The Indonesian Mental Health Act: psychiatrists’ views on the act and its implementation

Abstract

In 2014, the Indonesian government passed the Mental Health Act (MHA) to address the country’s complex mental health situation. The implementation of the MHA has been slow, and little is known about how the MHA is perceived by mental healthcare providers within local settings. This study aimed to obtain insight into psychiatrists’ views on the MHA, including on how it affected their clinical practice and on challenges of translating the MHA into practice. The study was conducted in Bali, and 27 psychiatrists (15 men and 12 women) participated in a semi-structured interview. Thematic analysis indicated four overarching themes: raising the profile of mental health, developing a shared understanding of mental illness, integrating psychiatric practice with other services and views on implementation of the MHA into practice. Overall, the psychiatrists viewed the MHA as a step in the right direction to improve mental health services and to create awareness at local and national levels. However, there was consensus that the meaning of the MHA’s concepts of mental problems and disorders were not compatible with psychiatric everyday practice or their patients’ understandings. As a result, many assumed that the MHA was targeted at government and policy officials. Furthermore, there was a perceived lack of clarity on issues relating to collaborating with other services and unequal access to resources among regencies that impacted on their clinical practice in a negative way. Moreover, a few psychiatrists raised concerns that local beliefs and practices were not acknowledged in the MHA. According to the participants, mental health remained a highly political issue and without national support, mental health would remain a low priority. In conclusion, insights into providers’ perspectives contribute to developing an evidence-base that can inform the implementation process of the MHA in Indonesia, and possibly elsewhere, into local level guidelines and regulations.

Full text

1
This is an Accepted Manuscript version of the following article, accepted for publication in
Health Policy and Planning: Bikker, A.P., Lesmana, C.B.J. & Tiliopolous, N. (2020) The
Indonesian Mental Health Act: Psychiatrists’ views on the Act and its implementation.
Health Policy and Planning. 36(2): 196–204.
Available online: https://doi.org/10.1093/heapol/czaa139
It is deposited under the terms of the Creative Commons Attribution-
NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits
non-commercial re-use, distribution, and reproduction in any medium, provided the
original work is properly cited.”

1
The Indonesian Mental Health Act: Psychiatrists’ views on the Act and its
implementation
Annemieke P Bikkera, Cokorda Bagus Jaya Lesmanab, Niko Tiliopoulosc
a The Usher Institute, Population Health Sciences, The University of Edinburgh, UK – MSc,
MSc
b Department of Psychiatry, Udayana University, Indonesia – MD, PhD
c School of Psychology, The University of Sydney, Australia – MSc, PhD
Corresponding author: Niko Tiliopoulos
School of Psychology
Rm 448, Brennan MacCallum (A18)
The University of Sydney, NSW, 2006, Australia
Niko.Tiliopoulos@sydney.edu.au
Keywords
Mental health; legislation; Indonesia; psychiatry; qualitative research
Abbreviated running title: Psychiatrists’ views on the Indonesian MHA

1
Key messages
• We conducted in-depth interviews with 27 psychiatrists in Bali, Indonesia, to obtain
insight into their views on the Mental Health Act (2014) and its implementation into
practice
• The MHA is seen as a welcome step to improve mental health services, create
awareness, and provide clarity on some specific topics.
• Lack of practical guidance, and the discrepancy in interpretations of mental health
between the psychiatrists and the MHA contributed to disengagement and questioning
the priority of the MHA
• The Ministry of Health and other key stakeholders should consider mental healthcare
providers’ perspectives to facilitate the MHA’s implementation process
Funding and acknowledgements
The work was supported by the Sydney Southeast Asia Centre, The University of Sydney
[30/6/2017]. We would like to thank all the psychiatrists who participated in our study.
Ethics approval
Ethical approval for the study was granted by the Udayana Ethics Commission (Bali,
Indonesia), ethical clearance no: 271/UN.14.2/KEP/2018, and by the University of Sydney,
Human Research Ethics Committee on 18/12/2017 (REF: 2017/1002).

1
The Indonesian Mental Health Act: Psychiatrists’ views on the Act and its
implementation
Abstract
In 2014 the Indonesian government passed the Mental Health Act (MHA) to address the
country’s complex mental health situation. The implementation of the MHA has been slow,
and little is known about how the MHA is perceived by mental healthcare providers within
local settings. This study aimed to obtain insight into psychiatrists’ views on the MHA,
including on how it affected their clinical practice and on challenges of translating the MHA
into practice. The study was conducted in Bali, and 27 psychiatrists (15 men and 12 women)
participated in a semi-structured interview. Thematic analysis indicated four overarching
themes: raising the profile of mental health, developing a shared understanding of mental
illness, integrating psychiatric practice with other services, and views on implementation of
the MHA into practice. Overall, the psychiatrists viewed the MHA as a step in the right
direction to improve mental health services and to create awareness at local and national
levels. However, there was consensus that the meaning of the MHA’s concepts of mental
problems and disorders were not compatible with psychiatric everyday practice or their
patients’ understandings. As a result, many assumed that the MHA was targeted at
government and policy officials. Furthermore, there was a perceived lack of clarity on issues
relating to collaborating with other services and unequal access to resources among
regencies, that impacted on their clinical practice in a negative way. Moreover, a few
psychiatrists raised concerns that local beliefs and practices were not acknowledged in the
MHA. According to the participants, mental health remained a highly political issue and
without national support, mental health would remain a low priority. In conclusion, insights

