; screening and treatment
of diabetic retinopathy [64]. As part of this initiative, Cipto
Mangunkusomo Hospital strengthened collaborations between the endocrinology clinic and the ophthalmology department for the treatment of diabetes retinopathy [65].
All newly diagnosed diabetes patients are referred for the
DR test and existing patients are checked once a year.
Screening and retinal photo grading are provided for free
and vouchers are distributed in the community to encourage people to visit the hospital to get screened [65]. The
cost of laser treatment varies depending on the insurance
scheme but it is free for non-insured people. Furthermore,
a registration card was introduced to facilitate keeping
track of patients [65].
685 Completed
686 To address
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the lack of trained staff in diabetes foot care

and the paucity of diabetes foot clinics (only four at the
beginning of the project), a training programme was
conducted between 2008 and 2011 [66]. As a result of
this, three internists and two nurses received intensive
foot care training, who then in turn trained 40 foot care
teams (40 internists and 68 nurses) from all provinces in
Indonesia in basic foot care training. Additionally, 14
new diabetic foot clinics have been established and two
clinics improved; 8,000 patients have been screened for
diabetic foot; and training modules, guidelines and education materials have been developed [66].
In an attempt to address the lack of awareness about
type 1 diabetes in children, a programme to improve
management of this condition was implemented [53].
Between 20082011, 381 paediatricians from seven cities
have been trained in the management of type 1 diabetes;
61 nurses have been trained as diabetes educators; 150
families with children having type 1 diabetes have been
trained in diabetes management; 731 children with diabetes have been registered and now receive care; treatment guidelines for type 1 diabetes have been revised;
and nearly 11 million people have been reached through
media awareness activities [53].
Between 2006 and 2008, 1,237 health care professionals have been trained in diabetes management in
eight cities/provinces (Jakarta, Yogyakarta, Surabaya,
Denpasar, Medan, Makassar, Bandung and Padang) in
order to improve diabetes care delivery [67]. This led to
an increase in the percentage of hospitals providing diabetes education from 52.8% to 67.7% and from 46.3% to
67.8% in primary health centres [67].
Page 13 of 17
Lack of awareness about the disease is particularly problematic in rural areas. This can lead to delayed diagnosis
and early onset of complications. To address this, but also
to increase the ability of healthcare workers to meet the
needs of patients, a public awareness raising and training
for healthcare staff was implemented between 20052008
in two rural areas (Kediri City and Kediri Regency). During this time period, social educators and health workers
have been trained and diabetes awareness information
posts have been established in 26 districts [68].
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PROLANIS
728
Prolanis is a chronic diseases management programme

that is part of Askes. The programme started in 2010
and focuses on the self-management of diabetes. It
shifted part of the consultation services and monthly
checks from the hospital to the health centre to benefit
patients in terms of significantly lower waiting times and
more time for counseling and patient education [69].
This is a positive change for Askes insurees but raises
questions of unequal access to information and education for those not insured by Askes.
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Policy and strategy to address diabetes
739
Indonesia has released its first diabetes programme at

the National Congress of Perkeni in July 2012. The
programme will include a variety of stakeholders involved in diabetes management and will focus on prevention and increasing the capacity for diagnosis and
management of diabetes. In addition to that, an extensive training programme for doctors in the field of diabetes is currently running.
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Discussion
A key focus area that needs to be addressed is the
current lack of formulated health policies, strategies and
action plans to tackle the emerging diabetes epidemic.
Isolated interventions do take place, but in the absence
of an overall framework guiding the process and ensuring sustainability, planning, and coherence, its overall
impact may suffer. On the positive side, a national diabetes plan was launched in late 2012.
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Health systems challenges in diabetes management
757
This section reflects on health system challenges from

