PANDU

PTM

2017
A COMMUNITY
INTERVENTION MODEL
ON PREVENTION AND
CONTROL OF NCDs
IN INDONESIA
INDONESIA’S
BACKGROUND
34 The world ‘s fourth
Provinces most populous
416 District country
and 98 City with More than 258
17,504 Decentralization
million people
Islands government
1,904,569 system
square kilometres
wide

Life
Years
Expectancy
70.1

9,767 Public
Health Care
(PHC) 341,536
PHC Ratio per Health
30,000 people Workers
is 1.13
including

289,465
Medical
professional

Source : Indonesia Health Profile, MOH 2016

Central Agency on Statistic (BPS) 2015
Indonesia is the largest archipelago in the
world which consists of 17,504 islands and
total land mass 1,904,569 square kilometer.
Divided into 34 provinces, 416 district and 98
city with decentralization goverment system.
The country is ranked fourth globally in terms
of population, with a population of more than
258 million people.
Population
density reaches
135.2 person/
square
kilometres
The population density is 135.2 people
per square kilometer with population
growth rate approximately 1.38% and life
expectancy 70.1 years.
The Indonesian health system has a
mixture of public and private providers
and financing. The public system is
administered in line with the decentralized
government system in Indonesia, with
central, provincial and district government
responsibilities. The central Ministry of
Health is responsible for management of
some tertiary and specialist hospitals,
provision of strategic direction, setting of
standards, regulation, and ensuring
availability of financial and human
resources.

Provincial governments are responsible

Population for management of provincial-level
growth rate is hospitals, provide technical oversight
approximately and monitoring of district health

1.38% services, and coordinate cross-district

health issues within the province. District/
municipal governments are responsible
for management of district/city hospitals
and the district public health network of
community health centres (puskesmas)
and associated subdistrict facilities.
National Health
Insurrance There are 9,767 primary health center
coverage (PHC) with PHC ratio per 30,000 people
171 Million is 1.13 but only 1,618 PHC have health
people (66.46%) promotors.

per December
Total health workers in Indonesia is
31 2016
1,618 341,536 and 289,465 medical professionals.
Indonesia has recently introduced a
PHC National health insurance (JKN) in
with health Januari 2014 as a part of national social
promotors
security system which have covered 171
workers
million people (66.46%).
 NCDs
CURRENT SITUATION
IN INDONESIA

10 CAUSE OF DEATH IN INDONESIA

Man and Woman Sample Registration Survey, 2014:

From 41,590 death in Indonesia :
- 8,775 people die because of stroke,
Diarrhea and 1.9 %
gastrointestinal infection - 5,365 people die because of CVD
- 2,786 people die because of DM and
Pneumonia 2.1 %
it’s complication
- 2,204 people die because of hypertension
Road injury 2.6 % and it’s complication

Liver 2.7 %

Lower respiratory tract infection 4.9 %

Hypertension and complication 5.3 %

Tuberculosa 5.7 %

Diabetes melitus and it’s complication 6.7 %

Cardiovascular disease 12.9 %

Stroke 21.1 %

Source : SRS 2014

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

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

NCDs PREVALENCE IN INDONESIA

Cancer (‰) 1.4

Renal Failure (‰) 2
Stroke (‰) 12.1
Coronary Heart Disease (%) 1.5
COPD (%) 3.7
Diabetes Melitus (%) 6.9
Injury (%) 8.2
Hypertension (%) 25.8

0 5 10 15 20 25 30

Source : National Health Survey 2013

The increasing burden of noncommunicable diseases highlights the need to

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

Mental Emotional Disorder 6

Insufficient Physical Activity 26.1
Eat Salty Food 26.2
Smoking 36.3
Eat Fatty Food 40.7
Eat Sweet Food 53.1
Eat Flavouring Food 77.3
Eat less vegetable and fruits 93.6
0 20 40 60 80 100
Source: NHS, 2013

In other hand NCDs behavioural risk factor

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

2014 2015 2016

7.4
6.9

4.4

2.7 2.5
2.4 2.2
1.6 1.5
1.1 1.2
0.74

Heart Disease Renal Failure Cancer Stroke

Source: Social Insurance Administration Organization

(BPJS)

Indonesia faces the challenge of increasing health expenditures, as nominal

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

Global
Target

Healthy National
Indonesian
Program with mid-term
Family development
Approach plan

NCDs MOH
Minimum
Standard Strategic
for Health Plan for
Services NCDs

National
Community Action
Empowerment Plan
(GERMAS)
for NCDs

NATIONAL MID-TERM DEVELOPMENT PLAN

INDICATOR OF NCDS PROGRAM 2015-2019
PRESIDENTIAL DECREE NO. 2, 2015

No Indicator

01 Hypertension prevalence

02 Halt Obesity prevalence

03 Smoking prevalence ≤ 18 years old

 STRATEGIC PLAN INDICATOR FOR
NCDs PREVENTION AND CONTROL PROGRAM
2015-2016

No Indicator

01 Smoking percentage for ≤ 18 years old

02 PHC percentage implementing PANDU PTM

Village/gampoong percentage with Posbindu PTM
03
(community based intervention)
Women age 30-50 years old percentage who had
04
breast and cervical cancer screening
05 District/city with No smoking area policy in
minimum 50% state school