1
into providers’ perspectives contributes to developing an evidence-base that can inform the
implementation process of the MHA in Indonesia, and possibly elsewhere, into local level
guidelines and regulations.
Introduction
Mental health is widely acknowledged to be an important part of health, however, health
services tend to be geared towards physical and infectious diseases (Patel et al., 2018; WHO
2013). Mental illness deserves further attention, given its global widespread prevalence and
its significant impact on morbidity and mortality. According to the Global Burden of Disease
Study around 10% of the global burden was related to mental health in 2016; the trend is
rising (Patel et al., 2018) while mental health disorders remain widely under-reported (Vigo,
Thornicroft, and Atun, 2016). Due to the growing number of people with mental disorders,
and the considerably lower priority given to mental health policy and government budget
expenditure on mental health services, a large number of the globally affected populous
remains untreated, misdiagnosed, or experiences low quality healthcare (Patel et al., 2018).
Additionally, relative absence of relevant education and fear of cultural stigma tends to lead
to treatment avoidance, subsequently leaving sufferers vulnerable to further mental health
deterioration. Indeed, in many cases, patients do not seek professional help until their mental
condition has severely deteriorated (Patel et al., 2018; Thornicroft, 2008). Finally, intense
stigmatisation, discrimination and human rights violations experienced by people affected by
mental disorders have been widely reported, thereby linking mental disorders inextricably
with human rights issues (Asher et al., 2017; Minas, 2009).
The urgency to address poor mental health outcomes and to scale up services to tackle the
growing gap between the need for treatment and the provision of appropriate mental

1
healthcare have become global priorities on the international health agenda highlighted in the
United Nations Sustainable Development Goals (SDG) (UN, 2015) and World Health
Assembly’s Comprehensive Mental Health Action Plan 2013-2020 (WHO, 2013). As a
result, there is increased pressure on countries to develop or improve legislation and policies
to deal with their state of mental health services and to respect the human rights of people
suffering from mental illness. A target of the WHO’s Mental Health Action Plan (WHO,
2013) is for 50% of the countries to have a mental health law in line with international human
rights conventions such as the Convention on the Rights of Persons with Disabilities (UN,
2006) and national human rights agreements.
The Indonesian government passed the Indonesian Mental Health Act (MHA) in 2014 to
address the country’s complex mental health situation that is hindered by a lack of available
or allocated resources (Diatri and Maramis, 2015; Pols et al, 2019). Six percent of the
Indonesian national health budget is spent on mental health, while the ratios of mental health
staff per 100,000 population is well below the global mean of 9:100,000 population (varying
between <2: 100,000 population in Low Income Countries and 70:100,000 population in
High Income Countries) (WHO, 2017a). In Indonesia, which is classified as a Middle Income
Country, the ratio for psychiatrists is 0.31:100,000 population, for mental health nurses
2.52:100,000 population, and for psychologists 0.17:100,000 population (WHO, 2017b).
The Indonesian National Health Survey estimates that an average of 9.8% of the population
(15+ years) suffers from mental and emotional problems (Balitbangkes, 2018), although due
to the sensitivity surrounding mental health, this is likely an underestimation. Additionally, a
relative shortage of accessible and adequate mental healthcare has led to ongoing practises of
restraining and confinement of individuals (pasung) with mental health problems (Human

1
Rights Watch, 2016; Irmansyah et al. 2009; Minas and Diatri, 2008; Suryani et al., 2011).
According to the National Health Survey (Balitbangkes, 2018), 14.0% of Indonesian
households have practised pasung.
Indonesia has ratified most of the human rights conventions (WHO, 2017), as reflected in its
MHA, by acknowledging patients’ rights, and improving the quality of and accessibility to
services, through the integration of mental health services within the general health services
at community and hospital levels (President of the Republic of Indonesia, 2014). The MHA
integrates with several national level health reforms toward decreasing the treatment gap (i.e.
the percentage of people needing treatment but not receiving it) and developing
comprehensive, integrated and sustainable care. In early 2014, the government implemented
the Jaminan Kesehatan Nasional, a scheme to provide Universal Health Coverage (UHC) for
a range of treatments from public providers and from private organisations that opted in the
scheme (Agustina et al., 2019). UHC is a key objective for health reform by the WHO
(WHO, 2017) and is part of the United Nation’s SDGs (target 3.8) (UN, 2015) as it aims to
increase access to healthcare, and thereby offers support for people with mental disorders
who are often marginalised.
To facilitate the UHC, the government launched a referral system with entitlements to
specialist care in hospitals, depending on referrals from primary care centres (Agustina et al.,
2019; Kutzin et al., 2017). As a result, primary care staff are more heavily involved in
screening for mental disorders and treating basic mental disorders, while referring the more
severe cases to district hospitals or mental health hospitals where patients are treated within a
set timeframe (Diatri and Maramis, 2015; Praharso et al., 2020).

1
Despite major reforms in the healthcare system, the implementation of the MHA into practice
is still in its early stages, and it has been hampered by the lack of detailed regulation and
adequate funding (Pols et al., 2019). A systematic review highlighted that slow and
inconsistent implementation and under-implementation of national mental health plans are
common. Furthermore, the severity of challenges facing implementation are greater in low
and middle income countries (LMICs) than in HICs due to underfunding, lack of human
resources and administration (Zhou et al., 2018). Implementation science literature gives
deeper insights into issues that influence the process. A recent systematic review by Means et
al. (2020) assessing the applicability of the Consolidated Framework for Implementation
Research (CFIR) in LMICs identified several features specifically relevant to LMICs at the
system level, such as the administrative design of the health system and the nature of
interactions across specific administrative levels, and the degree to which the perceived
priorities and needs of relevant stakeholders are aligned with system policies. In line with
implementation research (Esponda et al., 2020; Means et al., 2020), the WHO (2013)
suggests facilitating the implementation process by considering the expertise of mental health
professionals on mental healthcare delivery and interaction with the patients, as they are at
the heart of the MHA. To date there is a lack of research looking at the impact of changes in
the healthcare system from the providers’ perspectives in Indonesia. The aim of this study
was to obtain an insight into how the national level legislation of the MHA was perceived by
psychiatrists in Bali, within their local context, and whether the MHA affected challenges
encountered in their clinical practice.
METHODS

