Development from Below – Guided from Above

Indonesia has a rapidly ageing society; its dynamics feature two distinct characteristics in terms of quality and quantity: a high rate of generational ageing and a high number of people of older age. In 2023, average life expectancy in Indonesia reached 73.9 years and 32 million people were 60 years and over, making up 11.5% of the total population (Badan Pusat Statistik, 2023a). The increase of older Indonesians between 1990 and 2025 was projected to reach 414% implying a rapid growth of older people from about 8 million to 33 million within just 35 years (WHO, 1998). In 2050, Indonesia will have 75 million older persons which adds up to 22.5% of the total population (Badan Pusat Statistik, 2023b).

Chronicle of Social Welfare and Health Coverage for Older Persons in Indonesia

The first Indonesian act regarding older people’s social welfare in 1998 ensured health care, social protection, and mental-spiritual services for older persons; yet, the provision of elder care was assumed to be provided by and in the family (Department of Social Affairs, 1998). The 2003 National Aging Policy highlighted the role of children and family as main carers, the increasing number of older persons suffering from chronic illness, and the low number of older people covered by health insurance and social security schemes (Department of Social Affairs, 2003).

In 2012, a new ruling issued by the Department of Social Affairs clarified the provision of elder care: children, family, community, and NGOs were called upon to support older people in need of health care. The National Strategy for Older Persons in 2021 declared almost all societal groups (i.e., children, family, community, NGOs, private and government companies, and the state) as primary caregivers for senior Indonesian citizens (Regulation of the President, 2021). The three National Aging Policy decrees (2003, 2012 and 2021) provide a common, meaningful definition: An older person is a person of 60 years and over.

In 2014, the Social Insurance Administration Organization (BPJS) was introduced as the principal implementer of the current Indonesian National Health Insurance System (JKN). It provides access to health insurance for millions of older Indonesians and by virtue of that – for free or at moderate cost – to most public and private healthcare services (Eeuwijk, 2020). The government covers the monthly insurance fees for older persons living in precarious conditions; retired state employees and persons employed by private companies enjoy free access to these services on the strength of monthly salary reductions during their working life. Yet, our on-going studies in Eastern Indonesia reveal a significant urban-rural gap: 70-75% of older urbanites are members of the state health insurance scheme compared to only 25-30% of the same age group in rural communities (Eeuwijk, 2021).

Yet, our on-going studies in Eastern Indonesia reveal a significant urban-rural gap: 70-75% of older urbanites are members of the state health insurance scheme compared to only 25-30% of the same age group in rural communities.

Health Development for Older Persons: The National Strategy on Ageing Population

The above mentioned Indonesian strategic plan for older people (of 2021) consists of five major strategies. Strategy 2 addresses the health development of older persons by improving their health status and the quality of life; this health strategy is implemented through four policy directions (Regulation of the President, 2021):

1. Enhancing nutritional status and healthy lifestyle;
2. Expanding health services for older persons;
3. Reducing the morbidity rate of older people; and
4. Expanding the scope of long-term care for aged persons.

This ambitious strategy is backed by a series of concrete measures to improve and strengthen the health of older Indonesians such as promoting nutrient-rich food, providing regular medical check-ups regarding ageing impairments, screening for chronic diseases, promoting physical exercise, preventing infectious diseases, supporting long-term care, sensitizing health professionals for older people’s health issues, and establishing geriatrics in hospitals (Department of Health, 2022). The backbone of this national strategy is the community health centre at sub-district level assisted by the integrated health service post for older persons at the community level, and referral hospitals at the tertiary level.

Such an age-appropriate health policy provides a better focus on the health status and needs of older Indonesians and thus defines the national line of intervention regarding the health development of mainly older Indonesians. However, such a top-down approach based on external intervention certainly questions the way older people can be effectively encouraged and incorporated in their own health development. One response from the Indonesian government was the establishment of the so-called Elderly Group at community level and a vertical coordinating structure regarding social welfare and health issues.

This ambitious strategy is backed by a series of concrete measures to improve and strengthen the health of older Indonesians such as promoting nutrient-rich food, providing regular medical check-ups regarding ageing impairments, screening for chronic diseases, promoting physical exercise, preventing infectious diseases, supporting long-term care, sensitizing health professionals for older people’s health issues, and establishing geriatrics in hospitals.

