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Between the Mental Hospital and Community: A report to canvas opinions, options and actions for residential care in Java

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Abstract

This report is intended as a call for action; it is also an invitation for expert advice and opinions regarding bridging the gap between mental healthcare facilities and the community. We argue that although great strides have been made by the Indonesian government and civil society in ‘scaling-up’ mental healthcare facilities, patients often ‘slip through the gap’ during their reintegration into their families and communities. This gap can and is being filled by community residential care facilities. However, many of these facilities currently in operation are chronically lacking in resources, training and knowledge, and often resort to extreme measures of restraint for their clients, including Pasung or physical restraint. We undertake to provide an accurate description of a private residential care facility in Winong village, Central Java, Indonesia. Through a detailed needs based assessment of the facility and documentation of current and potential supporting structures in the area, we identify that the Winong village facility is responding to current unmet community need.
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Between the Mental Hospital and Community:
A report to canvas opinions, options and actions for residential care in Java
Prepared by Aliza J. Hunt and Dr. Robert Ern Yuan Guth for the Center for Public Mental Health,
Faculty of Psychology, University of Gadjah Mada
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Table of Contents
Figures and graphs ...................................................................................................................... 2
List of graphs ............................................................................................................................ 2
Note on photographs ................................................................................................................ 2
Terms of Reference ..................................................................................................................... 3
Executive Summary ..................................................................................................................... 4
The Problem with Pasung ............................................................................................................ 5
1. Introduction .............................................................................................................................. 8
1.1 Purpose and Scope ............................................................................................................ 8
1.2 Method ............................................................................................................................... 9
2. Background and Findings....................................................................................................... 10
2.1 The Village of Winong....................................................................................................... 10
2.2 Mental Health Care in Indonesia: The Case of Winong..................................................... 11
2.3 An Outstanding Need in Indonesian Mental Healthcare: The Case for Community
Residential Care Facilities ...................................................................................................... 16
2.4 Welcome to the House of Mbah Marsiyo .......................................................................... 19
2.5. Patient Communication, Daily Activities, History of Hospitalisation and Contact with Family
Members ................................................................................................................................ 21
2.6. Food, Water, Medicine and General Facilities ................................................................. 22
2.8 Through Mbah Marsiyo’s Eyes: A History of the Winong Village Facility ........................... 26
3. Discussion and Conclusion .................................................................................................... 29
References ................................................................................................................................ 33
Appendix A National legislation on mental health ................................................................... 36
Appendix B Central Java legislation on Anti Chaining .......................................................... 43
Appendix C BPJS Schedule ................................................................................................. 50
Appendix D Prayer .............................................................................................................. 57
Appendix E Surat, Indemnity Letter for Patient's Admission to the Winong Village Facility .. 58
Appendix F Implementing Team for Central Java ................................................................ 59
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Figures and graphs
List of graphs
Graph 1 Medicated Patients by Month 22
Graph 2 Total Number of Patients by Month and Year 23
Graph 3 Number of Patients Arriving and Leaving by Month and Year 24
Graph 4 Age of Patients 24
Note on photographs
The photographs used in this report were taken by Robert Guth. The faces of residents have been blurred
to obscure their identities. This was done as a courtesy and to conform to academic norms. Mbah
Marsiyo is open to the taking of photographs at the facility. Since he has been given custodial care of the
residents, his permission regarding photography is adequate. However, if any residents did not want to
be photographed, their wishes were respected.
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Terms of Reference
To provide an accurate description of the residential care facility for mentally ill persons in the
village of Winong, Central Java, Indonesia; to identify areas of intervention; barriers to care and
institutional change. We hope that the production of this report will assist us in canvassing expert
recommendations for future intervention and viable funding avenues to pursue. We see this as a
potential test case or pilot study to establish best practice community based residential care in
the Javanese setting.
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Executive Summary
This report is intended as a call for action; it is also an invitation for expert advice and opinions
regarding bridging the gap between mental healthcare facilities and the community. We argue
that although great strides have been made by the Indonesian government and civil society in
‘scaling-up’ mental healthcare facilities, patients often ‘slip through the gap’ during their
reintegration into their families and communities. This gap can and is being filled by community
residential care facilities. However, many of these facilities currently in operation are chronically
lacking in resources, training and knowledge, and often resort to extreme measures of restraint
for their clients, including Pasung or physical restraint. We undertake to provide an accurate
description of a private residential care facility in Winong village, Central Java, Indonesia.
Through a detailed needs based assessment of the facility and documentation of current and
potential supporting structures in the area, we identify that the Winong village facility is
responding to current unmet community need.
However, due to lack of resources, skills and knowledge, the facility fails to provide the basic
hygiene requirements, shelter or adequate nutrition; it also fails to protect the dignity and basic
human rights of its occupants. We realise that the current anti-Pasung legislation in Indonesia
prohibits the chaining of residents as they currently are in the Winong village facility. We also
understand that, simply shutting down the facility or using the law in its punitive capacity would
not solve the current problem. There is a need for residential care facilities to bridge between the
hospital and the community. We believe that this case study offers an opportunity for effective
reform due to the significant will in the current primary care facility that supports the Winong
village facility, as well is the openness to change that we see in the facility’s main caretaker,
Mbah Marsiyo. We hope that this report’s expert readership can offer us ideas and input on
appropriate models of transformation for the Winong village facility. We hope that the Winong
village facility could become a potential test case for best practice community based residential
care in a Javanese setting.
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The Problem with Pasung
“Physical restraint of people with mental illness has a long and inglorious history. Philippe Pinel is
credited with having released the mentally ill from their chains at the Bicêtre and the Salpêtrière
hospitals in Paris at the end of the 18th century. And yet physical restraint has continued in mental
hospitals, in religious shrines and healing sanctuaries, and other settings in many parts of the
world. Such restraint, including shackles, rope, stocks, cages, and being locked in confined spaces,
is applied to men, women and children. The practice seems to have aroused little human rights
concern, except when mentally ill people in chains have died.” (Minas, 2008: 2).
The Indonesian word Pasung translates loosely as physical restraint applied by family or
community members to a person suffering a mental illness. Pasung according to the 2012
Central Java Governor’s legislation aimed at tackling the problem, can come in a number of
forms including “wood stocks, chaining, locking someone in a cage, in a room or banishing them
to the middle of the forest; it can also include other types of forcible restrictions”
. Dealing with the
problem, the document continues, “involves prevention, improving service provision for those
suffering a mental illness, detection and…medication and rehabilitation both from the health and
non-health sectors” (Peraturan Gubernur Jawa Tengah, No. 1, 2012: chapter 1: article 14-15).