1
Study setting
The study was conducted in Bali, which is one of the 34 Indonesian provinces.
Administratively Bali is divided in nine districts or regencies. Bali has a population of 4.2
million (BPS, 2015) and an approximate 8.5% mental illness prevalence (Indonesian Ministry
of Health, 2018). Bali has two in-patient psychiatric units, which are in the main mental
hospital (in Bangli regency), with 400 beds, and in Sanglah General Hospital, in the regency
of the capital city Denpasar, with 16 beds. Nine further public hospitals, with outpatient
psychiatric units are located on the island. At the time of the study one regency (Jembrana)
did not have a psychiatrist and was served by visiting psychiatrists from Sanglah General
Hospital, while the single psychiatrist working in another regency was hospitalised. The
number of psychiatrists increased from 8 psychiatrists in 2004 to 52 psychiatrists in 2018, of
which 19 (36.5%) were female. These psychiatrists practise in the general, private, and
military hospitals, private practices, and NGOs, with most of them based in Denpasar.
Research design and reflexivity
To obtain insight into the psychiatrists’ experiences of the MHA, we conducted qualitative
face-to-face interviews in line with the interpretivist paradigm. This approach does not
attempt to reveal one ultimate “truth” but adopts the position that reality is both changing and
subjective, and that the data are co-created between the interviewer, interpreter, and
participants (Bunnis and Kelly, 2010; Hennick, 2008). Throughout the study, the team
discussed their own perceptions on the topic and kept memos to track biases and the
development of ideas. The research team had successfully collaborated before and consisted
of a psychiatrist from Bali (CBJL) specialising in community care, a psychologist based in

1
Australia (NT) and trained in mental disorders, and a social scientist based in the UK (AB)
teaching public health.
Recruitment and sample
The study population consisted of the 52 psychiatrists practising in Bali. To allow for a wide
range of relevant in-depth accounts to address the research question, the psychiatrists were
purposively sampled. This was done to ensure that the sample included participants with the
following characteristics: 1) male and female psychiatrists, 2) working in public hospitals
from all regencies (two regencies were without a psychiatrist), and 3) graduated before and
after the MHA was enacted. Potential participants were selected from the Psychiatry register
and approached by email. To increase the likelihood of data saturation, the target was to
interview at least half (26) of the psychiatrists. To reach our target we invited 32 psychiatrists
of whom 27 agreed to participate in an interview. Saturation was reached just before this
point after which no new relevant information was obtained from the interviews. Five
psychiatrists declined due to personal commitments during the data collection period,
including attending a religious ceremony or hospitalisation.
Participants received the study Participant Information Sheet and were given the opportunity
to ask questions prior to being interviewed. It was emphasised that participation was
voluntary and that they could stop the interview and/or withdraw from the study at any time.
Informed consent was obtained prior to the interview. Participants were reimbursed $50 AUD
for the time they spent on the study. Data collection took place during February 2018.

1
Interview guide and data collection
The literature review and team discussions formed the bases of the initial interview topic
guide that focused on awareness and understanding of the MHA, its applicability, the
implementation process, and views on the mental healthcare system. The interview schedule
was piloted during the first two interviews, which were longer in length as a result of
feedback sought during the interaction. As this was an explorative study, we used the guide
flexibly to allow for further exploration of new topics, while making sure that the interviews
also covered similar topics to allow for comparisons between transcripts. The interviews were
conducted in the privacy of the participant’s office or in a separate room in their workplace,
except for two that were done in a quiet public place. Interviews lasted between 45 and 90
minutes. We conducted the interviews in a mixture of English and Bahasa Indonesian, with
one of the study authors (CBJL), who is a native Indonesian/Balinese speaker, acting as an
interpreter when required. CBJL is also an acting psychiatrist in Bali and is familiar with all
the psychiatrists on the island. Interviews were audio recorded, anonymised, and transcribed
by an Indonesian professor of English and checked by the research team for accuracy.
Transcripts were not returned to the participants for comments.
Data analysis
Data were analysed through Thematic Analysis (Braun and Clarke, 2006). The field notes
and transcripts were read and re-read carefully by AB and a selection by NT and CBJL. After
careful reading of eight transcripts, we began to discuss potential codes and develop the
coding framework. This involved merging overlapping codes and discussing differences in
coding. The agreed coding frame was applied across the data, which was led by AB, while
deviations were explored and discussed by the team. In seeking to fulfil the research aim we

1
arrived at four themes. Three relate to challenges affecting everyday clinical practice in
relation the MHA: raising the profile of mental health; developing a shared understanding of
mental illness; and integrating psychiatric practice with other services. The last theme
addresses perceived challenges of the implementation of the Act into practice.
RESULTS
Overall 15 male and 12 female psychiatrists took part. Twenty-three participants worked for
public general hospitals and often in combination with a psychiatric position in another
setting (such as private hospitals or practices, NGOs or universities). Four participants
worked in psychiatric positions with the public health service. In total 6 psychiatrists had
graduated before 2015, and the rest in 2015 or afterwards. All participants had heard about
the MHA, though some participants reported they had not read the Act until the invitation to
the study.
Raising the profile of mental health (across all levels)
It was clear from the participants’ accounts that they welcomed having an MHA as they
claimed that mental health was not considered a priority in society, and was still a highly
stigmatised area. As such, having an Act was seen by default to raise awareness and
underline the importance of mental health across different levels of society, including by
some of their patients and other clinicians not working in mental healthcare.
Perceived level of awareness among patients
According to the participants, most people are aware only of severe mental illness. A
common remark by the participants was that in the community “being mentally ill equals
having schizophrenia or being psychotic” (e.g. participant 23). However, the psychiatrists had

1
noticed changes in the types of conditions that they saw. They attributed this change to an
increased awareness and to a lower threshold to seek help due to the UHC.
Yes there is a change, before people think psychiatrist is doctor gila, crazy doctor [laughs].
Doctor only for crazy people, before, but right now like patient here [in this hospital] or in
my private practice there are psychotic patients, but more neurotic patients, like their
problem with their sleep, emotions something like that. Not only for psychotic patient.
[participant 14]
While it was acknowledged that there was some progress in people’s thinking that mental
illness comes in different forms and presents in different ways, all highlighted the ongoing
stigma surrounding mental health.
Yes, they are afraid to go to psychiatrist here. My room is beside the internal medicine room.
Even though I have a lot of patients by that time, all of my patients will wait in front of the
internal medicine room. There is still a stigma, because they don’t know if there is, because
this is general hospital they don’t know if family come and see you by psychiatrist they don’t
know what to say. So yeah it is still a problem…Because they still think that mental problem
is just like schizophrenic yeah it is just like that, mental illness is just like a very bad illness.
Still the stigma. [participant 22]
Perceived level of awareness among non-mental health clinicians
Many reported that over the years they had also noticed more awareness of mental health
among other clinicians who consulted with them more frequently in the hospital albeit often
as a last resort. While all participants perceived mental health as part of a person’s overall
health status and closely linked to physical health, they noted some colleagues began to share
this view:

1
For the young specialists, they already understand that there is a link but for the older
specialists, they are still differentiate between the physical and mental health. [participant 19]
As a result, there was more collaboration with other specialities and several said, jokingly,
that they were no longer referred to as “the crazy doctor” [participant 3].
Developing a shared understanding of mental illness
Another perceived benefit of the MHA was that it could facilitate a shared vision of the
direction to improve the mental health services, which could also aid the successful
implementation of the MHA.
With this Act they will regulate all the stakeholders, all the people who work in mental health
can work in the same direction with the mental health regulation. [participant 21]
Having a shared understanding was perceived to be fundamental in providing information to
patients and family members with lay knowledge and to the community, especially with
mental illness having a high stigma. However, throughout the interviews it became evident
that the way the psychiatrists viewed mental illness differed from the way it was
conceptualised in the MHA.
The MHA distinction between mental problems and mental disorders
In the MHA the approach to mental illness is based on a distinction between mental problems
(ODMK) and mental disorders (ODGJ). A mental problem refers to: “a physical, mental,
social, and development disorder, and/or living quality problems, and carries the risk of
suffering from a mental disorder” (Art 1.2). Within the MHA, there is an indication that
people with mental problems do not receive medicines to alleviate the condition and are
capable to self-manage their condition (Art. 68/69). In the MHA a mental disorder is defined

1
as: “suffering from a psychological, behavioural, and emotional disorder which is manifested
through a series of symptoms and/or significant behaviour changes, which can potentially
cause suffering and detriments of such person’s performance of his/her function as a human
being” (Art 1.3).
The psychiatrists’ perception of mental problems and mental disorders
The psychiatrists viewed mental health from a medical angle and, in line with their
psychiatric training, within the context of the diagnostic framework of the Indonesian edition
of the ICD-10 framework (the 10th revision of the International Classification of Disease by
the WHO) (Depkes RI, 1993) and the drug treatment options available within their setting.
The importance of a diagnosis leading to an ICD code was emphasised throughout the
participants’ accounts, the reason being that since the introduction of the UHC the insurance
regulations require an ICD code for a patient in order for the hospital to be reimbursed for the
treatment.
Yes because the insurance, when the insurance coding for the payment, they should use the
code for ICD10. So if we give a diagnosis then the insurance has to make a coding of the
diagnosis with ICD 10 code. [participant 7]
When asked about the two concepts of mental problem and disorder many participants
explained the distinction in similar ways as in the MHA, i.e. by using an observable level of
severity with some cut-off point that made a person move from having a mental problem to a
disorder, and a variety of examples were given, such as becoming a burden to others through
violent behaviour, no longer being able to take care of oneself, the type of conditions, or
receiving a medical diagnosis as is illustrated by this quote:
People with a mental disorder are people diagnosed with a mental disorder. People with
mental problems are everybody, everybody has mental health problems. [participant 18]

1
Several participants commented that the MHA’s distinction influenced people’s attitudes to
mental health, though they explained it in different ways. Some claimed that the distinction
made mental problems more acceptable. Others said that it created more awareness for
mental disorders, and therefore, reduced people’s negative attitudes towards disorders, but
increased stigma for mental problems as is illustrated in the following quote:
People are more aware for the severe case. For the mild and moderate there is still stigma.
They don’t accept them having mental problems. But for the severe one they accept that they
have already mental issues. But when they have anxiety or depression then they still think this
is not mental health. [participant 5]
One participant explained the distinction by categorising Lesbian, Gay, Bi-sexual, and
Transgender in accordance with the MHA distinction, a disputed area heightened by
statements from the Indonesian Psychiatric Association (PDSKJI) and Ministry of Health.
They categorised people who are homosexual and bisexual as people with mental problems
(ODMK) and are at risk of developing a mental disorder (ODGJ), and people who are
transsexual as having a mental disorder (PDSKJI, 2016).
ODMK is people who just have a mental health problem but ODGJ is people with positively
suffering mental health disorder. For example LGBT, the gay people, if they still enjoy being
gay, is no problem then I will consider that as people with mental problems, but if this
person himself feel that there is something wrong with himself and ask for a help then for him
that is considered ODGJ (people with mental disorder). [participant 5]
Relevance of distinction between mental problem and disorder to everyday practice

1
While there was variety in the ways the participants interpreted the MHA’s definitions,
overall there was consensus that the meaning of the MHA’s concepts was broad and not
relevant to psychiatric everyday practice.
The universal health coverage is based on ICD. So our diagnoses are covered by insurance.
But in the universal health coverage, they do not talk about people with mental disorder or
people with mental problems. The pay based on the ICD code, the ICD10. [Participant 2]
I don’t know why they do it like that. Maybe for the government or for the health services it
would make it easier to see the difference, people with mental disorder and people with
mental problems. But in the implementation it creates more stigma because you start to
differentiate these two areas. Rather than saying mental health should be included in every
person, physical and mental health… The wholeness of human, must see the wholeness,
physical and mental. [participant 27]
With the MHA emphasising the categories of mental problem and mental disorder, and the
psychiatrists not applying this terminology in their diagnosis or using it in their interactions
with patients, many reported that they assumed that the MHA was targeted at government
and policy officials and not the psychiatrists:
I think it’s not uh related, related but only a little. It is the area of the department of health to
understand the law. Not the area for the psychiatrists. [participant 14]
No, it’s just for ministry of health and for the members parliament member. It was not from
all psychiatrists like psychiatric organization not from every region come and then meeting
and then socialisation, during the draft. [participant 23]
Integrating psychiatric practice with other services