some of the authors own experiences of working in the
country.
The provision of quality care for diabetes patients starting from early diagnosis to treatment and prevention of
complications in Indonesia is hampered by a fragile health
system. The health workforce has major deficiencies in
terms of numbers and quality of training, greatly affecting
the quality and efficiency of health service in Indonesia. In
2007, the number of physicians per 10,000 population was
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2.9, well below the regional average (5.6) and the world
average (14.2), while the number of nurses and midwives
per 10,000 population was 20.4, higher than the regional
average (10.9) but below the world average (28.1) [3]. In
terms of specialists, in 2010, there were only about 70 endocrinologists in the country [70]. Moreover, most general
practitioners and midwives work in urban areas and only a
limited number of them practice in remote areas.
In terms of public infrastructure at the primary care
level, Indonesia is generally regarded as having relatively
adequate levels of provision with one public health
centre for every 30,000 people on average [71]. However,
this figure conceals large variations in geographic accessibility, with people in remote interior or small island locations having particularly poor access.
Due to the lack of expertise and diagnostic equipment
at the primary care level, diabetes care is concentrated
in diabetes clinics at secondary and tertiary care levels
leading to higher costs for the healthcare system and the
individual which can lead to increased barriers to accessing care. In this context, it is hoped that efforts towards
reaching universal health coverage by 2014 will help
strengthen primary care capacity particularly in the area
of diabetes. The private sector is increasingly important
in the provision of health care in Indonesia, especially in
large cities, where there are wide variations in quality of
care. Furthermore, owing to lack of regulation on pricing
and quality of services, users are more susceptible to excessive treatment and overcharging [72].
Lack of resources in the public sector can partly be explained by low public spending on health. In 2010, total
health expenditure on health represented only 2.6% of
GDP corresponding to a total expenditure on health per
capita of US$ 77 at the 2010 exchange rate (US$ 112 at
purchasing power parity) [3]. Nearly half of it, 49.1%,
was publicly funded [73]. Further, health insurance remains limited in coverage, breadth and depth (number
of people insured and services covered).
Medicines to treat diabetes are not reaching everyone
due to limited affordability and availability, as well as other
factors. Medicines are generally available in main cities or
in the private sector but there are serious availability problems in public primary health centres and in rural areas.
At primary care level, drug availability is very limited; at
hospital level, availability varies widely. This is caused
mainly by the geographical barriers or supply chain problems due to underfunding. In addition, not all medicines
to treat diabetes are covered by health insurance, especially the newest and more expensive classes of medicines.
At the same time, the use of traditional medicines is widespread; this is particularly problematic due to the weak
quality control mechanisms in place [72].
These issues are further exacerbated by a weak health
information system hampered by poor coordination and
Page 14 of 17
integration between different data sources, duplication

of data collection efforts, ill-defined division of reporting
responsibilities and very little reporting from the private
sector which represents half of the total service delivery
[4,72]. These challenges were severely aggravated by the
decentralisation process which led to the partial collapse
of the health information system [4,72]. As a result, no
nationally representative data on health indicators has
become available since 2001 [4,72].
Without sound data, it is difficult to inform health
policy and programmes. Although diabetes mellitus type
2 is gaining importance on the national health agenda, a
coordinated framework of action for Government, donors, and the private sector is yet to be developed and
implemented.
822
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Further considerations on the data
837
Nearly all the studies reviewed were conducted at health

facility level. In a country like Indonesia, where incomplete insurance coverage affects access to healthcare for
those in lower socioeconomic groups who are not insured and have limited ability to pay out-of-pocket, it is
doubtful whether these data represent the actual incidence, prevalence, screening frequency and outcome
situation in the country.
In this respect, Riskesdas differs from the studies just
described, as it looks at the percentage of patients in the
community who were receiving treatment at the time of
the survey.
In general, only cross-sectional information is available. No longitudinal study following a cohort of patients and investigating risk factors for poor outcomes
was found.
Despite the development of a national renal database, no
recent study was found in the peer-reviewed literature,
raising questions about the use of the data collected to inform policies and programmes. The latest available estimates from the Indonesian Society of Nephrology showed
a general increase in ESRD incidence and prevalence rates
between 2002 and 2006 in East and Central Java, Jakarta
and Bali. The increase was probably due to improved availability of health facilities, experts and coverage through
Askes and Jamkesmas.
Moreover, there was no information available on care
seeking pathways or the role of the traditional sector,
which is known to be important especially in rural and
remote areas. There was also no information on compliance and reasons for non-compliance which are all essential pieces of evidence to inform an effective national
strategy to address diabetes.
There is a lack of information on the impact of programmes beyond intermediate outcomes such as the
number of people trained; percentage of health centres
providing education; or development of training material
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and guidelines (e.g. has detection rate increased as a result

