The health status of Indonesia’s provinces: the double burden of diseases and inequality gap

Vicka Oktaria and Yodi Mahendradhata

The Lancet | Open Access | Published: November, 2022 | DOI:

In The Lancet Global Health, the Global Burden of Disease Study (GBD) 2019 Indonesia Collaborators report on 30 years of disease burden and risk factors in Indonesia, expanding their analysis to a more granular subnational level.


 Given the ongoing challenges of obtaining comparable subnational data, the GBD data provides enlightening evidence for decision makers at the subnational level for future programmatic planning and policy strategies specific to their local health issues. These findings will ultimately help narrow down the inequality gaps at regional levels. This paper is perfectly timed to captured and illustrate the health status in Indonesia before and after the launch of the universal health coverage (UHC) programme Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS) in 2014. The BPJS has now covered more than 75% of the Indonesian population.


Although excellent programmatic interventions and policies have significantly reduced the disease burden in the past three decades, communicable diseases remain the main source of disability-adjusted life-years (DALYs) in Indonesia, along with the rising burden of non-communicable diseases (NCDs) such as diabetes. Diabetes has become one of the main priorities of the national government as programmatic research and efforts towards prevention, early detection, and treatment of diabetes are increasing. Apart from poor quality of life, health-care costs related to diabetes complications are high, with diabetic retinopathy accounting for nearly 2% of the total national state budget, and are estimated to triple by 2025.


Although progress has been substantial in communicable diseases, pneumonia is still the greatest problem in children younger than 5 years. Standardised community management of pneumonia through Integrated Management of Childhood Illness has been implemented since the early 2000s, but the national implementation at primary health-care centres is low.


 The good news is that the inclusion of the pneumococcal vaccine in the routine national immunisation schedule is underway. The vaccine hopefully could reduce the incidence of childhood pneumonia, which is reported to still be high (0·25 episodes per child-years of observation in infants),


 or at least reduce the pneumonia hospitalisation rate.

Smoking is a substantial problem, and remains in second place as a leading risk factor of death and DALY in male individuals of productive age (older than 15 years). The prevalence of male youth smokers (13–15 years of age) is also high (35·6%).


 The current national strategy (The Indonesia Ministry of Health Strategic Plan [STRANAS] 2020–24) for smoking reduction is to have smoke-free zones and smoking cessation services implemented in all districts by 2024.


 Evidence reported that the effects of smoke-free policies on adolescent smoking remains inconsistent.


 Still, current GBD data suggest efforts to reduce tobacco consumption should be enhanced and accelerated as the smoking reduction rate is still far behind the rates of DALYs and deaths attributed to smoking.

Despite progress in overall health status, disparities between the highest and lowest performing provinces have widened since 1990, with unequal resource distribution and a low level of health-care utilisation.


 Health metrics are key indicators to accurately measure the changes after robust implementation of policy and programmatic intervention at subnational levels. Reliable health metrics data require high-quality, uniform data collection at all administrative levels, which is still a challenge with the current Indonesian decentralisation policy. Several data entries to different databases with similar purposes are common, and there are some missing links where the national and subnational data often do not match.

The authors of the GBD paper


 suggest three approaches: address key modifiable risks (diet, smoking, and high body-mass index); improve access to quality of care in resource-limited areas; and address social determinants of health. So far, the current STRANAS has included food labelling strategies for sugar, sodium, and fat contents and increased the number of districts involved in the early detection, prevention, and control of NCDs (from 52 to 514 districts by 2024).


 There is a movement of healthy living focusing on physical activities, balanced diets, and no smoking campaigns (Gerakan Masyarakat Hidup Sehat) that have been implemented and should be continued. The national government should identify the root causes of subnational health disparities and revisit programmes and policies while engaging with regional actors.


 A minimum standard of health services, interventions, and policies needs to be equitably implemented in all provinces with flexible room for modifications for local contexts. Adapting the Indonesian health system towards long-term care for NCDs is required. It would be imperative to build this GBD 2019 analysis further to evaluate the catastrophic impact of COVID-19 on the health burden and health system performance in Indonesia during the pandemic.


We declare no competing interests.


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Published: November 2022




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