1
Collaborating with health services and social sectors
The MHA includes several articles (Art. 20, 33-35, 56) on improving integration between
psychiatric services and other services. Nearly all psychiatrists highlighted the lack of
collaboration between the primary healthcare services, the general hospitals and the main
mental health hospital as on ongoing challenge in terms of keeping track of patients. Due to
this lack of integration, they said that patients were generally not followed up if they did not
attend an appointment or after they were referred to another service:
In hospital they will ask the patient to come back, maybe in 2 weeks, and then after that they
always ask the patient come. But if the patient not come, they forgot it. So they don’t know,
the patient recover completely or not. [participant 1]
Lack of follow up or aftercare led to problems in the patients’ treatment, often leading to
relapse. Indeed, some psychiatrists did not refer patients back to the health centres due to the
lack of medicine and absence of trained mental healthcare staff:
We ask the patients to come back to the hospital and not go to the puskesmas [health centre]
because I know that in the primary care centre they don’t have the medicine and also not the
human resource for mental illness [participant 21]
A lack of collaboration with other sectors, such as the social housing sector or social care was
another challenge they hoped would be addressed once the MHA was implemented:
Since that regulation more cover, more broad area, more people what we call inclusive,
rather than exclusive. That means that mental health not only responsibility of hospital but
also other institution must work together with the hospital. Like social, also social
department, minister of social department, minister of what we call like internal affair. Like
inclusion so, we agree with department work with police, justice, something like that. So
every institution, each institution who [pauses a lot thinks about English] involved with

1
people cover by this regulation… in supporting our mental health like what we call home
care. Home care, supposed to be developed in each district area but there is no regulation to
make this happen home care. The transition home care to hospital, transition hospital to
home supposed to be developed. [participant 6]
The importance of having support from other sectors, when patients were discharged from
hospital, was explained by participant 8, who highlighted some of the difficulties people
faced when returning home:
It’s a difficult thing. It is not always easy thing because when they go back to their house
often some of them told me they don’t find right schedule as in the hospital. The breakfast, the
what, when they get cookies or refresh, singing dancing and when they go back to the family
the family keep busy working, so late to give the breakfast and that makes emotions so often
relapse and back again. [participant 8]
Collaborating with traditional healers
Interestingly, neither the MHA nor the psychiatrists mentioned working with traditional
healers as a suitable option within the current system. Yet all psychiatrists reported that many
of their patients associated mental health related issues with the supernatural. The majority of
the Balinese population practices Balinese Hinduism to which Balians (traditional healers)
are an intrinsic part. They reported that, as a result, many patients would consult a traditional
healer prior to a doctor, which would lead to delay in treatment:
Because our culture when the patient gets schizophrenia, they always link this with the
culture. So they think the patient don’t need to go to the hospital, they only need uh uh
alternative medicine maybe, a ritual maybe, yeah. So that’s why a little bit difficult.
[participant 7]

1
For some participants the lack of acknowledgement in the medical discourse of the role of
Balians or the link between mental health and the supernatural led to question the psychiatric
approach taken as is illustrated by this participant.
It is make it easy to follow the system [ICD10], but to understand the people there is
something missing. Their belief system, you cannot force them to understand that it is
hallucination, it is part of daily life and their culture. The element of culture is missing.
[participant 2]
Views on implementation of the MHA into practice
All participants highlighted that progress of the implementation of the MHA was slow.
Especially the participants with longer psychiatric experience viewed the MHA within the
wider legal and policy context and concluded that delays with or abandonment of regulations
were not uncommon in Indonesia.
Barriers to implementation
A perceived lack of priority of mental health at the structural level, combined with negative
attitudes to mental illness, were given as the most frequent reasons by the participants as a
barrier to progress on the implementation of the MHA:
The [hospital] management know already about the MHA, but they still have argumentation
“We already have a mental hospital” According to the management it is not profitable, even
more beds needed for mental illness. [participant 19]
Still, still stigma, but hard to change the stigmatization. It has changed, but minimal change.
First we got uh the mental health system from the generally, not as a priority… The
budgeting is not a priority and uh from the central to the local and the province district and

1
uh puskesmas the budgeting is not a priority. So uh that is uh providing resourcing budgeting
and so forth for mental health not. [participant 27]
Those experienced with working in the more deprived regencies or in remote areas
commented on the need for a more equal spread of resources across Bali to facilitate
successful implementation:
We need more psychiatrists spread around I not just concentrate on big cities such as
Denpasar or on Java island. Probably in Irian Jaya or other remote area. I hope more
psychiatrists spread. More access to the mental health as mentioned in the Act, to prevent
mental illness. Because if you have more access to the mental health then it also becomes less
of a burden for us. In that Act you have to prevent, right, but how can you prevent if there is
no psychiatrist in a very basic system? [participant 22]
The role of the Psychiatric Association
Finally, and quite interestingly, participants had different views on the role the Indonesian
Psychiatric Association could play in adding pressure or facilitating the implementation by
the federal or local governments. Some claimed that the Association should be more
involved, while others saw no connection between the implementation of the MHA and their
Association or themselves. As such, they questioned the potential influence of the
Association:
It needs infrastructure, they must prepare from the top to down because if, maybe from the
bottom to the top maybe that needs a long long long time to prepare the infrastructure.
[participant 23]
DISCUSSION

