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Pre-Conference Competition (PCC) for Asian Medical Students’ Conference (AMSC) 2015, Singapore 5 - 12 July 2015

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Original Article Government Policy Regarding Prevention of Elderly Degenerative Diseases in Indonesia Ivy Wenanto Tjandra1, Ediva Pradiptaloka1, Stephanie1, Iameresa Josephine Emisura1, Michael Jonathan Tan1 1

Faculty of Medicine, Atma Jaya Catholic University of Indonesia

INTRODUCTION In Indonesia, as in other countries around the world, the number of births is declining while life expectancy is rising. The world today is experiencing rapid demographic change, characterized by the fastest-growing segment of the world population being those aged 60 and over. This phenomenon is widely known to impact on issues of pensions, social insurance, taxation and most importantly, the welfare of the elderly. The Central Bureau of Statistics (BadanPusatStatistik) Indonesia census it is shown that Indonesia is heading toward an aging population. In 2010, the population census found that the number of people aged 60 years and above was 18.1 million, or 7.6 percent of the total population.

This number is projected to increase to 33.7 million, or 11.8 percent of the population, by 2025 and to reach 48.2 million, or 15.8 percent, by 2035. In Indonesia, provincial disparity of aging can be explained by disparity in family planning performance. Provinces with great success in reducing fertility, such as East Java, show the fastest aging process. The increment of older person in East Java will be 24.2 percent above the increment of total population 2010-2035. Meanwhile, the elderly will constitute only 17.4 percent of the increase in East Nusa Tenggara’s population. Therefore, policy makers should not only focus on the effect of fertility reduction, but also on the aging process.

Disability also increases significantly with age, with 26 percent of the older population being affected. The proportion of the older population reporting a disability in 2010 was 28.2 percent among older women, compared to 23.4 percent among older men. Difficulties in seeing, hearing and climbing stairs are common problems suffered by older Indonesians. These types of illnesses are degenerative diseases that accompany the aging process. Cerebral degeneration / degenerative disease is a process in which neurons in the cerebellum - the area of the brain that controls coordination and balance - deteriorate and die. Diseases that cause cerebellar degeneration can also involve other areas of the central nervous system, including the spinal cord, cerebral cortex, and brain stem. Cerebellar degeneration may be the result of inherited genetic mutations that alter the normal production of specific proteins that are necessary for the survival of neurons. Diseases that are specific to the brain, as well as diseases that occur in other parts of the body, can cause neurons to die in the cerebellum. Neurological diseases that feature cerebellar degeneration include stroke. In Indonesia, stroke or other degenerative diseases are classified as NCD(non-communicable disease).According to the data provided by Litbangkes (Ministry of Health Research and Development in Indonesia), stroke is the primary factor of death of the elderly in Indonesia. ! " # $% & ' ( # ( $) * $+ # & ! "

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Table 1 : The Causes of Elderly Death in Indonesia

Source : Registration of the causes of death in 2011, by the Ministry of Health Research and Development in Indonesia.

Among Southeast-Asian countries, Indonesia has the largest number of elderly who live in a relatively low-income country with limited old-age income security. Therefore, it will be a challenge for policy makers in maintaining quality of life for older citizens to give them appropriate health care in order to enhance their quality of life.

BACKGROUND The Indonesian government is aware of a great potential threat of stroke and other degenerative diseases, that a policy was made to help the elderly who are suffering with stroke to improve their quality of health and life. The policy is stated as the Decree by the Ministry of Health of Republic of Indonesia No. 264 / Ministry of Health / SK / II / 2010 about Guidelines of Health Problems and Intelligence Due to Degenerative Disorder. The policy itself is a modification of the previous enacted law Legislation No. 13 in 1998 about the elderly well-beings that state the age restriction of the elderly is 60 years old. Other guidelines and programs that has been carried out by the government are reflected in the Government Rules No. 43 in 2004 about Implemented Guidelines to Enhance the Well-being of the Elderly, which include : Building houses of worship that allow accessibility for the elderly to obtain mental and spiritual stability; Health services that emphasize on curative approach of health care; Broadening of geriatric / gerontological health care; Public infrastructure services, i.e. increase accessibility of using public facilities, reduction of cost, travel accommodation efficiency, sports and recreational facilities; Ready access public facilities, i.e. government administration services (citizen card), health services in the government’s health facilities, fee waivers for those who met the requirements to purchase travel tickets, accommodation, and many other facilities aimed to prioritize the elderly in Indonesia. Law No. 36 in 2009 section 138 stated the health care provided for the elderly should be directed to maintain healthy lives, socially and economically, in order to raise themselves according to human dignity. The government shall ensure the availability of health services and facilitation for the elderly, and to be able to live independently and productively. (Ministry of Health, 2009) The Elderly Health Care Policy also aims to improve the quality of life for those who are still in good health, potentially able to live independently, productively and useful. The purpose is to raise the awareness among the elderly to maintain their own health, participate in family and community events, reinforce trainers for better health services. Health Guidance for the Elderly is implemented with the hope of involving families and communities, as well as building partnerships with non-governmental organizations (NGO) or private institutions, emphasize holistic approach through basic services with qualified comprehensive referral system (promotive, preventive, curative and rehabilitative). The realization of the policy implementation are in the form of services such as Health Center Courtesy for Elderly, Referral Services in Poly Geriatric Hospitals, Mental Health Care Services, Elderly Home Care Services, Integrated Trainer Center for Non-communicable Diseases and Nutrition Services. The majority of these policies are not running very effectively because of various constraints, one of which is the Integrated Trainer Center for NGO. Theoretically, based on the goals set by the government, the program should run smoothly. Nevertheless there are liabilities in the practical implementation which act as hindrance towards the aimed goal that need to be criticized, both in the aspect of the policy itself, the government policy and also the implementation in the field.

PROBLEM The Decree by the Ministry of Health of Republic of Indonesia No. 264 / Ministry of Health / SK / II / 2010 about Guidelines of Health Problems and Intelligence Due to Degenerative Disorder contain the restriction which is the degenerative diseases of elderly, which means it is an aging process caused by declining cell functions in the body. Degenerative diseases can initially be prevented by minimizing the factors of risk. One of the most common risk factor centered around unhealthy lifestyle; lack of physical activity, consumption of poorly nutritional food and smoking that may add up the possibility of acquiring degenerative diseases in later life. Manifestation of the general organ dysfunction and any other disorders that suppress intelligence affects daily social activities and cause a decrease in quality of life. Those suffer with degenerative disorder may experience declining conditions if they are not handled properly with care, thus giving an impact the lives of family concerned in the socio-economic aspect.

Guidelines related to health intelligence problems due to degenerative disorder were conducted within various levels in terms of administrative and service that correspond the capacity of existing health care facilities. The first point that need to be touched upon regarding this policy is the guidelines carried out gradually; from Elderly Integrated Health Care Center (PosPelayananTerpaduuntukLanjutUsia), progressing to a higher form of facility provided, Community Health Center (PusatKesehatanMasyarakat) or hospital. Next, the implementation start from the time the disorder is detected, until rehabilitation is carried out. The third countermeasure is implemented in integrated manner by a variety of health care units, ranging from governmental to private institutions. The fourth measure is professionally managed by affordable integrated group of people, so that it reaches out to every citizens in need. The fifth point emphasize the predominant local government to accelerate the advancement of human life to be more productive on a daily basis. Finally, the last point centered around the development of the program; working group on community-based health or other kinds of organization can be made that correspond with the commitment and potential of the people in that particular area.

Ongoing Programs : 1. Social services for the elderly which are categorized into 2 systems; Community-based / Family-based and Institutional-based. For existing community / family-based services, the program require participation of family and community where elderly still lives with them, because the family and the community related are the most influential factor that are able to give emotional support and will eventually establish a successful social services. Whereas institutional-based services is the last alternative directed towards the elderly who are considered having inadequate potential, financially incapable, physically handicapped and those who are in need of guidance and support.

2. Social empowerment that aims to the elderly who are potentially good but neglected, and who are being cared for with skills training and financial aid.

3. Assistance and maintenance of social welfare given to those elderly having financial problem, disabled and displaced. The assistance given is only during particular period of time, or a lifetime, depending the condition of the elderly.

Theoretically, the policy mentioned above can be considered as a structured program that may potentially bring a positive result for those who suffered from degenerative diseases. However, very obviously seen, it still require some changes in the way that it is carried out. The fact that most citizens of Indonesia, especially the elderly, have no clue regarding the existence of these programs should not be brush over, because it is a crucial factor in heading towards the goal of implementing the health care. For example, the Elderly Integrated Health Care Center (posyandu) is classified as the first level of health institution service. It s a form of service specified to monitor the health of elderly, initiated by the community based on the needs of the elderly in that particular area that has been agreed upon, and the resources also comes

from the community (UKBM). This health care center is assisted by certified trainees, elected and had been given the education and training within the range from village to an administrative area. The goal is to improve health and quality of life until they reach a satisfying and productive life as a member of the society, in accordance with their existence in the social strata. The elderly themselves need to maintain their awareness of the importance of independent well being to the family and community as long as possible. Services that are implemented in the Elderly Integrated Health Care Center depends on the policies and mechanisms established by an area of health district or the organizer. The health care has executed either a 5 table or a 3 table service system. The activities include: registration, measuring body weight and height, blood pressure, heart rate, respiratory rate, BMI (Body Mass Index), simple health care services along with referral and counseling program such as nutritional education. Other activities that can be carried out according to the needs and conditions, such as routine inspection of daily activities; eating / drinking, bathing, walking, dressing up, getting on to bed and off bed, urination / bowel movement, mental status examination, administration of food additives, and all these inspections along with paying attention to the aspect of health and nutrition of elderly, also physical activities such as evening stroll and older adults aerobic to strengthen physical fitness.

Nonetheless, the practical implementation of such program is rarely conducted. According to the Elderly Integrated Health Care Center, the first stage of health service for the elderly should be implemented and established in every administrative area, but the insufficiency of human resources hindered the execution of the program, thus resulting in an uneven distribution of health care services throughout the region.

Limitations that restricts the elderly to join activities by the Elderly Integrated Health Care Center : 1. Unawareness of the benefits in joining activities Knowledge regarding the advantages of participating these activities can be obtained from personal daily experience. Attending the activities and counseling will give them an insight of how to live a healthy life regardless of their limitations or problems. These experience will add up their knowledge which act as a basis in forming attitude which have a powerful influence on their behavior, such as building motivation and interest to join any kind of activities available.

2. Problem with accommodation for those living in a remote area Building health care center at a closer distance (of increase its number) will reduce problem for transportation, also preventing the elderly from experiencing fatigue or even accidents due to limited physical endurance. It also ensure safety that may encourage them to take part in activities away from home, thus is a great external factor to further support their motivation to join activities provided by health care services.

3. Lack of family support The family concerned may feel obliged to drive or remind the elderly to go to the health care center, and eventually care less to do such things in a long period of time. But family support is a very compelling motivator for the elderly to broaden and skill up their interest by joining the activities, and so should always make themselves available to assist or accompany, remind them to come to the health care center and try to help resolve any problems they face.

4. Unfavorable attitude of health care center personnel Maintaining a good attitude of the health care personnel is the basis for encouraging the elderly to be willing to participate in health care center programs. With good service comes the discipline of active participation, because a person’s attitude reflect the formation of good relationship with another in activities that require social interaction.

5. Lack of care of the government towards the elderly which is considered as the minority incapable of contributing to the society

The last problem fall upon the governmental action that is insufficient to maintain the health of the elderly. Laws were enacted, but there are no official establishment to support the policy from the government, resulting in an ineffective system because the reality that does not correspond with the stated policy.

SOLUTION Cases of degenerative diseases are still rising, and handling those cases is not simple or straightforward, but rather a complex procedure that has high possibility to be accomplished although it requires a long period of time. The policy made by the Ministry of Health is a definite first step to enhance the quality of life by fighting against the disease, especially stroke. Practical implementation that can possibly lead towards a positive goal is not running very efficiently due to unawareness of the government to raise the health quality of the elderly in Indonesia. In order to accelerate the improvement, there are several solutions that will bring significant results to retreat the implementation of this policy.

First of all, it is very crucial that the countermeasure of the service focus on a preventive approach. For example establishing a seminar directed to the community that bring upon the subject of elderly health care to prevent degenerative diseases. The point of this seminar is to raise awareness of the community to start enhancing their lifestyle in terms of food consumption and participation in various activity since young, and also gain them knowledge regarding the degenerative diseases as well as the risk factors that increase the possibility of getting the disease.

Secondly, concerning to the unsatisfactory number of elderly integrated health care center in many areas due to shortage of human resources. It is advisable to empower the local citizens to volunteer as a helping hand to provide routine care for the elderly who suffer from diseases. But on the other hand, the requirement of a qualified health care personnel that must be competent in the field is not met, as stated in the written policy.

The third point deals with the insufficient facilities of health care provided. It is commendable to maintain the quality of facilities that has already been provided by routine maintenance, for example once a month, as well as maintaining hygiene health care center. Another facility necessary is a good circulation indoor air and air-conditioning inside the room.

With regard to services that have been considered poor quality due to ill behavior of health care personnel that affect the level of dissatisfaction of any patients seeking treatment, it needs to be entirely abolish.

One of the way is to recruit personnel in special training specified to handle the elderly, not only medically knowledgeable but also having good behavior.

The last point centered around the government action that does not give enough informative whereabouts and benefits of the programs that should be provided by the elderly integrated health care centers. It is advisable to reach all kinds of promotive approach so that the community will recognize and be encouraged to use the existing facilities in the elderly integrated health care centers. Such approach can be through promotion in general health care centers, local hospitals and nursing homes, in the form of brochure that are easy to obtain or even advertisement through mass media.

Degenerative processes due to aging are inevitable, but it can be delayed. Preventive actions should be seriously implemented, especially for the workers who will soon considered as elderly in a couple of years. Healthy lifestyle and regular exercise are among the alternative solutions.

References Depsos RI. (2003). Kebijakandan Program PelayananSosialLanjutUsia di Indonesia.

DirjenPelayanandanRehabilitasiSosial Kemenkes RI. (2013).

Meningkatnyaperanmasyarakatdankeluargadalammeningkatkankualitashiduplansia.BinaUpayaKesehatan Dasar (BUKD) Permenkes No. 264 / Ministry of Health / SK / II / 2010 about Guidelines of Health Problems and Intelligence Due to Degenerative Disorder Rahardjo, Tri Budi W., Tony Hartono, Vita PriantinaDewi, EefHogervorst and EviNurvidyaArifin. “Facing the Geriatric Wave in Indonesia: Financial Conditions and Social Supports�.

In EviNurvidyaArifin and ArisAnanta (eds) Older Persons in Southeast Asia: An Emerging Asset.

