Cost-effectiveness analysis of low-sodium potassium-rich salt substitutes in Indonesia: an equity modelling study.

Background: Evidence suggests low-sodium potassium-rich salt substitutes (LSSS) are effective in reducing blood pressure (BP). However, the health and economic impacts of LSSS in Indonesia are currently unknown. Methods: We developed a proportional multistate lifetable Markov model to assess a government-led strategy implementing the use of LSSS compared to current regular salt consumption. BP data were derived from the Indonesian Basic Health Research Survey (RISKESDAS 2018), while epidemiological data were from the Global Burden of Disease 2019 study. We estimated implementation costs and the impact of changes in BP on disease events and healthcare costs, and incremental cost-effectiveness ratios. Outcomes were simulated over different time horizons for the 2019 Indonesian population overall, and by income quintiles. Probabilistic sensitivity analysis was done to capture uncertainty. Findings: Over the first 10 years, LSSS could prevent 1.5 million non-fatal cardiovascular disease (CVD) events (8.3%-19.4% reduction) and 643,000 incident chronic kidney disease (CKD) cases (8.2% reduction), while averting over 200,000 CVD and CKD deaths (0.2%-5.2% reduction). This translated to over 24.6 million health-adjusted life years (HALYs) gained over the lifetime of the population, and reduced CVD-related health inequalities (concentration index, -0.075, 95% CI: -0.088 to -0.062). Implementation cost (US$ 1.2 billion [IDR 17.2 trillion] total; US$ 4.5 [IDR 63,665] per capita, as of July 2019) was outweighed by the net health expenditure savings (∼US$ 2 billion [IDR 27.7 trillion] total; US$ 7.3 [IDR 103,300] per capita) in the first 10 years. LSSS were cost-saving over the lifetime, and very cost-effective even with a high LSSS price. Interpretation: Scaling the use of LSSS nationally could be a cost-saving strategy to prevent substantial cardiovascular and kidney disease burden in Indonesia. Funding: Griffith University Postdoctoral Fellowship.

Sexual Intercourse and Its Correlates Among School-aged Adolescents in Indonesia: Analysis of the 2015 Global School-based Health Survey.

OBJECTIVES: This study aimed to determine the prevalence and correlates of sexual intercourse among junior secondary and high school students in Indonesia from the 2015 Global School-based Health Survey (GSHS). METHODS: The survey was conducted among 11 110 students from 75 schools in Indonesia using a self-administered questionnaire. Univariate and multivariate analyses were conducted to explore associations between sexual intercourse and socio-demographic variables, substance use, mental distress, and protective factors. RESULTS: Overall, 5.3% of students reported having ever had sex (6.9% of boys and 3.8% of girls). Of students who engaged in sexual intercourse, 72.7% of boys and 90.3% of girls had an early sexual debut (before reaching the age of 15) and around 60% had multiple sex partners. Sexual intercourse was associated with gender, school grade, smoking, alcohol consumption, drug use, suicidal ideation, truancy, peer support, and parental supervision. CONCLUSIONS: These findings indicate a pressing need to develop more comprehensive sexual health education in the national curriculum. An effective strategy should also address other risky behaviours.

Urban-rural distinction of potential determinants for prediabetes in Indonesian population aged ≥15 years: a cross-sectional analysis of Indonesian Basic Health Research 2018 among normoglycemic and prediabetic individuals.

BACKGROUND: Based on Basic Health Research (RISKESDAS) conducted by Ministry of Health, Indonesia, prediabetes prevalence tends to increase from 2007 until 2018. The numbers are relatively higher in rural than those in urban area despite of small discrepancies between the two (~ 2-4%). The purpose of this study was to identify urban-rural differences in potential determinants for prediabetes in Indonesia. METHODS: This analysis used secondary data collected from nationwide Health Survey in 2018. Respondents were aged ≥15 years who met inclusion criteria of analysis with no history of diabetes mellitus. Prediabetes criteria followed American Diabetes Association 2019. Multiple logistic regression was also employed to assess the transition probability of potential determinants for prediabetes in urban and rural Indonesia. RESULTS: Up to 44.8% of rural respondents were prediabetics versus their urban counterparts at 34.9%, yet non-response bias was observed in the two. Young adults aged 30 years were already at risk of prediabetes. Urban-rural distinction for marital status and triglyceride level was observed while other determinants tended to overlap across residence. Several modifiable factors might contribute differently in both population with careful interpretation. CONCLUSIONS: The minimum age limit for early prediabetes screening may start from 30 years old in Indonesia. Urban-rural distinction for marital status and triglyceride level was observed, yet non-response bias between the two groups could not be excluded. A proper model for early prediabetes screening need to be developed from a cohort study with adequate sample size.