1
Our study explored the views and experiences of the MHA by psychiatrists working in Bali
and attempted to identify whether the MHA affected challenges encountered in their clinical
practice. The study provided insight into how the MHA related to the Balinese psychiatrists’
conceptualisation of mental health and illness and to their everyday practice. We found that
overall the psychiatrists viewed mental health by looking at a person in a holistic manner, and
by emphasising the integrated link between mental and physical health. While this overall
state of health is widely acknowledged in the literature (WHO, 2005) this is less the case in
the MHA, which does not explicitly address its link to physical health.
Within the participants’ psychiatric practice, the ICD-10 framework informed the diagnosis
of a disorder – ICD-11 had not yet been published when this study was conducted. While
there are ongoing debates on whether this diagnostic model leads to adequate representations
of reality (Mellsop et al., 2007; Byng et al., 2019) and on challenges from exporting mental
health expertise from Western to non-Western settings (Cooper, 2016; Cox and Webb, 2015),
only a few participants showed similar concerns and questioned the lack of cultural context
and determinants of health. The study showed that the psychiatrists found it difficult to
identify with the MHA’s approach due to its distinction between people suffering from
mental problems and mental disorders. The MHA has a continuum approach to mental health
with mental disorders (ODGJ) on the one side of the spectrum and mental problems (ODMK)
in between those and healthy states. Through the MHA the Indonesian government highlights
the view that anyone can suffer from a mental problem but that not all people will develop a
mental disorder. With high levels of stigma and little, yet increasing, information on mental
health for the lay public, this broad approach to mental health in the MHA could positively
affect the acknowledgement and acceptance of mental health and in turn identify earlier those
who are at risk of becoming mentally ill (Art 7). However, the implementation science
literature (Means et al 2020) has shown that a discrepancy in the psychiatrists understanding

1
of the content of an intervention can hinder the subsequent implementation process.
Moreover, some participants pointed out that the distinction could increase stigma due to an
ongoing lack of understanding of mental problems.
The lack of consensus among the psychiatrists on where the cut-offs are in terms of moving
from suffering from a mental problem to a more specific episode of a mental disorder reflects
a wider problem in the mental health literature on what underlies mental disorders and how to
define boundaries (Brugha, 2015). Since many participants said that they did not feel
involved with the MHA or that it was not the role of the Psychiatry Association to facilitate
the implementation or promote their views on legislation, it could explain why quite a few
psychiatrists did not engage with the MHA. Moreover, within the broader bureaucratic
organisational healthcare structure, psychiatrists may not see the relevance or opportunities to
be involved in shaping its implementation, which in turn can affect the implementation
success at a later stage as highlighted by the implementation literature (Esponda et al., 2020;
Means et al., 2020). Interestingly a recent study in Indonesia by Sustani et al. (2020) reported
on growing willingness by patients and family members to be more involved in shaping
mental health services for their care. Yet engagement happened mainly in the third sector as
community organisations were perceived to be more open to patient and public involvement
(PPI) and with less power imbalances than the formal mental health system (Sustani et al.,
2020). Future research may focus on third sector organisations and patients’ and their carers’
to explore their perceptions of their needs and legal rights contained in the MHA.
Moreover, all participants reported that many patients believed in the association between the
supernatural and mental health, leading patients seeking help from traditional healers. This is
in line with other studies conducted in Bali (Muryani et al., 2018; ; Suryani et al., 2011) and

1
other parts of the world (Nortje et al., 2016), showing that traditional or spiritual healers play
a large role in mental health care. The WHO (2013b) endorses engagement of traditional
health practices to improve the healthcare system. However, the participating psychiatrists in
the current study saw it as part of their role to educate people and primary care staff on
mental health in line with the medicalised discourse of healing, but not to work with
traditional healers. The ongoing debate in the literature on whether the diagnostics of Western
psychiatry are applicable within the local setting (Ecks, 2016; Suryani et al., 2011) was
hardly raised by the participants in this study nor were local belief systems or practices raised
in the MHA.
According to the participants, mental health remained a highly political issue due to
stigmatisation. This was heighted by the Health Ministry and Indonesian Psychiatric
Association (PDSKJI) announcing the classification of LGBT+ as people with a mental
problem (homosexual and bi-sexual) or a mental disorder (transgender), as alluded to by one
participant. This categorisation led to national and international responses (APA, 2016;
HRW, 2016). Without national support, mental health would most likely remain a low
priority. Unsurprisingly, the low priority of mental health was regarded the main barrier to
the implementation of the MHA at the local level. This was further exacerbated by previous
experiences of other Health Acts that had been passed but had still not been implemented.
Despite this, the psychiatrists reported the potential of the MHA and observed positive
changes, however small, that had already occurred. The participants welcomed the MHA
because it contributed to the importance of mental health, which in turn raised awareness and
could address the stigma surrounding mental illness. In line with other studies in Indonesia
(Irmansyah et al., 2020), the participating psychiatrists often attributed stigma to patients
experiencing discrimination or treatment delay. The wider literature shows that mental health

1
related stigma prevents family members and patients from seeking help (Irmansyah et al.
(2020). The underlying factors contributing to and the devastating effects of stigma are
increasingly researched and reported in the literature (Agustina et al., 2019; Henderson and
Thornicroft, 2009; Thornicroft, 2008). According to Mascayano et al. (2015), the lack of
investment in the mental health infrastructure and the absence of interest at national and
institutional decision-making levels influence stigma. As such, it could be argued that the
slow implementation of the MHA could indicate a lack of interest in people with mental
health conditions and could potentially increase negative attitudes towards mental illness.
One of the biggest challenges the participants faced that could be resolved by further
implementation was the integration with the other health services and social sectors. The
referral system had led to a push of dealing with mental health at the primary care level, a
development that is strongly promoted by the WHO. Task-shifting helps to address the
mental health needs at community level and in remote areas, though recent studies raise
questions about training and overburdening of primary care workers (Hoeft et al., 2018;
Praharso et al., 2020). With most participants being hospital-based they reported having little
contact with primary care staff and most were not engaged with mental healthcare at the
community level. As a result, the extent the psychiatrists can be aware of the scale of mental
health issues beyond their practice can be questioned.
This study found that treatment focuses mainly on medicalising patients with little help from
sectors outside the health service. Research shows the need for inter-sectoral collaboration for
mental health patients to deal with their lives (Patel et al., 2018). Without the implementation
of the MHA the participants noted a lack of accountability by other sectors and felt that
without this inter-sectoral approach their treatment would be less sustainable, thus increasing
the chance of patients’ relapse. The need for partners across other sectors to address the
treatment gap and the social and economic burden has been widely supported in the literature