The Organization for the Coordination of Social Welfare

Under the umbrella of the Department of Social Affairs, the Indonesian National Council for Social Welfare (DNIKS) was founded in 2010 as a coordinating body for public and private participation in social welfare activities. Its implementing structure comprises the Organization for the Coordination of Social Welfare (LKKS), which corresponds to the government’s administrative-political levels (i.e., province, district, sub-district, political community). Each level has a LKKS board whose members are appointed by the corresponding executive state authority such as governor or mayor.

The DNIKS domiciled in Jakarta is partner of the government; the latter has mandated the council to coordinate and advance social welfare organisations, to develop models of social welfare services, to foster consultation among social welfare organisations, and to advocate emerging social welfare issues (Dewan Nasional Indonesia Untuk Kesejahteraan Sosial, 2021). It targets all persons vulnerable to physical, social and economic hardships such as people with a disability, terminally ill persons, street children, the homeless, people in absolute precarity, victims of violence and of natural disasters, and older people. Achieving social justice by strengthening these social groups is the driving force behind this development model.

The corresponding lower vertical structure (i.e., the Organization for the Coordination of Social Welfare [LKKS]) serves the purpose of carrying out the coordinating role of DNIKS in terms of the above-mentioned tasks, above all at province and district levels, each with its own board based at the respective Social Welfare Office. Each vulnerable social group (e.g., persons with disability or older people) has its own division within LKKS. Board members of the older people division are in general women and men aged 60 years and over and include a combination of retired state employees, ex officio high state representatives, older people of political influence, and activists for older persons’ rights. They represent a public-private mix but with a significant bias towards people with an affinity to government.

The Elderly Groups are at the bottom of this vertical structure and are assigned to implement the LKKS tasks, to address the older persons’ aspirations, expectations, and needs, and to actively engage in the network of Elderly Groups network of the same administrative unit. In fact, the long-term strategy of LKKS is to establish one Elderly Group in every political community in Indonesia.

The Community-Based Elderly Group

Local, regional faith-based organizations (FBO) (e.g., mosque, church and temple congregations) were the forerunners of these older persons’ groups, yet with the specification that membership was practically restricted to people of the same faith, respectively. In the light of this, the Indonesian government established about fifteen years ago through the Organization for the Coordination of Social Welfare (LKKS) the state-approved Elderly Groups; they are devised as neutral, nondenominational bodies, open to everybody, and thus backed by the entire community.

Official recognition is provided by the head of political community and subsequently (that is, after registration) by a formal certificate issued by the Province Social Welfare Office. What makes a state-approved Elderly Group appealing for a community with many older persons is the possibility of claiming support (e.g., material and financial) from the Province and District Social Welfare Office while FBOs and NGO-run groups are not entitled to such benefits.

What makes a state-approved Elderly Group appealing for a community with many older persons is the possibility of claiming support (e.g., material and financial) from the Province and District Social Welfare Office while FBOs and NGO-run groups are not entitled to such benefits.

The board of an Elderly Group consists of a chair, a treasurer, and a secretary. They are usually 60 years or over, and most of them are women. These three officials constitute the group’s management and, at the same time, represent the group in the LKKS at sub-district and district levels.

An Elderly Group comprises anything between 50 and 150 members – the lower age limit for membership is 60 years. In general, members meet twice a month alternately at a member’s house; the group’s chair conducts these meetings (usually in the late afternoon for two hours). Such gatherings are not only an occasion for exchanging information while enjoying a cup of coffee and snacks, they also provide an opportunity for financial matters such as paying back a loan or taking out a new one. Many Elderly Groups serve as informal rotating saving and credit associations (ROSCA) where group members can borrow money (at low interest rates), particularly in matters concerning health. Important health information is spread such as the date and venue of the monthly integrated health service post, of the weekly physical exercise sessions, of a workshop for the safe handling of traditional herbal medicine, or of an information event for diabetics. Moreover, members exchange personal health experiences, for example, regarding a particular drug or a new diet.