See Appendix B for a selected sections of the Governor of Central Java’s Anti-Pasung Legislation.
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The Indonesian Ministry of Health in December 2014 estimated that there were 57 000 cases of
Pasung involving mentally ill persons. Only ten percent of these cases were directly handled (i.e.
freed or medicated; Kemenkes, 2015). Most of the Pasung cases referred to are individual level
cases confined by family members or neighbours, but there are the occasional reports of non-
government organisations practicing mass chaining and subsequently being shutdown by
government teams.
In 1991, the United Nations General Assembly Resolution 46/119 for the protection of persons
with mental illness and the improvement of mental health care declared that "all persons with a
mental illness shall be treated with humanity and respect for the inherent dignity of the human
person." Twenty-five years earlier Indonesia had already legislated that those with a mental
illness must be treated and given medication in a place of treatment (UU No. 23, 1966).
November 11th 1977 saw a Ministerial Letter from the Department of Domestic Affairs
(PEM.29/6/15) be sent to all governors asking them to not allow Pasung for the mentally ill and to
deliver sufferers to the mental hospital. Many years later in 2010 the Indonesian Department of
Health recognised the extent of the Pasung problem and established a Directorate for the
Building of Mental Health who launched the Indonesian Program for Freedom from Pasung.
This was followed by a national level
legislation in 2014 enshrining in law the
rights of the mentally ill (See Appendix
A) and rendering any violence against
persons with a mental illness, including
actions that involved Pasung against the
law (Appendix A: article 86). During this
time a number of the provinces,
including Central Java in 2012 (relevant
to Winong village) enacted their own
Provincial level proceedings to outlaw
Pasung (See Appendix B). Only two of
the thirty-four provinces are not
currently involved in someway in the
anti-Pasung movement. The activities
related to this movement include
national and provincial teams geared
towards case identification and release.
The National Ministry of Health’s
Android Application has a function to
allow community reporting to occur and
cross departmental implementing teams
at the provincial level (Unit Pelaksana
Teknis Dinas or UPTD) specifically
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called Tim Pelaksana Kesehatan Jiwa (TPKJM
) are engaged to map the extent of community
mental health problems more generally, implement short, medium and long-term prevention and
treatment programs for those at risk and carry out monitoring and evaluation using a coordinated
approach led by the Mayor’s office.
Application specifically of the anti-Pasung legislation in the field seems wholly geared towards
restorative rather than punitive action, in which health and government officials are mandated to
act. Family members or caretakers of facilities that use Pasung tend not to be prosecuted.
However, it does occasionally happen. In the case of the Winong village facility
, the main
caretaker Mbah Marsiyo has previously faced legal proceedings after a recovered patient, a
Primary School Teacher who had formally been chained at the facility recovered and decided to
press charges. The national legislation, no 18, 2014 regarding the rights of the mental ill also lists
a number of sanctions for those who fail to act to counteract cases of Pasung. For example, if a
government official does not respond to a case of reported Pasung, he/she can be sent a letter of
warning, which would constitute an incredible loss of face for the individual before his/her
coworkers/constituents. Other actions are more geared towards the overall ‘scaling up’ of the
mental healthcare apparatus.
See Appendix C, subsection 1, points 12 and 13 for details regarding these implementing teams at the
national level. Also see Appendix F Pacific details on these implementing teams and their responsibilities in
Central Java.
Introduced in detail in section 2.4.
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1. Introduction
1.1 Purpose and Scope
This report undertakes a critical needs assessment of a residential care facility for mentally ill in a
private residence located in Winong, Central Java, Indonesia. We begin briefly by locating this
discussion of the Winong facility within its geographical and the local mental healthcare
landscape. This is not intended as a systematic review, but rather offers a preliminary sketch of a
prospective patient’s likely journey through the mental healthcare apparatus - identifying its key
formal and informal institutions and personnel - to assist the reader in understanding the place of
residential care facilities in this specific context. The needs assessment of the facility in Winong
village uses existing data from the area’s Primary Care Facility, in-depth interviews with
associated healthcare workers, the facility’s main caretaker and briefer interviews with families
and patients to outline target areas in need of assistance or intervention. By providing a detailed
description of both the physical and specific cultural context of the Winong village facility, we also
hope to highlight existing barriers to care and/or institutional change.
This report does not conclude with a list of recommendations for future action, but rather seeks to
canvas these recommendations from its expert readership. This report was conceived as a
means to seek input on models of care that could be used to reform/build-a-new a model
example of a community residential care facility that respects the rights and dignity of its patients
and provides them with appropriate levels of care. Our secondary aim is to identify possible
funding avenues to facilitate the building of such a model care facility.
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1.2 Method
Background information on Indonesian mental healthcare was collected through a review of the
relevant literature and information from key actors, i.e. psychiatrists, psychologists, community
nurses, historians and other social scientists, as well as government officials. Data from the
RISFASKES (The Health Facilities National Survey) and the RISKESDAS (The Indonesian Basic
Health Survey, 2013) were also used, as was the Kebumen, Mirit and Winong Government
Statistics to help complete the picture on mental healthcare in Indonesia and provide background
subdistrict and village level data for a better understanding of the village of Winong. The needs
assessment of the Winong village facility was undertaken through targeted interviews of
Puskesmas (Community Health Centre) staff on three separate visits. It also involves data taken
from two visits to the Winong facility in which interviews with the prime caretaker Mbah Marsiyo,
some family members of new patients and selected patients were undertaken. We also made
observations of existing facilities on the premises available to patients.
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2. Background and Findings
2.1 The Village of Winong
Winong village is located in the subdistrict of Mirit, In Kebumen, Central Java Province covering
approximately 171 hectares of flat fertile land. It has a total population 1513 persons (785 male),
with a population density of 884 persons per kilometres squared. Most residents are between 26-
55 years of age; there are also significant numbers of residents between the ages of 66 and 75.
Most residents are day labourers or farmers; although there are also a number of teachers and
civil servants. The village has one kindergarten, two primary schools, a junior and senior
secondary school. It has a birthing and doctor’s clinic, a supporting primary healthcare centre and
three grass roots community healthcare centres that care for children under 5 and the elderly
(Kelurahan Winong, 2016).
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2.2 Mental Health Care in Indonesia: The Case of Winong
The Indonesian National Insurance Scheme (BPJS) is intended to facilitate access for patients
suffering from mental health issues at the primary, secondary and tertiary levels
of care. Primary
care includes the Puskesmas (community healthcare centre), the assisting Puskesmas,
Polyclinic, army or police clinic or family doctor. Here a patient with psychiatric symptoms can be
screened and treated using an outpatient treatment model, including private psychiatric
consultations, or if severe can be potentially admitted and/or transferred to one of the district or
private hospitals (RSU) in the area that caters for psychiatric illness or the mental hospital (RSJ).
