Currently, 60% of Indonesia’s 273.5 million population is under the age of 30 [1]. Since the late ’90s, Indonesia has worked vigorously to alter their policies and government framework to transition from a low-income to a middle-income country [14]. They worked hard to develop urban areas, as well as develop a more office worker focused lifestyle. These changes resulted in a cut in poverty rates by more than 50% in the last 22 years [10]. However, with these lifestyle changes, a stark change in diet was becoming more noticeable. Many Indonesians turned to easier and quicker options for food, which tended to be more processed foods, that were high in sugars, salt, and bad fats [8]. This led obesity rates to double in Indonesia in the last 15 years, which has been linked to significantly increasing non-communicable disease (NCD) rates [8].

NCDs are chronic diseases that cannot be passed from person to person and are instead developed inside one’s body, on its own. All heart diseases are classified as NCDs. NCDs account for 73% of deaths in Indonesia [4]. The most prominent NCD is cardiovascular disease that accounts for 35% of the death related to NCD [4]. Cardiovascular disease affects the heart and blood vessels. The majority of cardiovascular disease in the world occurs in low to middle-income countries, like Indonesia [2][6]. The #1 leading cause of death in Indonesia is coronary heart disease (disease of the blood vessels that provide blood to your heart) [13]. In addition, Indonesia is ranked 44^th in the world for death due to coronary heart disease [13].  These statistics highlight the high prevalence of heart disease in Indonesia.

Researchers have thoroughly researched heart disease to find what risk factors lead individuals to develop heart disease. The highest modifiable risk factors (i.e. risk factors that we can change) are cigarette smoking, hypertension (high blood pressure), diabetes, elevated total cholesterol, and excess body weight [3][4].

In the province of East Java, Indonesia, a study was conducted with over 22 000 participants, where they found that 29.2% of the population already had a high risk of developing various heart diseases, including cardiovascular disease, stroke, and others [6]. In addition, they found a high rate of cardiovascular disease in Indonesians aged 40+ years. They also noticed a lack of preventative care. For instance, hypertension is the leading risk factor for heart disease, but the study found that only 11% of total participants were using blood pressure-lowering medication [3][6].

A different 2014 study conducted in Indonesia found that older individuals had more nutrition-related chronic diseases, like heart disease [9]. A good diet is important in fighting heart disease, as obesity is a large modifiable risk factor associated with heart diseases. In addition, a poor diet can lead to the buildup of plaque in your arteries which can lead to a variety of heart problems, like cardiovascular disease, atherosclerosis, and even a heart attack [9]. The 2014 study also found that regular consumption of instant noodles and soda in the Indonesian population was associated with the increasing obesity levels in the country, as they are both high in sodium and sugars, respectively [3][9]. 20% of all school-aged children in Indonesia, and 15% of adolescents are now classified as obese [8].

By creating a nutritional approach to fight rising obesity levels and poor diets, Indonesia will, in effect, be fighting the high rates of heart disease in the country as well. A media campaign was launched by the Indonesian government, with a goal to take action for healthy diets, in order to combat overweight and diet-related NCDs, like heart disease [12]. The government ran this in partnership with universities and NGOs located in Indonesia. The aim was to raise the general population’s awareness of the health effects of diets with high levels of fats, sugars, salt, and sodium [12]. By providing better nutritional information, they are hoping everyone will gain the knowledge to make better decisions on what they consume. For example, some of the information includes how individuals can incorporate more fruits and vegetables into their daily lives [12]. The campaign was run through TV, radio, and social media. Topics also included portion size information regarding how to control portions, as well as how to read nutritional labels, in addition to learning how to better analyze nutrition and health claims [12].

Another major health issue in Indonesia is malnutrition. Malnutrition is in complete contrast to obesity. Malnutrition is when individuals are not getting enough to eat, which has resulted in high levels of stunting in children [14]. Stunting is when a baby is prevented from growing and developing properly, increasing their risk of developing diseases, and dying prematurely [14]. The wealth disparity in Indonesia is highlighted by the fact that within the same country, they are facing both a crisis of malnutrition and obesity. The healthcare system in Indonesia is not immune to the effects of this wealth disparity in the nation.

Since 1993, Indonesia has been reworking their healthcare framework to decrease healthcare disparities based on income [7]. This may be attributed to the expanding healthcare insurance program by the government, JKN, as well as the decentralization of the healthcare sector [7][15]. JKN increased the number of insured citizens from 56% in 2010, to 83% in 2020 [7][15]. However, JKN was found to be overambitious and improperly implanted [7]. For instance, by 2020, the government had aimed to have 100% of citizens insured, but the rollout of the program was not well communicated [5]. JKN has also resulted in a ballooning deficit due to poor allocation of funds [15]. In addition, not all hospitals have opted to join JKN, thus lower income citizens are unable to access all the same hospitals that richer populations can [5]. Private facilities have been found to have shorter wait times, more equipment, and cleaner facilities [5].