1
(Patel, et al., 2018; Pathare et al, 2018) and highlighted by the Mental Health Plan 2013–2020
(WHO, 2013).
Another perceived barrier to achieve the quality care promoted in the MHA was the
insufficient resources. Some participants reported that the availability of resources and staff
varied across the regencies with wealthier regencies having better access for patients. This
overlaps with the finding by Tristiana et al. (2018) who found that patients on the island of
Java experienced ongoing barriers due to a lack of equal spread of resources and
psychiatrists. Future research is needed to look at the mental health care provided at the
primary care centres in the community.
Strengths and weaknesses
A strength of the study was that this is the first study that looks into the MHA from the
viewpoint of mental healthcare staff. According to the WHO (2013) this perspective is
important to facilitate the implementation of mental health laws and policies. Another
strength is the variability and regional coverage of the study sample, which included just over
half of the psychiatrists, who are the main professional group working with an expertise in
mental health in Bali. Finally, the international collaboration and expertise in the research
team allowed us to explore the broader mental health agenda in a cultural context.
Furthermore, several methodological considerations need to be taken into account. Firstly, the
participants were voluntary, and their responses could have been subject to social desirability
bias. While most participants spoke English, cross-cultural and linguistic elements, especially
when the interpreter translated concepts and meanings into the shared language of the team,
may have resulted in degrees of loss of meaning (e.g. Hennick, 2008). We counteracted this
possibility by cross-checking topics across interviews and through ongoing team discussions,
but we acknowledge that some meaning and context have been lost in translation.

1
CONCLUSION
With the above considerations in mind, the study demonstrated that psychiatrists in Bali
viewed the MHA as a welcome step in the right direction for Indonesian mental health
services. The study identified challenges regarding the implementation that can assist in
developing an evidence-base that can in turn inform the implementation process of the MHA
in Indonesia, and possibly elsewhere, into local level guidelines and regulations. Ultimately,
this would improve the quality of life of the people suffering from a mental health condition
and those who care for them.

1
REFERENCES
Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K.A., Suparmi, Achadi,E.L., et al.
(2019) Universal health coverage in Indonesia: concept, progress, and challenges. The
Lancet. 393: 75-102.
American Psychiatric Association (APA) (2016) APA denounces IPA-LGBT classification.
www.psychiatry.org [accessed 16/7/2020]
Asher, L., Fekadu, A., Teferra, S., De Silva, M., Pathare, S., & Hanlon, C. (2017). “I cry
every day and night, I have my son tied in chains”: Physical restraint of people with
schizophrenia in community settings in Ethiopia. Globalization and Health, 13(1), 1–14.
https://doi.org/10.1186/s12992-017-0273-1
Balitbangkes (2018) Riskesdas. https://www.kemkes.go.id/resources/download/info-
terkini/hasil-riskesdas-2018.pdf [accessed 16/7/2020]
BPS(2015)https://www.bps.go.id/publication/2016/11/30/63daa471092bb2cb7c1fada6/profil-
penduduk-indonesia-hasil-supas-2015.html, [Accessed 12/1/2020].
Braun, V., & Clarke, V. (2006) Using thematic analysis in psychology. Qualitative Research
in Psychology, 3:2, 77-1-1
Brugha, T. (2015). Mental Health. In International Encyclopedia of the Social & Behavioral
Sciences: Second Edition (Second Edi, Vol. 15).
Bunnis, S., & Kelly, D.R. (2010). Research paradigms in medical education research.
Medical Education Research. 44: 358-366.
Byng, R., Groos, N., & Dowrick, C. (2019). From mental disorder to shared understanding: A
non-categorical approach to support individuals with distress in primary care. British Journal
of General Practice, 69(680), 110–111.

1
Cooper, S. (2016). Global mental health and its critics: moving beyond the impasse. Critical
Public Health, 26(4), 355–358.
Cox, N., & Webb, L. (2015). Poles apart: Does the export of mental health expertise from the
Global North to the Global South represent a neutral relocation of knowledge and practice?
Sociology of Health and Illness, 37(5), 683–697.
Depkes RI (1993) Pedoman Penggolongan dan Diagnosis Gangguan Jiwa di Indonesia
(PPDGJ) III. 1st ed. Jakarta: Departemen Kesehatan Republik Indonesia.
Diatri, H., & Maramis, A. (2015). Indonesia. In D. Bhugra, S. Tse, R. Ng, & N. Takei (Eds.),
Routledge Handbook of Psychiatry in Asia (1st ed.). London: Routledge.
Ecks, S. (2016). Commentary: Ethnographic critiques of global mental health. Transcultural
Psychiatry, 53(6), 804–808.
Esponda, G.M., Hartman, S., Qureshi, O., Sadler, E., Cohen, A. & Kakuma, R. (2020)
Barriers and facilitators of mental health programmes in primary care in low-income and
middle-income countries. The Lancet Psychiatry, 7(1), 78-92.
Henderson, C., & Thornicroft, G. (2009). Stigma and discrimination in mental illness: Time
to Change. The Lancet, 373(9679), 1928–1930.
Hennick, M.M. (2008) Language and communication in cross cultural qualitative research. In
Doing Cross-Cultural Research. Ed. Liamputtong, P. int.: Springer.
Hoeft, T. J., Fortney, J.C., Patel, V. & Unützer, J. (2018). Task-Sharing Approaches to
Improve Mental Health Care in Rural and Other Low-Resource Settings: A Systematic
Review. Journal of Rural Health, 34(1), 48–62.
Human Rights Watch. (2016). Living in Hell: Abuses against People with Psychosocial
Disabilities in Indonesia. Retrieved from https://www.hrw.org/node/287537/