The other potential treatment pathway is directly from the community to the general or mental
hospital. After a psychiatric patient has been treated successfully in the general or psychiatric
hospital, he/she is returned to the community and in theory continues outpatient treatment at the
available primary care facility. In additional to covering the cost of primary care, the BPJS
supports access to secondary care and tertiary care (for chronic diseases including
schizophrenia and epilepsy) in hospital through a referral process. This is intended to increase
ease of access and reduce/eliminate the payment burden for patients
.
Annual amounts claimable by illness category, including psychiatric disorders are zoned. The village of Winong and
the Kebumen district falls within zone 1. An extract of the BPJS’s schedule for the relevant psychiatric categories for
Winong village can be viewed in Appendix C.
All data (including the above graphic) on the basic structure of the national mental healthcare apparatus was taken
from the Indonesian Ministry of Health’s new Android application Sehat Jiwa (Mental Health or Healthy Mind)
launched by the Ministry on October 10th 2015. This application offers a centralised place for the community to
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The reality is that although Indonesia has taken great strides towards building a coherent and
comprehensive system of mental healthcare, resources are severely limited. The 2011 National
Survey of Healthcare Facilities (Risfaskes) indicates that consistent with the Ministry of Health’s
new App
a number of general hospitals and Puskesmas have been given specialised training,
extra staff and/or other resources supporting the provision of mental health services. However,
there are still 6 provinces with no mental hospital, 252 state hospitals and 6141 Puskesmas that
do not provide any mental health services.
Regarding Winong village, the supporting Puskesmas and doctor’s clinic in the area provides no
mental health related care or expertise, but rather collects data and refers patients on. The
closest Puskesmas (Prembun) and the Puskesmas for that area (Mirit) provides one staff
member who organises referral services for residents with mental health problems within their
subdistrict only
. Although Mirit also undertakes to the best of its ability to provide ongoing
support services to the Winong village facility.
Interviewed staff within both primary care facilities report having never received mental health
related training by government or other providers except in their initial medical training
. There
are two hospitals in the area closest to Winong. The first is the Dewi Queen Hospital for mothers
and children. This hospital has no available facilities or personnel for treatment of mental illness.
By contrast the state run RSUD Kebumen, class C hospital has two clinics offering mental health
services. The first offer psychological testing and counselling facilities and is staffed by two
psychologists. This clinic opens from 730, sees patients from 900 and closes at 1400 everyday.
The other clinic is staffed by a psychiatrist and nurse and provides outpatient mental health
services and medication. This clinic is also open from 730 sees patients from 900 to 1100 on
Thursday and 900 to 10.30 on Saturday. There are no emergency or inpatient services and
patients arriving outside these times requiring urgent care are referred on to the areas model
Puskesmas, Puskesmas Pejagoan (see footnote 4 for services offered) or the mental hospital.
There are four mental hospitals in the district, including: Rumah Sakit Jiwa Daerah Dr. Amino
Gondohutomo Semarang (154km) and Dr. RM. Soedjarwadi Klaten (116km), also Rumah Sakit
Jiwa Surakarta (156km); Rumah Sakit Jiwa Prof. Dr. Soerojo Magelang is the closest one at
learn about mental health, available services, relevant news and screening tools. It also offers a unique reporting
service, in which cases of those chained/restrained in the community and cases of addiction/drug abuse can be
reported to the Ministry.
Ibid.
Prospective mental health patients are referred onto the hospital/mental hospital or the region’s model
Puskesmas for handling mental health issues: Puskesmas Pejagoan. Puskesmas Pejagoan is directly funded by the
provincial government of Central Java to create a holistic, integrated mental health service for their immediate
community (the Pejagoan district). This primary care facility includes emergency shelter and treatment, transfer of
patients to the mental hospital, integrated discharge planning and ongoing care, livelihoods education and
rehabilitative services, education for families and early detection facilities/personnel within their district. This
primary care facility is the model facility within the region; unfortunately, Puskesmas Pejagoan does not offer any
longer-term residential facilities for individuals who do not have their family support/are being mistreated by their
families or no longer have families. The facility also only offers BPJS accredited treatment for emergency inpatient
care if the patient resides outside the facility’s subdistrict. All care is BPJS accredited for persons residing within the
subdistrict.
We did not discover any indications of links back into the national Community Mental Health Nursing Scheme
(CMHN) in Winong village.
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nearly 80km away from Winong village (about 2 hours on a good day by car). RSUD Kebumen
and the mental hospitals are BPJS accredited and therefore accessible via National Insurance
Scheme if a person has registered. Unfortunately, a large number of the Indonesian populous
have not registered with the BPJS, including the patients we interviewed in Winong village. In
addition, even if patients were registered with the BPJS, the lack of knowledge about mental
health care delivery in the community provide a series a of stumbling blocks to continuity of care.
Specialised staff are also in short supply nationally with only 773 Psychiatrists, 451 clinical
psychologists and 6500 mental health nurses concentrated in the major cities: ninety percent on
Java island and eighty percent of this ninety percent in the capital of Jakarta (Risfaskes, 2011).
Winong and the surrounding primary care facilities also have no specialised mental health
workers.
The need for these services have been established. Central Java Province, in which the village of
Winong is located has a point prevalence rate of diagnosed schizophrenia of 1.7 per 1000
persons and six percent of the population is said to suffer from probable mood or anxiety
disorders (Riskesdas, 2013). These estimates are consistent international standards. However,
additional data such as the results from a survey undertaken by the Center for Public Mental
Health in the Special Province of Yogyakarta, which boarders Central Java suggest these figures
might not provide a complete picture of the extend of unmet need in primary healthcare provision.
The survey results indicate that thirty to fifty percent of patients attending the Puskesmas in the
Sleman district have some sort of “psychological problem” (CPMH, 2013 cited in Kedaulatan
Rakyat; CPMH, 2016, cited in Liputan6, 2016). In places like Winong village in Mirit subdistrict,
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the absence of any mental health services at the Puskesmas level means that only informal
community support is available to people unless their condition deteriorates enough to warrant
hospital admission.