Singapore: Institute of Southeast Asian Studies, 2009 UU No. 13 tahun 1998 about Elderly Social Society UU No. 36 tahun 2009 about Health of The People

Original Article Tackling the Upcoming Silver Tsunami: Indonesia’s Community-based Healthcare Eunike Kosasih1, Theodora Kristoforus1 1

Faculty of Medicine,Atma Jaya Catholic University of Indonesia

Indonesia is a nation which consists of more than 17,000 islands making it the largest archipelago in the world. 6,000 of these islands are inhabited by 252 million people (3.5% of the world’s population), easily making Indonesia the 4th most populous country in the world. From the year 1971 to 2010, Indonesia has seen its population double in size from 110 million to 240 million people. These numbers are expected to rise although in a slower fashion, mostly due to better birth control strategies and modernization. Currently, most of the population consist of people from the age group of 50 or lower.

With the advancement of medical services and elevated global life expectancy, this age group will retain longer life span. It is predicted that by 2050, the elderly population in Indonesia (age group 55 or higher) will scope to a staggering 69.5 million (22% of the whole Indonesian population). This will lead to one of the biggest Silver Tsunami ever recorded in history.

Figure 1. Indonesia’s population pyramid (2015).

Figure 2. Indonesia’s population pyramid (2050).

Due to Indonesia being a developing nation, the government hasn’t been able in putting sufficient attention to healthcare service, especially the healthcare of the elderly. Similar to other developing nations, Indonesia’s policies are focused primarily on the growth of the economy and less in non-major sectors (e.g. elderly healthcare). If healthcare policies concerning the elderly remain like status quo for another 30 years, the condition could wreak havoc upon the survivability of the population as a whole.

Indonesia’s healthcare policy making adapted a decentralization nature which meant the central government only generates general regulations upon healthcare. At the national level, The Ministry of Health is in charge of policy formulation and designing standards and guides for lower levels systems. At the provincial level, Provincial Health Office supports, directs, and monitors the operations on the district level, the sub-district level (Puskesmas), and the urban village level (Pustu, Klinik Bidandes, and Posyandu). While The Ministry of Health continues to make healthcare policies, it is proven to be onerous to monitor each province’s implementation regarding policies. Hence, difficulties arise to reach equal healthcare standards among the provinces. These difficulties surrounds the availability,

accessibility, adequacy, and the affordability of healthcare. In some remote areas, the most proximate community healthcare centre is kilometers away and considering Indonesia’s doctor-patient ratio of 1:5000, it has been arduous for the society living in the area to access healthcare. Furthermore, there is a large discrepancy between urban and rural areas which translates to shortcomings of medical appliances and medical professionals. Some rural areas doesn’t even have an ultrasound device. With the shortage of medical prowess and technology in these areas, the health of the society especially the elderly are often neglected. For the elderly, the difficulty in accessing the healthcare centres are doubled due to less physical endurance. Hence, the expected numbers of mortality and morbidity in these areas are high.

In accordance to the advancement of age, an individual’s working capacity becomes diminished and pension is inevitable. In many developed countries, the pension wage is enough to support basic needs of the elderly. Sweden had spent approximately 13% of its GDP on elderly care and it was projected to increase annually. In contrast, the pension wage for the elderly in Indonesia is hardly sufficient, amounting only 0.49% of the GDP based on a 2009 survey. Only 77.5% of Indonesians receives pension wage and they derive from civil and military workers. While private sectors also hand out pension wages, they only cover 14% of their employees. With the upcoming Silver Tsunami, this amount of GDP will not be enough for the elderly to afford their basic needs without the help of family members.

Ensuing the globalization surge in the year 2000, there has been increasing demand of working hours and higher economic needs. This forces family members to spend more time on working and have shifted their care to the elderly from personal contact to solely financial support. Hence, the elderly are at risk of being left alone to care for themselves. Currently, there has only been 278 nursing homes accounted for by the year 2011 with an average capacity of 70 persons. The majority of these nursing homes are located in urban areas and don’t reach out to rural areas. If we were to assume that every nursing home utilize its full capacity, they can only care for approximately 20.000 elderly (0.625% of the total elderly population).

Both the impaired healthcare system in Indonesia and the lack of personal support from family members set the elderly in a course to being physically and mentally debilitated. If this continues on until the predicted Silver Tsunami hit, Indonesia will face unsurmountable challenges ahead. We have a 30 year window period to make new healthcare policies and/or change the current policy to provide better health service to the elderly.

After pondering the elderly healthcare system in Indonesia, we propose a community-based elderly healthcare system. We base this system by observing that a centralized policy will not suffice due to the geographical difficulties faced. Hence, by making a policy that can be implemented by each community, we can reach a much larger society and pay more attention to the elderly living in the rural areas. The inaccessibility of primary healthcare centres becomes problematic because the elderly seeks them only when they feel unwell. Moreover, they tend to utilize traditional and alternative medicines first before finally complying to go to the doctor. Hence, the medical problems that reach primary healthcare centres are usually difficult to diagnose due to the lack of medical appliances and lack of expertise. To counter this, we will create a community which members constitute the entire elderly population in a kelurahan (the same level as an urban village). Currently, the total amount of kelurahan in Indonesia is 75.052, which meant that we will make the same number of elderly communities.

Apart from the elderly, these communities will consist of at least one individual with medical knowledge (either a doctor or a nurse) as well as volunteers willing to take part in the care of the elderly.

Due to the high doctor-patient ratio in Indonesia, we believe that we should make use of every resource regarding medical profession. That said, it becomes compulsory for nurses to take part in these communities when no doctors are available. To further enhance the availability of medical professionals in the system, first year doctors (fresh graduates) in Indonesia should spend at least 1 year to serve these communities. This will help greatly to the availability of doctors in every community considering that in

Indonesia there are approximately 10.000 students entering medical school each year. These medical professionals are going to teach volunteers so that the community will be self-sustaining in the long run.

Through the community-based care, the elderly will be able to feel comfortable due to the high exposure to social interactions with their own peers. Social interactions in the elderly are essential in reducing the risk of dementia and depression, one of the highest morbidity in the elderly. The system also prevents the elderly from having a sedentary lifestyle, simply by them partaking in the community activities scheduled. The medical professionals in charge of each community will conduct routine checkups (at least once a month) to ensure early diagnosis of diseases. Early diagnosis will serve as a method to screen individuals that needs further evaluation and hence can be transported to the nearest hospital or healthcare centre. This system creates a setting in which the elderly no longer need to put big efforts to seek healthcare service. The healthcare service will come to the elderly itself. Furthermore, the community will also host routine exercise programs to ensure the physical fitness of the community.

These exercise programs are also intended to reduce the risks of cardiovascular diseases and hyperlipidemia prominent in the elderly population.

While this self-sustaining community is set on the course to improve social, physical, emotional and mental well-being in the elderly, the system is not at all perfect. The system requires full coordination from the central government right down to the head of the kelurahan. This in itself requires a lot of bureaucracy and needs strenuous efforts. Supervision of policies are often obscure in Indonesia, which adds to a difficulty in ensuring the communities will work out like it should be. However, due to the unique Indonesian population pyramid, we have a window of at least 30 years to modify and perfect the system. Moreover, more GDP should be allocated to healthcare in the years to come. This is due to the stability of Indonesia’s economy in the recent years. The increase in GDP allocation will support more elderly communities in the future and could even construct new healthcare centres and hospitals in rural areas.

All in all, the elderly community healthcare system is a great way to ensure the health of the elderly population while in the same instance taking into consideration the geography, economy and decentralization policy in Indonesia. Morbidity rates regarding mental diseases, cardiovascular diseases and even neoplasms can be reduced by implementing early diagnosis in this community-based system.

While our proposal hasn’t been up to par compared to the policies of the developed nations, we believe that this system is the best fit for the largest developing archipelago in the world. $ $ $ $ $ $ $ $ $ $

REFERENCES$ 1. Turun, jumlah penduduk miskin capai 27,7 juta orang - Kompas.com [Internet]. [cited 2015 Mar 15]. Available from: http://bisniskeuangan.kompas.com/read/2015/01/03/070700226/Turun.Jumlah.Penduduk.Miskin.

Capai.27.7.Juta.Orang 2. Wiseman M, Y!as M. The Canadian safety net for the elderly [Internet]. [cited 2015 Mar 15].

Available from: http://www.ssa.gov/policy/docs/ssb/v68n2/v68n2p53.pdf 3. Appleby J. Spending on health and social care over the next 50 years: why think long term?

London: The King’s Fund; 2013. 55 p.

4. Revitalisasi optimal puskesmas [Internet]. [cited 2015 Mar 15]. Available from: http://www.jamsosindonesia.com/cetak/print_externallink/4973 5. Many hospital deaths due to poor sanitation: Health Minister - The Jakarta Globe [Internet]. [cited 2015 Mar 15]. Available from: http://thejakartaglobe.beritasatu.com/archive/many-hospitaldeaths-due-to-poor-sanitation-health-minister/ 6. Shrestha J. Evaluation of access to primary healthcare: a case study of Yogyakarta, Indonesia [Internet]. International Institute for Geo-Information Science and Earth Observation Netherlands; Available from: http://www.itc.nl/library/papers_2010/msc/upm/shrestha.pdf 7. Data and statistics about pensions and aging in Asia | Asian Development Bank [Internet]. [cited 2015 Mar 15]. Available from: http://www.adb.org/features/numbers-asias-looming-pension-crisis 8. Challenging opportunity for aging population | The Jakarta Post [Internet]. [cited 2015 Mar 15].

Available from: http://www.thejakartapost.com/news/2011/07/02/challenging-opportunity-agingpopulation.html 9. Biaya Kesehatan Mahal: PPnBM Peralatan Kesehatan Harus Dihapus [Internet]. [cited 2015 Mar 15]. Available from: http://www.kpmak-ugm.org/news/bpjs-update/619-mahalnya-biayakesehatan-ppnbm-peralatan-kesehatan-harsu-dihapus.html 10. BBC Indonesia - Indonesia - Hanya sekitar 10% penduduk Indonesia punya pensiun [Internet]. [cited 2015 Mar 15]. Available from: http://www.bbc.co.uk/indonesia/berita_indonesia/2012/09/120925_asiapensiun 11. Chomik R, MacLennan M. Aged care in Australia: part I - policy, demand, and funding [Internet]. [cited 2015 Mar 15]. Available from: http://www.cepar.edu.au/media/127442/aged_care_in_australia_-_part_i_-_web_version_fin.pdf 12. Remain Socially Active | Alzheimer’s Association [Internet]. [cited 2015 Mar 15]. Available from: http://www.alz.org/we_can_help_remain_socially_active.asp

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Original Article YOUTH REVOLUTION TO CHANGE THE INEQUALITIES OF ELDERLY LIFE QUALITIES AlvianGunawan1, Erika Indrajaya1, Felix Hindarto1, KirtiAnindita1, Quinta Febrianti1, Robert1 1

Faculty of Medicine,Atma Jaya Catholic University of Indonesia

I. OUR NATION’S PROBLEMS ARE OUR PROBLEMS Nowadays, our generation is in a condition where every country is competing to advance their country by improving their technology and infrastructure in every aspect, which consists of social, economics and politics. Do you realize that there is a huge calamity, which is slowly surging our country, not only developing countries but also developed countries? Silver Tsunami, this phenomenon is an occurrence of the increase in the number of elderly who can carry a variety of negative effects if there is no focus from the government to provide a solution to this incident.

Indonesia, as one of the developing countries in Southeast Asia, according to Central Bureau of Statistics Indonesia, in 2000 the life expectancy in Indonesia is 64.5 years with 7.18% of population percentage, in 2011 there was an increase in the life expectancy of 5.25 years (69.65) with 7.58% of population percentage. The problem is not on the quantity of the increase, but the quality of life of the elders. (1)

Has Indonesia constructed a policy to give prosperity to the elders? The answer is yes, we have.It is written in Republic of Indonesia Constitution No. 13 in 1998 about the welfare of elderly and also in Republic of Indonesia government’s regulation No. 43 in 2004 about the Implementation of Improving Elderly Welfare, which consists of religion service, health field in geriatric or gerontology, public or particular facilities, and identity card which is valid throughout their life. Have those policies performed well enough with the other supporting regulations? The answer is no, not yet. (2) (3)

The point of our country’s current problem is that the government has already provided the policies to support the quality of life of the elders, but is still lacking in the realization part. However, this task is not entirely delegated to the government but we, as the future generation, need to make a revolution! Don’t just be silent and criticize the government only with words; together make a change with the government to actualize the welfare of the elderly. Remember that each youth will be an elderly, and with tackling the problem of the elderly from now on, we can improve the elderly’s quality of life today and in the future for our own good and also for the next generation.

II. WHAT SHOULD WE DO?

Active Cure and Care Center Every state, including Indonesia, surely has hospitals or other health services, which aim to improve health and also to heal the society including the elderly, so are the nursing homes as a place to give the elderly care and treatment. But do you realize that a good quality of life for the elderly is not only determined by the cure only but also the care and affection that they received?

It is obvious that we have seen that there is a social facility for the elderly that is not only giving them cure, but also provide a protection in the form of care and affection. In Indonesia, these kind of places have been formed, either private or government’s properties. Nevertheless, the problem is not only for small scale, such as elderly, but also whether the program and the treatment have been fulfilled in accordance with the values to be achieved and continue. There is no point if the amount of these social places is big enough, but no cooperation to build the quality of the elderly in Indonesia, which has been spread widely in a large scale.

We have to look at the elderly as a social being who needs some activities and also interactions with other individuals. This is where the change that we build; a value that can touch every individual of the elderly that they belong in the society, in hopes that they will realize that they are not alone! As future doctors, we need to work together to improve health, not only physically but also psychologically.

We know that with the absence of a social life, it will bring the mental condition of the elderly into depression. Not only because of a diseasebut also because of the lack of quality in their life. The increase in depression may lead to suicide, and this will add more problems in our state – an increase in mortality, while the rate of birth is constant – plus the countries that have developed have a workaholic society that tend to has no interest in continuing their descent. Because of this, the government needs to establish a real and active place for the elderly, where includes the value of cure and also care. With the realization of this, the quality of life of the elderly will also be more meaningful.

As citizens, we youth generation – and also the main subject in the progress of our state’s development – need to conduct a mental revolution. Too many youth generation are insensitive and ignorant about this condition. This is a cultural decline that is embraced by the nations in East Asia, which as we all know, put manners first. Although the health workforce can only hold the cure system, the care system is a value that can be applied to all citizens without a single exception. By conducting a revolution to evoke the spirit of the youth, we hope that in the future, Indonesia and other countries will have future leaders and generations with caring minds. Silver Tsunami, which is an increase in the number of the elderly, should never be feared anymore if only the youth are the ones who care enough to take advantage to improve the quality of our life together.

Complete Health Care System Realization A complete health care system consists of promotive, preventive, curative, and rehabilitative measures. These four elements act and correspond with one another to achieve a complete healthcare system. One of the problems in improving the health quality of the elderly in the Silver Tsunami era is too focus towards the incomplete and halfhearted healthcare. The strategy that the government used is focusing on the recovery of the subject at that time, not the long-term improvement of the quality of life that in fact can reduce morbidity rate. Why does it happen? The fact is, the education in Indonesia is not equally distributed and this problem hasn't been well solved for a long time. The elderly population from the previous generation received very little knowledge about a healthy lifestyle. Furthermore, the environment where they live doesn't support a healthy lifestyle.