1
Human Rights Watch (2016) Letter to Indonesian MoH on LGBT.
https://www.hrw.org/sites/default/files/supporting_resources/hrw_letter_to_indonesia_moh_o
n_lgbt_final.pdf [Accessed 11 August 2020]
Indonesian Ministry of Health (2018) Riskesdas 2018.
http://www.kesmas.kemkes.go.id/assets/upload/dir_519d41d8cd98f00/files/Hasil-riskesdas-
2018_1274.pdf [Accessed 26/3/2020]
Institute of Health Metrics and Evaluation (IHME), Global Burden of Disease (GBD) -
http://ghdx.healthdata.org/gbd-results-tool. [Accessed 5/1/2020]
Irmansyah, I., Prasetyo, Y.A., & Minas, H. (2009). Human rights of persons with mental
illness in Indonesia: More than legislation is needed. International Journal of Mental Health
Systems, 3, 1–10.
Irmansyah, I., Susanti, H., James, K., Lovell, K., Idaiani, S., Imah, S., et al. (2020)
Civic engagement and mental health system strengthening in Indonesia: a qualitative
examination of the views of health professionals and national key stakeholders. BMC
Psychiatry, 20(1), 1-15.
Kutzin, J., Witter, S., Jowett, M., & Bayarsaikhan, D. (2017). Developing a National Health
Financing Strategy: a Reference Guide. Retrieved from http://apps.who.int/bookorders.
Mascayano, F., Armijo, J. E., & Yang, L.H. (2015). Addressing stigma relating to mental
illness in low- and middle-income countries. Frontiers in Psychiatry, 6(MAR), 1–4.
Means, A. R., Kemp, C.G., Gwayi-Chore, M., Gimbel, S., Soi, C., Sherr, K., et al. (2020)
Evaluating and optimizing the consolidated framework for implementation research (CFIR)
for use in low- and middle-income countries: a systematic review. Implementation Science,
15(1), 1-19.

1
Mellsop, G.W., Menkes, D.B. & El-Badri, S.M. (2007) Classification in psychiatry: does it
deliver schizophrenia and depression? International Journal of Mental Health System. 1:7.
Minas, H. (2009). Mental health and human rights: Never waste a serious crisis. International
Journal of Mental Health Systems, 3, 1–3.
Minas, H., & Diatri, H. (2008). Pasung: Physical restraint and confinement of the mentally ill
in the community. International Journal of Mental Health Systems, 2.
Muryani, N. M. S., Winarni, I., & Setyoadi, S. (2018). Balinese Traditional Treatment
(Balian) in Patients With Mental Disorders. Belitung Nursing Journal, 4(4), 397–402.
Nortje, G., Oladeji, O., Gureje, O. & Seedat, S. (2016) Effectiveness of traditional healers in
treating mental disorders: A systematic review. The Lancet Psychiatry, 3(2), 154-170
Patel, V., Saxena, S., Lund, C., Thornicroft, G., Baingana, F., Bolton, P., et al. (2018) The
Lancet Commission on global mental health and sustainable development. The Lancet,
392(10157), 1553–1598.
Praharso, N., Pols, H. & Tiliopoulos, N. (2020) Mental health literacy of Indonesian health
practitioners and implications for mental health system development. Asian Journal of
Psychiatry. https://doi.org/10.1016/j.ajp.2020.102168 (in press).
Pathare, S., Brazinova, A., & Levav, I. (2018). Care gap: A comprehensive measure to
quantify unmet needs in mental health. Epidemiology and Psychiatric Sciences, 27(5), 463–
467.
PDSKJI - Perhimpunan Dokter Spesialis Kedokteran Jiwa Indonesia (2016) Indonesian
Association Statement Letter. http://www.idionline.org/berita/pernyataan-sikap-pdskji-
tentang-lgbt-2/ [Accessed 11 August 2020]

1
Pols, H., Setiawan, G. Marchira, C., Irmansyah, Suci, E., Good. B. & Good., M. (2019) Jiwa
sehat, negara kuat: masa depan layanan kesehatan jiwa di Indonesia. Jakarta: Kompass
Publishers Ltd.
President of the Republic of Indonesia (2014) Mental Health. www.mindbank.info/item/5193
[accessed 02/04/2016]
Suryani, L.K., Lesmana, C.B.J., & Tiliopoulos, N. (2011). Treating the untreated: Applying a
community-based, culturally-sensitive psychiatric intervention to confined and physically
restrained mentally ill individuals in Bali, Indonesia. European Archives of Psychiatry &
Clinical Neuroscience, 26 (2), 140-144.
Susanti, H., James, K., Utomo, B., Keliat, B., Lovell, K., Irmansyah, I., et al. (2020)
Exploring the potential use of patient and public involvement to strengthen Indonesian mental
health care for people with psychosis: A qualitative exploration of the views of service users
and carers. Health Expectations, 23(2), 377-387.
Thornicroft, G. (2008). Stigma and discrimination limit access to mental health care.
Epidemiologia e Psichiatria Sociale, 17(1), 14–19.
Tristiana, R.D., Yusuf, A., Fitryasari, R., Wahyuni, S. D., & Nihayati, H.E. (2018). Perceived
barriers on mental health services by the family of patients with mental illness. International
Journal of Nursing Sciences, 5(1), 63–67.
United Nations (2015) Sustainable Development Goals.
https://sustainabledevelopment.un.org/?menu=1300 [accessed 6/10/2019]
United Nations (UN) (2006) Convention of Protection of Persons with Mental Illness and
Improvement of Mental Health Care. United Nations: New York.

1
Vigo, D., Thornicroft, G., & Atun, R. (2016). Estimating the true global burden of mental
illness. The Lancet Psychiatry, 3(2), 171–178.
WHO. (2005). Promoting mental health. In WHO. https://doi.org/10.5840/ncbq201616462
WHO. (2013). World Health Organisation Mental Health Action Plan 2013-2020.
WHO (2013b) WHO Traditional Medicine Strategy 2014-2023. Retrieved from
https://www.who.int/medicines/publications/traditional/trm_strategy14_23/en/ [Accessed
28/7/2020]
WHO (2017a). Mental Health ATLAS 2017 member state profile. Retrieved from
https://www.who.int/mental_health/evidence/atlas/profiles-2017/IDN.pdf?ua=1 [Accessed
8/3/2020]
WHO (2017b). Indonesia Mental Health ATLAS 2017 member state profile. Retrieved from
https://www.who.int/mental_health/evidence/atlas/profiles-2017/IDN.pdf?ua=1 [Accessed
8/3/2020]
Zhou, W., Yu, Y., Yang, M., Chen, L., & Xiao, S. (2018). Policy development and challenges
of global mental health: A systematic review of published studies of national-level mental
health policies. BMC Psychiatry, 18(1), 1–9.