After patients suffering from acute and severe mental illness are discharged from hospital care,
they are returned to their families, the local primary care facility is supposed to offer ongoing
outpatient services, including counselling, medication and referral back to the hospital in the case
of a relapse. However, the reality in a place like Winong village is that the local primary care
facility has not the staff, training, resources, (including budget and/or medical supplies) to support
this type of outpatient care. Patients do not always have supportive families; in other cases,
patients have no family members left to assist in their care. In these situations, the individual
sufferer becomes the responsibility of the local government
. In cases where families are
supportive, families are faced with returning their afflicted family member to difficult-to-access
and at times expensive hospital care. Families have also just watched their afflicted member
undergo days, sometimes weeks or months of mental health care in hospital. Patients are
discharged with medication that they are to take usually on an ongoing basis. Medicine inevitably
runs out and families need to navigate the referral system, generally unaccompanied, back to the
hospital to receive the medication they need. Stories from family members who have dropped
patients off at Winong village suggest that these obstacles are significant deterrents.
In addition, patient families seem to have curative models of medication. They believe that
patients exhibiting an absence of symptoms of their mental illness due to their ongoing
medication are in fact illustrative of their family member being cured
. Hence, they feel no need
to source continuing medication from the hospital, as they feel their family member no longer
needs it. Then when the family member relapses because they have been discouraged by the
system of care that they had just experienced (via the hospital), they turn to other facilities run by
the community such as the one in Winong village. Similarly, sufferers who do not have family
support will in all probability relapse on their own and often find themselves in altercation with
village security or police. Village security and police are familiar with informal community systems
of referral into places like the Winong village facility and often accompany patients and deposit
them directly into these facilities.
Apart from health services organised to accommodate the mentally ill, there also exists a number
of initiatives by civil society, private providers and in many places the Ministry of Social Welfare.
Civil Society has a number of mental health awareness raising support groups. Probably the
most relevant for the current case of Winong Village area these are the Schizophrenia survivor
and carer groups that maintain a transnational presence via their constant activity and
coordination over social media
. Members of these civic groups reside in Kebumen area. Private
religious and secular community groups and individuals also provide some outpatient type
services applicable for those suffering mental illness, including various types of
traditional/religious healing, counselling or hypnotherapy. We have not yet undertaken a
comprehensive appraisal of the availability and current activity level of such resources in the
See Appendix A, article 80-82.
This is evidence base includes observation of families at the Winong village facility only and therefore requires
further verification through systematic study.
E.g. Komunitas Peduli Skizofrenia Indonesia, see www.peduliskizofrenia.org; other examples include Bipolar Care
Indonesia (BCI), MotherHOPE Indonesia (NHI) And into the Light (ITL).
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15
Winong area other than the inpatient facility under review, however, some of these also have
residential care facilities. Currently in the Kebumen area, the provincial level government has not
provided a government run residential care facility. In the absence of government facilities
offering a bridge between the mental hospital and community, a number of community-run
institutions have sprung up.
The Winong facility is not the only one of its kind. A brief media search and our interviews with
mental healthcare workers identify at least one other privately run facility in the Kebumen district
area
and another four in the Central Java Province
. We believe there are many more.
However, to the knowledge of the authors, a comprehensive mapping of these institutions has
not yet been done and would be incredibly difficult to undertake given the high level of stigma
and shame associated with mental illness in Indonesia. Testimonials from healthcare workers in
the region and the depiction of the Winong facility in the media
suggest that this facility is a
more extreme version of the others in its lack of basic hygiene facilities, nutrition and shelter for
patients. These community based residential care facilities, regardless of form or resource
availability, emerge in addition to state provided facilities suggesting an outstanding need that
state facilities are currently unable to meet.
See http://www.beritakebumen.info/2013/03/puluhan-tahun-prihatin-rawat-orang-gila.html. This facility uses an
Islamic religious healing approach and has previously received financial aid from the Kebumen district government
to build a system of basic sanitation.
See http://www.beritadunia.net/berita-dunia/indonesia/utiyah,-warga-wonosobo-jateng-ini-rela-merawat-gratis-
para-pengidap-gangguan-jiwa; http://shinta-ardhan.blogspot.sg/2013/02/mereka-merawat-orang-gila-dengan-
tulus.html; http://berita.suaramerdeka.com/tanpa-bantuan-sumar-ikhlas-merawat-orang-gila/;
http://www.solopos.com/2016/05/05/kisah-inspiratif-pendeta-di-sragen-rawat-8-orang-gila-716923. These facilities
are run by religious organisations and use a combination of traditional therapies and medicine (massage, water
therapy, jamu) and prayer.
See http://www.sorotkebumen.com/berita-kebumen-525-rumah-sederhana-yang-jadi-tempat-kumpul-puluhan-
orang-gila.html
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2.3 An Outstanding Need in Indonesian Mental Healthcare: The Case for
Community Residential Care Facilities
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Research indicates transitioning to living in a community setting as opposed to in-patient
treatment or psychiatric hospital facilities is an important step in attaining recovery for sufferers of
mental illness (Thornicroft & Tansella, 2003). Community-based services promote better
continuity of care and flexibility of services ensuring better adherence to treatment and detection
of relapses (Thornicroft & Tansella, 2003; Killaspy, 2007). Community based services also
perform better in comparison to other models of care resulting in reduced clinical symptoms,
improved quality of life, housing stability and better success of vocational rehabilitation initiatives
(Braun P. et al.,1981; Conway M. et al.,1994; Bond et al, 2001). Community living is generally the
preferred choice of patients (Horan et al., 2001), has the potential to reduce stigma (Browne and
Courtney, 2004) and protect patients’ basic human rights (Thornicroft & Tansella, 2003); it is also
cost effective (Grimes, 2011). However, low quality community housing for people with severe
mental illness is related to worse overall global functioning and quality of life and increased
relapse rates (Browne & Courtney, 2004).
The data above presents a compelling case for community based residential services, but it also
highlights the importance of the quality of these services in patient outcomes. Facilities like the
one in Winong village would struggle to outperform inpatient care or psychiatric models of care
here in Indonesia due to chronic resource shortages, which in this case has resulted in appalling
hygiene standards, a lack of shelter and basic facilities as well as food, clean water and
medicine. However, the potential exists in facilities like the one in Winong village to fulfil the
potential of community based residential services in a similar way as they do in the studies
discussed above.
In Indonesia, concerted efforts do need to be undertaken to complete the implementation of the
national mental health strategy of providing more facilities and personnel, better training and
resources for mental health management. Government run community based residential facilities
must be supported and their number increased to meet the growing need. However, facilities like
the one in Winong have the potential to fill the current gap in mental health care service delivery,
whilst the government ‘scale-up’ is completed. Given the current spending on mental health -
only 2% of the Indonesian health budget as compared to Australia 8-9% and the UK 12% (Minas,
2015), this will take some time. Community initiatives that support the basic human rights and
dignity of patients, provide them with adequate care and appropriate referral pathways to
government services have the potential to provide a plan for best practice in community based
residential care in the Javanese setting. The next section examines the current reality that is the
residential care facility in Winong village in order to demonstrate the urgency of the need for
action, as well is pointing out some of the major opportunities and obstacles to instituting
sustainable change.