An Elderly Group meeting is governed by fixed schedule and a formalized procedure. It starts with a short prayer, singing, and words of greeting by the chair and the secretary, followed by the sharing of official community-relevant information, financial matters, and a discussion of planned activities, coffee and snacks, and closes again with a prayer and singing. It is an open secret – and an observation which tallies with the author’s experience (Eeuwijk, 2021) – that only few men participate in these meetings and that more than 90% of the active group members are women, most of them widows. One challenging question is therefore how to reach out to older men in a community, especially to widowers and male caregivers looking after a frail wife.

The Elderly Group’s board also functions as a connecting link, both vertically and horizontally. The vertical line includes the task of coordinating between the group and the state service offices at sub-district and district levels. Both are significant: the link with the community health centre (at sub-district level) covers the group’s community and provides regular health services; the Social Welfare Office (at district level) provides financial and material support for older persons in need of care. It depends on the networking skills of the group’s chair to convince these state offices to provide assistance, for example, by means of health services and social welfare aid specifically aimed at aged community members. The horizontal line includes bridging and maintaining good relations with other community-based Elderly Groups, usually in the same district. This may, for instance, result in biannual meetings at a public beach, including a joint meal and cultural performances thus serving as a basis for shared recreation and relaxation that is beneficial to health.

It is an open secret – and an observation which tallies with the author’s experience (Eeuwijk, 2021) – that only few men participate in these meetings and that more than 90% of the active group members are women, most of them widows. One challenging question is therefore how to reach out to older men in a community, especially to widowers and male caregivers looking after a frail wife.

Health, Elder Care, and the Elderly Group

The regular participants at the bimonthly meetings of an Elderly Group and the monthly health service post represent a community’s active and visible older persons. The board and the group’s active members share the task of keeping an eye on such older community members who do not show up at these events, who are not present at public and private occasions, and who often do not leave their house for days. This surveillance network actually corresponds with the culturally rooted social control and sense of solidarity common in Indonesian communities. When hearing of a worrying case (e.g., after a fall at home or in the case of low blood sugar), the group’s board approaches the afflicted person and his/her family and offers assistance. This may include the forwarding of specific information to the health district centre and, in emergency cases, helping out with money for medical aid. Likewise, in case of the death of a member, the Elderly Group may help to cover the costs of the funeral.

Yet, there are quite a few aged persons who remain invisible owing to the fact that they are physically immobile, bedridden, suffer from a disability and often live in social isolation. These individuals do not show up at the monthly local health service post, yet they at least need regular medical check-ups (e.g., blood pressure) and medication. Moreover, since immobile and bedridden patients are confined indoors and fully dependent on the care provided by family or kin, these caregivers ought to be instructed on how to provide core healthcare-related activities such as preparing diet food, administering medication, and positioning a bedridden body. The harsh reality of elder care is a challenge to every Elderly Group and its board – a task which older lay persons cannot provide but which could compromise a family’s care responsibility.

The harsh reality of elder care is a challenge to every Elderly Group and its board – a task which older lay persons cannot provide but which could compromise a family’s care responsibility.

Many active Elderly Groups have set up the institution of volunteer community health workers – known as ‘health cadres’ in Indonesia – to provide care for older persons. It involves younger, married women living in the community who have undergone a two-week training course in basic elder care. Each woman visits one or two bedridden, older patients almost on a daily basis and provides general care support at home. Some health cadres organize sessions of physical exercise; in addition, they are also often called to provide first aid in emergency cases such as bone fractures or strokes. After the Covid-19 pandemic, many of these special lay health cadres were not reactivated again and replaced by health professionals, who are based at the community health centre in the sub-district capital; this shift corresponds to the current state policy trend of health professionalization (i.e., one nurse for each political community).

In fact, nurses do make home visits once a week to provide care for the elderly, but only after the Elderly Group board has officially reported a specific case to the community health centre. Moreover, nurses who run the monthly health service post often visit older persons in need of care at home before the service post opens in the morning, if they are informed beforehand. In summary, older people evaluate this new structural situation involving professional caregivers from outside as the missing link between the community health centre, the Elderly Group, and the people concerned.

