Indonesia top 3 disease burden

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Indonesia's Top Three Disease Burdens

Indonesia [1] is the largest economy in Southeast Asia with nearly 260 million people, but like so many other countries, it has passed into the third stage of the Epidemiological Transition Transition: The Age of Man-made Diseases. Indonesians must recognize non-communicable diseases as their largest health burden and ensure their health infrastructure can meet the unique and increasing demands resulting from these types of diseases.

Table 1. The Epidemiologic Transition in Indonesia 1990-2013 [1]

Epi Transition Indonesia 1990-2013

Table 2. Snapshot of Country Profile by the World Health Organization (WHO)[2] As their focus shifts to their top three non-communicable diseases of Ischemic Heart Disease, Stroke and Tuberculosis; as defined by the Institute of Health Metrics and Evaluation in Table 3 (below), Indonesia must understand each disease and assess their health system's ability to manage the resulting health needs.

Table 3. All-cause mortality for both sexes and all ages in Indonesia 2013 [3]

Table 3. All-cause mortality for both sexes and all ages in Indonesia 2013

Stroke (both sexes) = 18.24% total deaths (16.48%-19.89%), annual percent change of 2.08%

  • Stroke in women = 21.31% (17.79%-23.84%) with an annual percent change of 2.•3%
  • Stroke in men = 15.62% (13.59%-17.72%) with an annual percent change of 1.84%

Legend: Blue = non-communicable diseases Red = communicable, maternal, neonatal and nutritional diseases Green = injuries

Primary Cause of Indonesian Pre-mature Mortality - Stroke (Cerebrovascular Disease, or CVD)

Definitions and Risk Factors for Stroke

Stroke, sometimes referred to as cerebrovascular disease (CVD), is an acute neurological injury either due to too much or too little blood in the brain. Strokes are classified into two broad types: ischemic and hemorrhagic. Ischemic is, by far, the more common (global incidence 68%) and is characterized by tissue death at the cellular level. Ischemic strokes are caused by a lack of blood supply (carrying oxygen and sugar) to the brain. Insufficient supply of blood to the brain is usually caused by:

  • thrombosis: a local blood clot, often due to atherosclerosis or hypertension
  • embolism: debris often coming from the heart due to atrial fibrillation, valvular disease or cardiomyopathy
  • systemic hypoperfusion (insufficient blood to the brain due to a circulatory problem, often caused by cardiac arrest, arrhythmia, traumatic bleeding or a blood disorder).
  • Less frequent are hemorrhagic strokes (32% global incidence), which is the result of too much blood within the brain. Hemorrhagic strokes are grouped into two categories:
  • Intracerebral hemorrhage (ICH): causes include hypertension, bleeding disorders and trauma
  • Subarachnoid hemorrhage (SAH): causes include ruptured aneurysm, bleeding disorders and trauma

Regardless of the type of stroke, there are often overlapping causes related to cardiovascular disease.[4]

Risk Factors As indicated in Table 4 (below), Stroke is largely effected by Behavioral Risk Factors (including: diet, exercise, tobacco and substance abuse) as well as major metabolic risk factors (including: body mass index (BMI), fasting glucose, blood pressure, total cholesterol and kidney function). While Environmental risk factors (air quality/pollution and occupational risk exposures) are less attributable as of 2013, they should not be ignored. And it should be noted, regardless of type of stroke, risk factors can be traced back to behavioral, metabolic and environmental origins in a roughly equal fashion for both ischemic versus hemorrhagic stroke. Table 4. Attributable Risk for Ischemic and Hemorrhagic Stroke, both sexes in 2013[5]

Table 4. Attributable Risk for Ischemic and Hemorrhagic Stroke, both sexes in 2013

Scope of the problem

In 2013, stroke was the leading cause of premature death (for all ages and sexes) in Indonesia. As we will continue to see, the vast majority of strokes are preventable. Risk factors for stroke in Indonesia are largely behavioral (related to diet and tobacco use) and metabolic (related to hypertension).