Even the elderly population's capability to understand some educational courses is low. We can't keep it that way. We need some promotive actions like teaching and giving examples how a healthy and active lifestyle should be. Active means every elderly should take part in activities like workouts and arts to spend time and interact with nature. A healthy lifestyle is a state where every elderly is taught to be able to organize their own life, for example, a healthy diet that is beneficial to their own health so that the primary caregiver is the elderly themselves, and us as the secondary caregiver constantly providing promotive activities. In fact, this effort has already been done, but the government needs to expand their programs. Also, it needs us to go hand in hand and help them to make itcome true.

There is a condition of elderly in rural areas that demands them to work in a retiring age to sponsor their families. This condition makes them susceptible to sickness because their bodies are not as fit as they used to be. The government needs to do something about this problem through preventive measures. Preventive means that focusing on the prevention of the health problems. For example, we need to focus on the economics of our country, Indonesia. There is a strong correlation between the economic policy and the coming generations. What we can observe right now is that the income that is given from the governmental or private bodies is not stable. The ratio between the low-class workers and office workers are too high. From the business side, maybe it is a good strategy to have it that way, but from humanity, it is a problem that needs to be solved by the government to create an equal welfare.

It is known that the income generated by foreign workers from developed countries in our country is very high compared to that generated by ours. This is a huge question if our country really wants to be built better. The income that is generated should be equal or lower for foreign workers. Let us discuss it together. If the quantity of the workers from our country is too big, it will have a big impact when a worker has reached his retiring age. We all often hear the saying, “The rich gets richer, and the poor gets poorer�. This condition takes them to a state where they wouldn't be able to change their life until they get older. This will take effects such as the rise of the quantity of the elderly people, unstable income, poverty, and so on. From this statement, the government must stop these negativities by having a change that supports our own people and brings equal welfare in our country, so that problems like Silver Tsunami can be faced positively and the quality of life of the elderly people can be improved.

The next revolution is the curative and rehabilitative actions that are intended to improve the quality of life of elderly in terms of physical and mental health. This stage depends on the quantity of human resources and the focus of the development in medical technology and medical care. We need to understand that it is not only important to provide a good service, but also a follow up for the treatments given. The high quantity of elderly people needs that service but, will it end after the treatments given, or will the healthcare providers follow them up? This is a weakness that indirectly alleviates their sickness, because there are passive and active elders. If they are active, they can make a change for their own good.

Those who are passive mean they have disabilities ranging from physical to mental disabilities.

Rehabilitative measure needs to be done for these passive elders. Government needs to accommodate them with the principles that have been described above. All in all, the rise in quantity of elders that we call the Silver Tsunami has already been happening. This is the time for us as youth generation to not only stand still, but by working together with the government, we can find a way and make a revolution for the youth in improving the quality of the elders in the future. Because we are the people of tomorrow and we dare to care. Together we can find a solution to this geriatric problem. If not us, then who else?

REFERENCES 1.

Abikusno N, Turana Y, Santika A. Gambaran Kesehatan Lanjut Usia di Indonesia. Kementrian Kesehatan RepublikIndonesia.

2.

Undang – Undang Republik Indonesia Nomor 13 Tahun 1998 tentangKesejahteraan Lanjut Usia.

3.

PeraturanPemerintahRepublik Indonesia Nomor 43 Tahun 2004 tentang Pelaksanaan Upaya Peningkatan Kesejahteraan Sosial LanjutUsia. $

Original Article An Ageing Society, Are We Ready? A Review of Transportation Infrastructure for Elderly Robby Hertanto1, Sheilla Khonada2 1

Faculty of Medicine, University of Indonesia

2

Faculty of MedicineTarumanagara University

Osteoarthritis (OA) is one of the most disabling diseases, ranked fourth worldwide, and affects more than 80% of those aged over 75 years old.1,2 It occurs when the cartilage covering the joint wears down, and its cause could be either idiopathic or secondary (i.e. trauma, inflammation, genetics, etc.). Risk factors for OA include age, race, high body mass index (BMI), and post-menopause woman due to lack of estrogen.3 OA is worse in the joints supporting the body weight, such as the knee (articulatio genu) and hips (coxae). The degradation process is often very painful, and is able to immobilize people due to the unpleasant experience. Unfortunately, even until this paper is written, there is no available curative treatment, except for knee or hip replacement at the late stage of OA. The current approach for OA involves symptomatic relieve using NSAIDs or steroids if indicated. Another type of drugs claimed to be able to modify the structures (glucosamine sulphate, chondroitin sulphate, and hydrochloride) are yet to be proven effective.4 In conclusion, the best approach against OA is to prevent and slow down the progression of the disease by reducing the degradation progress. This could be achieved with an active lifestyle and lowering the impact on the supporting joints, especially people with higher BMI5. Ironically, this is hard to do, since doing the activity itself could be a painful experience for the elders. Moving towards the ageing society, OA will be a major threat to be addressed and prevented.

Indonesia is one of the countries that need to put attention to OA prevention, since the currently high population of productive will soon move into the elderly section, expecting 223% of elderly population increase in 2040. However, there is little (if better than none) effort from the government to prevent the problems that may emerge from the elderly booming phenomenon. The phenomenon will introduce two kind of elderly: (1) independent childless elderly, which will increase in number in the economically emerging country; or (2) dependent elderly, mostly taken care of by his or her family.6 The first kind of elderly may or may not have an attendant to take care of them, therefore they would need to do daily activities and go outside. On the other hand, the dependent elderly may sound like they do not need extra care from the government; yet, the working hour and increasing number of dual-income household will render them alone in the daylight.7 This condition will lead to a boring, sedentary, unhealthy lifestyle, in contrast to the prevention of OA. In order to prevent this, the community has built the so-called community centers that gather the elderly to do activities together. The approach is proven to be effective in developed countries, yet it does not apply so in Indonesia. One of the reasons of this ineffectiveness is the failure of our government to build a decent transportation infrastructure for all ages. This condition leads to unpleasant experiences, often stressful and deterrent, for both the first and the second kind of elderly. The first kind of elderly could not do daily activity with ease, meanwhile the second ones will be lazy to go outside, preferring to be driven around by family members which are absent during daylight.

This condition leads those elderly without OA into a sedentary lifestyle, which could lead to OA, or giving a deterrent experience for those who have developed OA. Looking at the condition, an urgent change is needed upon the current regulation to build a better transportation system that is able to mobilize people, young or old, OA or not, with ease and comfort, hoping that they will live more active and healthy lifestyle benefiting their condition.

The transportation system is basically composed of the infrastructures and the vehicles. We would like, in our paper, to highlight the importance of the correct measurements and construction of public transportations, especially in Jakarta, capital city of Indonesia, in order to produce a more active generation of elderly and increase the country’s productivity and life quality. We choose Jakarta because it is the most populated area in Indonesia, sheltering 10 million people in 661 km2 area of land.8 This

infers to two conclusions: (1) the elderly will have no people to support them, drive them around, or take care of them to have a more active lifestyle, which the current public infrastructure is unable to attend; and (2) there will be increasing number of elderly in 20-30 years of time, since the productives will soon to be elders.

There are mainly five most important emerging and traditional transportation components that we would like to highlight in Jakarta. These five will tickle your conscience and make you laugh a little, because even though millions of people use them everyday, they are often neglected by the government. They are sidewalks, zebra crossing, crossing bridges, Transjakarta buses, and commuter trains. These infrastructures are regulated in: 1. Peraturan Menteri Pekerjaan Umum No. 19/PRT/M/2011 (translation: Minister of Public Works Regulation No. 19/PRT/M/2011), will be addressed as reference (a), about sidewalks and crossing bridges.9 2. Keputusan Menteri Perhubungan No. KM 65 Tahun 1993 (translation: Minister of Transportation Decree No. KM 65 Year 1993), will be addressed as reference (b), about zebra crossing.10 3. Peraturan Gubernur Provinsi Daerah Khusus Ibukota Jakarta No. 35 Tahun 2014 (translation: Governor of Capital City District of Jakarta Regulation No. 35 Year 2014), will be addressed as reference (c), about Transjakarta buses.11 4. Peraturan Menteri Perhubungan No. PM. 29 Tahun 2011 (translation: Minister of Transportation Regulation No. PM. 29 Tahun 2011), will be addressed as reference (d), about commuter lines.12 The regulations will be analyzed in depth with holistic approach from the aspect of architecture and basic biomechanics before addressed for a change.

First, the sidewalks are meant to be the main infrastructure for those going by foot. It must be designed to provide safety and comfort for pedestrians, young or old, traveling the streets with ease. The sidewalks in Jakarta are regulated with the reference (a), with example in chapter 2, part 6, article 16, section 3: Di kedua sisi jalur lalu lintas harus disediakan trotoar sebagai fasilitas bagi pejalan kaki dan petugas pemelihara dengan lebar paling sedikit 0,5 (nol koma lima) meter.

(The side of the streets must be allocated for sidewalks as a facility for pedestrians and maintenance worker with 0.5 (zero point five) meter of minimum width.)

Technically, this sidewalk regulation is quite irrational and insufficient for actual use. There are several reasons: (1) the size of 0.5 meter is too small for even an Asian adult, whose shoulder breadth ranges from 0.4 until 0.45 meter13 and it does not satisfy the need for safe gap between shoulder and street, especially people with broader shoulder width; (2) the size of 0.5 meter is even smaller than the average size of wheelchair (0.6-0.8 m); (3) the size of 0.5 meter does not provide enough space for people to walk side by side on opposite directions, or overtake in hurry or emergency. Two examples of good regulation that we would like to refer to and offer as a solution are the United States Access Board’s regulation of public sidewalks and the old Indonesian regulation dated back in 1963. The United States’ regulation puts a minimum of 1.5 meter for areas of free spaces, taking account of a condition with two people or even two wheelchairs, although it might be a little cramped.14 Additionally, Keputusan Menteri Perhubungan No. 65 Tahun 1963 (translation: Minister of Transportation Decree No. 65 Year 1963) offers a wide range of width, from 2-4 meter, depending on the place and number of people expected to walk.10 We would like to recommend that we use either the United States Access Board’s regulation for simplicity or the old regulation which is more complicated but with a broader sidewalk.

Moving from technical, the sidewalk must be at least implemented, kept on a good shape and from being misused. However, the sidewalks with the current regulation are not even implemented in uniform on all roads, leaving several places without sidewalks. Some are also not being maintained on the best level possible, leaving them cracked or even broken down; and the usage to them have been severely transgressed and misused. The first example of this misuse are street food sellers and merchants. Street food sellers and merchants tend to gather around the sidewalks, build their own shelter, and inhabit the narrow piece of path almost permanently for themselves without authorization. Even worse, the people

inhabiting it refuse to be moved to another site because it is their major income, from the people passing by and buying their goods. This forces people to walk outside the pavement, on the streets, and cause danger to themselves. This is especially important in Jakarta because everyday, the mass medias are filled with news of pedestrians being hit by motorcycles or cars, and many people have beared silent witness to one. Can you imagine how elderly should walk on the streets in this situation? Not in any circumstances they can make it to their destinations in peace safely. There should be a sweeping of merchants and street food sellers off the streets, especially the crowded ones, to clear off the sidewalks and used them the way they are created to be. The street sellers should be relocated to a specially provided place, which is aesthetically and functionally better. Collectively, they can also make more money together by selling their goods in one site. Second example is the utility pole construction in the middle of the sidewalks themselves. Utility poles are the poles holding both electricity and phone cables from the source, bringing and distributing them to houses. The building of utility poles in Jakarta are not yet strictly and wisely regulated. Fundamentally, these poles should be made weather-proof, accident-proof, and standing in the clear, away from the activities of the streets. Meanwhile, in Jakarta, these poles can be built in the middle of the sidewalks. The cables are sometimes not firmly attached to the appropriate sites, causing them to dangle downward. These situations undoubtedly reduce the sidewalks’ functionality, and increase the odds of people running into one or getting electrocuted. The government should regulate these seeminglypetty things well, if we wish for elders to travel the streets more safely, easily, and live a happier, healthier lives.

Secondly, zebra crossing or commonly known as zebra cross in Indonesia is a set of stripped white lines on the streets meant to be used by pedestrians to cross over streets safely, without the need to go up and down the staircase. The zebra crossing is regulated in the reference (b), chapter 2, article 3, section 3: Tempat penyeberangan sebagaimana dimaksud dalam ayat (1) huruf b, berupa zebra cross atau dinyatakan dengan marka berupa 2 garis utuh melintang jalur lalu lintas dan/atau berupa rambu perintah yang menyatakan tempat penyeberangan pejalan kaki.

(Crossing which defined by section (1) alphabet b, as in zebra cross or drawn with 2 connected line crossing the road and/or sign that describes a crossing.)

Unfortunately, the decree does not describe how the zebra crossing should be made technically. Ideally, it must be equipped with a crossing light which can be used by crossing people by simply pressing the button. It will turn the traffic light red, which will make cars and motorcycles wait until the pedestrians cross safely during a short period of time. Now, there are funny things about zebra crossings and crossing lights in Jakarta. Some zebra crossings do not even make it to the other end of the road (somehow not donely painted until the other side, or they could be perfectly painted, but instead of streets, they end on fences). Jakarta’s zebra crossings also do not meet safety regulations of public transportation common sense because they are not fluorescent or even easily noticeable from far at night. This will cause both pedestrians and vehicles to fail to spot it in dim light, which will increase the odds of vehicles running into pedestrians on the streets during nightime. What’s even worse is cars and motorcycle drivers in Indonesia have a bad tendency to ignore traffic lights and passing pedestrians. If anything, these zebra crossings will only increase the accident numbers and statistics in Jakarta, if changes are not made for them. The crossing lights are also not always available – even if they are, they are often broken or not functioning. Indonesia should start obeying and caring about little things that mean worlds for the lessstrong group of society. We would like to recommend that (1) zebra crossings should be painted fluorescent and able to glow at dim light, or at least to be bold enough to be easily noticeable; and (2) Crossing lights should also be put to use and made functional. These little changes can impact many elderlies lives, especially the ones not able to afford expensive transportations and rather tend to walk on the streets.

Thirdly is about crossing bridge. A crossing bridge is a bridge that is used to cross the road, functioning like a zebra crossing but with extra efforts, but safer. The new crossing bridges built in Jakarta are often

connected to the Transjakarta bus shelter, which will be explained in the next part. The crossing bridge is regulated under reference (a), part 6, article 26: (3) Jembatan penyeberangan pejalan kaki memiliki lebar paling sedikit 2 (dua) meter dan kelandaian tangga paling besar 20o (dua puluh derajat).

(Crossing bridge should have a minimum width of 2 (two) meters and maximum of 20o (twenty degrees) of inclination.)

(5) Pada bagian tengah tangga jembatan penyeberangan pejalan kaki harus dilengkapi bagian rata yang dapat digunakan sebagai fasilitas untuk kursi roda bagi penyandang cacat.

