In this week’s World of Genomics, we’re heading to Indonesia. Made up of over 17,000 islands, this southeast Asian nation is the world’s largest archipelago and is the fourth most-populous country. Due to its location in the “Ring of Fire”, Indonesia experiences a relatively high number of earthquakes and volcanic eruptions, although this does not stop over a million tourists visiting party capital Bali every year. Read on to find out more about the healthcare landscape in this island nation!
The population of Indonesia
Indonesia is situated between the Indian and Pacific Ocean. Indonesia shares land borders with Malaysia, Papau New Guinea and Timor Leste, but the archipelago also has maritime borders with Australia, India, Palau, Philippines, Singapore, Thailand, and Vietnam.
It is believed that humans have inhabited what is now Indonesia since 43,000 BC. The area thrived due to its optimal location as a trade hub and the ideal conditions to farm rice and other vital crops. This led to an influx of outside influence, which led to the introduction of different religions and cultures to the region. Islam eventually took over as the dominant faith and today Indonesia is the world’s largest Muslim country.
As with many other southeast Asian nations, the region eventually came under the control of European colonists. Whilst Portuguese and British traders were drawn in by the lucrative crops and optimal trading routes, it was the Dutch who eventually took control of the archipelago in the 1700s. Dutch rule continued until as recently as World War II, when Japanese forces took control of the nation. An Indonesian independence movement had been growing in the latter years of the war, and two days after Japanese occupation, the country declared itself independent.
Geographic and demographic information
Summary statistics
- Land area: 309,500 sq km
- Gross domestic product (GDP):
- Total: $88.19 billion (2021)
- Per capita: $19,509.5 (2021)
Population statistics
- Population size: 4,520,471 (2021)
- Birth rate: 19 per 1,000 people (2020)
- Death rate: 3 per 1000 people (2020)
- Infant mortality rate: 9 per 1,000 live births (2021)
- Life expectancy: 75 (2020)
- Male 2020 estimate: 73
- Female 2020 estimate: 77
- Ethnicities: Arab, Baluchi, South Asian (Indian, Pakistani, Sri Lankan, Bangladeshi) and African. Immigrants make up approximately 46% of the total population (2019).
Healthcare system
Indonesia’s healthcare system was decentralised in 1999 and healthcare in the country has steadily improved during this time. Reforms were introduced in 2014 in a bid to implement universal health care in the country. At the centre of these reforms is a scheme known as the JKN, which has continued to expand over the years with the ultimate goal of providing high-quality healthcare to all. The government wished to achieve this aim by 2019, although this initial target was missed. However, great progress has been made since introduction of the JKN and as of 2020 over 82% of the population was entitled to care through the scheme.
The JKN serves as a form of national health insurance. At present, this is subsidised through mandated contributions equalling 5% of an individual’s monthly pay. This is split between employee and employer, with the latter footing most of the contribution (4%). Whilst reports suggest the scheme operated well in its early years, the JKN has been criticised for failing to meet targets and many believe the plans were over-ambitious. In fact, out-of-pocket payments and private insurance fees still make-up around 60% of Indonesia’s total health expenditure. In order to assist the Indonesian government in achieving the goal of healthcare for all, the World Bank announced in 2021 that they would be loaning the nation $400 million.
As of 2019, Indonesia had 2,813 hospitals, the majority of which were operated by private providers. With only 1.17 hospital beds per thousand individuals, Indonesia has the least hospital resources of all southeast Asian nations.
Health priorities
The leading causes of death in Indonesia are stroke, cancer and tuberculosis.
Indonesia’s population is relatively young. However, healthcare improvements have led to increased life expectancy. Therefore, it is likely that the country will need to accommodate an ageing population in the future.
Tobacco-use is common in Indonesia. The country is one of only nine that have not signed WHO’s Framework Convention on Tobacco Control. Over a third of the population smoke, although there is a significant gender bias – over 60% of men compared to only 5% of women smoke. This contributes to over 300,000 deaths a year. Moreover, there is no country-wide legislation governing the restriction of tobacco-use, and smoking is permitted in many public places. Furthermore, cigarettes remain relatively cheap and manufacturers face very low taxes on their products. In 2009, Bogor became the first city in Indonesia to introduce smoking restrictions, including bans in indoor spaces and substantial fines for non-compliance. These restrictions have been successful in decreasing tobacco-use but have yet to be implemented in other Indonesian cities.
Given that tuberculosis is such a common cause of death in Indonesia, the country is committed to decreasing the burden of infectious diseases. The nation aims to end multiple ongoing epidemics, including malaria and HIV, by 2030. Indonesia has received significant aid from the United States Center for Disease Control (CDC) over the last 50 years. Most recently, the CDC provided support to implement COVID-19 testing and vaccinations in Indonesia.
Around 10% of Indonesians suffer from mental illness. However, there is limited provision for mental health-care in Indonesia. Concerns have been raised over accessibility to care for those in rural regions and a lack of trained professionals. However, in 2014 a law was passed that mandated each province must have at least one mental health treatment facility.