Table 5: Risk Factor Attribution for Stroke in Indonesia, 2013 for both sexes[6]

Broad Categories of Risk Specific Risks Percent
Behavioral Risks 74%
Dietary 61%
• Low fruits 32%
• Low vegetables 30%
• Low whole grains 16%
• High sodium 10%
Tobacco 24%
low physical activity 10%
2nd hand smoke 3%
Alcohol 2%
Metabolic Risks 69%
High systolic blood pressure 62%
High BMI 16%
High plasma fasting glucose 9%
Low glomerular filtration rate 5%
High total cholesterol 4%
Environmental/Occupational Example 27%
Air Pollution 25%
• Household air pollution from solid fuels 16%
• Ambient particulate matter 11%
Lead 2%

Time trends of Stroke in Indonesia Premature mortality from stroke has been steadily increasing since 1990, and affects women at a higher rate than men.

Table 6. Percent of Total Deaths due to Stroke in Indonesia 1990-2013 by Sex[7]

Table 6. Percent of Total Deaths due to Stroke in Indonesia 1990-2013 by Sex

Health system Response to Stroke in Indonesia Despite stroke being the leading cause of death (and increasing with time), there are few references specific to stroke prevention or treatment efforts. Generally speaking, focus on non-communicable disease does not appear at the top of priority lists. One reason for this may be the quality of health services: “While there are greater efforts at improving basic public services, the quality of health clinics and schools is uneven by middle income standards, contributing to alarming indicators, particularly in health.” [8]

Additional reasons preventing concerted focus on stroke prevention and treatment may include insufficient access to certain types of care: “Indonesia’s primary public health care system is extensive: more than 90 percent of the population has access to primary care facilities…While Indonesia has a well-developed primary health system, it has fewer hospital beds than comparators…and fewer health workers…The ratio of physicians to population also masks significant inequities among urban and rural areas.” [9]

In 1998, Indonesia adopted a new health paradigm which focused more “on health promotion and prevention rather than on curative and rehabilitative services. The new vision was reflected in the motto Healthy Indonesia 2010.” [10] Given that stroke is primary caused by preventable risk factors, as we saw above, it is reasonable to expect that a focus on health promotion and prevention will address the leading cause of death. Six Priority Areas:

  1. 1. Health policy and system development
  2. 2. Prevention and control of communicable diseases
  3. 3. Health of women, children and adolescents
  4. 4. Non-communicable diseases, mental health, health and environments
  5. 5. Emergency preparedness and response
  6. 6. Partnership, coordination and WHO’s presence in countries


Table 7. Strategic Directions of Indonesia’s Health System in 2011 (4th related to non-communicable diseases)[12]

File:Stroke Table 6.tif
Table 7. Strategic Directions of Indonesia’s Health System in 2011 (4th related to non-communicable diseases)

Table 8. Indonesia’s 2011 Strategy on Noncommunicable diseases, mental health and health environment[13] “Priority area 4 – Noncommunicable diseases, mental health and the environment: This area would benefit from special assessments to determine local strategies and priorities in line with the available global best practices. Extra effort needs to be made to put the neglected public health problems such as noncommunicable diseases, mental health, injury and tobacco use higher on Indonesia’s health agenda. Periodic reviews also need to consider the extensive work of other development partners who may have a much larger impact and role than WHO. It is essential to identify where WHO can make a key contribution in these areas and play a proactive role in integrating with other partners to maximize the health benefit.” (page 33) [14]

Secondary Cause of Indonesian Pre-mature Mortality - Ischemic heart disease According to the Institute for Health Metrics and Evaluation, ischemic heart disease (IHD) is the second leading cause of mortality in Indonesia.[15] In 2013, IHD was responsible for 43.62 deaths per 100,000, or 13.17% of all deaths.[16] In 2013 CAD was the most common cause of death globally, resulting in 8.14 million deaths (16.8%) up from 5.74 million deaths (12%) in 1990.[17]