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2.4 Welcome to the House of Mbah Marsiyo
Stepping down from the vehicle we were greeted by a gaggle of shy, eager young men. Each
naked to the waist, or wearing worn colourful tee shirts, a contrast to the length of chain many of
them had clamped around one ankle. These were their ‘ID bracelets’, letting us, and the village
know they were residents here. One by one they extended a dirt caked hand in welcome -they
had been harvesting yam bean, one of the attempts at farming the house undertakes. We tell
them we are visiting Mbah Marsiyo, the proudly self-proclaimed Raja Gila (The Crazy King).
Today, a year after one of the author’s first visit, the facility has filled up; it is now home to 60
patients in addition to the extended family of Mbah Marsiyo.
Through the gate on the right-hand side a small bare concrete building acts simultaneously as
the musholla (prayer room) and housing for many of Mbah Marsiyo’s unchained residents and
families when they are visiting. At one end of the structure is a dirt floored bamboo lean-to; it is
full of bags of old cloths used now as lumpy mattresses for people to sleep on. At the other end
of the building are more haphazard structures housing a collection of tethered goats and other
livestock. The livestock weave their way in and around old horse carts, piles of firewood and
other tired or exhausted items that have accumulated over years. Across the large dirt courtyard
are piles of gravel and sand, these are left over from the cheap concrete bricks produced and
sold by the patients when one of the authors was last here. Today the mouldering earth of the
courtyard is concealed under a collection of tarps, covered with mashed cassava drying in the
sun. These kibbled roots are important, boiled, they are the patients’ main food stuff. Twice daily
they get a modest portion supplemented with fruit from the surrounding trees. At the back of the
courtyard, past they shed full of stale hay and the rusted becak (bicycle taxi), is the main kitchen
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used to cook for the residents. Inside there is no running water, just a pile of palm fronds and
scrap wood used to boil large pots of cassava. These are set up on bricks on the uneven ground,
which may be supported by areas of concrete or paving under the dirt.
The family home is behind the musholla, accessed past the collections of cows, goats, chickens,
pigeons, squirrels and birds in cages. The unchained residents gather there for biweekly healing
prayers
. It is also where the chained female residents live. The chained men are housed to the
left of the courtyard, past the mossy concrete laundry facilities covered with rotting cloths. These
troughs also serve as alternative washing facilities to the river for patients when they do manage
to convince one of the twenty-nine unchained residents to take them to bath.
The stench was nauseating at first, the ground littered with human shit. Faces peered around the
corners of the rows and rows of concrete cells on either side of a long corridor. Partial shelter
was offered by leaky roofing made from a combination of tiles, asbestos compressed concrete
and tin. The increase in resident numbers means that those chained at the front were still soaked
when it rains and there would be no dry floor for anybody. Heads were sometimes shaven and
sprouting new tufts of hair or scared from road accidents and hard living. Some residents
managed to maintain thick bushy heads of hair and beards, these framed harrowing eyes sunken
into slowly starving faces. Some were quick to greet us, seeking to connect through stories of
their adventures ‘in America’ or normalising the meeting through talk of the outside world and
how they wanted to take us out to eat food their home areas are famous for. Some were quiet
and withdrawn, others giggled nervously and muttered anxiously to themselves, picking at their
sores, their ragged clothing or their dirt encased bodies, one cried; some sang to pass the time.
A few, four in total remained motionless in almost a catatonic state during the hour one of the
authors spent talking to these thirty-one
patients. Each patient was chained around the
ankle and the short length of chain was bolted
to the cement floor or lump of concrete
scavenged from a building demolition. One was
chained to a truck wheel that they could
probably move; we wondered if this was a
token showing trust.
We spoke to the chained male residents for an
hour. At that time, there was only one female
chained on the premises. We then entered the
family home and spoke to the main caretaker
Mbah Marsiyo and two patients’ families for
another hour.
See Appendix D for a copy of the main prayer used
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2.5. Patient Communication, Daily Activities, History of Hospitalisation and
Contact with Family Members From the thirty-one patients chained in
these cells, one of the authors was able
to communicate sensibly with twenty-four
of them. Other than the four that
remained almost in a catatonic state, one
was a mute and the other was highly
disorientated, crouching naked and
frightened on top of a scattering of dirty
straw. We did not speak to the female
chained resident. The other twenty-nine
patients/recovered patients roamed free,
although they retained their ‘ID bracelet’
or chain wound around one leg so if they
wondered into the village others would
know where they had come from and
promptly return them to Mbah Marsiyo. A
convenience sample from this free
roaming group indicated that for all
purposes they communicated normally
and according to Mbah Marsiyo were all
quite independent (able to self-feed, bath
and pray appropriately). This group
busies themselves caring for their
counterparts who were still chained up,
growing, harvesting and preparing the
little food they had, bathing patients on request, handing out medicines and hygiene kits supplied
by the Puskesmas (community health care centre) when available. They are also involved in the
community brickworks, caring for the cows, goats, chickens et cetera and undertaking general
maintenance at the Winong village facility. Their chained counterparts by contrast, have very little
to keep them occupied. In addition, patients’ family members very rarely visit.
Almost all newly arrived patients are initially chained. Only when they establish trust that they
won’t flee, and they can eat, drink, pray and bathe unassisted will they be released and able to
roam the facility. Large number of patients spoke about their hospital treatment at local hospital
facilities or extended stays in mental hospitals when questioned. Many of the patients’ families
had attempted to ensure their family members had appropriate levels of inpatient mental health
care, but were left with no ongoing support when patients were discharged. When they relapsed,
some patients were alternatively brought back and forth to the hospital/mental hospital and
Winong village facility. If the Winong village facility offered appropriate levels of care and links
into appropriate facilities in the primary and secondary care centres (i.e. the Puskesmas and
hospitals), this would be ideal. However, the Winong village facility’s use of chaining and its dire
lack of resources mean this is not currently the case.