NATIONAL ACTION PLAN INDICATOR FOR

NCDs PREVENTION AND CONTROL 2015-2019
( MOH DECREE NO.5/2017 )

No Indicator

01 Morbidity and mortality

02 Biologic Risk Factor

03 Behavioural Risk Factor

04 Health System Services Response

PHC percentage for implementing PANDU PTM

GOVERNMENT COMMITMENT ON
PREVENTION AND CONTROL OF NCDs
Addressing NCDs issues, the goverment needs to develop a comprehensive strategy which
take consideration the growing interregional disparities in terms of resources, services and
health outcomes. With a large, widespread area and population, and with the commencement
of a universal health coverage system, the need for a reliable and integrated health system to
support planning and decision-making is becoming even more urgent.
The goverment is commited to preventing and controling NCDs by setting up indicator of
achievement in National mid-term development plan, National action plan 2015-2019 and
MOH strategic plan 2015-2016. The president of Indonesia officialy instructed community
empowerment to promote and prevent NCDs risk factor by GERMAS (Gerakan Masyarakat
Hidup Sehat) or community movement for healthy life such as: 1. Stop smoking, 2. Physical
activity and 3. Eat more vegetable and fruit.
NCDs
PREVENTION
AND CONTROLING STRATEGY
IN INDONESIA

HEALTHY INDONESIA
PROGRAM

Health system
Strengthening
Advocacy, infrastructure,
partnership, Enchancing primary
leadership and care delivery system to
management detect NCD risk factors,
diagnoses and HT
(Providing PEN)
PREVENTION
AND CONTROL
OF NCD
Enchanching Research,
Data base collection,
NCD Health Promotion Web-based
through lifecourse surveillance system,
and NCD risk Reduction strong management
information system and
data reporting mechanism

STRATEGY
NCDs PREVENTION AND CONTROL STRATEGY
THROUGH THE HEALTHY INDONESIAN PROGRAM :

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

01 Advocacy and partnership inter

program and inter sector

02
Strengthening of health services capacity
for risk factor early detection, diagnosis
and integrated prompt treatment of NCDs cases.

03 Community empowerment with health promotion,

prevention and reducing NCDs risk factors)

04 Strengtening surveillance, monitoring and NCDs

researches.
 SCOPE OF NCDs
INTEGRATED
HEALTH SERVICES
(PANDU PTM)

CBI PHC Hospital

REVERSE REFFERAL

NCDs risk factor Early NCDs risk factor Early

detection, monitoring, detection, monitoring,
counseling and doing counseling and doing
healthy activity healthy activity

Physical and laboratory

Reffering NCDs examination, diagnosis
cases to PHC and prompt treatment
based on Pandu PTM
are being done by the
medical profesional.

Reffer NCDs cases with

complication or target
organ damage to the
hospital

Limited rehabilitation
and paliative care for
NCDs cases
SCOPE OF NCDs INTEGRATED HEALTH SERVICES

The Ministry of Health also organizes and directs health

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

For example, the Posbindu is a community engagement

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

In PHC , health workers do early detection risk factor of

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

The National Health Insurance covered for promotive,

preventive, curative and rehabilitative NCDs cases including
the referral expenditure from hospital to the primary
health care.
INTEGRATED HEALTH SERVICES
(PANDU PTM)

Adapted from WHO-PEN and adjusted to Indonesian Health program

Strengthening Health system and primary health care services

It’s a prioritized set of cost effective intervension for an acceptable

quality care that affordable for the local goverment.

It is a minimum essential intervension in National Health Insurrance.

Focused on Hypertension and Diabetes management with additional

core set of cancer, sight disorders, hearing disorders and community
based rehabilitation.

Involving the development of community based intervention

(Posbindu PTM) as apart of referral mechanisme to the primary
health care.
 DIFFERENCE BETWEEN CORE SET
OF
WHO-PEN AND PANDU PTM

CORE SET WHO-PEN PANDU PTM

Primary prevention
01 of heart attacks and strokes √
02 Acute myocardial infarction √
Secondary prevention
03 (post myocardial infarction) √
04 Secondary prevention
(post stroke) √
05 Secondary prevention
(Rheumatic heart disease) - ADDITIONAL PACKAGE OF PANDU PTM

06 Type 1 Diabetes - Sight disorders

07 Type 2 Diabetes √ Hearing disorders

08 Prevention of foot complication

through exmination and monitoring √ Community based rehabilitation

09 Prevention of onset and delay

in progression of chronic kidney √
10 Prevention of onset and delay of
progression of diabetic retinopathy √
Prevention of onset and
11 progression of neuropathy -
12 Bronchial asthma -
13 Prevent exacerbation of
COPD and disease progression √
14 Cancer √ Focus on Breast and
cerviks cancer