(The middle section of the crossing bridge must be equipped with a ramp for wheelchairs for difables,) *The crossing bridge must also comply to the minimum height of 5.1 meter, based on reference (a).

Before starting the analysis, it is a must to know several terms: bordess, anthrede and opthrede. Bordess is a flat stop between stairs (usually after 15 steps) for aesthetic and comfort purposes. Anthrede (A) is the height of each staircase and opthrede (O) is the length of each. There are two common rules used for stairs in Indonesia, the first one is [2O+A= 64-66] and the second is using the tangent with 24-45o of inclination. Since Indonesia’s regulation determines 20o as the degree of inclination, we will use the common foot step length of people to determine the ophtrede. The common foot stride length is 0.8-1.2 hip height,15 and Asian’s average is about 80-88 centimeters, or around 64-105 cm (32-52.5 step length).

We will use 32 cm as the lowest number for tangent calculation, which produce 11.6 cm as the result. For calculation, the height of the bridge will be adjusted to 5.3 meter for the stable structure of concrete, based on Indonesian Standard (SNI), which will not be discussed since it has been described clearly. The 5.3 meter then will need around 45 steps and 14.4 meter of length, plus twice a bordess length of [width+10 cm] or around 2.1 meter each, summed up into 45 steps and stretching 18.6 meter horizontally.

However, using the appropriate rules of [2O+A=64-66] or tangent with 24-45o of inclination, each anthrede will be 16-18 cm.16,17 If we took the median anthrede of 17 cm, it will make the total of 30 steps and 7.2 meter horizontally, taking account of one bordess of 2.1 meter. From biomechanical aspects, there has been a study with 8.5 step height and 17 cm step height where the average minimal human locomotory power shows 295 W and 515 W respectively. Dividing the height of 5.3 meter with each and summed it roughly, there will be a difference of 2,339 W total with 17 cm step height, which is more efficient.18 Taking account also on how long of the horizontal length will need to be walked through, the 50% decreased height (or the 20o inclination rule) will make a very big difference on people with OA. The elderly will be able to conserve power and decrease the burden, physically and psychologically, and it will be a huge advantage to keep people active and moving. Hence, we would like to give a recommendation to change the maximum inclination into a range of step height (16-18 cm), and also including the use of bordess as a part of the regulation.

The next item to be analyzed is about the width of the crossing bridge, which is regulated to be minimum 2 meters and at least 3 lanes, consisting of two stairs and a ramp. Taking into account a safe space for stairs that occupies 0.6 meter and the ramp size of 1 meter that is designed for wheelchairs, it will sum into 2.2 meters minimum, but we would like to propose a minimum of 2.5 meters to help the elderly that might need to use helping equipment. The current composition would be too cramped, and does not allow the younger people to go pass through the elderly, which could induce stress to the elderly because of being shouted at, guilty because of being slow, or being bumped by the younger people. For a healthy adult or young adolescent, tripping or stumbling after bumped at may be an unsignificant thing, but to the elderly, it could mean their lives because their bones are so much weaker. A simple trip and fall can cause fractures and permanent immobilizations for them. The objective would be to reduce the stress, psychologically or physically, for those elderly to help them being active and healthy, as a prevention or slowing the degradation from OA. Fourthly is about Transjakarta Buses which are increasingly popular in recent time, mobilizing 4 million people a month.19 The buses operate from 5 a.m. until 11 p.m., and several are operating 24 hours,

circulating between 214 stops in Jakarta with a flat rate, a quarter US Dollar (Rp 3,500.00). This transportation system is regulated under reference (c) with the article 8, section 1: Kesetaraan sebagaimana dimaksud dalam Pasal 3 huruf e merupakan standar minimal yang harus dipenuhi untuk memberikan perlakuan khusus berupa aksesibilitas, prioritas pelayanan dan fasilitas pelayanan bagi pengguna jasa penyandang disabilitas (difable), manusia usia lanjut, anak-anak dan wanita hamil.

(Equality, as described in article 3 alphabet e is the minimum standard that must be met to give special attention in term of accessibility, priority and facility in order to service the difable, elderly, children, and pregnant women) However, the standard is hard to meet since the shelter and the bus is not maintained or regulated clearly.

First, the shelter is usually built connected to the crossing bridge, but it rarely complies to the rules of reference (a). The bridge that connects the crossing bridge and the shelter seldom has any ramp in between and does not meet even the 2-meter criteria. Second, there are many examples of the bus shelter that does not have enough benches or having a far gap between the bus and shelter. The gap itself is sometimes too far, even a healthy adult need to make a little jump to reach the bus. Third, there are very little shelters that provide a special lane for those in special need, even if there is, the operators do not enforce it and the passengers do not take the lane into account. Fourth, the bus itself is not a pleasant experience for adults, moreover the elderly. This condition is caused by the lack of maintenance on the bus, leaving the shock absorber and air conditioner often broken. Fifth, as in the shelter, there is a lack of education on the passengers about the so-called priority seats, which are seats prioritized for those in special need. These five conditions are the reasons, why the Transjakarta Buses system is increasingly popular yet harsh for the elderly, and it makes them lazy to use public transportations, thus preferring to stay at home. In conclusion, we would not like to revise, but to reinforce the rules as stated in the articles to motivate the elderly to go outside, be active and healthy. We would like to propose a ramp construction for all stairs connected to the Transjakarta Bus shelters, reinforce the lane for special needs, reeducate society about priority seat, and also improve a good maintainance of the buses so they will be comfortable and safe.

The last one is the commuter line that is also an increasingly popular public transportation in Jakarta and the surrounding province. This transportation system is regulated under reference (d) which stated a need of facility for elderly or difable in the appendix. This however, is not compliance to the facility provided.

First, the access to the station is often using the stairs, without ramps, bordess, or railings for grips, which is very dangerous and taxing for elderly. Second, there is no available lift in the station that is needed if the elderly or difable is unable to get into another floor because of the ineffective design of stairs. Third, the gap between the electric check in machine is designed for only one person (50-60 cm) and no space for wheelchairs (if somehow they reached the entrance) or even walking crutches. Fourth, there is a high vertical gap between the platform and the train, depending of the platform, it ranges from 20 cm until even another steps (there is a step around 20-30 cm under the train’s door), which is sometimes even harsh for adults. Fifth, even if there is a priority seat designated for the special needs, people tend to forgot and do not prioritize. Hence, we also would like to reinforce the rules as stated in the articles to motivate the elderly to go outside, be active and healthy. We propose a lift and stair restructure to be made, at least to build a railing for each 3 or 4 meter wide of stair to help the elderly; lowering the gap between the platforms, at least to be even with the height of train’s floor; and reinforcing the rules of priority seat into the passengers.

In conclusion, we would like to improve the current infrastructure, as a mean to reduce the incidence of OA in the future and slow the progression of current OA. The improvement of infrastructures could mean a very big difference, since it could raise the motivation to lead an active lifestyle, instead of a sedentary and passive one. An active lifestyle will lead into a slower progression or incidence of OA, lower the BMI of overweight elderly, and suppress the symptoms that might emerge because of OA. In order to improve the condition and motivation of the elderly, we would like to:

1. Revise the current regulation on sidewalks, increasing the width from 0.5 meter, into either 1.5 meter, according to US’ regulation, or 2-4 meter, according to old Indonesian’s regulation dated back to 1965.

2. Reinforce and maintain the condition of sidewalks, free from obstacles.

3. Add a clause into the regulation of zebra crossing, including the visibility of zebra crossing, crossing lights, and reinforcing the regulations.

4. Revise the current regulation on crossing bridges, increasing the inclination into 16-17 cm and the width into 2.5 meter.

5. Reinforce the current regulation on Transjakarta buses and commuter lines, reconstructing the infrastructures connecting to and inside the station or shelter to comply to the special needs.

Hopefully, all of these proposals could lead to a better future for the current and future elderly in our rapidly ageing country.

Reference 1. Arden N, Nevitt M. Osteoarthritis: Epidemiology. Best Practice & Research Clinical Rheumatology.

2006 Feb;20(1):3–25. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16483904 2. Fransen M, Bridgett L, March L, Hoy D, Penserga E, Brooks P. The Epidemiology of Osteoarthritis in Asia. International Journal of Rheumathic Diseases. 2011;14:113-121. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21518309 3. Centers for Disease Control and Prevention. Osteoarthritis [Online]. 2014 [Cited: 16 March 2015].

Available from: http://www.cdc.gov/arthritis/basics/osteoarthritis.htm 4. Wieland HA, Michaelis M, Kirschbaum BJ, Rudolphi KA. Osteoarthritis — an untreatable disease?

Nature Reviews Drug Discovery.

2005 Apr;4(4):331–44.

Available from: http://www.ncbi.nlm.nih.gov/pubmed/15803196 5. Medline Plus. Exercise, Lifestyle, and Your Bones [Online]. 2015 [Cited: 17 March 2015]. Available from: http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000492.htm 6. Kinsella K, He W. An aging world: 2008 [Online]. 2009 Jun [Cited: 16 March 2015]. Available from: http://www.census.gov/prod/2009pubs/p95-09-1.pdf 7. Tjaja RP. Wanita Bekerja dan Implikasi Sosial: Naskah No. 20 [Online]. 2000 Jun [Cited: 16 March 2015]. Available from: http://old.bappenas.go.id/get-file-server/node/8632/ 8. Badan Pusat Statistik. Berita Resmi Statistik BPS 12/02/31/Th.XVII: Komuter DKI Jakarta Tahun 2014 [Online].

2015 Feb 16 [Cited: 16 March 2015].

Available from: http://jakarta.bps.go.id/fileupload/brs/2015_02_16_12_36_47.pdf 9. Berita Negara Republik Indonesia. Peraturan Menteri Pekerjaan Umum No. 19/PRT/M/2011 [Online].

2011 Dec 15 [Cited: 16 March 2015].

Available from: https://pu.go.id/uploads/services/infopublik20130415165931.pdf 10.

Menteri Perhubungan Republik Indonesia. Keputusan Menteri Perhubungan No. KM 65 Tahun 1993 [Online].

1993 Sep 17 [Cited: 16 March 2015].

Available from: http://hubdat.dephub.go.id/km/tahun-1993/124-km-65-tahun-1993/download 11.

Standar Pelayanan Minimal Unit Pengelola Transjakarta- Busway. Peraturan Gubernur Provinsi Daerah Khusus Ibukota Jakarta No. 35 Tahun 2014 [Online]. 2014 [Cited: 17 March 2015]. Available from: http://www.jakarta.go.id/v2/produkhukum/search 12.

Menteri Perhubungan Republik Indonesia. Persyaratan Teknis Bangunan Stasiun Kereta Api: Peraturan Menteri Perhubungan No. PM. 29 Tahun 2011. 2011 [Cited: 17 March 2015]. Available from: http://jdih.dephub.go.id/assets/uudocs/permen/2011/pm._no._29_tahun_2011.pdf 13.

Lin Y-C, Wang M-JJ, Wang EM. The Comparisons of Anthropometric Characteristics among Four Peoples in East Asia. Applied Ergonomics. 2004 Mar;35(2):173–8.

14.

X02 New Construction: Minimum Requirements: X02.1 Public Sidewalks. United States Access Board.

Available from: http://www.access-board.gov/guidelines-and-standards/streetssidewalks/public-rights-of-way/background/access-advisory-committee-final-report/x02-newconstruction-minimum-requirements-x02-1-public-sidewalks 15.

Alexander RM. Bipedal Animals, and Their Differences from Humans. Journal of Anatomy. 2004 May;204(5):321–30. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1571302/ 16.

Herjana J. Teknologi arsitektur III. Jakarta: Universitas Tarumanegara; 2012 17.

Setiadi T. Ilmu Konstruksi Bangunan Gedung. Jakarta: Universitas Tarumanegara; 2012.

18. Spanjaard M, Reeves ND, van Dieen JH, Baltzopoulos V, Maganaris CN. Lower-limb Biomechanics during Stair Descent: Influence of Step-height and Body Mass. Journal of Experimental Biology.

2008 May 1;211(9):1368–75. Available from: http://jeb.biologists.org/content/211/9/1368.full 19. Data Bulanan Jumlah Penumpang Transjakarta.

Available from: http://www.transjakarta.co.id/publikasi.php?q=1pXPwtjR4g==

Original Article Unequally Distributed Geriatric Cares Hardi Hutabarat1, Kevin Gabriel1, Jevonda Edria1, Ruth Angelia1 1

Faculty of Medicine, Indonesia Christian University

Introduction The Silver Tsunami is one of the problems the world is currently facing. Silver Tsunami is a term to define the increase in the number of the elderly with poor quality of life. In all parts of the world, the number of elderly citizens (age 60+) is growing faster than the number of citizens of any other age group.

It is estimated that by 2025 there would be 1,2 billion elderly and in 2050 2 billion (21% of the total population). Around 80% of elderly live in developing countries and the Asia-Pacific region is where the growth of the number elderly is at its peak. Indonesia is one of the Asian countries with one of the fastest growing number of elderly citizens. In the year 2000 there were already 14.4 million elderly in Indonesia(7,18% of total population) and in 2020 it is estimated that that number will double to 28,8 million (11,34% of total population). In 2007 BPS conducted a census, and the data shows that there were 18,96 million elderly (8,42% of total population) comprising of 9,04% female and 7,80% male.

The increase in the number of elderly citizens is primarily due to declining birth rates and rising life expectancy. However, this increase in elderly population is not followed with good quality of health, but is instead followed by the increase of chronic diseases in geriatric patients. The Silver Tsunami does not only involve chronic disease problems, but also takes into account mental health and social health of the elderly. In general, the quality of health of elderly citizens are still low and the percentage of elderly population who has health complaints continues to increase; in 2003 48,95% and in 2007 54,25%. The number of the sick elderly also follows this rising trend; from 28,48% in 2003 to 31,11% in 2005.

This rapid increase in elderly population will, in the future, become a major problem to families, communities and the nation. The economic burden placed by geriatric patients of which families, communities and the nation have to bear will ever continue to increase. It is for this reason, that it is important for every citizen to become aware of this Silver Tsunami and that it must be dealt with seriously. Our concern as citizens is required in the form of involvement to find a solution to this Silver Tsunami, whether it be as individuals, in a group or in organizations. It is not only the developed countries in the West, but China, Japan and Korea have also felt the adverse effects of an ageing population to social life, the economy, and health which even influenced the creation of new political policies to handle these problems.

Content People who are considered to be elderly are those who are at the final stage of the human life cycle, whereas in chapter 1, verse 2, 3 and 4 of UU No. 13 1998 states that the elderly are those who are aged above 60 years (Maryam, dkk 2008). According to general opinion, a person is considered to be elderly if that person is aged 65 or above. Being in an elderly state does not mean that person is diseased or sick, but it simply means that that person is at the next stage, in the life cyle, which is marked by the

gradual decrease in the body’s ability to adapt to the stress in the surrounding environment. Being elderly is a condition marked by failure of the body to maintain balance(homeostasis) in the prescence of physiological stresses. This failure is related to the decreasing ability to survive, as well as increasing sensitivity as an individual (Efendi 2009). The definition for the term ‘elderly’ differs to that of ‘geriatric patient’. Geriatric patients are those patients who are aged 60 years and above (by Indonesia’s standards) with multipathologies resulting from disturbances in physiological and spiritual function, and or social function.

