MLM Pasung “ East Java Quick Way Free Deprivation”
Menur Mental Hospital, East Java Provincial Government

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Mistreatments toward people with severe mental disorders are evident in Indonesia. Particularly in East Java, many of them found chained under trees or locked in goat pens, or their legs shackled in wood logs. Many of them have to live in these inhumane conditions. These practices are known as pasung, which have been adopted by traditional and indigenous communities to treat mentally ill person from generation to generation. Despite the practice of pasung has been nationally banned since 1977 under the Ministry of Internal Affair Article Number 06/29/1977, the incidence was never stop increasing. Not until the MLM-Pasung first implemented in mid-2014, the Indonesian National Health Research Board (Riskesdas) reported that the incidence reached the highest number in 2014. It was reported that 57,000 of the 400,000 populations with severe mental disorderswere shackled. Particularly in East Java, the Department Health recorded that in 2010 about 3,011 patients were beingpasung. Until the first half of 2013, there were 2,179 cases of pasung reported spread acrossin 38 cities and regions. A field analysis suggests that the pasung was contributed by economic powerlessness and lack of knowledge of the families in caring for the patients. On the other hand, the insufficiency in mental health promotion efforts andsystem to handle the patients and government’s attention fostered the high incidence of pasung. Both economic limitations and lack of understanding toward mental disorders led many families to consider pasung as the practical way in caring mentally ill patients. On the other hand, the government’s lack of attention to mental health issues had caused the availability of mental health facilities limited to only in towns and bigger cities. This made many patients who lived in smaller villages unable to access the service. The pasung causes at least three negative impacts, including poor quality of life, potential revenue loss, and, the decreasing government's credibility. Not only does the practice cause the patientsunable to move their feet, andfurther to fulfil their daily needs. This practice is considered as human rights violations and deliberate attempts to harming the patients.Secondly, this will contribute to the loss of potential income. For example, if the local minimum wage is Rp.2.000.000,- per month (equivalent to US$ 500), any person suffering from mental disorders will contribute to the loss of local revenue as much as Rp.24 million (equivalent to US$ 6,000) per year. On a national scale, this will lead to the revenue loss of around Rp. 1,368 trillion(equivalent to US$ 257 billion) per year. All these consequences highlight the need for a feasible solution that can be implemented immediately. In 2014, Menur Psychiatric Hospital introduced the idea of adapting the Multi-Level Marketing system as the strategy to eliminate pasung practice in East Java. In the following years, it attracts other provinces to replicate the strategy, and brings several national recognitions and awards.

B. Strategic Approach

 2. What was the solution?
MLM-Pasung offers a feasible solution in reducing pasung victims. It involves communities and stakeholders to participate in assuring equal human rights for all mental-health patients. It aims to promote mental-health in Indonesia.