On the verge of a chronic disease epidemic: comprehensive policies and actions are needed in Indonesia.

In the midst of tackling the persistent burden of maternal mortality and infectious diseases, Indonesia is facing an increasing burden of non-communicable diseases (NCDs). Although there are increasing national efforts in NCD prevention and control, the worsening trend of NCD risk factors and morbidity is alarming. We provided assessment and discussion on the policies and actions needed in the country including comprehensive efforts to reduce tobacco use and unhealthy diet, the need to reorient the health systems for better NCD prevention and control, and the promotion of NCD-related research that are still lacking.

Subnational regional inequality in the public health development index in Indonesia.

BACKGROUND: Achieving the Sustainable Development Goal of 'ensuring healthy lives and promoting well-being for all at all ages' necessitates regular monitoring of inequality in the availability of health-related infrastructure and access to services, and in health risks and outcomes. OBJECTIVES: To quantify subnational regional inequality in Indonesia using a composite index of public health infrastructure, services, behavioural risk factors and health outcomes: the Public Health Development Index (PHDI). METHODS: PHDI is a composite index of 30 public health indicators from across the life course and along the continuum of care. An overall index and seven topic-specific sub-indices were calculated using data from the 2013 Indonesian Basic Health Survey (RISKESDAS) and the 2011 - Village Potential Survey (PODES). These indices were analysed at the national, province and district levels. Within-province inequality was calculated using the Weighted Index of Disparity (IDISW). RESULTS: National average PHDI overall index was 54.0 (out of a possible 100); scores differed between provinces, ranging from 43.9 in Papua to 65.0 in Bali. Provinces in western regions of Indonesia tended to have higher overall PHDI scores compared to eastern regions. Large variations in province averages were observed for the non-communicable diseases sub-index, environmental health sub-index and infectious diseases sub-index. Provinces with a similar number of districts and with similar overall scores on the PHDI index showed different levels of relative within-province inequality. Greater within-province relative inequalities were seen in the environmental health and health services provisions sub-indices as compared to other indices. CONCLUSIONS: Achieving the goal of ensuring healthy lives and promoting well-being for all at all ages in Indonesia necessitates having a more focused understanding of district-level inequalities across a wide range of public health infrastructure, service, risk factor and health outcomes indicators, which can enable geographical comparison while also revealing areas for intervention to address health inequalities.

Socio-economic, demographic and geographic correlates of cigarette smoking among Indonesian adolescents: results from the 2013 Indonesian Basic Health Research (RISKESDAS) survey.

BACKGROUND: The prevalence of adolescent tobacco use in Indonesia is among the highest in the world. Monitoring the extent and distribution of adolescent cigarette smoking is crucial to being able to target prevention and reduction strategies and evaluate the effectiveness of interventions. OBJECTIVES: To quantify the prevalence of adolescent cigarette smoking in Indonesia and assess the association with key socio-economic, demographic and geographic factors. METHODS: We used data from the 2013 Indonesian Basic Health Research (RISKESDAS) national household survey to quantify the prevalence of cigarette smoking in adolescents aged 10-18 years by sex, age, education, economic status, place of residence and province. We used logistic regression to assess the adjusted association between adolescent smoking and these factors. RESULTS: The overall smoking prevalence among Indonesian  adolescents was 7.2% (95% Confidence Interval/CI: 7.1-7.4). The prevalence was substantially higher among males (14.0%; 95% CI: 13.6-14.4) compared with females (0.2%; 95% CI: 0.1-0.4). After controlling for socio-economic, demographic and geographic characteristics, higher odds of smoking were observed among males (OR = 118.1; 95% CI: 91.2-153.0) as compared to female and among  adolescents aged 13-15 and 16-18 years as compared to those aged 10-12 years (OR = 13.2; 95% CI: 10.8-16.2 and OR = 72.7; 95% CI: 59.1-89.4, respectively). The odds of smoking were greater among adolescents with higher education as compared to those with lower education (OR = 1.3; 95% CI: 1.1-1.4) and adolescents in the poorest quintile had more than twice the odds of smoking compared with adolescents from the richest quintile (OR = 2.5; 95% CI: 2.2-2.8). CONCLUSION: Smoking prevention and cessation interventions in Indonesia need to be specific considering the sex, age, socioeconomic status and geographic location of adolescents. Ongoing monitoring of adolescent smoking is important for targeting interventions at higher-risk groups and assessing the effectiveness of current tobacco control strategies.