Geratric patients has 5 characteristics in general. First is multipathology, which means that in one patient there is more than one disease present, usually being chronic degenerative in characteristic.

Second is the decrease in functional reserve ability or regeneration which causes most geriatric patients to fail to recover from diseases. Third, the change in signs and symptoms from the classical ones. Fourth is the hindrance of the functional status of geriatric patients, that is the ability to do their daily activities.

Fifth, the tendency of geriatric patients to have nutritional disturbances or poor nutrition. Nowadays, the most common diseases in the elderly are hypertension, diabetes mellitus, cataract, and other diseases that commonly occur due to aging and degeneration of organs in the body.

The increase in the number of elderly will become a burden to society and, eventually the nation since a large amount of funds is required for care of geriatric patients. The appropriate method of action to handle this problem is prevention, that is to maintain the quality of health of the elderly preventing them to become geriatric patients. A number of steps could be done to maintain the good health quality of the elderly. Some measures the government took includes; 1) Increasing the quantity and quality(by training) of health services, specifically for the elderly, in basic health care facilities, 2) To improve the Geriatric Polyclinic sector in hospitals, 3) More health promotion programmes to spread information about health and nutrition, specifically for the elderly.

Despite the measures attempted by the government, as mentioned above, these methods have not been effectively implemented. Geriatric health care is vital to maintain the health quality of the elderly, however it is not evenly distributed between the urban areas as opposed to the rural areas. This inequality is because now there are only 8 Type A and Type B public hospitals which has an integrated geriatric clinic, such as RSUP Ciptomangunkusumo, RSUP Karyadi Semarang, RSUP Sardjito Yogyakarta, RSUP Sanglah Denpasar, RSUP Hasan Sadikin Bandung, RSUP Wahidin Makasar, RSUD Soetomo Surabaya, and RS Mawardi Solo. The rest of the geriatric clinics are in the mental health institutes or mental health hospitals because some of the problems in geriatric patients are related to mental or social well being. In the present, special geriatric care can only be given in only 300 public health centers in Indonesia. This geriatric care gives special elderly care via the concept “Puskesmas Santun Lanjut Usia”. Ideally, all hospitals and health centers should be able to provide special geriatric care via the concept mentioned above, however there are still very few who has a geriatric clinic. Increasing number of the elderly means that there must be enough attention for each of them, so they do not only live a long live but also live a fullfilling one and improve their quality of life. Care and medication of geriatric patients differs to that of other patients, and this must be considered in every hospital in order for each of them to develop an integrated geriatric clinic.

Indonesia ranks as one of the top 5 countries with the largest number of elderly citizens at 18,9 million or 9,6% of the total population. According to Rifaskes 2011, the availability of geriatric clinic is still minimal; only 5% out of all public hospitals has this type of clinic. Most provinces do not have public hospitals with geriatric care provision. 18,9 million people against 8 hospitals and 300 health

centers with geriatric care. From this data, an uneven ratio can be observed and it proves the inadequacy in the availability of geriatric care. This inadequacy is as a result of many constraints. Geriatric care provision is an attempt by the government which arose from recent policies.

The policy that controls the implementation of geriatric care in hospitals is “MINISTRY OF HEALTH OF THE REPUBLIC OF INDONESIA REGULATION NUMBER 79 YEAR 2014”. In this policy, the health care service is divided into 3 groups based on quality of service; from basic level to excellent and planary level, and it also discuss the type of service, equipments, standardised construction of facilities, human labour, etc. But in this policy there is no chapter which makes it obligatory for every hospital to be able to provide geriatric care, and this is the reason for the uneven distribution of geriatric care provision. In conclusion, this policy only controls the technical aspects of geriatric care. Nonetheless, even if there was a chapter which makes geriatric care obligatory, there would still be problems related to funding and there would still be this inequality of distribution. The effects of this policy have not yet been felt in the community due to problems related to time and the lack of coordination in the remote regions of Indonesia. This policy, which was only declared on October 2014, is proof of the government’s tardiness in detecting problems regarding geriatry. Secondly, poor cordination and uneven distribution of facilities for elderly care is an indicator for poor communication between the central government and its brances. Government policies are supposedto create new facilities for elderly care in both rural and urban areas. Even distribution of provision of elderly care is much needed since the frevalence of geriatric patients are greater in urban areas (51,46%) than that in rural areas (38,99). The percentage of the elderly population in rural areas does not differ much from that in the major cities, however the rural areas is still lacking elderly care and is only dependent on small health centers. In conclusion, the government’s geriatric care policy is not yet effective in raising the health standards of the elderly.

Every country has its own policy regarding to the provision of social service for the elderly. The programmes born from those policies has their own uniqueness as they are related to the demographic characteristics and the economic state of a nation. Elderly care in developed countries differ from that in the developing countries. In comparison to other countries, Indonesia is still lacking in terms of elderly care. In the United States programmes like The National Family Caregiver Support Program (NFCSP) are made to cope with the increasing number of the elderly. NFCSP is a program born from the Older Americans Act, a set of regulations for implementing and managing elderly care. This program offers assistance to the family member who takes the role of taking care for the elderly, of which most of them are their own family member (a father, mother, uncle, aunt or other family members). This program is held by the United States government to remind the citizens that domestic care for the elderly is one of the rights of elderly citizens. Approximately 21-23% of households in the United States offer free care (unpaid care) to its family members. This incentive aims to help the caregivers in managing the responsibilities and the burdens in providing elderly care. This attempt by the government proves that the actual application of policies in society requires the participation and the support of other sectors, in this case the government needs to work together with its citizens to maximize the effects of this policy of geriatric care.

A policy has to be supported by many sectors to achieve its target goal. Our opinion is that to maximise the effects of current geriatric policies, a chapter has to be added to make elderly care provision and geriatric clinics a must in all hospitals. This aims to make even the distribution of elderly care between the cities and rural areas. Improving the health quality of the elderly is not entirely the task of the government, but all parties have to participate to solve this problem. The government can work together with private health care providers so that not only the government funded public hospitals have geriatric

care service. So the problem is not that the policy is impaired in any way, however it is the application that has not reached the target level. One reason for the uneven distribution of care is uneven funding between the urban and rural areas. A solution to this problem is so that the government could work with the private health care sector to fund geriatric care provision in all parts of Indonesia. The people in the community could contribute in the fight against this Silver Tsunami by giving support, attention and care to the elderly, similar to what is being done in the United States. Members in the community could help by becoming caregivers in their own familiies or by becoming helpers in nursing homes. So in the meantime, while the government is building the facilities needed for geriatric care, the community could help to fill in the gaps in areas where geriatric care is unavailable. We medical students have a big role to promote information about health to young and middle aged people so that when they become elderly they still have a good quality of health. However, this is not limited to only young and middle age groups, as health promotion can be done to promote health and nutritional information specifically for the elderly.

Conclusion The Silver Tsunami has become one of the world’s issues. Silver Tsunami is a condition where the number of elderly with low quality of life is increasing. The rapid increase in the number of elderly is primarily the result of declining birth rates and the advances in the field of medical science which has increased life expectacy. The increase in the elderly population is not followed with good quality of health, and is instead followed by the increase of chronic diseases in geriatric patients. Rising number of the elderly population will become a burden to society and the country has to provide a large amount of funds to accomodate the overflow of geriatric patients. Some methods can be done to maintain the health quality of the elderly. Some measures the government took includes; 1) Increasing the quantity and quality(by training) of health services, specifically for the elderly, in basic health care facilities, 2) To improve the Geriatric Polyclinic sector in hospitals, 3) More health promotion programmes to spread information about health and nutrition, specifically for the elderly. “MINISTRY OF HEALTH OF THE REPUBLIC OF INDONESIA REGULATION NUMBER 79 YEAR 2014” is Indonesia’s policy that sets the standard for the implementation of geriatric care in hospitals and health centers, however its application in society is not yet maximised. The solution to cope with this issue, is to complete and clarify current standing policies, to work together with other sectors, and for the people in the community to also participate in caring for the elderly and for medical students to become active in promotive and preventive measures which aims to increase the quality of health of the elderly.

References Komnas lansia; http://www.komnaslansia.go.id/; diakses tanggal 05/03/15; pukul 20:00 RSCM; http://www.rscm.co.id/; diakses tanggal 05/03/15; pukul 20:01 Jurnal Medika; http://jurnalmedika.com/edisi-tahun-2013/edisi-no-06-vol-xxxix-2013/576-dariredaksi/1272-pelayanan-kesehatan-bagi-lansia-di-indonesia-belum-sesuai-harapan; diakses tanggal 05/03/15; pukul 20.08 Buletin Lansia, Departemen Kesehatan Republik Indonesia; www.depkes.go.id/download.php?file...lansia.pdf ; diakses tanggal 05/03/15; pukul 20.46

“PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR 79 TAHUN 2014” ; http://www.hukor.depkes.go.id ; diakses tanggal 05/03/15 ; pukul 22:57 Iwan Rusdi, Kebijakan Khusus Lansia, http://ocw.usu.ac.id/course/download/1280000150keperawatan-komunitas/pks_123_slide_kebijakan_khusus_lansia.pdf ; diakses tanggal 05/03/15 ; pukul 23:01

Original Article Be Active Be Healthy Mudia Dwi Ningtyas , Anastasia Basaria1, Kevin Gabriel Anurantha1 , Rizka Mutiara1, Chandrika Najwa Malufti1, Gogma Firmansyah Sirait1, Puti Aisha1 1

1

Faculty of Medicine, Indonesia Christian University

Introduction Indonesia is a country who is entering an era of aging structured population, because from year to year the number of elderly people increases rapidly. According to the result of population census in 2010, it shows that Indonesia is one out of the top five countries with the highest number of elderly in the world that reached to 18,1 million in 2010 or 9,6 % of total population of Indonesiaand is predicted that in 2020 the numbers will reach to 11,34% out of the whole population in Indonesia (28,8 million people). The increasing numbers of elderly people is the success of health program and economy of a country.

It proves that standard of living and health care of elderly people in Indonesia are getting better each year. But in the other hand, it can cause some health problems and social vulnerability due to a lot of neglected elderly. Inappropriate management of the elderly population can cause new problems, considering the fact that in the psychological aspect, the elderly rarely find a suitable environment in society. The elderly population is often considered as a group of people who has a high susceptibility to disease, including those related to mental health, such as depression.

Content Elderly people are the next stage of life in which is marked with decrease of the body’s capability to adapt. According to Indonesian’s laws about commonweal, it is said that if elderly people is a women or men who reached their sixties or above. Aging is not a disease but cannot be denied that there are some changes of physiological functions which cover some physical changes, mentally and decrease of cognitive functions. Physiological disorders can cause lots of other disorders such as depression.

Physiological changes in the elderly usually start right after they retire from work. In Indonesia pension starts at about 55 to 60 years of age. The age for pension in Indonesia does not differ much from those in other South East Asian countries, like Thailand and Malaysia which both have the age of pension at 60 years old. Even though the ideal purpose of pension is so that the elderly could enjoy the time in their old age or for them to have financial security, but in reality pension is usually interpreted very differently. Pension is sometimes defined as the loss of income, job, role in society, status and self worth.

The reaction of a person after they enter their pension period is dependent on their personality. The community and the government have to establish a suitable place or environment and role in society in which the elderly can do activities according to their capabilities. This way, the elderly can regain their sense of self worth as they have a purpose, and they will no longer think of themselves as a burden to society.

Number of elderly can be a term to determine life expectancy of a country, so if there is more prosperity elders can be confirmed life expectancy in that country is high. The large number of prosperous elderly is the result of successful social, economic and health programs that was made and implemented by the government. Life expectancy in Indonesia is 71 years old and if we compare to other Southeast Asia country such as Malaysia with life expectancy 74.04 years old and Thailand with life expectancy 73.83 years old, Indonesia’s life expectancy is low. In comparison to others countries such as Malaysia and Thailand, the programs made by the Indonesian government, which aims to improve the

social well being, economic condition and the health quality of the elderly population (especially those who have entered their pension period), have not yet been very effective.

If we look at Thailand policy for pensioner, we can assume that they made it into three pillars, which is Old Civil Service Scheme and Social Security Fund make up the first pillar or state pension, which is intended to secure the basic needs. The second pillar consists of the Government Pension Fund and the National Saving Fund. The Government Pension Fund (GPF) is a defined contribution pension system for civil servants. The third pillar is a privately-financed personal provision and is voluntary.

Provident Fund is an occupational pension. Unlike normal savings, it is incentivized with tax advantages and can be used as a means of closing pension gaps. In addition, voluntary retirement saving can be made through personal saving plans, including the Retirement Mutual Funds, which is opened for all including the employees not covered by provident funds. In 2012, the government introduces the National Saving Fund (NSF), a new voluntary retirement savings program. It is intended to cover Thai citizens who are not covered by any pension schemes especially the informal workers.

Meanwhile in Malaysia, elderly people is given financial assistance from the Social Welfare Department (SWD) has a financial assistance scheme for the poor older persons especially those without next of Kin. Scheme is called Aid for Older Persons (BOT) in which a monthly allowance of RM 200.00 per person will be given upon approval. Day care centre for elders and home for older persons.

While in Indonesia, the program dedicated to retired employee are pension fund and educational programs like skills training for those who can still do work and activity as normal. But the implementation of these programs for retired employee isn’t evenly distributed in all of Indonesia. Most of these programs can only be found on the big cities and rarely found on small rural areas. Although the numbers of retired employee that lived in rural areas compares vastly to those on the big cities. Aside from the fair distribution of these programs, Indonesian people still hold on to old ideas that retired employee are better off staying at home and rest rather than using their spare time for outdoor activities.

Thus causing most of the retired employee to stay at home rather than joining the program set up by the government in their area.

Solution Indonesia government has made and set up an ordinance of elderly in constitution No. 13 year 1998. That regulation explains in detail the programs to empower the elderly, especially those who can still do their daily activities. In chapter 5 verse 2 it is stated that: “the elderly has the right to social prosperity, and this can be achieved by creating education and training programs, and also by providing health services for the elderly.” Chapter 16 verse 1 states that: “ education and training programs aims to increase the knowledge, skills and gives experience for the elderly.”, whereas in chapter 2 it is stated that: “the educational and training servicesheld by the governement or the community mentioned in verse 1 will be managed by well qualified educational and training institutes,according to current regulations.

This policy is excellent in preventing depression in the elderly, especially in those elderly who have retired, because depression in the elderly usually occurs prior to the start of pension as they no longer have role or activity in society. Depression can even be more severe in those retired elderly who had been the primary bread winner in the family. So it is the duty of the government to think about the education and training for the elderly so they can still be productive in their daily lives. Training is done according to the elderlies’ physical capacity. The government could make a training programme which is both useful and simple for the elderly, such as knitting, sewing, and cooking. Besides providing an alternative activity for the elderly, training and skill development can provide an opportunity for them to socialize with each other. Those who follow the training program can interact with each other, potentially reducing depression.