 3. How did the initiative solve the problem and improve people’s lives?
A strong commitment between mental health stakeholders (including the Department of Social Service, The Department of Health, national security forces and psychiatric hospitals) and end users (families and the community) is required to solve complex social problems caused by Pasung. The Multi-level Management Pasung (MLM-Pasung) presents a creative and innovative way to engage all stakeholders and end users to work together in providing the proper care for mentally ill patients under the coordination of the community mental health managing team (Tim Pengarah/PelaksanaKesehatanJiwaMasyarakat, or TPKJM) of East Java. The MLM–Pasung initiative adapts the framework of multi level marketing (MLM), where up-liners feed and support the down-liners. The Governor, Provincial Secretary, Bureau of Public Welfare, Department of Social Services, Department of Health, and the main referral mental hospital are the highest order of stakeholders that are responsible to prepare regulations and policies and technical guidelines in pasungliberation, to receive a referral from the lower level, and to facilitate capacity building programs to strengthen the human resource. These products are run by the secondary level of stakeholders in caring mental health clients with the most possible-proper care. City Mayors and Regents, Health Office, Social Office, Resort Police, and Public Hospitals are the secondary level stakeholders who responsible in coordinating the Districts Social Welfare Taskforce (TenagaKesejahteraanSosialKecamatan or TKSK) and the Puskesmas (The Primary Healthcare Service run under the Ministry of Health). These stakeholders work in coordination with Puskesmas collecting and reporting data, providing assistance and refferal for pasungpatients, and monitoring the progress of ex-pasungpatients. At this level, the Department of Social service is responsible in providing shelters for ex-patients who are not accepted by their families, as well as facilities and other infrastructures to support the care delivery for the patients. On the other hand, the Department of Health holds the responsibilities to prepare and ensure referral hospitals for ex-pasung patients in terms of their health-needs and medical supplies, as well as evaluating the MLM-Pasung implementation under its working area. The Primary level stakeholders, the patients’ families, community leaders, local authorities, NGOs, and criticises are actively involved in active case finding, report making, assisting, unleashing and further to providing a community-based rehabilitation program for the patients; while Psychiatric Hospitals (like Menur and Lawang Mental Hospitals) role as the referrals for the patients.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The MLM-Pasung initiative is regarded creative and innovative at least in three ways. The involvement of multiple stakeholders in a tiered collaboration work is a new strategy in the management of Pasung that has never been implemented anywhere else before. Secondly, the initiation also facilitates the growth of ideas, such as “Pasung Award” and “Pasung Jamboree”. The idea of “Pasung Award” is proven effective to trigger many city mayors and regents to promote pasung-free area througout the province of East Java. This effort is in-line with the Governor’s projection in pioneering East Java as pasung-free province. The Pasung Jamboree, on the other hand, facilitates all ex-pasung patients to participate in several competitions. All these made the MLM-Pasung unique and bring additional benefits yet more to come. All in all, this initiative has had invited all mental-health stakeholders to take part in handling the pasungphenomenon, which in turn improves the mapping of pasung status throughout the province.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
A team of nurses of the Menur Mental Hospital of Surabaya offered the idea of MLM-Pasung. It is the increasing incidence of pasung practice in East Java idea was the team's concern, particularlyin how to look for a feasible solution. However, the TPKJM was not yet able to offer a strategic idea to solve the problem. In mid-2014 the nurse team then proposed the adaptation of a multi-level marketing framework as the strategy to reduce pasung practice in East Java. At the end of the year, this idea was firstly implemented in East Java. The pilot project of the MLM-Pasung was conducted in the city of Ponorogo. The main targeted service users of MLM-Pasung are patients subjected to pasung practice and their families who were financially poor and unable to access mental health services. Out of the targeted victims in Ponorogo, as many as 50 people was successfully released from pasung in 2015. On the following year, the project was disseminated to other cities like Pasuruan, Tuban, Lamongan, Sidoarjo, Mojokerto, and Bojonegoroand began to be implemented in the 38 cities and regions of East Java. This initiative has successfully released 276 pasung patients in 2016. This year (2017), it is expected that the MLM-Pasungcould reach more patients and further support East Java as a Pasung-free area.