Data source mapping: an essential step for health inequality monitoring.

The task of health inequality monitoring is not possible without the availability of appropriate and high-quality data at various levels. Data source mapping - a process by which data sources are systematically enlisted, their properties detailed and each source appraised for the purposes of monitoring - is an essential initial step for health inequality monitoring. We outline a simple process along with a template for data source mapping and its application in Indonesia, concluding with the lessons learned from this process, in terms of both challenges as well as the opportunities and advantages arising from the use of equity-related data from the Indonesian health information system.

Capacity building for health inequality monitoring in Indonesia: enhancing the equity orientation of country health information system.

BACKGROUND: Inequalities in health represent a major problem in many countries, including Indonesia. Addressing health inequality is a central component of the Sustainable Development Goals and a priority of the World Health Organization (WHO). WHO provides technical support for health inequality monitoring among its member states. Following a capacity-building workshop in the WHO South-East Asia Region in 2014, Indonesia expressed interest in incorporating health-inequality monitoring into its national health information system. OBJECTIVES: This article details the capacity-building process for national health inequality monitoring in Indonesia, discusses successes and challenges, and how this process may be adapted and implemented in other countries/settings. METHODS: We outline key capacity-building activities undertaken between April 2016 and December 2017 in Indonesia and present the four key outcomes of this process. RESULTS: The capacity-building process entailed a series of workshops, meetings, activities, and processes undertaken between April 2016 and December 2017. At each stage, a range of stakeholders with access to the relevant data and capacity for data analysis, interpretation and reporting was engaged with, under the stewardship of state agencies. Key steps to strengthening health inequality monitoring included capacity building in (1) identification of the health topics/areas of interest, (2) mapping data sources and identifying gaps, (3) conducting equity analyses using raw datasets, and (4) interpreting and reporting inequality results. As a result, Indonesia developed its first national report on the state of health inequality. A number of peer-reviewed manuscripts on various aspects of health inequality in Indonesia have also been developed. CONCLUSIONS: The capacity-building process undertaken in Indonesia is designed to be adaptable to other contexts. Capacity building for health inequality monitoring among countries is a critical step for strengthening equity-oriented national health information systems and eventually tackling health inequities.

One Step Back, Two Steps Forward: An Economic Evaluation of the PEN Program in Indonesia.

Abstract-The economic and health burden of noncommunicable diseases (NCDs) is significant globally. To counteract this problem, the World Health Organization (WHO) introduced the Package of Essential Noncommunicable disease (PEN) interventions. Several countries, including Indonesia, implemented the PEN program. To assess the value of the investment in the current program, an economic evaluation of the program was conducted with collaboration between the Ministry of Health in Indonesia, the WHO, and the International Decision Support Initiative (iDSI). Even in low- and middle-income countries (LMICs) such as Indonesia where there is lack of data and health technology assessment (HTA) expertise, the study aims not only to inform policy but to build HTA capacity in the country through the working partnership between international HTA experts and local partners. This study evaluated the delivery of screening and treatment for diabetes and hypertension, which are part of NCD interventions in the PEN program. Several screening strategies were compared to explore the options for improving the current PEN program. The findings show that implementing the PEN program is better than a base case of no policy in place, though it can be improved through a targeted screening policy of high-risk groups of population aged 40 and above (as opposed to screening for 15 years old and above as is the current practice). Adopting the recommended policy is a major challenge to policy makers due to a potential negative public perception of the disinvestment from an option that yields higher health outcomes. However, this study demonstrates that with the same budget currently invested in the program, the changes proposed will result in improvements on the current low uptake and poor coverage, thus yielding cost savings for the government and a possibility to reallocate resources to the country's priority health concerns, consequently leading to better health outcomes.