But in reality, the policies have not yet been effectively applied in society. Ideally the governmental policies are supposed to have an impact to society. Considering that Indonesia is an archipelago in the geographical aspect, it is hoped that training and skill development programs can be evenly distributed in all the regions. However, after further investigations it can be observed that these elderly development programs are only existent in Jakarta, Indonesia’s capital city. Many villages in rural areas are not being given much attention by the government, whereas the number of the elderly population in rural areas are greater than that in urban areas.

Conclusion Based on the statements above, we can conclude that the government’s policies for elderly people are good enough but there are some flaws like the inequality of social services more specifically in the suburbs. So goverment should pay more attention to the elders in country side and schedule routine visits to the elders. It would be best if we, as medical students, would take part in those social services for the elders like routine check up and held seminars about geriatric.

Original Article A Little Place for The Old One Alvin Saputra , Bella Anggi Afisha1, Tioky Sutjonong1 1 Facultyof Medicine, Airlangga University 1

Indonesia is one of the largest country in the World and it’s in the 4th place of the most population after China, USA, and India. It has so many citizens from baby to the elderly. According to the population census on 2012, total of elderly (people with age 60 above) in Indonesia reached 18 million or 7.56% from the total population which 8.20% are women and 6.90% are men. (Badan Pusat Statistik, 2013). The total of elderly in Indonesia is estimated going to increase every year. In fact that, United Nation predicted Indonesia will have elderly population more than 50 million in 2050 along with China, USA, and India too (United Nations, 2009). The increase of the elderly population can cause the increase from the other aspect such as social support and health service for elderly whereas Indonesia itself is still dependent on the aspects of their health care services. But from the chart below, there is a decline in population numbers of elderly in Indonesia from 2008 to 2012. This could be a good or bad news may be due to the family planning programs for just have 2 kids that has been running long ago or maybe indeed many elderly who died as a result of many disease they experienced. But that need to be considered here is, we have to lead the elderly to live independently and preparing adults and adolescents from now to be ready to face their future when they become an elderly too.

Picture: Percentage of Indonesian Population based on Age year 2008, 2009 and 2012.

Source: Susenas year 2008, 2009 and 2012, Badan Pusat Statistik RI

In this modern area, everyone needs money to fulfill their daily needs. So do the elderly, they need money too. The fact that if you grew older, your needs will also increase, so that you even need a lot of money to spend for it. In Indonesia most of them are not have a proper job to fulfill their needs by themself so it makes so many elderly live in poverty. The fundamental problem of elderly now is they do not get a good social service such as health service, education, clothing, food, house, etc. Because of that, the numbers of displaced elderly are improved each year. According to the Badan Pusat Statistik (Central Bureau of Statistics) Indonesia 2006, 15.3% of elderly are displaced, 26.6% elderly near displaced, and 58.1% are not displaced. If we compare with the statistic in 2003, the percentage of displaced elderly are improved. Displaced elderly have no money, asset or savings to fulfill their needs. They live in poverty, that’s why government should give their attention to elderly in Indonesia.

In 2011, 45.42% of elderly in Indonesia is still actively working to earn money so that they can live independently without the help from the others. While 28.69% of them taking care of the household, 1.67% don’t work, and 24.24% do another thing just to fulfill their needs (Survei Angkatan Kerja., 2011).

Most of the Indonesian elderly work as labors and they work without gets salary. Some studies said that the reason why elderly having trouble with their job not because of their body but it is because they have the low education so they can’t grow and just focus on their old one thought alone so they do not develop according to their time of life. Because of low education, most of elderly in Indonesia have such an informal job which do not need any special skill to learn it first and it just get a low salary (WHO., 2001).

In educational aspect, most of elderly in Indonesia are not have a good education. According to Susenas Badan Pusat Statistik (Central Bureau of Statistics) Indonesia 2012, 26.84% of Indonesian elderly never goes to school, while 32.32% goes to primary school, and just about the rest go to the junior high school above. But, 3.29% of elderly went to the university and have a higher education because of their economic condition are made them able to do it.

Based on the fact above we know that economy is one of the aspects in elder’s life but there is an aspect that is more important than economy, it is health aspect because if you are not healthy enough, then you can’t work and earn money too. As we know, when people are getting older their body goes weaker because of the decrease of anatomy structure and physiology of human’s body as the result of aging process. When their body goes weaker they are easily infected by infectious disease such as, tuberculosis, diarrhea, and pneumonia. Beside that, many elderly suffer from degenerative disease such as, diabetes mellitus, hypertension, rheumatic, etc. Morbidity of elderly in Indonesia from 2005 to 2007 is increased by 0.25%. Even though from 2007 to 2009 and 2009 to 2012 are decreased, but the demand of social support and health service are still high. In 2007, many elderly in Jakarta suffer from joint disorder, hypertension, anemia, stomach disease, and cataract. 74.6% in elderly in Jakarta suffer from chronic disease (Hanjayani., 2009). According to Susenas year 2012, many elderly come to the doctor with symptoms such as, cough (17.81%), fever (8.62%), intense headache (9.02%), etc. But, Indonesia Population Census on 2010 shows that ± 18 million elderly suffer from disability. 17.57% of which are hard to see while 12.77% of which are having trouble with their hearing, and 12.51% are hard to walk or move. In fact that all kind of disability can be prevented.

Picture: Percentage of disabilities among elderly 2010 Source: Sensus Penduduk Tahun 2010, Badan Pusat Statistik RI (Population Census 2010, Indonesian Statistic Department)

From the chart above, 12.51% of elderly have some difficulty in walk and move. That is still one of the high prevalence and cause many secondary problems because it can bother many people around the

elderly. Disability of the elderly movement can be caused by osteoarthritis, arthritis rheumatoid, and gout. Those disorders can cause pain, swell, limitation of movement, etc. Because of this disability, elderly can’t do their activities like a normal people, usually elderly rarely move and mostly they stay in a place for a long time because their accessibility has already gone down. After that, they can more easily get caught by another disease because the blood circulation of their body do not run properly. If disability isn’t treated well enough, it can become double burden, which means it takes a long term care and needs high cost that is assured by government or family.

To keep in mind that family is the first social institution to create a good living elderly. If we talk about the culture of western countries, they adapt Nuclear Family concept, which means when their children get married they live with their new husband/wife to make a new family. But in Indonesia we still use the Extended Family concept which means if their children get married they can still live with their parents but mostly their children will live with them. Research by Rawlins and Spencer about elderly said that beside their husband/wife, their daughter is one of the important factors in welfare of elderly. If their daughter leaves them, they are high possibly feels like lost a person who can take care of them (Marini et Hayati., 2012). In Indonesia is quite a lot of elderly people who abandoned by their family because they felt that the elderly will bother them so they put the elderly in a nursing home. Elderly without family or with family but there is no communication between them will feel so lonely. When they feel lonely they can feel so much desperation, impatient boredom, and self-deprecation (Marini et Hayati., 2012). Some research said that feel alone or lonely can cause elderly easily get sick, depressed, suicide, or even death (Ebersole, Hess, et Touhy., 2005). In the other hand, if the income of the family are inadequate, they cannot carry out their function to give protection and service to the elderly. Because of that, the family was forced to leave them so there are so many elderly are living alone without any money or relatives, which can cause they suffer from many physical and mental illness.

Beside the effect from the family, environment around elderly is one of the most important factors that can support their quality of life. Another aspect is important also, but the environmental aspect is an aspect that is easy to implement and have a major impact to the lives of elderly. As an “agents of change” if we want to do it, it can be realized and it’s very useful for them. We know that in their old life, elderly are hard to breath so a good environment, which is low pollution, can supply more oxygen for them.

Beside that, a wide sidewalk can improve the safety of elderly when they walk. A good transportation makes elderly easy to reach their destination without any worries and the important one is a special places for elderly, it will be easier for their accessibility.

Indonesia already has a Law that regulate all about the welfare of elderly. Government already realized some policies that really help elder’s life. Policies for elderly in Indonesia are meant to prolong their life expectancy and productiveness of elderly. The laws that regulate about elder’s problem such as: UU No: 13 tahun 1998 Tentang kesejahteraan lanjut usia

Law No. 13 of 1998 About the welfare of the elderly

Pasal 1 Meningkatkan dan memperkuat peran keluarga dan masyarakat dalam penyelanggaraan pelayanan sosial bagi lansia dengan melibatkan seluruh unsur dan komponen masyarakat termasuk dunia usaha, atas dasar swadaya dan kesetiakawanan sosial sehingga dapat melembaga dan berkesinambungan.

Article 1 Improving and strengthening the role of families and communities in the social services for the elderly by involving all elements and components, including the business community, on the basis of non-governmental and social solidarity that can be institutionalized and sustainable.

Pasal 4 Membangun dan memperluas aksesibilitas bagi kesejahteraan lanjut usia.

Article 4 Build and expand accessibility for the welfare of elderly.

[Online] Source: www.bpkb.go.id/uu/filedownload/2/45/438.bpkb Peraturan Pemerintah No. 43 Tahun 2004

Government Regulation No. 43 of 2004

Pasal 1 (8) Aksesibilitas adalah kemudahan untuk memperoleh dan menggunakan sarana, prasarana dan fasilitas bagi lanjut usia untuk memperlancar mobilitas lanjut usia.

Article 1 (8) Accessibility is the easiness to obtain and use of the facilities, infrastructure and facilities for the elderly to facilitate the mobility of the elderly.

Pasal 8 Article 8 (1) Pelayanan kesehatan dimaksudkan untuk (1) Health services are used to maintain and improve memelihara dan meningkatkan derajat the health status and the elderly ability so the kesehatan dan kemampuan lanjut usia agar physical, mental, and social condition kondisi fisik, mental, dan sosialnya dapat functioning appropriately. berfungsi secara wajar.

(2) The healthcare for the elderly referred to in (2) Pelayan kesehatan bagi lanjut usia paragraph (1) shall be implemented through an sebagaimana dimaksud dalam ayat (1) increase in: dilaksanakan melalui peningkatan: a. counseling and dissemination of elderly a. penyuluhan dan penyebarluasan informasi health information; kesehatan lanjut usia; b. an effort to cure disease (curative), which b. upaya penyembuhan (kuratif), yang expanded in the field of geriatric care / diperluas pada bidang pelayanan gerontologic; geriatric/gerontologik; c. development of aged care agencies who c. pengembangan lembaga perawatan lanjut suffer from chronic and / or terminal usia yang menderita penyakit kronis illness. dan/atau penyakit terminal.

(3) In order to get health care for the elderly who (3) Untuk mendapatkan pelayanan kesehatan bagi can’t afford, given waivers in accordance with lanjut usia yang tiak mampu, diberikan the applicable laws. Have regard to the keringanan biaya sesuai dengan ketentuan provisions of the applicable laws. peraturan perundang-undangan yang berlaku. dengan memperhatikan ketentuan peraturan perundang-undangan yang berlaku.

Pasal 21 sendiri-sendiri maupun bersama-sama sesuai (1) Pemerintah dan masyarakat menyediakan dengan bidang tugasnya masing-masing fasilitas rekreasi dan olah raga khusus kepada lanjut usia dalam bentuk: Article 21 a. penyediaan tempat duduk khusus di tempat (1) The Government and the community provide rekreasi; recreational and specified sports facilities to the b. penyediaan alat bantu lanjut usia di tempat elderly in the form of: rekreasi; a. provision of special seating in recreational c. pemanfaatan taman-taman untuk olah raga; areas; d. penyelenggaraan wisata lanjut usia b. provision of aids elderly in recreational areas; e. penyediaan tempat kebugaran c. use of parks for sports; (2) Ketentuan mengenai penyediaan fasilitas dan d. tourist organizing for elderly rekreasi dan olahraga khusus sebagaimana e. provision of fitness dimaksud dalam ayat (1) diatur lebih lanjut (2) The certainty concerning the provision of oleh Menteri dan Menteri lain, baik secara recreational and specified sports facilities referred to in paragraph (1) shall be made by the Minister

and other Ministers, either individually or jointly in accordance with their respective duties

[Online] Source: http://bpjt.pu.go.id/uploads/files/26/2e686b26b6a291eb7a6c9fb7e9786628.pdf Based on Indonesia Laws above, many Policies has been issued by government such as health and social service. In Indonesia elderly rights has been applied well enough. In health service aspect, many hospitals have applied special facility for elderly such as special car park, special locket, and special chairs for elderly, and many more. But, health service is not the only aspect that important to improve welfare of the elderly. It is proved that the morbidity of elderly decreased in 2012. We are prioritizing more from the accessibility and social aspect because that two aspect are having a profound impact on the lives of the elderly in the future but often forgotten by us. In Indonesia, government has been built places special for elderly but it isn’t optimal yet. Indonesia already has a big sidewalk, but some of the sidewalks are closed or crushed by big tree or closed by people vending. People in Indonesia are still less aware of others rights especially for elderly. If we see, there are still less places for elderly to gather, it’s really not safe for elderly.

In this paper we want to offer a new policy that can improve elderly welfare by at least build an Age-friendly Park in every city in Indonesia first, when it’s done well then we propse that policies to the rest of the world.

Age-friendly Park for elderly can become a place for elderly to do their exercise, social activity, and so on. If we can improve their accessibility and social aspect we can prevent them from illness.

Age-friendly park is a park that is designed specifically to be able to optimize the accessibility of the elderly. Actually, this policies to make these age-friendly park is already available, but less emphasized its implementation so that only a few cities in the world who has this age-friendly park. The impact of the construction of this park is very much older starting from the effects for the elderly themselves and effect for the people who live in the vicinity. With the age-friendly park in the middle of an urban city, it can make the city will be more green and lush, transform into a new recreation areas and free for everyone, can exercise free without having to go to the gym and many more. Effects for the elderly apart from their increased accessibility side, they can also interact with each other, meet new friends, get rid of boredom after a few days stay at home, and can do a bit of exercise and sports are also here.

To build an age-friendly park, it takes some necessary condition that must exist. Starting from: 1. This park space should be an open one and free of air pollution so that the elderly can breathe easily 2. It is an environment that is comfortable and clean and has a green space that contains many kinds of plants 3. Provide plenty of sitting place (resting place) scattered around the park 4. There are special pavement/sidewalk for elderly rather be wide and free of bicycles and pets 5. There is a safe cross-road using a traffic light to cross 6. It is a safe environment with the availability of good roads and comfort 7. The provision of public toilets around the park 8. Provide a walking aid for the elderly so that they are not too tired to do it All of it are some necessary condition that must be had in an age-friendly park, but there is something unique that we find in the age-friendly park from our home town Surabaya, East Java province of Indonesia.