DIFFERENCE BETWEEN CORE SET IN WHO-PEN AND PANDU PTM

We adopted eleven core set of WHO-PEN, except secondary prevention
of rheumatic heart disease, Type 1 Diabetes and Neuropathic management
Additional core set in PANDU PTM are management of sight disorders,
hearing disorder and comunity based rehabilitation.
 DEVELOPMENT OF NCDs
INTEGRATED HEALTH SERVICES
(PANDU PTM) IN INDONESIA

-DevelopGuidelines
-Develop Pandu PTM
Guidelines
Pandu PTM
-Piloting
-Piloting
PanduPTM
Pandu PTM in in 5 Province
5 Province
(Sumbar,
(Sumbar,Sumut,
Sumut,Lampung, Assesment of
Bali, Aceh) readiness for
Lampung, Bali, Aceh) Assesment of readiness
56 District/City implementing
56PHC
92 District/City for implementing
PANDU PTM
92 PHC
124 medical workers PANDU PTM in Cimahi
124 medical workers and Palembang City

2011 2013 2015

2012
2014

Workshop Piloting Assesment of

Workshop
WHO-PEN Piloting
Pandu PTM di Assesment
readiness for of
Participant:
WHO-PEN Pandu PTM in
26 Province readiness
implementingfor
MOH inter-program, medical
Participant: 258 district/city, PANDU PTM
26 Province implementing
professional organization, 343 PHC,
MOH inter-program, medical
Representative of District health 258 district/city, PANDU PTM
561 medical workers
professional
office organization, 343 PHC, in Cimahi and
Representative of District health 561 medical workers Palembang City
office

DEVELOPMENT OF NCDS
INTEGRATED HEALTH SERVICES (PANDU PTM) IN INDONESIA
WHO-PEN was first introduced by Prof. Shanty Mendez in 2011 , some
participants were invited such as inter programme in MOH,
representative of Province and District Health Offices, PHCs and
health professional. We adapted WHO- PEN as PANDU PTM ( Pelayanan
Terpadu Penyakit Tidak Menular) as an Integrated health services for
NCDs.
 
 In 2012 we developed a guidelines Pandu PTM and piloted it in five province
and we continued doing that in another 26 provinces in 2013 in the same
year MOH set up the PANDU PTM as one of 2014 to 2015 strategic plan
indicators.
In 2014 and 2015 MOH did assesment on readiness for implementing
Pandu PTM in four district. In 2016 and 2017 we had national training
three times on WHO-PEN which Prof. Shanty Mendez attended as an technical
consultant and other participants from cross programme in MOH,
representative of Province and District Health Offices, PHCs, health
professional, University and State school.

3 National training for

implementing WHO-PEN
TOT Pandu PTM for
13 Province
Pandu PTM training for
4 Province
18 District/City
20 PHC,
60 medical workers
Pandu PTM training for
34 Province
34 District/city,
68 PHC,
180 medical workers
Pandu PTM implementation
evaluation in 14 Province

2017 2019

2016 2018

TOT Pandu PTM for Targetting 50%

21 Province PHC implements
Pandu PTM training for PANDU PTM
18 Province
211 District/city,
301 PHC,
501 medical workers

We also executed Training for Trainer in 34 Provinces for province program

manager of NCDs and MOH master of training. Beside that we conducted
some training for primary health workers on PANDU PTM in 321 primary
health care of 22 province.
In 2018 we are planning to have another training PANDU PTM for untrained
primary health workers and evaluation of implementing PANDU PTM will
follow. We are targetting that 50% PHC will have conducted PANDU PTM in 2019.
 
 OBSTACLES
&CHALLENGES

OBSTACLES

Limited budgeting

NCDs program is not priority yet in province and

district

Frequent rotation among the trained health worker.

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

Recent advances in IT in operation of district offices

Developing PANDU PTM as a curriculum of medical and

nursing faculty.
 Written by :

dr. Lily S Sulistyowati, MM

dr. Zamhir Setiawan, M.Epid
dr. Tristiyenny Pubianturi, M.Kes
dr. Juzi Delianna, M.Epid
dr. Prihandriyo Sri Hijranti, M.Epid
Jamaludin SKM, M.Epid
Nengsih Hikmah Sensiawati, SKM, MKM
Rindu Rachmiaty, SKM, M.Epid
Ridho Ichsan Syaini, SKM, M.Epid
dr. Elmi Suryani

Graphic Director :

drg Anitasari SM
Ira Carlina Pratiwi, S.Sn
 Directorate of Non-communicable Disease,
Directorate General of Disease Prevention and Control,
Ministry of Health of Indonesia

www.p2ptm.kemkes.go.id @p2ptmkemenkesRI
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