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2.6. Food, Water, Medicine and General Facilities
Residents, including chained and free
roaming patients, are given two small
meals of boiled kibbled cassava root a day
with a little salt. This is supplemented by
the occasional fruit, usually bengkoang,
which is eaten raw. The local Puskesmas
has organised informal systems of
collecting funds to support bringing one
rice meal complete with vegetables and
protein (usually fish or chicken) every week
to residents on Friday. They also provide
another similar meal when they deliver
medication to residents on the second
Thursday of every month. They also have
previously given supplements,
toothbrushes, soap, shampoo, clothes
detergent, biscuits, occasional fruit and
cooking implements. One-off donations
include meals of meatball or chicken soup,
additional rice meals, fruit, biscuits and
milk.
Well water from the facility’s six wells is
available and boiled by the free-roaming
residents for consumption. However, chained residents do not have ongoing access to water.
They are required to yell for unchained residents to come to their aid and offer them something to
drink.
Routine medical care was identified as the responsibility of the local Puskesmas by the local
Department of Health (Dinas Kesehatan) after their visit in April 2014 (Puskesmas Mirit, 2014a).
According to the nurse in charge of the mental health program, medical supplies, including
antipsychotics medication is supplied by the Department and delivered by the Puskesmas to the
Winong village facility every second Thursday of the month. The medical supplies received have
been inadequate for the number of patients living in the Winong village facility. Therefore, the
Puskesmas staff have been forced to prioritise and provide medication to the newest patients
and those considered in greatest need. Please see graph 1 for more detail on the number of
patients medicated by month since 2014.
Many patients do receive antipsychotic medication, but their supply is inconsistent and those
interviewed at the primary health care facility question whether or not the medication provided is
given to the intended patients according to the required schedules as they have no way of
monitoring this reliably. The bulk of the medication given to patients are to supplement failing
immune systems, combat high levels of anaemia, treat basic infections, lice and skin disease.
Data from the Mirit Puskesmas medication database for patients at the Winong facility indicate
that the quantity and types of medication from the Department of Health have varied over time;
the staff from the Puskesmas indicate less and less medication is available over time to the
extent that only vitamin supplements were provided to patients, some who had previously been
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on antipsychotic medication in the last recorded month, October 2016 (Puskesmas Mirit, 2014b).
The Puskesmas had previously attempted to supplement the medication provided by the
Department of Health with their own supplies by using funds from the primary care facility service
fees paid by patients and government allowances. However, this is no longer possible and the
Puskesmas is now struggling to meet its previous target of supplying additional foodstuffs on a
weekly basis and supplementary medicines from private funders that amount to Rp. 1 410 000.00
(Approximately AUD 140).
Additional funding for the running of the Winong village facility does of course come from the
facility itself. However, the combination of funds coming from assorted brickworks and building
projects are small and inconsistent. Patient families contribute approximately IDR 500 000.00
monthly (AUD 50) in total funds to assist with the upkeep of their family members. Existing
funding sources within the facility itself are failing to provide adequate nutrition for residents who
rely on the now struggling informal funding systems within the local Puskesmas to provide a
weekly source of protein, vegetables and other nutrition. Existing building facilities are also
extremely inadequate. The free-roaming residents are lucky enough to be accommodated in the
Musholla or in rickety dirt floored lean-tos, where they sleep on rag filled bags or piles of straw.
The chained residence by contrast are chained on top of concrete floors; very few have access to
sacking or a smattering of straw for comfort. The roofing material which is a combination of tiles,
cement pressed asbestos and tin barely cover the residents who are chained towards the front of
the concrete cells. These individuals are drenched every time it rains (which is frequent given
that now is rainy season). There are no bathrooms, so urination/defecation occurs on site for
those who are chained and in the nearby river for the free roaming residents. Similarly, the
washing facilities most utilised by residents is the nearby river.
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2.7 Current Official Data from Puskesmas Mirit
Official data tracking at the Winong village facility commenced in March 2014. From March 2014
to August 2016, the Winong village facility has treated a total of 202 individual patients. The
numbers in residence during any one time at the facility have ranged from the twenty-
eight/twenty-nine to a high of fifty-four patients in August 2016; (see graph 2) when we visited the
residence in October (2016), there were sixty patients in the Winong village facility. Numbers in
and out of the facility have varied month by month. Unfortunately, the low quality of the data,
shown by the large number of unknown cases, in conjunction with our restricted knowledge of
what happens to patients post discharge, limits our ability to draw any firm conclusions about the
meaning and function of the facility for patient prognosis (see graph 3). The nurse in charge of
the mental health program at Puskesmas Mirit suggested a number of patients go home to their
families when their physical condition deteriorates due to malnutrition and physical disease. She
indicated a number of these patients do not survive long after they have returned home
.
Residents at the Winong village facility are in the majority of cases from Central Java, followed by
lesser numbers from West Java and Jogjakarta; a few patients are also coming from as far away
as Jakarta, Sulawesi and Lampung. Residents are majority male (85%); 13% are female, whilst
2% of patients’ sex was not recorded. Graph 4 depicts age distribution of all 202 patients ever
treated (since March 2014-August 2016) at the Winong village facility. The majority of patients
whose age data is recorded fall in the 26 to 40-year-old age groups. However, a large number of
patient age data is missing (35%). Patients tend to visit the facility 1 to 2 times, although there
was one case of a patient returning three times. The length of stay ranges from one month to 30
months, with an average of a six-month stay for any patient.
In order to corroborate these claims, further work would be necessary to follow-up and identify exactly what
happens to patients post discharge from the facility in Winong village.
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2.8 Through Mbah Marsiyo’s Eyes: A History of the Winong Village Facility
Mbah Marsiyo, the self-proclaimed Raja Gila (The Crazy King) is now 80 years old. He’s been
running the Winong village facility out of his own home now for 40 years. He willingly accepts the
role that he sees God has prescribed for him and takes in patient after patient from their
desperate families, offering them the little that he has. He ensures that the proper paperwork is
completed
, but asked no financial remuneration in exchange for the care of the patients; people
give what they are able, but feel no compulsion. He does not want to add to their burden. This is
important to Mbah Marsiyo. So how did it all begin we asked him.
At first Mbah Marsiyo is a little hesitant, indicating he is just a simple man who has received no
education and that he may struggle to answer my questions, but he will try. “This is Buddha’s
land, from ancient times until now, this small expanse of land has been occupied by humans for
only a short time. To answer your question, it would be better to ask the land directly”. He goes
on to explain that he did not expect people to bring their insane family members to him, but they
did. Only a few at first. “I tied them to trees, to their wooden trunks and they got better… Until this
very moment I’m not sure how. There was no medicine, there was no payment of any kind. But
See Appendix E for a copy of the legal contract signed by patient's families when surrendering their affected
family member into the Winong village facility. This document involves patient's families signing over all rights and
legitimises any treatment that a patient may receive during their stay at the Winong village facility. This ensures that
Mbah Marsiyo and his extended team cannot at any time be prosecuted by a patient or family member for any
perceived wrongdoing resulting in injury or even death. This document was introduced after legal proceedings were
brought against Mbah Marsiyo by an ex-patient primary school teacher who felt wronged by the treatment she
received during her stay at the facility. Please see the section on Pasung for further details.