Genomic medicine capabilities
The first genetic services were introduced to Indonesia in the 1970s, yet these remain very limited. A shortage of infrastructure coupled with a lack of education on the topic means that genomic medicine is not yet widely used in Indonesia. Generally, genetic disease is not a prominent health priority in the country, with much more attention focused on the control of infectious disease. Historically, there has also been relatively little genomics research in Indonesia.
Congenital malformations, some of the most common genetic maladies, are thought to occur in nearly 1% of all Indonesian births. However, there is no robust data regarding the incidence of these malformations. Down’s syndrome and other genetic conditions, such as the enzyme processing disorder G6PD, are also thought to be relatively common in Indonesia.
Most genetic testing in Indonesia is performed at research institutes, rather than dedicated laboratories. This testing is limited, and not many diseases are covered. Some of these research institutes can provide genetic counselling following results, although this is often performed by medical professionals with little formal training in the subject. One research institute, the Eijkman Institute, does have a dedicated genetic counselling department, and also provides pre-marital and pre-conception screening for preventative purposes.
In spite of the lack of emphasis on genomic medicine, a 2021 study revealed that medical students in Indonesia had relatively good literacy regarding genetics.
Notable projects
Indonesia National Genome Project: This project was announced in 2022 and is overseen by the Indonesian Ministry of Health. The project aims to collect genetic data from over 10,000 Indonesian individuals by 2024. The results will be used to inform research into a number of different diseases.
Indonesia Genome Diversity Project: The Indonesian Genome Diversity Project is a dataset consisting of genome sequences of 161 individuals from Indonesia and Papau New Guinea. The data is held by the European Genome-Phenome archive and has been used to further our understanding of human evolution and migration patterns in southeast Asia.
GenomeAsia 100K Project: The GenomeAsia 100K Project was set up to combat the lack of diversity in genomics research. The data collected includes whole genomes from over 1,700 individuals across Asia, including 68 from Indonesia.
Notable organisations and companies
Indonesian Institute of Sciences: The Indonesian Institute of Sciences is the governmental body responsible for overseeing science and research in Indonesia. It is responsible for managing 47 research centres across the nation. The institute is currently in the process of being dissolved and replaced by organisations that will oversee more specific research areas such as life sciences and engineering.
Eijkman Institute: The Eijkman Institute is Indonesia’s biggest molecular biology research centre. The institute is responsible for carrying out forensic identifications, genetic testing and also genetic counselling, including pre-marital and neonatal screening.
Faculty of Medicine, University of Indonesia (FMUI): Based in Jakarta, FMUI’s Medical Biology Department carries out a limited number of genomic tests, including for chromosomal aberrations. Genetic counselling can be provided following test results.
Notable individuals
Prawiti Sudarmono: An Indonesian microbiologist, Sudarmono is known for her research on salmonella typhi. She was awarded a WHO grant for her early work. Alongside her interests in microbiology, Sudarmono was invited to take part in a NASA Space Shuttle mission in 1985. However, the mission was ultimately cancelled.
Antonius Suwanto: An Indonesian biologist who is famous for his discovery of circular chromosomes in rhodabacter. He is currently a faculty member at Institut Pertanian Bogor.
Djoehana Wiradkarta: A microbiologist and serologist, Djoehana Wiradkarta played an integral role in the development of higher education in Indonesia. He founded the Faculty of Medicine at Padjadjaran University and was one of the founders of the Bandung Institute of Technology.
The future genomics landscape
Genomic medicine is taking a leading role in upcoming healthcare initiatives in Indonesia, despite the current infrastructure limitations. In 2022, the Ministry of Health announced a healthcare transformation strategy that places an emphasis on the use of genomics. As part of this strategy, The National Research and Innovation Agency built a genomics research centre with whole genome sequencing capabilities. Research at the Centre will focus on both health and biodiversity, in a bid to further Indonesia’s research capabilities.
Furthermore, the Ministry of Health have also launched the Biomedical and Genome Science Initiative (BGSi). The initiative comes off the back of the COVID-19 pandemic, in which genomics played a huge role in disease control. The objective of the initiative is to utilize whole genome sequencing to not only tackle infectious diseases but also to integrate precision medicine methodologies into the healthcare system.
Overall, Indonesia’s healthcare system appears to have a promising future due to the ongoing commitment to universal healthcare and increasing interest in genomic medicine.
References
- Ariani, Y., Soeharso, P. and Sjarif, D.R., 2017. Genetics and genomic medicine in Indonesia. Molecular genetics & genomic medicine, 5(2), p.103.
- Asia Pacific Observatory on Health Systems and Policies. 2017. The Republic of Indonesia Health System Review. Health Systems in Transition. Vol. 7. Issue 1.
- Britannica. 2023. Indonesia. Available at: https://www.britannica.com/place/Indonesia
- International Trade Administration. 2019. Healthcare Technologies Resource Guide – Indonesia. Available at: https://www.trade.gov/healthcare-resource-guide-indonesia
- Pratiwi, A.B., Setiyaningsih, H., Kok, M.O., Hoekstra, T., Mukti, A.G. and Pisani, E., 2021. Is Indonesia achieving universal health coverage? Secondary analysis of national data on insurance coverage, health spending and service availability. BMJ open, 11(10), p.e050565.
- World Bank. 2023. Indicator. Available at: https://data.worldbank.org/indicator
