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Tackling shackling of the mentally ill in Indonesia

Patient at Galuh Foundation clinic in Bekasi, West Java
Patient at Galuh Foundation clinic in Bekasi, West Java (Jefri Aries/IRIN)

Indonesia is seeking to boost its community mental health services in an effort to end the lockdown and shackling of thousands of mental health patients.

“The practice of shackling mentally-ill people still exists and eliminating it is one of our priorities for 2013,” Diah Setia Utami, director of mental health at the Health Ministry, told IRIN, noting that the country’s “serious” shortage of mental health professionals has been one of the biggest obstacles.

The government aims to provide 30 percent of the country’s 9,000 community health clinics and 1,700 general hospitals with staff to provide basic mental health care by 2014, Utami said.

The Health Ministry estimates 19 million people nationwide have various mental health disorders, including anxiety and depression, and another one million have severe psychoses.

Currently, 33 specialized mental health hospitals and 600 psychiatrists offer public mental health care. “These hospitals are adequately equipped to treat mental patients, but in the future, patients will be encouraged to have treatment outside [the] hospital under the care of families and community caregivers,” Utami added.

The Health Ministry estimates some 18,000 people with mental disorders, mostly in rural areas and bereft of any mental health services, are still subjected to `pasung’ (shackling) to prevent them from attacking others. In villages, people with mental disorders are typically chained behind their homes, while in cities, limited space and stigma confine a number of them to small rooms.

Slideshow: Indonesia’s sick mental health system

Patients at Galuh Foundation clinic in Bekasi, West Java

Patients at Galuh Foundation clinic in Bekasi, West Java
Jefri Aries/IRIN
Patients at Galuh Foundation clinic in Bekasi, West Java
Monday, December 24, 2012
Patients at Galuh Foundation clinic in Bekasi, West Java
January 2013 - Galuh Foundation rehabilitation centre, one hour’s drive from Indonesia’s capital, Jakarta, provides traditional healing to some 250 mentally ill patients in a country with few medical treatment options. A shortage of trained health workers, lack of treatment options and widespread misconceptions about mental illness in Indonesia have led to reports of abusive treatment. There is one hospital bed for in-patient mental health care for every 31,000 residents, far short of needs, the Health Ministry has warned. But gauging those needs is difficult when the sick and grieving often turn to black magic in lieu of health centres, leaving no medical paper trail and scant proof of treatment failure.
View slideshow

Opposition to the practice has grown along with local media reports of people - at times undiagnosed - wasting away after years in chains.

Yusuf said people still resort to `pasung’ - banned since 1977 - because they cannot afford mental health care and to escape stigma associated with mental illness.

A psychiatric consultation costs on average US$25, not including drugs. The government plans to implement nationwide universal health coverage in 2014, which is expected to cover most mental health costs.

Government initiative

In 2011 the Health Ministry launched the `Menuju Indonesia Bebas Pasung’ programme (Towards a Shackle-Free Indonesia), but lack of trained health professionals and funding have stalled progress, say officials.

Nova Rianti Yusuf, a member of a parliamentary health commission, noted the lack of data and research on `pasung’, with the exception of two recent studies of 49 shackled mental health patients that showed 90 percent of them had schizophrenia and 70 percent were receiving improper treatment.

The country’s decentralized health care system accounts for uneven attention to mental health care across the country’s 34 provinces, said Utami. “There are some regional governments that pay little or no attention to mental health and, therefore, allocate little or no budget.”

But, in some places, there are signs of improvement.

Asmarahadi (one name), a psychiatrist at the state-run Soeharto Heerdjan mental hospital in Jakarta, said mental health care has improved there “significantly” over the past 10 years. “People used to call the place a prison, but now it’s like a hotel - at least a one-star hotel.

" People used to call the place a prison, but now it’s like a hotel - at least a one-star hotel. " The hospital receives 150 patients daily and has a policy of not turning anyone away even if they cannot pay, he said.

“People in Jakarta and its surrounding areas are increasingly aware of mental problems,” he said. “Mental health care is not expensive and even atypical, third-generation anti-psychotic drugs are accessible at affordable prices,” he said.

“Treatment failure is usually caused by a lack of patients’ compliance and family support,” he said.

This is if someone seeks formal medical treatment at all. Large pockets of the country still believe magic spells cause mental illness, with families turning to shamans and religious leaders for cures.

WHO plan

Under the 2013-2020 World Health Organization (WHO) global mental health action plan, 80 percent of member countries are expected to update their mental health policies and laws by 2016, while allocating at least 5 percent of public health expenses to mental health care by 2020.

It also seeks to decrease the number of beds used for long-term stays in mental hospitals (which medical studies link to poor treatment and human rights abuses) by 20 percent by 2020, and increase the availability of places for community-based residential care and supported housing.

“The government has the responsibility to provide mental health care for the poor and it should do so by involving local communities,” said Yusuf.

The WHO plan also calls for doubling the treatment of severe mental disorders. Up to 85 percent of such disorders are not currently treated in low- and middle-income countries,WHO estimates.


This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions

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