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they got better.” Mbah Marsiyo
draws on traditional animus belief
structures embedded in Javanese
worldview that see different types of
energy concentrated in different
objects and land formations. Mbah
Marsiyo sees his land as imbued
with a sacred energy that calls
people with mental disease to it and
simultaneously allows them to be
healed. This is consistent with him
having no interest in offering
anything that he conceives as
therapy.
For Mbah Marsiyo therapy equates
to massage, which he will not allow
under any circumstances for his
patients because “you can’t touch
[the patients]”. Even the stink of their
sweats can lead to contagion he
says. Therefore, Mbah Marsiyo has
instituted a system of care in which
functional unchained or recovered
patients care for the remaining acute
cases, attending to their everyday
needs. “Crazy people caring for crazy people”. Although he offers no explicit therapy, other than
the Islamic prayers that the group gathers biweekly to recite in Mbah Marsiyo’s home
, he does
offer the free roaming patients what might be termed vocational training and relaxation
opportunities. Free roaming patients work in the fields, on the brickworks and occasionally on
building projects in the village. They are also taught to care for the other patients, as well as the
Buffalo, the goats, chickens, the pigeons, squirrels, snake and other kept wildlife. The facility
also has badminton equipment for patient use.
Mbah Marsiyo’s model of the aetiology of illness rests in God’s hands. All is God’s secret. The
reasons Mbah Marsiyo’s patients fall sick are many he says. Sometimes it’s a woman, a broken
heart or unfulfilled dreams and wishes. He’s had patients who wanted to get into the army, but
failed, others that have been spurred on by family quarrels have ended with them attacking and
wounding or killing a family member. These explanatory models of mental illness were shared by
some other mental health workers and patients themselves. Some patients might be the victim of
their parents’ unceasing quest for wealth, which according to Javanese superstition will cause the
child to go crazy.
Physical signs of mental illness, according to Mbah Marsiyo include red eyes, or a finger
abnormally shorter than the others; this is a sign that the afflicted individual will never recover.
Again, see Appendix D for a copy of this prayer.
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The insane, he says are non-responsive; even if they were tended to by “a beautiful naked
woman”, they would not register it or react.
Classic stereotypes of the mentally ill as seen in the Western world do appear in Mbah Marsiyo’s
narrative. The mentally ill are stupid: Mbah Marsiyo’s demonstrates that many of his patients
believe in his greatness because he fell a tree by punching it. Because they’re crazy people he
says, they did not understand that the tree was already weakened by decay and therefore easy
to fell. Someone of sound mind would not fall for this he said. He explains that he goes to some
lengths to build an image strength in the eyes of his patients as they are violent. “They will hit
you he says… “But they won’t hit me”. He sees that the work he does in the home he keeps is a
dangerous place for even his own children. He does not want them to continue the family
‘business’. Mbah Marsiyo admits that currently they are overrun with numbers of people. “We
don’t have enough space and so many keep arriving... Really it’s up to the government to handle.
We’re full here. There is a need to find another place”. Mbah Marsiyo’s openness and generous
hospitality in receiving guests, taken in combination with the above statement, suggest that the
caretaker of the Winong village facility does possess a real openness to change and assistance
from the outside. One may even question whether he himself is losing heart in the sacred quality
of the land when he says: “when [patient x] has tried everything else, when [their family] runs out
of money and medicines, he is brought here. Here is just a band-aid [not a solution] for the
leftovers/those too far gone. They are waiting to die”.
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3. Discussion and
Conclusion
Like other similar community run
residential care facilities, the Winong
village facility emerged in response to a
community need. Although Indonesia is
training more mental health care
workers, building more primary,
secondary and tertiary healthcare
facilities and improving cross-sectoral
communication, there remains
significant shortages in personnel and
facilities and outstanding obstacles to
related policy implementation. This
means that villages like Winong
struggle to provide the necessary
primary care and referrals for its own
residents, let alone for the vast
numbers of mentally ill who were
brought from outside into the Winong
village facility. We also know that there
are some supporting secondary care
facilities in the area that provide
mental health services. Hospital
resources for those suffering from
mental health problems in the area include two available clinics (one for counselling one for the provision
of outpatient medication) on one campus, RSUD Kebumen. However, patient treatment is only accredited
with the BPJS if they are from the Kebumen region unless they register with the BPJS first. In addition,
restrictive hours of operation and the absence of emergency care mean that many patients are referred
directly over to the model Puskesmas for mental health care in the district: Puskesmas Pejagoan.
Although the facility in Pejagoan is incredibly comprehensive (see footnote 4), it does not offer patients
any options for long-term care and/or progressive reintegration into their respective communities.
Puskesmas Pejagoan also is only BPJS accredited for emergency, inpatient care and will not provide
psychiatric medication for patients referred to them from outside their area. This means that anyone
suffering from a mental illness in Winong or surrounding areas, including many patients residing in the
Winong village facility, will have difficulty accessing medication at this Puskesmas using the current type
of outpatient care model that the Indonesian mental health system increasingly favours. Individuals with
identification (KTP, Kartu Keluarga) from outside the Kebumen area will also struggle to access the
hospital clinics without direct payment for services. Without provision of medication from their local
Puskesmas, anybody suffering from mental health issues in the area of Winong village may have to travel
as far as the 80 km to the mental hospital in Magelang to receive services covered by the national
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insurance scheme. This stresses the importance of providing ongoing support, training and resources for
each areas area’s own Puskesmas, in this case Puskesmas Mirit. This centre does not currently have a
psychiatrist, any psychologists or mental health nurses. The Centre’s nurse who is in charge of the mental
health program and other staff members who continue to provide ongoing support to the Winong village
facility have not yet received any additional training related to mental health management other than
their initial training. We do know, however, that despite restricted resources at Puskesmas Mirit, there
exists significant will to continue supporting improvements in care for the residents of the Winong village
facility.
