While struggling to contain COVID-19 infections, Indonesia like many in the world is facing a “second pandemic.” As a consequence of the pandemic, many Indonesians are suffering from various forms of psychological issues such as anxiety, depression and trauma. Confounding this is the implementation of social distancing measures, a response to the virus’ quick transmission, that impacts access to health services. It is, thus, important to evaluate the impacts of the COVID-19 pandemic on mental health services in Indonesia and measures to address this issue.
Limited Mental Health Services in Indonesia even Prior to COVID-19
Indonesia possesses 9,831 community health centres, locally known as Puskesmas, spread across 34 provinces. Of which, 92.4% administer mental health programmes. This indicates the Indonesian government’s reliance on them to provide mental health services to the community. Though some form of assistance are rendered to them by the Ministry of Health such as service guidelines and Mental Health and Psychological Support (MHPSS) during the pandemic, it is uncertain how many of these programmes are still running and how effective they are to reach the community. Unfortunately, there is also a lack of in-depth research that evaluates the sustainability of these mental health programmes, especially in areas that are remote and with limited resources.
Key to ensuring the sustainability of such programmes in these community health centres is the availability of resources, namely financial and health personnel. When conducting research in Lombok after it encountered a disaster in 2019, the author found that mental health programmes were not administered in several community health centres because of limited funds. To confound matters, available funds were also redirected to other programmes as mental health was not deemed to be an urgent issue. This was despite the discovery that around 60% of the elderly had developed PTSD; none were treated.
At the national level, the budget for mental health is also insignificant. However, from this meagre sum, 90% of it is allocated for psychiatric hospitals. Additionally, the human resources for mental healthcare are still far from ideal. For every 100,000 citizens, Indonesia only has 0.31 psychiatrists, 0.17 clinical psychologists, and 2.52 trained mental health nurses. Similarly, these numbers are insufficient to serve more than 260 million Indonesians. Furthermore, these specialists are not evenly distributed; most are largely concentrated in Java. With such limited resources, mental health programmes may only be present in name at these community health centres as they lack impactful activities.
With the onset of COVID-19, Indonesia was reported to have experienced a disruption in its mental health services. Globally, disruptions occurred due to reasons including 1) outpatients could not come for their appointments, 2) social restrictions, and 3) a decrease in the number of inpatients due to the cancellation of elective services. Although the types of services that were disrupted and the scale of disruption were not specified, any disruptions could further burden Indonesia’s already fragile mental healthcare system, potentially leading to its breakdown. As an example, the author discovered a psychiatric hospital in a major city in Indonesia was forced to discharge their inpatients earlier due to disruptions. Unfortunately, such disruptions can lead to a knock-on effect of overwhelming Indonesia’s primary healthcare due to a surge in patients. If the primary healthcare was to fail, patients can be left untreated, thus widening the mental health treatment gap in the community.
Tele-psychiatry: An Ideal Replacement of Conventional Mental Health Services Model
Despite the grim mental healthcare situation in Indonesia, there were several innovative strategies to respond to the people’s mental health needs during the pandemic. First, the Indonesian government launched a psychological service programme called Sejiwa, abbreviated from Sehat Jiwa (literally Mentally Healthy) at the end of April 2020, in collaboration with the Indonesian Psychological Association (HIMPSI). This service entails providing psychological assistance via the telephone, thus improving accessibility. A month into its launch, this programme has received nearly 15,000 calls from all over Indonesia, or an average of about 500 callers per day. Some local governments have also provided online-based mental health services. For example in Jakarta through a programme called Mental Health Friend (Sahabat Jiwa) and in West Java with Online Mental Health Consultation (KJOL).
Second, many mental health practitioners have themselves taken the initiative to provide their services via online communication platforms such as WhatsApp, Zoom, and Meets. These individual initiatives help overcome the absence of such services that are supposed to be integrated into healthcare facilities. The community also benefits from the presence of various psychological consulting applications, for example: Getbetter.Id, Riliv, Kalm, Klee and Kariib. These proliferation of online-based service innovations can further reduce the gap in mental health services.
Demonstrating the potential of such innovations, tele- medicine as well as mental and psychosocial helplines were the two most widely used strategies to manage psychiatric issues during the COVID-19 pandemic. Tele-medicine (or tele-psychiatry specifically for mental health) and the helplines were used in about 70% and 67.7% of respondent countries, respectively. This approach is beneficial for the continued provision of healthcare services in this pandemic, considering the highly-contagious nature of the virus. The conventional mental health services model which emphasizes three factors (i.e. providing face-to-face consultations between therapists and patients, conducting consultations in a healthcare faculty, and is provided by specialists) is, thus, becoming less relevant. Continued emphasis on these three factors will only widen the service gap.
Innovations such as tele-psychiatry that were developed in the midst of the COVID-19 pandemic were found to possess three characteristics: 1) offering spatial flexibility, 2) entailing health and social aspects, and 3) leveraging on technology. Therefore, it can be argued that this pandemic is a catalyst for the development of tele-psychiatry in Indonesia. In just one year, many have switched from conventional services to adopting this innovation; a feat difficult to achieve under normal conditions.
Towards Sustainability and Scaling up of Tele-psychiatry
However, it should be noted that this innovation is only at its infancy because of the current pandemic. Also known as imposed service innovation, such innovations are not triggered due to the strength or development of services, otherwise known as extant service innovation. Unfortunately, such innovations can end abruptly if the compelling circumstances no longer exists and / or if there is no further effort for development. Moreover, many tele-psychiatric services are currently provided as a private initiative with minimal facilities. Even though such services are beneficial, they will encounter issues in sustainability and scaling up.
Sustainability and scaling up are important due to two reasons. First, regardless of the pandemic, tele-psychiatry is considered a strategy that has the potential to reduce inequalities in mental health services. It is important to highlight that while developing countries such as Indonesia require such innovations, many have yet to implement it on a large-scale. Second, sustainability would be dependent on factors such as relevance of the innovation. Tele-psychiatry’s relevance can be ensured by using the behaviour of current users during the pandemic as a reference to envision the future market. Such massive developments would thus require political will from the government and support by its stakeholders.
Noteworthily, tele-psychiatry is not a strategy that can be applied in all situations, considering the socio-demographics of Indonesia. However, it is an effective stopgap measure to reduce the gap in mental health services that have been disrupted due to the pandemic. Moreover, with the limitations of mental health specialists, tele-psychiatry can be used to reduce spatial and temporal needs of service delivery. What the provincial governments of Jakarta and West Java are implementing should be adopted by other regions, although ideally this service should be meted out in every district / city while working closely with the community health centres to reach the community at the grassroots. Investment in this field will greatly impact everyone as they can access mental health services wherever they are, even after the pandemic.