 6. How was the strategy implemented and what resources were mobilized?
Initially, the secondary and tertiary levels of stakeholders map to analyse the situation in the 38 regions and cities of East Java. This mapping process is essential to set up the priority and the outcome targets of each region. The mapping initial result recommends the necessity for city Mayors and Regents to launch the local movements (GerakanAksi Daerah). The mapping process also stratifies cities and regions into four levels of classifications, including pasung-free zone, pasung-alert zone, pasung-high alert zone, and pasung-crisis zone. The pasung-free zone refers to any region or district where none of mental health patients were being shackled or pasung, while the pasung-alert zone are to describe cities that have approximately 5 incidencesof pasung practice. The high alert zone refers to any region where up to 20 pasungcases can be found, otherwise can be classified as a pasung-crisis zone. This mapping process would bring invaluable information for the government to initiate “Pasung Award” and “Pasung Jamboree” as triggers for regions and cities to suppress pasung practices. Like in 2015, the government of Jombang, a small town located 2 hours driving to the west of Surabaya, won the award and the city of Sidoarjo took the first prize of the 2016’s Pasung Jamboree. Respectively, the MLM-Pasung relies on four phases, namely policy provision, capacity building and skill preparation, infrastructure and service improvement, and cross-sector commitment reinforcement. First, it is the role of the provincial government at the tertiary level by supporting the MLM-Pasung with policies and assigning the taskforce of TPKJM. Like in East Java, this team was firstly assigned in June 15th, 2013. In another instance, the governor also launched a program of “East Java: a Pasung-Free Area” in June 20th, 2014. The issue of the technical guidelines in releasing pasung victims followed this step under the Governor’s Letter number 460/11166/2014. As the support, another political product was issued under the Governor’s Regulatory Act number 86 year 2014 to endow medical treatments for ex-pasungpatients (under the scheme of East-Java Social Health Insurance, namely the JAMKESDA). As the following phase, the MLM-Pasung envisions the capacity building programs for all health professionals in the primary level. The programs are prior to their main role as the first referral for families and patients to seek professional help. Some of the examples that have been conducted in East Java are trainings for doctors and nurses who were working in the Puskesmas (Primary Health Centres), education and trainings for mental health volunteers, and technical assistances for social workers and families. All of these, the government of East Java has to invest around US$ 7,500 for the health professional trainings, and US$ 37,500 for family supporting programs. Third, improvement in supporting infrastructures and services are fundamental in the implementation of MLM-Pasung. The focuses of this effort are to support early case finding through Posyandu(a monthly community-based health screening program run under the coordination of local Puskesmas), promoting pasung-free villages, providing ambulance services for mental health patients, developing electronic database for pasung (e-pasung), and assigning social-welfare taskforce (TenagaKesejahteraanSosialKecamatan or TKSK) to cover areas of sub-districts in every city or region.Specific to the need of an ambulance, the cost is estimated around US$ 22,500, and about US$ 37,500 to develop the electronic database. The fourth element is the strong commitment among all stakeholders to assure the continuation and sustainabilitythe MLM-Pasung. As the case of East Java, the commitment was declared in a Memorandum of Understanding.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The stakeholders involved in the design and implementation were: 1). Tertiary Level: • Governor as the head of the province had supported the movement of East Java Free of Pasung by means of MLM-Pasung Innovation. • Regional Secretary of East Java Province. • Regional Planning and Development Agency ( Bappeda ). • Menur Mental Hospital. • Social Sevices. • Health Department. • Community Welfare Bureau • Lawang Mental Hospital 2). Secondary Level: • Regents and Mayors of East Java. • Regency / city Health Department • Regency / city Social Services • Regency / city Regional Secretary • Regency / city Regional Public Hospital 3). Primary Level: • Community Health Center • District • Village • Public / religious figures • Mental Health Cadre • Non-governmental Organization • Health Education sector • Mass Media