There are large issues affecting Indonesia’s healthcare as a whole, such as a lack of medical equipment, doctors, and beds, as well as the growing deficit in the sector, resulting in a lack of money in the government to properly supply growth [5]. These issues are felt more in lower income households, as wealthy Indonesians have access to private insurance plans and are also opting to go abroad and travel to other countries like Malaysia, Singapore, or Australia for treatment [5][15]. Richer citizens can avoid the healthcare systems issues through medical tourism, but this creates a paradox as the Indonesian healthcare system misses out on their money, and therefore do not have the money to fix their own system [5]. A lack of supplies, equipment, and doctors has resulted in some hospitals turning away poorer patients who are unable to pay [15]. The result can be deadly, as was the case with Rusdin Zakaria. Rusdin Zakaria was an Indonesian citizen who was having issues regarding shortness of breath. While at the ICU in a hospital in South Jakarta, his family was told to pay a down payment of $800 for his treatment, which they could not afford. Rusdin Zakaria was transferred to another hospital that was charging less but died on route to the new location [15].

Inequalities in the healthcare system do not stop at income disparities, as there are also regional inequalities. There are a higher number of hospitals in urban areas. In addition, rural clinics have very limited supplies. Populations that live in more remote areas also have a very difficult time getting their prescriptions filled [5].

In summary, Indonesia has a growing heart disease problem that must be addressed. The link between this and their rising obesity levels is clear. Thus, based on nutritional studies conducted in the country, the government and other organizations should work on spreading nutritional knowledge and ensuring everyone is up to date with accurate information.

As heart disease rates increase, it is increasingly important for the government to work out their universal healthcare plans and eliminate the regional and income disparities that exist within the system. Healthcare is a right, that everyone deserves, regardless of income or status.

Nutrition, heart diseases, and healthcare are all very deeply intertwined and it’s important we look at each country through these lenses in order to find solutions for a better future for everyone living there, and not just those who can afford it.

Author: Javaria Bhatti

References

[1] 12Go. “20 Unusual, Interesting and Fun Facts About Indonesia.” 12Go, https://12go.asia/en/indonesia/interesting-facts#:~:text=Indonesia has the worlds biggest young population&text=Although a relatively effective family,United States should nothing change.

[2] “Cardiovascular Diseases (CVDs).” World Health Organization, World Health Organization, 11 June 2021, https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)#:~:text=Over three quarters of CVD,38% were caused by CVDs.

[3] Hussain, Mohammad Akhtar, et al. “The Burden of Cardiovascular Disease Attributable to Major Modifiable Risk Factors in Indonesia.” Journal of Epidemiology, vol. 26, no. 10, 2016, pp. 515–521., https://doi.org/10.2188/jea.je20150178.

[4] WHO. Indonesia, WHO NCD Country Profiles, 2018. https://www.who.int/nmh/countries/idn_en.pdf

[5] “Indonesia’s Failing Healthcare Industry and How Medical Tourism Can Help.” RSS, https://www.magazine.medicaltourism.com/article/indonesias-failing-healthcare-industry-and-how-medical-tourism-can-help.

[6] Maharani, Asri, et al. “Cardiovascular Disease Risk Factor Prevalence and Estimated 10-Year Cardiovascular Risk Scores in Indonesia: The SMARThealth Extend Study.” Plos One, vol. 14, no. 4, 2019, https://doi.org/10.1371/journal.pone.0215219.

[7] Mulyanto, Joko, et al. “The Evolution of Income-Related Inequalities in Healthcare Utilisation in Indonesia, 1993–2014.” Plos One, vol. 14, no. 6, 2019, https://doi.org/10.1371/journal.pone.0218519.

[8] “Nutrition.” UNICEF Indonesia, 22 Sept. 2021, https://www.unicef.org/indonesia/nutrition.

[9] Oddo, Vanessa M., et al. “Risk Factors for Nutrition-Related Chronic Disease among Adults in Indonesia.” Plos One, vol. 14, no. 8, 2019, https://doi.org/10.1371/journal.pone.0221927.

[10] The Jakarta Post. “Collaboration to Drive Nutrition Awareness in Indonesia.” The Jakarta Post, https://www.thejakartapost.com/academia/2021/01/24/collaboration-to-drive-nutrition-awareness-in-indonesia.html.

[11] “Understanding Indonesia’s Healthcare System.” International Citizens Insurance, 6 Apr. 2021, https://www.internationalinsurance.com/health/systems/indonesia.php.

[12] WHO. World Health Organization, World Health Organization, https://extranet.who.int/nutrition/gina/en/node/29766.

[13] WLE. “Coronary Heart Disease in Indonesia.” World Life Expectancy, https://www.worldlifeexpectancy.com/indonesia-coronary-heart-disease

[14] Woodhouse, Nadia. “’I Thought She Was Getting Enough Food’: Indonesia’s Fight against Stunting and Malnutrition.” CNA, https://www.channelnewsasia.com/asia/indonesia-goal-reduce-stunting-malnutrition-children-poverty-342046.

[15] World Bank. Review of Indonesia Publix Expenditure Review Launch 2020, Https://Thedocs.worldbank.org/En/Doc/384161592968065208-0070022020/Original/IDPERHealth.pdf.