The unique case is a road consist full of rocks that arranged tightly between each other. It turns out that the preparation of this stone has a purpose when people are walking on these rocks by barefoot, according to some studies it may help they are getting lower blood pressure and improving their physical fitness. This is needed for the elderly because walking on rocks by barefoot can be a personal therapy to improve their physical fitness. In addition, along the stone-pressure streets, there are many poles that serves as a handle of hands so that when the elderly feeling a bit tired, it can help them without having to call someone else to help them, and in this age-friendly park is a special line that is made from tiles and used for the elderly who have disabilities so that they are using a wheelchair despite having a limited but they still can enjoy the pleasures

like other normal elderly. All of these things could be a consideration for future age-friendly park development. And these are some photos that show the state of this age-friendly park in Surabaya Source: photo taken by ourself

Besides that, all of the age-friendly park can also be used as a handy place by conducting regular exercise program for the elderly. Gymnastics event here led by an instructor with gymnastic participants were elderly. Held an event like this in order for the health of elderly also remain stretched even though they

are old but it still needs to be done in order to keep their bodies fit and away from diseases. And here are also many voluntary organizations that teach many techniques to maintain the health of the elderly, such as gymnastics tiptoe along with anal stretching should be done as often as possible in order to prevent some common diseases in the future.

And the last is that we as a medical student and agent of change can also contribute to the community and especially the elderly. By doing a little thing we've been able to give a great effect on our environment.

We propose some policies for the medical student all over Indonesia to provide a time to conduct a free health checks to the surrounding community. Here we give an example of doing a bit of history taking, check blood pressure, and fasting blood glucose checks to the elderly who visit the age-friendly park Surabaya on Sunday for free. Hopefully it can be useful to them and make them healthier than ever.

We hope that our policies are acceptable in the entire city in Indonesia and the whole country in the world. We just want to try to promote health and accessibility for the elderly by build an age-friendly park in your city. So, our final message is respect for the elderly around you not only your parents, they still have a long lifespan if you want to take care of them. Respect them because of them too we are now able to live in this world.

Citation: BPS, 2007. Statistik penduduk lanjut usia. Jakarta: Badan Pusat Statistik.

BPS, 2011. Statistik Indonesia 2011.

BPS, 2013. Proyeksi Penduduk Indonesia 2010-2035. Jakarta: Badan Pusat Statistik.

BPS, 2013. Survei Ekonomi Nasional (Susenas) Tahun 2012. Jakarta: Badan Pusat Statistik.

Marini, L., Hayati, S., 2012. Pengaruh Dukungan osial Terhadap Kesepian Pada Lansi DI Perkumpulan Lansia Habibi dan Habibah.

WHO, 2001. Global Health expectancy research among older people. Ageing and Health technical report (1), WHO Kobe Centre.

Original Article “HOME-VISIT COMPREHENSIVE CARE” POLICY : AS THE ANSWER TO DEAL WITH GERIATRIC BARRIERS TO GET HEALTH SERVICES Athaya Febriantyo Purnomo1, Isma Dewi Masithah1, Kaorie Bunga Saviestya1, Nurul Cholifah Lutfiana1, Puspita Widyasari1, Raehani Ajeng1 1

Faculty of Medicine, University of Brawijaya

INTRODUCTION One country needs to focus on elderly problems in order to increase the national health status. In Indonesia, the number of aging people in 1970 (5.3 milions) increases 3 times higher in 2000 (17, 2 millions). Indonesia is one of the country that has many elderly residents, it showed by elderly people percentage from 2008-2012 reach 7% of all residents (depkes, 2013). It’s predicted in 2020, the number and proportion of aging residents in Indonesia are about 28 millions and 9,5%, respectively. The increasing number and proportion of aging people, if not followed by quality improvement of health services tend to be serious social and public health problem. The numbers of already neglected and high risk of neglected aging people in Indonesia are about 3,274,100 and 5,102,800 people, respectively. The aging people who are homeless and begging on street is 9.259 persons, and those suffered from abuse is 10.511 persons.

It shows to us that geriatric problems are also become all of nations’ concern in terms of their wellbeing as an elder. The problematic condition happened whenever they cannot be independent and happy in their golden age which imply to the quality of life of the elderly at the end of the day. If the quality of elder is not good in one country, could be mentioned the health status of that particular nation is not good enough as well.1 Therefore the goal of the nation to overcome geriatric problems are using policies in order to improve elder well-being and health status of a nation as a whole.2 POLICIES APPLIED Ministry of Health in order to increase health status among elderly make an effort through several programs: 1. Enhance health care for elderly in primary health care, especially Community Health Centre (Pusat Kesehatan Masyarakat) and elderly community through Elderly Mannered Community Health Centre (Puskesmas Santun Lanjut Usia) program. This program is primary health care program for elderly which have priority in promotive and preventive aspects beside currative and rehabilitative aspects, that being pro-active, respect, and provide facility and support for elderly. They provide waiting room and examination room special for elderly. They also have skilled health care workers in geriatric unit.3 2. Improvement referral system for elderly through hospital geriatric unit development. Using “TACC” Criteria consists of Time-Age-Complication-Comorbidity if the patients are monitored well and admitted to hospital or primary health care like in Community Health Centre.3 3. Enhance promotive, preventive, curative, evaluative, and rehabilitative program to improve elderly health status. Programs include: 1) promotive program about health behaviour and elderly nutrition; 2) disease and disorder early detection as secondary prevention and do monitoring-evaluating; 3) Mild medication management for elderly 4) Rehabilitative activity, e.g. medical, pshycosocial and educative effort.3

CURRENT HEALTH INFRASTRUCTURE The status quo of Indonesia has provided one of program named Elderly Integrated Health Centre (Pos Pelayanan Terpadu Lanjut Usia). Elderly IHC is primary care in community level which they will be educated about the diseases they may get when they are gathered in one place, usually takes place at Community Health Centre or elder health cadres (Kader Kesehatan Lansia) house.4 Health care provided by Elderly IHC include physical and mental examination recorded in Road-to Healthy Card (Kartu Menuju Sehat) for elder. This card aimed to screen anykind of disease in elderly, exercise improvement, skill development, and religious conseling.5 The goal of this facility is to improve knowledge, and then cues to action, positive behavior, and improve healthy among elderly.4 Thus, it is important for elder to have not only a strong willingness to participate in a routine event done in the IHC, but also capability to reach the IHC to get the services. This policy works well on several people, which still be able to walk and strong enough to stand by their own.

Based on a study of Elderly IHC in Kauman Village, District Polanharjo, obtained information that in January to December 2011 period, from 132 members, the average of elderly absence to the IHC reached 60% of all members.6 As the consequence, health condition of inactive-participation elder on the IHC won’t be able to monitored well meanwhile it is still the government and health providers’ job to do so. Thus, if they have a risk of disease caused by their condition and aging, they will be more susceptible to more fatal or life treathening condition.

FACTORS AFFECTING GERIATRIC PARTICIPATION IN ELDERLY INTEGRATED HEALTH CENTRE Family Support There are links between social support in its various forms and morbidity and mortality. For instance, social integration has been shown to affect mortality from diseases such as diabetes, while belonging support (characterized by interaction with friends, family, and other groups) was a consistent predictor of selfreported disease outcomes (included diabetes, hypertension, arthritis and emphysema) in an elderly residents.7 Mostly elderly didn’t have any support from family members so that their activities become restricted, and elder are more likely to have activity in home rather than joined gathering activity. For example, if family members did not have time to bring elder together to Elderly IHC because the business of each family members and the distances between their home and Elderly IHC location is not easy to reach.

This condition also found if the family members work in the morning, while Elderly IHC conduct its event also in the morning, so that family members can’t bring elderly to the IHC.8 Activity Daily Living Barrier The ADLs are self-care activities that people must accomplish to survive independently. They include bathing, dressing, toileting, transferring, continence and feeding. The sequence is not arbitrary; patients generally lose these skills in that order and they are regained in the reverse order during rehabilitation.9 Patients who cannot perform these tasks usually require caregiver support 12 to 24 hours per day. Other ADLs include communication, grooming, visual capability, walking and the use of the upper extremities.8,9 These movement-inhibiting disorders would be barrier for them to get the health service done in both Elderly IHC or primary health care in Community Health Centre.

Knowledge-Attitude-Perception Health behaviour derived from a belief that oriented toward health. That belief affected by several factors, such as knowledge, attitude, and perception, and not to mention also external factors that support or even against health behaviour.10 Based on the study, mostly elder respondents knowledge about benefit to

participate in Elder IHC are still lacking and also the elder are more likely to be less motivated to be cured so they won’t go for any health care help for their condition no matter what, because they know that they are having “old condition” and it’s their destiny to get those disease because merely they are old and they accepted it the way they got the diseases or disorders.6 This stigma are still occurred in the conservative society nowadays. Meanwhile the goal of the government in terms of health, is make sure the healthy condition for every people living in the nation including geriatric society.1,2 CRITIQUE OF EXISTING POLICIES Difficulties to Reach Primary Health Care New problem occurred when the elderly are not capable enough to walk and reach the place where POSYANDU being held. As the age grows high, many complications happened in the geriatric people, they prone to get degenerative complications, such as Parkinson disease, Osteoporosis, Osteoarthritis, and many other disease that will inhibit their movement.2 These movement-inhibiting disorders would be barrier for them to get the health service done in both Elderly IHC or primary health care in Community Health Centre.

Capability of reaching the health service doesn’t merely determined by the capability of walking and moving to other places. Mental disorders like Alzheimer disease and forgetfullness also become the other barriers of them to get health service, especially for them who don’t have any family member surrounds.

Which is the elderly are also prone to get the mental disorders which leads to forgetfullness, apathetic, stress, and even less motivated to get help.2,8 Low Level Implementation of Comprehensive Geriatric Assessment in Health Care Providers From Indonesian Ministry of Health research about mortality causes in 15 cities at 2011, the biggest proportion of mortality cause of elderly group (55-64 and >65 years old) are Stroke dan Ischaemic Heart Diseases when actually the consequence of dead or fatal morbidities could be prevented earlier.1 The late of health providers to choose to treat is the highlighted problems in this case.

Health care staffs (nurses) are internal customers and their level of satisfaction at work should also be evaluated. In this study, level of satisfaction in acute geriatric care unit was not significantly different from those in the conventional ward. Important thing to be pointed out was that CGA did not lower their level of satisfaction at work, although CGA implementation was not an easy job to do.11 From cost-effective analysis, for each unit of effectiveness produced in CGA group, total cost which must be spent by the patient is lower (Rp 418.199.00 vs. Rp 628.695.00). In CGA group (medical rehabilitationis an integral part of geriatric care), total cost would be lower than those in non-CGA group (medical rehabilitation is not an integral part) [Rp 418.199.00 vs. Rp 431.505.00].11 CGA for the management of geriatric patients is more cost-effective. Geriatric patients managed with CGA has significant shorter length of hospitalization, better functional status at discharge, higher QALD’s, lower re-hospitalization, higher level of satisfaction, without lowering the nurse‘s satisfaction level, nor increasing the cost spent. Impact of health service doesn’t spread its benefits effectively and efficiently for elder people as a whole in order to reach the objectives of geratric quality of life and in the bigger range of main goal is national health status improvement.

GOVERNMENT SOLUTION The ideal condition in order to be effective and efficient, government policy should have minimal barrier toward the target of the policy. Therefore, if the problem is the hard access of the elderly to reach the health providers, such as Elderly Integrated Health Centre, Community Health Centre, or even hospital, which is really beneficial not only for the sake of elderly’s health and quality of life, but also for nation’s health status as a whole, hence the writers would propose the idea of “Home-visit for the geriatry” which gives comprehensive care (from promotive, preventive, curative, evaluative, and rehabilitative) done by the health

providers, such as primary health care physician, nurse, and health providers as the solution for this problematic health care access happened in the status quo. In the principle, if the elder could not bring themselves to the health service, then the government will bring health service to the elderly.

Our review of the results of home visiting programmes shows that home visiting is effective in reducing mortality and admission to long term institutional care among members of the general elderly residents and frail older people who are at risk of adverse outcomes.12 Study by Ayumi Kono, 2011 in Japan, shown that home visit program could improve Activity Daily Living (p=0.0311), Instrumental Activity Daily Living (p=0.0114), and reduce depression (p=0.0001)13. Home visit program also improve functional status (e.g. mobility, p = 0.029).14 In several studies, home visiting programme is also more cost-effective for the elderly compared to health care cost, because the elderly health care cost also provided by the government as long as they are covered by governmental insurance, which is universal health coverage (in Indonesia covered by an governemental organization named BPJS Kesehatan stands for Badan Penyelenggara Jaminan Sosial Kesehatan).15 Home Visit Target Target of this program is determined by the elderly health status. The healthy elderly will be recommended to visit Elderly IHC regularly to get the primary prevention done by health volunteers or cadres, medical students, or other health providers. The unhealthy elderly will classified depend on Activity Daily Living (ADL) score. The elderly with impaired ADL score will receive home visit programs. They have to reconfirm about family support status, if they have good family support they will get home visit from health care volunteer once a month. But if they don’t have good family support they will get home visit from physician once a month and health care volunteer every week. This program will continue until the elderly has improvement in ADL score. Elderly report case will be reported to Elderly IHC and it will send to primary health care to get appropriate management and recording.

Elderly with unimpaired ADL score will not receive home visit programs, but they are must go to the elderly IHC for general/regular check up, so do the healthy elderly. If they don’t go to the elderly IHC, health care workers must be find the reason about. One of the reasons about why elderly doesn’t go to the elderly IDC is they get bored with the activities in the IHC and they also feel that they are healthy so it doesn’t require general/routine check up. Health care workers in the eldery IHC have the task not only to do general examination, but also have the task to improve elderly’s perception about importance of general/regular check up and to give education about healthy elderly living.

Based on Guidelines for Elderly IHC (Pedoman Pelaksanaan Posyandu Lanjut Usia) 2010, for giving optimal health and social care toward elderly in their groups, it is necessary to make a well-planned workplans, right and on-time implementation, and also accurate monitor.16 Several data which is necessary in planning home-visit are: 1. Number of elder residents and Family Card (Kartu Keluarga) in the coverage area (could be coordinated by Chairman of Neighborhood/Citizen (Ketua Rukun Tetangga/Rukun Warga).

2. Socio-economic condition of residents in coverage area.

3. Number of elderly as a whole (per-age groups).

4. Health status of elderly in coverage area.

5. Number of independent elderly.

6. Number of disable elderly.

7. Number of neglected, prone to neglected, and not neglected elderly.

8. Number of productive elderly.

9. Number of elderly who experienced negligence, abused, discrimination, and violence.

Data above could be obtained from District or Village Office (Kantor Kelurahan / Kantor Desa) by the activity of Family Welfare Coaching (Pembinaan Kesejahteraan Keluarga-PKK).