Definition and risk factors IHD: Ischemic heart disease (IHD), also known as coronary artery disease (CAD), is a narrowing of the small blood vessels that supply blood and oxygen to the heart.[18] IHD is used to classify a group of cardiovascular diseases including angina, angina, infarction, and cardiac death.[19] Symptoms may include chest pain; discomfort in the shoulder, arm, back, neck, or jaw; and/ or shortness of breath. Complications include heart failure or irregular heartbeat.[20] Risk factors for IHD include blood pressure, [2], [3], lack of exercise, [4], blood cholesterol, poor diet, and alcohol, among others.[21][22] Smoking is associated with about 36% of cases and obesity 20%, while 7–12% of cases are related to lack of exercise.[23][24]

Time trends: As Figure 9 shows, from 1990 to 2013, there has been an increase in the percent of total deaths attributable to IHD in Indonesia. Figure 10 shows the total number of deaths caused by IHD in the country over the same time period, and we also observe an increase over time, from approximately 96,000 deaths in 1990 to more than 209,000 deaths in 2013.

Figure 9. Percent of total deaths caused by ischemic heart disease in Indonesia across all ages and both sexes, 1990-2013. Data source: Institute for Health Metrics and Evaluation (IHME). GBD Compare. Seattle, WA: IHME, University of Washington, 2015. Available from (Accessed October 5, 2016)

Figure 9: Indonesian deaths from IHD

Figure 10. Total number of deaths caused by ischemic heart disease in Indonesia across all age groups and both sexes, 1990-2013. Data source: Institute for Health Metrics and Evaluation (IHME). GBD Compare. Seattle, WA: IHME, University of Washington, 2015. Available from (Accessed October 5, 2016)

Figure 10. Percent of total deaths caused by ischemic heart disease in Indonesia across all ages and both sexes, 1990-2013

Health system response to IHD in Indonesia While the WHO’s Country Cooperation Strategy for Indonesia shows that communicable diseases remain the number one priority area, non-communicable diseases, which include IHD, have also been marked as a strategic priority. The main focus areas for the WHO and the Indonesian health system include measures to “promote public health approaches to prevention and control of non-communicable diseases…:

  • Support monitoring of the prevalence of non-communicable diseases and related risk factors
  • Support implementation of best practices in tobacco control; and adherence to, and implementation of, the WHO Framework Convention for Tobacco Control
  • Support prevention and health promotion to control and prevent NCD”[25]

Tertiary Cause of Pre-Mature Mortality in Indonesia - Tuberculosis

According to the Institute for Health Metrics and Evaluation (IHME), tuberculosis (TB) is estimated to be the third leading cause of pre-mature mortality in Indonesia, having caused an estimated 6.85% of deaths in 2013.[26] As of 2011, the estimated prevalence of TB in Indonesia was 690,000 (all types) and the estimated incidence was 450,000 new cases per year.[27] In 2014, Indonesia was among the six countries with the highest number of incident TB cases. These were: India, Indonesia, Nigeria, Pakistan, China, and South Africa.[28]

It is important to note that the World Health Organization (WHO) identified TB as the fifth leading cause of mortality in Indonesia in 2012 (after stroke, ischemic heart disease, diabetes, and lower respiratory infections).[29] The difference in ranking of causes of mortality may be driven by the width of the confidence intervals around different estimates. For the percentage of deaths in Indonesia caused by TB, IHME reports a 95% confidence interval of 4.67%-8.08%. For the percentage of deaths in Indonesia caused by diabetes and lower respiratory infection, respectively, IHME reports 95% confidence intervals of 4.37%-5.55% and 3.37-5.09%. Thus, there is overlap in the confidence intervals for IHME’s estimates of the percentage of deaths in Indonesia in 2013 caused by TB, diabetes, and lower respiratory infection.

Whether tuberculosis is the third or fifth leading cause of morality in Indonesia, its high ranking demonstrates that Indonesia is facing the “double burden” of non-communicable and infectious diseases. Julio Frenk describes this “double burden” that many developing countries face: “on the one hand, the unfinished agenda of infections, malnutrition, and reproductive health problems; on the other, the emerging challenges represented by non-communicable diseases (along with their associated risk factors such as smoking and obesity), by mental disorders, and by the growing scourge of injury and violence.”[30]

Definitions and risk factors[31]

Definition: Tuberculosis is a curable and preventable infectious disease, caused by the bacteria Mycobacterium tuberculosis. It is spread through the air, and primarily affects the lungs. Symptoms of tuberculosis include cough, fever, night sweats, and weight loss.