of training, have outcomes improved, are there fewer complications arising due to better screening?)
For example, based on the available information online,
a number of questions and concerns have arisen regarding
the diabetic retinopathy initiative at Cipto Mangunkusomo Hospital. In which communities are the screening
vouchers being distributed and who uses them? Are the
vouchers reaching those who are most in need? Who pays
for these free screening services? Who pays for the free
laser treatment for uninsured patients and how should this
service be sustainably financed in the long-term if more
and more uninsured people start to ask for it? Will the
achievement of universal health coverage be delayed? Further, are there plans to expand this initiative to other hospitals? At the moment only people living within a
reasonable travelling distance from the referral hospital
are able to benefit from these free screening services.
Conclusions
Despite methodological limitations affecting the studies
reviewed, evidence suggests that the prevalence of diabetes in Indonesia has increased over time. Our findings
also highlighted wide disparities in the prevalence of diabetes across the country and the presence of a very large
number of undiagnosed patients.
The paucity of available data (particularly for type 1
diabetes) and its unrepresentativeness of the whole
country, calls for more evidence to be collected on the
direct and indirect cost of diabetes. Such evidence is
needed to uncover existing disparities within the country
and to estimate the resources that will be needed to provide comprehensive diabetes care as part of the Governments plan to provide universal health coverage.
Access to preventive and curative services is further
challenged by disparities in health service provision, human resource distribution, and treatment availability.
These disparities appear to be strengthened by the archipelago formation of the country which is conducive to
unequal distribution of services and tends to favour
urban areas over rural and remote areas.
In addressing these issues, the Ministrys plan to reach
universal health coverage represents an opportunity to
strengthen access to healthcare and the number and the
quality of services offered at primary care level. However, it must ensure that increased access also focuses on
marginalised communities and that it will be backed by
the necessary funds to ensure its scaling up and longterm sustainability.
In the light of these challenges, the authors suggest
the following priority actions:
Building on the initial positive results achieved by
Askens/Perkeni, to improve training of primary
Page 15 of 17
health care doctors and nurses to include

management of non-communicable diseases with
particular emphasis on diabetes and its related comorbidities and complications
To reform referral patterns from the current focus on
inpatient care to a strong primary health care system
To increase coverage of essential drugs as part of
universal health insurance
To improve availability of equipment in public
primary health care facilities
To improve health service delivery to remote areas
by sharing lessons with other countries experiencing
the same challenges
Provide education on self-management of diabetes
to patients and emphasis on the importance of
undergoing regular checks for complications
To increase awareness in the population about
NCDs by launching mass information campaign
through main national media and education of
pupils in schools
To focus on prevention and develop strong antitobacco legislations and food policy to protect vulnerable groups such as children
To strengthen data collection systems for type 1 and 2
diabetes by collecting routine data at local level;
centralising them at national level for analysis; using
these data, complemented by regular surveys such as
Riskesdas, to inform planning and decision-making
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Endnotes
i
Yunir, E. 2008. Diabetic Foot in Indonesia. Presentation at the Kyoto Foot Meeting. Training of Diabetic
Foot Care for Young Doctors. 57 March 2008.
955
Abbreviations
CAPD: Continuous ambulatory peritoneal dialysis; ESRD: End-stage renal
disease; NCDs: Non communicable diseases; CDs: Communicable diseases;
FPG: Fasting plasma glucose; Perkeni: Perkumpulan endocrinologi Indonesia;
IDMP: International diabetes management practices study; IDR: Indonesian
Rupee; ISE: The Indonesian society of endocrinology; Askes: Asuransi
Kesehatan; Jamkesmas: Jaminan Kesehatan Masyarakat; OGTT: Oral-glucose
tolerance test; TB: Tuberculosis.
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Competing interests
The funding to conduct this study was provided by Novo Nordisk
Switzerland. The sponsor had no involvement in the study design, data
collection and analysis, and writing. AF received travel reimbursement and
speaker fees from Novo Nordisk for delivering two presentations on diabetes
in EU5 at national diabetes conferences in Portugal and Spain.
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Authors contribution
PS retrieved data from the Ministry of Health Republic of Indonesia and
Askes. All authors contributed to the literature review and in the appraisal of
the retrieved information. PS and DT wrote the first draft, AF redrafted
subsequent versions of the article up to its final version. All authors
approved the final manuscript.
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Authors information
Pradana Soewondo currently serves as President of The Indonesian Society
of Endocrinology. In this role, he provides leadership of scientific and
medical activities, including research programs, professional publications,
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medical information, and professional education. He received his doctoral