 8. What were the most successful outputs and why was the initiative effective?
The number of pasung victims decreased to 65.7% in the period of three years which was 2179 people in 2013 to 749 people in the end of December 2016. It is targeted that by the end of 2018 East Java will become a province that is free of pasung cases. The increasing participation and concern of the society whether individual or non-governmental organization involved in the pasung victims management is proven with the establishment Mental Health Cadre and financial support from CSR in order to empower the victims of pasung. The increasing cross sectoral and program cooperation among the stakeholders is indicated by the signing of the shared commitment. E-Pasung is an electronic based application that contains names, addresses, photos and the latest conditions of the patients. This application is helpful in terms of accuracy of pasung victim data in East Java. The 217 cured patients have returned to their families, and have been successfully empowered in business sector that generates income. The “Unit of Pasung Services” has been established that serve transportation of refered patients from and to Mental Hospital. Ex-psychotic and ex-pasung shelters are available in several regencies. These shelters can provide advantages for the families of pasung victims who are ready to accept the cured patients after having the treatment in the hospital.

 9. What were the main obstacles encountered and how were they overcome?
• The rejection from the families and society when the pasung victim is going to be returned to his home after the treatment in the hospital was the main obstacle during the process of MLM-Pasung implementation. • The recurrence of physical restraint by the family and society after the treatment in the Mental Hospital. • Unequal awareness of the regency / city government had some impacts in MLM-Pasung innovation. • Limited budget allocated for the innovation implementation became an obstacle in the output achievement. • Lack of publication through national newspapers has made this innovation is not wellknown to the public.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Some of the major benefits of the innovation are the improvement in health service accessibility, and better quality of life for patients and families. It is reported that at the end of 2016 about 1,430 mentally ill patients were released from pasung. Not only does this suggest that their health is improved, but also their human rights are regained. On the other hand, it also facilitates poor families to take care of their mentally ill members properly through the referral system and financial support provided by the government. This assures that all ex-pasung patients are properly taken care in mental health facilities, while families are prepared to accept their members when discharged from the hospitals. It is the role of the government to provide financial support and entrepreneurial assistance for families and ex-pasung patientsto regain their incomes and proper living. In wider aspect, the MLM-Pasung enhances larger groups of people’s awareness about and attention to mental health and pasung practice. Field notes gathered from the e-pasung suggest that there is a positive trend in community’s participation in ending the inhumane practices of pasung. It is reported that in 2014 about 472 of people assigned themselves as mental health volunteers in about 38 cities and smaller towns wide spread throughout the province. To date, it is reported that about 682 people assigned them selves as volunteers. This number was increased by 30% when compared with the total volunteer in 2016. Likewise, the CSR participation is also increasing along the years. It was only 2 CSR participating in the first year of the MLM-Pasung. To date there are 7 CSRs participating in ending the pasung, all of which concern to empower patients’ financial stability. In regard to positive exposure, the MLM-Pasung does improve the government’s good name. The decreasing trend of pasung practice contributes invaluable credits to the government’s good image, particularly in reassuring the progress of mental health development. This achievement was only made possible by the improved coordination among stakeholders at all level. Not only is the achievement appreciated by the Ministry of Health of the Republic of Indonesia (2016), but also in several awards, such as the top 99 national innovation documented by the Public Service Innovation Network (JaringanInovasiPelayananPublik) in 2016, the 2016’s top innovation award under the subject: bureaucratic reform in public service, and nominated in the 2017 public service innovation competition that will be held by the Ministry of Administrative Affairs and Bureaucratic Reform. As a reward, the governor of East Java assigns an independent body to assist the MLM-Pasung’s document and promotes the innovation in an international competition in 2016.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The initiative of MLM Pasung does improve the integrity of mental health service in terms of availability, continuity of care, and empowerment. Given that in old days patients accessibility was low due to the absence of mental health services in rural and small villages, the MLM-Pasung offers farther reach nearly to the most remote community housing. The service is now more available through the active involvement of Puskesmas, Puskesmas Pembantu (small branch of Puskesmas), and empowered mental health volunteers and community leaders. Secondly, the involvement of tiered stakeholders guarantees the continuity of care by providing systematic referrals both in regard to patient care and capacity building programs. This way, the MLM-Pasung allows better management in mental health care in East Java. Thirdly, the initiative is proven to regain active participations of all stakeholders to empower patients, families and communities. For instance, the Puskesmas is now actively promoting mental health, and recruiting and training the volunteers. In another instance, public hospitals are now available for caring the mentally ill patients; mental hospitals are now actively providing occupational therapies and family empowerment programs. On the other hand, the initiative also improves the accountability of service by sharing proportional responsibilities for each level of stakeholders. Under the implementation of MLM-Pasung scheme, all involved stakeholders are reinforced to declare their commitment in MoAs, through which their parts are accounted and regularly reported to the government.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
This initiative is not yet legally supported to operate. However, it is politically supported under the Governor’s Act number 86/2014 that regulates the claim and reimbursement of health services provided for poor patients and financially vulnerable communities. This policy assures the accessibility of free-of-charge services for patients and families who cannot afford proper mental health care in all public hospitals spread out in the province. This act also covers the cost of ambulance transports, and medical and medication supplies for the poor. The initiative is also financially supported to allow stipends for families who have to stay accompanying the patients in hospitals. As much as Rp. 450,000 (equivalent to US$ 45) is provided to cover the transport costs for these families per three days of visiting the patients while being taken care.

Contact Information

Institution Name:   Menur Mental Hospital, East Java Provincial Government
Institution Type:   Local Government  
Contact Person:   Adi Wirachjanto
Title:   Doctor  
Telephone/ Fax:   +6231 5021635 (Tel), +6231 5021636(Fax)
Institution's / Project's Website:  
Address:   Menur Street No. 120
Postal Code:   60282
City:   Surabaya
State/Province:   East Java

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