Risk factors for developing active TB: According to the WHO, “about one third of the world’s population has latent TB, which means people have been infected by TB but are not (yet) ill with the disease and cannot transmit the disease.” People infected with TB have an average 10% lifetime risk of developing active TB. However, this risk differs across groups of people. It is greater among those with compromised immune systems. This includes people living with HIV, people with malnutrition or diabetes, and people who use tobacco.

Table 11 shows the risk factors for deaths caused by TB in Indonesia in 2013, using data from the Global Burden of Disease.[32] The majority of deaths caused by tuberculosis were attributable to behavioral risks (smoking and alcohol) while a smaller portion were attributable to metabolic risk (high fasting metabolic glucose).

Table 11: Risk Factors for Deaths Caused by Tuberculosis, both sexes in 2013[33]


Broad Categories of Risk Specific Risks Est. percent of total deaths
Behavioral Risks Smoking 1.13%
Alcohol use 0.2%
Metabolic risks High fasting plasma glucose 0.78%
TOTALS 2.11%

Time trends As shown in Figure 12, Global Burden of Disease data indicates a decrease over time, from 1990-2013, in the percentage of deaths in Indonesia caused by tuberculosis. Global Burden of Disease estimates also indicate a decreasing trend in the absolute number of deaths caused by tuberculosis, from 129,468 in 1990 to 108,723 in 2013.

Figure 12: Percent of total deaths due to stroke in Indonesia 1990-2013, by sex [34]

Indonesia Deaths from TB by Year

3. Indonesian Health system response to Tuberculosis[35]

Organization: The health response to TB in Indonesia is organized under three Directorate Generals in the Ministry of Health: the Medical Service, Community Health, and Center for Disease Control. The focus of the TB response is in health centers at the district level, with services also provided by other providers such as prisons and the military service.

Focus: Indonesia began implementing DOTS (or Directly Observed Treatment Short course), the internationally recommended strategy for TB control, in 1994 and has continued to expand the reach of the package to all districts in the country.[36] DOTS has five components:[37]

Figure 13: DOTS 5 Components

Indonesia’s National TB Control Strategy, developed in 2014, was focused on “universal access.”[38] Its aims included:

  • Expand and improve quality DOTS service.
  • Address TB/HIV, MDR-TB, pediatric TB, the needs of poor populations and other vulnerable groups.
  • Involve all public, community and private health providers in PPM-DOTS and ensure their compliance to International Standards for TB Care.
  • Empower TB patients and affected communities.
  • Contribute to health system strengthening including health workforce development and strengthen TB control management.
  • Strengthen policy and central-local government commitment in the TB control program.
  • Promote research, development, and utilization of strategic information.

The WHO highlighted the following major challenges facing the TB program in Indonesia: Commitment and contribution of local governments to TB control.

  • Unreached populations in remote areas (eastern part of the country, particularly), migrants in big cities, in prisons, and populations at high risk of HIV.
  • Expansion of quality DOTS in hospitals, both government (MoH and other ministries) and private, including private practitioners.
  • Rapid expansion of PMDT while maintaining high quality
  • Expansion of laboratory networks for culture and DST with EQA.
  • Introduction of new diagnostics (LPA, Xpert MTB/RIF) and integration into the general health system.
  • Expansion of TB/HIV collaborative activities
  • Maintain the capacity of TB-related staff amid high turnover rate.
  • Prevent the problem of stock-out of first-line drugs, second-line drugs and commodities.