We vigorously support efforts directed at ‘scaling-up’ Indonesia’s mental health system in terms of
personnel, resources, facilities and cross-sectoral communication. We also support the shift away from
institutional-based mental healthcare towards community outpatient care. We do, however, believe
there is a missing piece of the puzzle. That missing piece is community based residential healthcare
facilities, which have emerged on their own in communities across the archipelago to meet an existing
unmet need. We have argued the general merits of this type of bridge between the mental
hospital/hospital, primary care facilities and the community and application in a Javanese setting in
section 2.3. We have identified that in the community/family setting there exists significant obstacles to
recovery and ongoing compliance with medication/mental health care due to misinformation and
resource shortages. We see the
community residential care facility as a
safe space for patients and their
families to learn self-management and
to be assisted in their efforts to
effectively navigate essential
healthcare services. We also see such
as facility functioning as a shelter for
patients who do not currently have
family or family support. In the specific
case of Winong, we want to briefly
discuss some of the opportunities and
obstacles involved in reforming existing
systems of inadequate care such as is
presented by the Winong village
facility.
Clearly the Winong village facility fails
to provide them with basic hygiene,
shelter, nutrition or medical care to
protect patients’ basic human rights
and dignity
. However there exists
considerable commitment and will to
support ongoing change and reform
See section on Pasung, which explains the history and legal standing of the issue in Indonesia and particular
Central Java. It also sets up some of the sensitivities and challenges involved in handling the reform of the Winong
village facility.
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from the local Puskesmas, Puskesmas
Mirit. In addition, although the
caretaker of the Winong village facility,
Mbah Marsiyo, does holds some beliefs
about mental health which may initially
present as obstacles to change, his
openness to guests and general
assistance are clear from his interview
(see section 2.9). The level of
community awareness of the Winong
village facility (covering Central Java
and links into Jakarta and even
Lampung and Sulewesi) means that
building a new model facility on or near
this site would capitalise on existing
local flows of information. Then, if the
facility offered something different to
what is currently presented by Mbah
Marsiyo in Winong village, you do not
split the clientele basis, but rather have
access to those with Mbah Marsiyo’s or
similar model of mental illness and
those also who support a medical
model. You are then provided with the
opportunity to start to change
underlying problematic models of mental illness like those held by Mbah Marsiyo, which (along with
resource shortages) prevent people in need obtaining treatment that respects their dignity and basic
human rights. Such knowledge structures need to be sensitively challenged, as do other belief structures
which see modern psychiatric medication as curative rather than palliative and therefore result in
patients with severe mental illness stopping their medication.
One of the most significant issues in instituting change in a place like the Winong village facility is their
current use of chaining. The practice of Pasung (see inset on Pasung) is currently illegal in Indonesia and
places found to be using Pasung are to be reported and then are usually shut down. The authors of this
report see this as an immediate concern. Although the law appears to be formulated to encourage action
to combat Pasung cases, rather than punish for inaction, the punitive pathway still exists and has been
used in such cases, including this one. This illustrates the potential risks for significant actors in the
Winong village facility. Efforts taken towards reform must progress carefully and sensitively as punitive
action can occur given the current state of Indonesian law. The authors strongly believe such action is
counterproductive for a number of reasons. Firstly, Mbah Marsiyo has undertaken in good faith to care
for persons with mental health issues surrendered to him by their families and has done so (probably in a
similar form) for the best part of 40 years. He has not the resources to offer better forms of
accommodation, nutrition or care and so does what he can. Families are often at a loss and given their
often low levels of mental health literacy and challenges of accessing health services and ongoing support
their actions should not be faulted either. Other members of the community, including the local
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Puskesmas do so much to alleviate the suffering of the Winong village facility, but they are simply
overwhelmed with the scale of the problem. Secondly, any punitive action would severely damage
relationships and trust within the target community, compromising any subsequent efforts aimed at
solving the current situation and towards improving patients’ quality of life. Finally, the reality is that the
facility in Winong village, like those in so many other places fulfil an existing community need. If the
facility was simply to be shut down without any viable alternative, patients would again enter mental
hospitals for another round of treatment. But when discharged, they would in all likelihood end up in
another facility like the one in Winong village.
We see the purpose of this report as an urgent call for action. Our hope is for action that will overcome
the existing immediate problem of the failure of the Winong village facility to protect the dignity and
basic human rights of its patients. We hope for a solution for the patients in the Winong village facility
here and now so that they will be fed, given water, appropriate shelter and access to medical care free
from their chains. We also hope also that solving this immediate problem will include a more sustainable
solution that bridges the gap between the hospital and the community: the building of a model
community residential care facility in Winong village. The building of such a model facility, we would hope
would provide patients with a space that not only protects their rights and dignity, but offers education to
them and their families about mental
illness, whilst ensuring compliance
with ongoing treatment in a way that
normalises the patient’s condition.
We desire such a facility would be
fully integrated with existing
healthcare facilities at primary,
secondary and tertiary levels. We
hope that such a facility could
become an example of best practice
in community-based residential
mental healthcare in the Javanese
setting. Obviously, the building of a
successful community based
residential care facility would require
considerable planning, expertise and
funding. This is where we turn to you,
the audience for this report, the
experts. We are looking for opinions,
options, suggestions for actions and
funding that you might be aware of
that might be able to assist in the
endeavour of alleviating the suffering
of current residents of the Winong
village facility and in building a-new
appropriate systems of residential care.
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District) (Table List) (p. 12). Winong, Mirit, Kebumen, Central Java: Puskesmas (Community Health
Centre), Mirit, Kebumen, Central Java.
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Appendix A National legislation on mental health
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Appendix B Central Java legislation on Anti Chaining
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Appendix C BPJS Schedule
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Appendix D Prayer
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Appendix E Surat, Indemnity Letter for Patient's Admission to the Winong
Village Facility
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Appendix F Implementing Team for Central Java
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Utiyah, Warga Wonosobo Jateng Ini Rela Merawat Gratis Para Pengidap Gangguan Jiwa (Utiyah, Resident of Wonosobo, Central Java, Willing to Take Care People with Mental Disorder for Free)
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Berita Dunia. (2016). Utiyah, Warga Wonosobo Jateng Ini Rela Merawat Gratis Para Pengidap Gangguan Jiwa (Utiyah, Resident of Wonosobo, Central Java, Willing to Take Care People with Mental Disorder for Free). Retrieved November 17, 2016, from http://www.beritadunia.net/berita-dunia/indonesia/utiyah,-warga-wonosobo-jateng-ini-rela-merawat-gratis-para-pengidap-gangguan-jiwa
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Berita Kebumen. (2016). Puluhan Tahun "Prihatin" Rawat Orang Gila, PP As Syamiyah Butuh Bantuan (Decades, "Prihatin" Taking Care Peoples with Mental Disorder, PP As Syamsiyah Needs Help). Retrieved November 17, 2016, from http://www.beritakebumen.info/2013/03/puluhan-tahun-prihatin-rawatorang-gila.html
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