The working mechanism of home-visit proposed to be in several steps below17,18: 1. Recording of daily activities conducted elderly, as well as weighing and height measurement and recorded on a chart of body mass index (BMI). At this stage carried out by cadres and assisted by health workers; 2. The mental status examination. This examination is associated with mental emotional, using the guidance method 2 minutes. Mental status examination conducted for elderly mental process has begun and is on the decline. For example, they complain very forgetful, difficulty in accepting the new terms, also could not stand the pressure, feeling like their mental shape as if asleep in the belief that he was too old to do certain things so that they withdraw from all forms of activities; 3. Measurement of blood pressure using a sphygmomanometer and stethoscope as well as the calculation of the pulse for one minute; 4. Taking of urine and blood samples for simple laboratory examination regularly; 5. Implementation of a referral to the clinic if there are complaints or abnormalities detected on examination; 6. Education could be done either inside or outside the group in accordance to home-visit and health and nutrition counseling toward health problems faced by individuals and/or groups of elderly; 7. Giving Additional Feeding (Pemberian Makanan Tambahan-PMT) as an example of diet counseling with due respect to the elderly toward health and nutrition using food ingredients derived from these areas.

Stakeholders This proposal will take stakeholders in terms of several levels. Medical students here as the initiator and advocator of the proposal. As medical students who aware toward the real problem happened in their respective field of study, in this case is health policy field, therefore students can see the problems happened in the society and become the mediator between society and government. Medical students also could be an executor for primary prevention to educate and entertain the elder people and can act as a health care volunteer so they are not only give solution, but also do their solution. Health care volunteer for home visit should be determined by the head of the IHC. One of many problems about IHC in Indonesia is the lack of health care workers, so in this case the volunteer is necessary19.

In the policy-maker level, there is government who make decision toward the incoming proposal. After mediation process with medical students, then the idea is accepted, government become instructor for the policy which will give instructions to the health workers and its element to be the part of the policy.

As an executor is health workers have duties on particular area to reach every elder house to do mechanism of policy, in terms of promotive, preventive, curative, evaluative, and rehabilitative actions for the elderly. Health workers in here are in terms of family physician, general-physician, primary health care physician (dokter layanan primer), and nurse splitted into several teams who responsible for divided regions of elder people. In order to get each elder people house or living place data, government will instruct the Chairman of Neighborhood/Citizen (Ketua Rukun Tetangga/Rukun Warga) to cooperate with the health workers in charge in that area to give information about the house or living place of each elder residents.

More importantly, our proposal is a supportive hand-in-hand proposal with the governement policy nowadays. Which is Indonesian government has universal-health coverage for all people in the nation15, and will be enforced primary health care physician (dokter layanan primer) and family doctor issues in the next policies applied. Therefore, this proposal is going to be a solutive pathway for geriatric problematic access and supportive mechanism with the government issues and policy at the same time, which brings more benefits to the whole stakeholders for the sake of better national geriatric health provision as the government duty.

REFERENCE 1. Ort, E. P. (2000). Health Systems: Improving Performance. World Health Organization. 78, 1–215.

2. Well, A. (2015). Let ’ s Talk About Aging. Canada: Government of Alberta.

3. Ministry of Health, Republic of Indonesia. (2013). Bulletin Data Window and Health Information.

Available at http://www.depkes.go.id/folder/view/01/structure -publikasi-pusdatin-buletin.html 4. Notoatmodjo. S. (2007). Public Health : Science and Art. Jakarta : Rineka Cipta 5. Azizah Ma’rifatul. (2011). Elderly Nursing. Yogyakarta : Graha Ilmu 6. Suseno D. (2012). Factors Affecting the Elderly liveliness In Elderly IHC Activity Following Kauman In Polanharjo District of Klaten. Available at eprints.ums.ac.id/20530/28/2._NASKAH_PUBLIKASI.pdf 7. Reblin, M. Uchino,B. (2008). Social and Emotional Support and its Implication for Health. Curr Opin Psychiatry. 21(2): 201–205.

8. Indang, T. (2007). Blurred Images Elderly Health Services in Indonesia. Public Health. National Community Health Journal (Jurnal Kesehatan Masyarakat Nasional).1(5):1-2.

9. Better Health Channel. (2015). Physical Activities – Overcoming the Barriers. Available at http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Physical_activity_tips_to_overcome_t he_barriers?open 10. Bernard, J T. (2011). Essentials Of Public Health. USA: Jones and Bartlett Publisher 11. Soejono, CH. (2008). The Impact of Comprehensive Geriatric Assessment (CGA)’Implementation on The Effectiveness and Cost (CEA) of Healthcare in an Acute Geriatric Ward. Acta Med IndonesIndones J Intern Med. 40(1):1-10.

12. Elkan, R., Kendrick, D., Dewey, M., Hewitt, M., Robinson, J.,et al. (2001). Effectiveness of Home Based Support For Older People: Systematic Review And Meta-Analysis. Bmj 2001;323:1–9.

13. Kono, A., Kanaya,Y., Fujita,T., Tsumura, C., Kondo, T., et al. (2012). Effects of a Preventive Home Visit Program in Ambulatory Frail Older People: A Randomized Controlled Trial. J Gerontol A Biol Sci Med Sci. 67A(3):302–309 14. Beck, AM., Kjaer, S., Hansen, BS., Storm,RL., Bitz,C., et al. (2013). Follow-up home visits with registered dietitians have a positive effect on the functional and nutritional status of geriatric medical patients after discharge: a randomized controlled trial. SAGE Journal. 27(6):482.

15. Ministry of Health, Republic of Indonesia. (2015). Universal Health Coverage (Badan Penyelenggara Jaminan Sosial Kesehatan). Available at bpjs-kesehatan.go.id 16. Ministry of Health, Republic of Indonesia. (2010). Guidelines for Elderly IHC (Pedoman Pelaksanaan Posyandu Lanjut Usia) 2010.

Available at http://www.depkes.go.id/folder/view/01/structure-promosi-kesehatan-pedoman-dan-buku.html 17. Ministry of Health, Republic of Indonesia. (2003). Elderly Health Development Guidelines For Health Officer (Pedoman Pembinaan Kesehatan Usia Lanjut Bagi Petugas Kesehatan). Jakarta : Ministry of Health, Republic of Indonesia.

18. Ministry of Health, Republic of Indonesia. (2005). Elderly Health Development Guidelines For Health Officer I (Pedoman Pembinaan Kesehatan Lansia Bagi Petugas Kesehatan I). Jakarta : Ministry of Health, Republic of Indonesia 19. Efnileli (2014). Analysis of Implementation Elderly IHC Program in Cirebon 2013 (Analisis Implementasi Program Posyandu Lansia di Kota Cirebon Tahun 2013). Semarang: Diponegoro University.

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Photography

CURE AND CARE Robert Atma Jaya Catholic University of Indonesia

Indonesia is currently experiencing problems in geriatric healthcare delivery, the overemphasis on cure and forget care. As the healthcare provider, we need to see the patient, asa subject to be treated physically and psychologically, not an object. Elderly patients require more attention to treat them with love rather than fast treatment.

This photo was taken in Papanggo-Jakarta where we do monthly socialtreatment.

Majority of the patients are elderly who didn’t enroll government health social-service program (BPJS). They prefer the voluntary treatment that is given by us to BPJS. They said, government healthcare provider didn't treat them as kind as us.

Cycling in Old Age for Healthy Body and Healthy Relationship VaniaAlodiaTambunan Atma Jaya Catholic University of Indonesia

This photo was taken in Tangerang, Indonesia. This photo shows an elderly man, Hanafi.

Despitehis old age, he still works as security guard and he often rides bicycle. Doing routine exercise, especially regular cycling is good for geriatric’s healthiness, because it can reduces stress and the risk of coronary heart disease by 50%.Another benefit is that cycling need no cost.

It also expanses social opportunities, so they can keep their relationships well. Let’s invite geriatrics tocycling for healthy body and healthy relationship!

Invisible Michael Jonathan Tan Atma Jaya Catholic University of Indonesia

Well-developed and developing countries are still facing health issues, one of them homelessness among the elderly. In 2010 the U.S Census Bureau estimated that there were 44,172 homeless elderly in the U.S alone. Homeless elderly are prone to mental and physical health issues, have lower health rate and higher mortality rates. These elderly incomes have not kept pace with escalating rents, cost of medications and health care in general.

As we can see from the photograph, bystanders were ignoring the plight of this old man.

We as future doctors, should be concerned about their health well-being.

Late Retirement Michael Jonathan Tan Atma Jaya Catholic University of Indonesia

The WHO found that the average man would leave the formal workplace before the age of 64, with expected retirement of 18 years. One study of German assembly line workers found that the average age-productivity of workers increases until age 65. Whether older people would spend more years working will depend on the jobs available to them. In the photograph, this elderly man is working in the informal sector as a street entertainer. As medical students, we should increase the public awareness in providing a safe and suitable workplace, which will increase the ease of older people to work.

ONE HANDS, ONE THOUSAND HOPES Robert Atma Jaya Catholic University of Indonesia

Lack of health workers in Indonesia led to the range of health services didn't cover the entire region, especially in remote areas and slums that far from clinic. These area has a more number of elderly from adults with their children that tend to move to urban areas, this raises geriatric problems that reduce the quality of elderly life.

This photo was taken under the bridge-toll sub-district of Tj.Priok-Jakarta. There is a TB patient in his 50s who didn't get healthcare because no government health services that provide access to the healthcare facility to that place, also far from clinic.

Small Action, Big Impact Ferdy Iskandar Atma Jaya Catholic University of Indonesia

Since human bodies deteriorate as they grow old, the elderly has increased demands for medical services as well as social support services. This picture depicts an abandoned old woman who had a hip surgery that makes her immobile. As the family rarely visits her, simple visit and chat makes her very grateful and may improve her quality of life. As future medical professionals, we may not realize how these simple things are very meaningful for them. It may be one small action for us, but gives them big impacts.

To Correct My Mistake Clarissa Kokon Atma Jaya Catholic University of Indonesia

We all for sure love our parents and will do our best to make them happy and enjoy the rest of their lives. Thereby, sometimes we allow them to do everything they want, eat anything they like, without realizing the bad impact. For example, an old woman was permitted to consume anything and anytime she liked. Gradually, she became obese but it still didn’t make her children worried. Until one day she got a stroke, combined with lung restriction and atrial fibrillation. This time, all of her children got very shocked and started to give her only healthy food.

A Cheerful Heart is a Good Medicine Andreas Billy Dharmala Krida Wacana Christian University

According to WHO, Southeast Asia has 142 million geriatrics and it has been predicted that in 2050 the amount of it will increase three times. In the beginning of 21st century, degenerative and non-communicable diseases will rise.1 In this photo, I would like to urge everyone to take actions to improve the life quality of geriatrics, along with the increasing number of their population. In facts, we do not need to do a lot of things. It is very simple, feeling welcome is the only thing they need. By feeling accepted, they will feel happiness that will cure anything.

Warm hold to Protect Them Andhika Rezky Bahrizal Trisakti University

As the elderly population is now increasing, we need to start supporting them. It can be started in the family, by giving more attention. This photo tells us about the role of the family which is important in protecting elderly. Holding elderly’s hand shows empathy expressions and trust to make them feel safe in facing their functional deteriorations.

With hope, this photo can be a great reminder for people that the frail hands of the elderly would be perfectly supported when it is covered by the warmth of the family as a responsibility in taking care of the elderly.

CARE for Them, Make Them Healthier Faradina Nabila Indrajaya Jenderal Achmad Yani Univeristy

Stroke is the second leading cause of death and many surviving stroke patients are disabled.

It takes away their smiles and laughter. As Medical Student, are we just gonna stand in silence?

We are the ones who would make better change. By visiting their home, giving them helps and sharing our warmth, me, you, families, health care providers and social institutions, we can bring their tender smile and love back. Make their laughter fills the air and make them healthier in their lives.

Does anyone still care?

Tjiauw Erlyn Jayadi Brawijaya University

He’s frail, lonely, homeless, and have nowhere to go. Yes, He’s depressed. Many people nowadays are too busy with their own life. And it ends up with neglecting the elders and not knowing what really happens to them. It makes the conditions even worse. Does anyone know they grieve inside or probably suffer from depression? Does anyone know making a little time for them can make a better life? Does anyone can imagine if it happens to your loved ones or even to you? Does anyone still care?

I Won’t Lose To Be Young Marselina Azalia Mahar Brawijaya University

Almost in every morning this old man turns cycling or just take a leisurely walk to train leg muscles. But what is the meaning of the routine exercise if it is not accompanied by the family members or the people around him? Actually, take a time for him show how we care about his health. Our caring could be a spirit for the elderly to live because from the bottom of his heart, he said “I won’t lose to be young.�

Guide Me, Tender and True Ryka Marina Tadulako University

How does one respond to aging? Aging brings impact throughout the society especially for aged care and carer services. Individuals become more dissimilar as they age, belying any stereotype of aging and experience an abrupt decline in any system or function which is always due to disease and not to “normal aging�.

By providing care and access to education and support, pharmacotherapy and nursing assistance could significantly contribute to better outcomes, slowed disease progression and reduced patient burden.

This photo aims to encourage society’s awareness to reduce stigma and the discrimination of aging and notify the difficulties in geriatric medicine.

The Challenge Ahmad Aulia Rizaly Hasanuddin University

According to WHO, number of people aged 60 years or over is increasing to more than 2 billion in 2050. As it happens, challenge in providing healthcare gets bigger. Unfortunately, the world is not ready. For example, in Indonesia, over 243 Puskesmas (Primary Healthcare Facility) are heavily damaged and not capable of providing service to patients. Even in proper Puskesmas, there are only general physicians with basic equipment that are taking care of geriatric patients.

If we cannot provide proper healthcare today, are we ready to face the challenge in 2050? This is the case I’m portraying in my photograph.

The Neglected Ahmad Aulia Rizaly Hasanuddin University

This is a photograph of a neglected and suspected-to-have-mental-illness elderly in Jalan Sulawesi, Makassar Around 2.8 millions of people aged 60 years or older in Indonesia alone are being neglected by their families. Neglect is one of form of elderly abuse that may lead to depression and more severe complications. To make it even worse, the abuser is oftentimes the family of the elderly himself.

To reduce the number of elderly abuse, the government must act to take care of these 2.8 millions elderlies. It also requires the understanding and care from the families to improve the status quo.

The Successful Ageing Ahmad Aulia Rizaly Hasanuddin University

This is a photograph of an elderly couple on the Hong San Tang Temple in Surabaya during Chinese New Year.

This is one of the real example of Successful Ageing. Successful Ageing is multi dimensional concept that is connected to physical, psychological, and social function of an elder.

As shown in this photograph, the elderlies are showing compassion to each other, which reflects good psychological state. In other words, they both experience Successful Ageing.

If the government can somehow help other elderlies to have Successful Ageing, then embracing The Silver Tsunami will no longer be a problem.

The Working Old Man Ahmad Aulia Rizaly Hasanuddin University

This is the photograph of Daeng Naba, 70 year old man who has been selling newspaper since the last 25 years everyday from 11 am to 9 pm.

In such age, this elder is making himself vulnerable to abuses and infections. The loss of hearing and sight makes the risk even higher. For the young, the moving car in the night may look clear, but for the elder, it may look like a light trail, as shown in photograph, due to the loss of sight. Being active in old age is important, but keeping the elders safe is above everything.