  1. Source:
  2. Source:
  4. Caplan L.R. (February 2016). UpToDate: Etiology, Classification, and Epidemiology of Stroke. Accessed online 10/4/16.
  5. Data Source:
  6. data source:
  7. data sources:
  11. Source:, pg 26
  12., pg 27
  15. Institute for Health Metrics and Evaluation (IHME). GBD Compare. Seattle, WA: IHME, University of Washington, 2015. Available from (Accessed October 5, 2016)
  16. Institute for Health Metrics and Evaluation (IHME). GBD Compare. Seattle, WA: IHME, University of Washington, 2015. Available from (Accessed October 5, 2016)
  17. GBD 2013 Mortality and Causes of Death, Collaborators (17 December 2014). "Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.". Lancet. 385: 117–171. doi:10.1016/S0140-6736(14)61682-2. PMC 4340604. PMID 25530442
  18. "Coronary heart disease". NIH. Retrieved October 5, 2016.
  19. Wong, ND (May 2014). "Epidemiological studies of CHD and the evolution of preventive cardiology.". Nature reviews. Cardiology. 11 (5): 276–89. doi:10.1038/nrcardio.2014.26. PMID 24663092
  20. "What Are the Signs and Symptoms of Coronary Heart Disease?". 29 September 2014. Retrieved October 5, 2016.
  21. Mehta, PK; Wei, J; Wenger, NK (16 October 2014). "Ischemic heart disease in women: A focus on risk factors.". Trends in Cardiovascular Medicine. 25: 140–151. doi:10.1016/j.tcm.2014.10.005. PMID 25453985.
  22. Mendis, Shanthi; Puska, Pekka; Norrving, Bo (2011). Global atlas on cardiovascular disease prevention and control (PDF) (1st ed.). Geneva: World Health Organization in collaboration with the World Heart Federation and the World Stroke Organization. pp. 3–18. ISBN 9789241564373.
  23. Kivimäki M, Nyberg ST, Batty GD, Fransson EI, Heikkilä K, Alfredsson L, Bjorner JB, Borritz M, Burr H, Casini A, Clays E, De Bacquer D, Dragano N, Ferrie JE, Geuskens GA, Goldberg M, Hamer M, Hooftman WE, Houtman IL, Joensuu M, Jokela M, Kittel F, Knutsson A, Koskenvuo M, Koskinen A, Kouvonen A, Kumari M, Madsen IE, Marmot MG, Nielsen ML, Nordin M, Oksanen T, Pentti J, Rugulies R, Salo P, Siegrist J, Singh-Manoux A, Suominen SB, Väänänen A, Vahtera J, Virtanen M, Westerholm PJ, Westerlund H, Zins M, Steptoe A, Theorell T (October 2012). "Job strain as a risk factor for coronary heart disease: a collaborative meta-analysis of individual participant data". Lancet. 380 (9852): 1491–97. doi:10.1016/S0140-6736(12)60994-5. PMC 3486012 . PMID 22981903.
  24. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT (July 2012). "Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy". Lancet. 380 (9838): 219–29. doi:10.1016/S0140-6736(12)61031-9. PMC 3645500 . PMID 22818936
  25. WHO Country Cooperation Strategy at a Glance – Indonesia. WHO (2014). Retrieved October 5, 2016.
  27. Stop TB Partnership, Indonesia Profile,
  28. WHO Media center, “Tuberculosis.” Fact sheet number 104, reviewed March 2016. Visited: 5 October 2016.
  29. WHO, “Indonesia: WHO Statistical Profile.” Last updated: January 2015. Visited: 5 October 2016.
  30. Julio Frenk, Bridging the divide: global lessons from evidence-based health policy in Mexico, The Lancet, Volume 368, Issue 9539, 9–15 September 2006, Pages 954-961, ISSN 0140-6736, (
  31. WHO Media center, “Tuberculosis.” Fact sheet number 104, reviewed March 2016. Visited: 5 October 2016.
  33. Data source:
  34. Source:
  35. Stop TB Partnership, Indonesia Profile, Visited: 5 October 2016.
  36. “Fighting Tuberculosis in Indonesia,” The Global Fund to Fight AIDS, Tuberculosis, and Malaria. April 2013. Visited 5 October 2016.
  37. World Health Organisation, “What is DOTS (Directly Observed Treatment, Short Course.” Visited 5 October 2016.
  38. “Indonesia TB Programme – Technical Information,” WHO Country Office for Indonesia.
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