A recurring request voiced mostly by aged, widowed persons is the establishment of a local day-care centre run by the Elderly Group, offering activities such as cultural events, common leisure actions, religious services, handicraft workshops, joint cooking, and sports. Although the physical and mental health benefits of such day-care centres are evident, the community-based Elderly Groups neither feel competent nor legitimated to run such centres for: the required resources (e.g., financial, infrastructural, personnel) are not available, cultural acceptance by the community is doubtful, and the state legal regulations are not clear.

In summary, older people evaluate this new structural situation involving professional caregivers from outside as the missing link between the community health centre, the Elderly Group, and the people concerned.

Older Indonesians’ Participation in Health Development

Health issues and concerns about good care are recurring issues in the lives of older people. It is therefore essential that those affected take on an active part in the development of activities, in particular of health measures. The Indonesian model with its central institution of Elderly Group has emerged from a specific history of development politics with the intention of less reliance on foreign support and pushing a genuinely national strategy of transformation. Older persons’ participation occurs within the scope of state-approved institutions, induced and guided by the government but enriched and reinforced by people of advanced age – not as individuals, but as a social unit furnished with a certain degree of autonomy and self-responsibility.

The Indonesian model with its central institution of Elderly Group has emerged from a specific history of development politics with the intention of less reliance on foreign support and pushing a genuinely national strategy of transformation.

Older persons’ health and social welfare does not yet take high priority in the development agenda of Indonesia although this age group ranks among the most vulnerable societal groups. A major challenge for older people is the sharp increase in chronic illnesses and age-related impairments; the best way to manage these challenges is a smooth and sustainable elder care system at the household and community level. Whether the Elderly Groups are able to meet this demanding task and not be overwhelmed depends on strong support from public as well as private resources.

References

• Badan Pusat Statistik 2023a. BPS-Statistics Indonesia. Jakarta: Badan Pusat Statistik. https://www.bps.go.id/en
• Badan Pusat Statistik 2023b. Proyeksi Penduduk Indonesia 2020-2050. Hasil Sensus Penduduk 2020. Jakarta: Badan Pusat Statistik. https://www.bps.go.id/id/publication/2023/05/16/fa...
• Department of Health 2022. Rencana Aksi Kegiatan. Kesehatan Usia Produktif dan Lanjut Usia 2022-2025. Jakarta: Departemen Kesehatan Republik Indonesia. https://de.scribd.com/document/673404514/1-465909-...
• Department of Social Affairs 1998. Undang-undang Republik Indonesia Nomor 13 Tahun 1998 Tentang Kesejahteraan Lanjut Usia. Jakarta: Departemen Sosial Republik Indonesia.
• Department of Social Affairs 2003. The National Plan of Action for Older Person Welfare Guidelines 2003-2008, Republic of Indonesia. Jakarta: Department of Social Affairs, Republic of Indonesia.
• Department of Social Affairs 2012. Peraturan Menteri Sosial Republik Indonesia Nomor 19 Tahun 2012 Tentang Pedoman Pelayanan Sosial Lanjut Usia. Jakarta: Departemen Sosial Republik Indonesia.
• Dewan Nasional Indonesia Untuk Kesejahteraan Sosial 2021. Gambaran Umum Dewan Nasional Indonesia Untuk Kesejahteraan Sosial. Masa Bakti Kepengurusan Periode Tahun 2021-2026. Jakarta: Dewan Nasional Indonesia Untuk Kesejahteraan Sosial.
• Eeuwijk, P. van 2020. Precarity, Assemblages, and Indonesian Elder Care. Medical Anthropology 39.1, 41-54.
• Eeuwijk, P. van 2021. Waiting for ‘Good Care’. Biomedicine and the Elderly in North Sulawesi, Indonesia. Moussons 38.2, 29-56.
• Regulation of the President 2021. Peraturan Presiden Republik Indonesia Nomor 88 Tahun 2021 Tentang Strategi Nasional Kelanjutusiaan. Jakarta: Kementerian Hukum dan Hak Asasi Manusia Republik Indonesia.
• WHO 1998. World Atlas of Aging. Kobe: World Health Organisation, Centre for Health Development