degree from Faculty of Medicine University of Indonesia. In addition to his
role, Professor Pradana holds an academic appointment as a Manager of
Education and Student Affairs at the Faculty of Medicine University of
Indonesia. He is currently a staff member at the Division of Metabolism and
Endocrinology, Department of Internal Medicine, Faculty of Medicine
University of Indonesia.
Dicky Levenus Tahapary is also a staff member at the Division of Metabolism
and Endocrinology, Department of Internal Medicine, Faculty of Medicine
University of Indonesia and also a member of The Indonesian Society of
Endocrinology.
Alessandra Ferrario is a Research Officer in health and pharmaceutical policy
within the Medical Technology Research Group, LSE Health and a PhD
candidate in the Department of Social Policy at the London School of
Economics and Political Science.
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Acknowledgements
The authors would like express their gratitude to Askes and The Ministry of
Health Republic of Indonesia for providing the required data for this study
and to Novo Nordisk Switzerland for funding this study. We would like to
thank Ms Marsha Fu and Ms Danica Kwong for their excellent editorial
assistance.
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Author details
1
Division of Metabolism and Endocrinology, Department of Internal
Medicine, Faculty of Medicine University of Indonesia, Dr. Cipto
Mangunkusumo Hospital, Jakarta, Indonesia. 2LSE Health, London School of
Economics and Political Science, Houghton Street, WC2A 2AE, London, UK.
1009 Received: 20 February 2013 Accepted: 11 November 2013

1010 Published: 3 December 2013
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doi:10.1186/1744-8603-9-63
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Dear Author,

Soewondo et al. Globalization and Health 2013, 9:63

Challenges in diabetes management in Indonesia:

Pradana Soewondo1*, Alessandra Ferrario2 and Dicky Levenus Tahapary1

was 68 years, which is slightly higher than the Southeast

Soewondo et al. Globalization and Health 2013, 9:63

However, marked geographical variations exist. While

(diabetes retinopathy, neuropathy, nephropathy, chronic

A limited number of data sources on the burden and 155

Soewondo et al. Globalization and Health 2013, 9:63

Area of diabetes Number of

samples were collected from 24,417 urban residents aged 192

[18,21-32] and unpublished

These included international studies, national surveys,

A1chieve was a large multicountry observational study

159 Diab care

DiabCare Asia is an international collaboration between

Most direct cost information available is unpublished 210

The Jakarta NCD-S study is the result of a collaboration

Indonesian renal registry

A national registry for end stage renal disease has been

A few local cross-sectional studies on the prevalence of

172 International diabetes management practices study (IDMPS)

ies of diabetes patients in developing countries. This

Soewondo et al. Globalization and Health 2013, 9:63

257 Diabetes prevalence

According to the International Diabetes Federation (IDF),

This urban vs. rural divide concerning the burden of

At the time of writing there was no published evidence on

A study on the costs of diabetes of 100 diabetic patients at

Soewondo et al. Globalization and Health 2013, 9:63

Table 2 Prevalence of diabetes mellitus in Indonesia

Study year Sampling frame and sample

19.6%, men 21.9%, women

Peak age group was

Sample: 495 individuals, 187

1.7% (1982),5.7% (1993), 12.8%

Sampling frame: Suburban

Criteria: ADA 1997

Sampling frame: 33 provinces,

Sample: 24,417 urban

t2:23 Rural area of Ende, found a

Clinical screening: 17.08%,

1.63%, n = 44, N = 2,704, 18

Sampling frame: A group of

Sampling frame: Koja Utara

Data from local

Sample: Population screening:

Sample: 2,704, > = 15

t2:47 Peak age was 5564 for both

Study year: Sampling frames: Cities of

t2:51 28 patients with

was IDR 208,500 (USD$ 21) of which 59.5% was spent on

The combination of biguanid, alpha glucosidase inhibi- 349

Soewondo et al. Globalization and Health 2013, 9:63

These two studies suggest that in tertiary care facilities

367 Askes data

In 2010, Askes covered around 16.5 million people in

377 International diabetes management practices study

related resource use in different countries from 2006

384 Diabetes complications

Published studies on the prevalence of complications in

of the current year per million people) of ESRD between

A study of type 2 diabetes patients who failed (the study