Questions/Answers

Ministry of Health reported that in 2014, 57,000 people with mental disorders were held in restraints, wellknown as pasung in Indonesia. In East Java, 1033 cases of restraints were spread across 38 regencies and cities. Restraint or Pasung is a subtle human right violation as the victims of restraints are locked in the cattle cage or tied to the tree or isolated in the small room for years. URL:(http://rsjmenur.jatimprov.go.id/system/application/views/download/Foto%20korban%20pasung%20di%20jawa%20timur.pdf) The impacts of the restraint, among are: 1. Worsened physical and psychological conditions of the victims 2. Loss of victims’ rights to attain adequate treatment 3. Loss of potential income if eventually the victim is possible to be cured and work for family support. Problems before the innovation was applied are as follow: 1. Negative stigma of mental disorders from communities. 2. Limited numbers of trained health workers and facilities in the primary care centre. 3. Lack of treatment access for the victims Thus, Provincial Government of East Java created an innovative breakthrough named Multi Level Management (MLM – Pasung) “An Effective Way Towards Restraint-Free East Java”. It is a strategy of treating the victims of restraints by three tiers of stakeholders (tertiary, secondary and primary levels) including government, private sector and community. They synergize and collaborate to handle the victims of restrain in accordance with their functions and tasks. MLM- Pasung can shorten the steps of bureaucracy, thus the restraint issue management becomes more effective. This innovation has four strategic approaches: 1. Strengthen the policy and regulation 2. Strengthen the competencies of human resources 3. Provide facilities 4. Strengthen inclusive services Since the innovation was launched in 2015, the number of restraint cases decreased from 3451 to 749 people in 2017. Next target is East Java Province - free from restraints in 2019.

Previously, Provincial Government of East Java treatment system of restraint victims was not effective yet, despite the Indonesia Free from Restraints program was launched in 2010. It was proven by the finding of Kampung Gila (Crazy Village) by the mass media in Ponorogo Regency. The kampung is occupied by 62 people with mental disorders and 19 mentally retarded people. The massive coverage by media has encouraged the provincial government to accelerate the treatment for the victims of restraints through MLM-Pasung innovation. The innovation aims to: a. Provide comprehensive treatment, from prevention, care/medication to recovery and empowerment through inclusive services that enable mental care providers to reach all levels without long bureaucracy. b. Offer solution to treat victims in collaborative and tiered way as a reference and guidance to empower all stakeholders in eliminating the practices of restraints aligned with their functions and tasks. c. Empower the victims and their families, and also the communities through mental care provider trainings. d. Accelerate the achievement of East Java - Free from Restraints in 2019 program. Provincial government chose the third category of SDGs in order to ensure good health and promote well-being for all within every ages.

The MLM-Pasung innovation is a unique and creative innovation that provides collaborative mental care services by all tiers of government to manage the victims of restraints (pasung) which shorten the steps of bureaucracy, thus the restraint issue management becomes more effective. The innovation includes: 1. Comprehensive services a. Victims of restraints will obtain treatment and medication without any charge. b. The services include: released from the restraint, pickup, reference, hospital treatment, repatriation, rehabilitation, home visit and family empowerment. 2. Through integrated services based on partnership between government, community and private sector, MLM-Pasung innovation offers a real solution in treating victims of restraints in comprehensive and sustainable way by conducting prevention, medication, rehabilitation, family empowerment, stigma elimination, family’s financial capacity enhancement, and easy access to health care services. 3. Socialization and promotion of mental health care services in several regencies and cities through interactive dialogues in electronic media, printed media coverage, mental health care trainings for doctors, nurses and community health centre personnel, and cooperation with inclusive schools for special needs children. 4. The steering/organizer committee for Public Mental Health conducts coordination meeting every three months to evaluate the achievement of East Java - Free from Restraints program.

The effects of MLM-Pasung innovation toward people’s lives im East Java are: 1. Decreased number of restraint cases in East Java. According to the data from Health Office, the number of restraint victims decreased up to 80% from 3451 people in 2015 to 749 in 2017. 2. Improved primary mental health care services (Puskesmas or Community Health Center) along with the establishment of 14 Supporting Puskesmas for Mental Health Care Service in several regencies and cities. 3. Increased community awareness of the mental health treatment shown by the increased number of patients visiting the outpatient clinic in Menur Mental Hospital from 33,975 in 2014 to 39,332 in 2017. 4. Faster response of handling the restrain cases by simplifying the mechanisms and procedures. For example, Puskesmas will contact the Emergency Department of Menur Hospital if they need referral information or assistance for releasing the restraints. Previously, Puskesmas would refer the patients to the City/Regency’s General Hospital before sending them to the Menur Mental Hospital. 5. Increased financial income of the victim’s family through the Productive Economy Entrepreneurship (PEE) program from Social Office at Provincial level who has distributed funds of IDR 4,000,000/family.

The MLM-Pasung innovation covers important issues on healthy psychosocial and prosperous life of mentally-disabled groups and poverty eradication for restraint victims and their families. a. People with mental disability whom are victims of restraint practices shall receive quality, affordable and safe healthcare services. Successful treatments will help the victims and their family to regain their social and economy power. b. The release of restraint and comprehensive treatment will lower the negative stigma towards the victims and their families as well as avoid them from the rejection coming from their neighbourhood or surrounding people. For example, the victim who was successfully cured can go back to their community, working and socializing. This will send positive image to the public that the victims of restrains suffering from serious mental disorders are possible to be cured. c. Increased social participation in mental health development which is proven by the formation of mental health personnel. d. Increased socio-economic dependency of the families through the assistance from productive economy entrepreneurship program.

The victims of restrains are people with serious mental disability whom oftenly experienced social discriminations and difficulties to access healthcare services. Most of them came from poor family. Since the MLM-Pasung innovation was applied in East Java in 2015, its positive impacts include: 1. The victims received comprehensive services, from the releasing, pickup, reference, hospital treatment, repatriation, rehabilitation, home visit and family empowerment. 2. The victims received comprehensive and sustainable treatment through prevention, medication, rehabilitation as well as family empowerment, stigma elimination, financial ability improvement and easy access to health care services. 3. This innovation empowered the victims and their families through financial assistance and skill trainings.

The MLM-Pasung innovation is an original idea from Menur Mental Hospital as one of the regional organizations (OPD) under Provincial Government of East Java and has never been conducted in other regions. The uniqueness of this innovation includes: 1. The term MLM (Multi-level Marketing) in business/direct selling world refers to the product selling system where the upline drives the downline to achieve selling targets. While in the MLM (Multi-level Management)-Pasung, the tertiary level drives the secondary and primary level to manage the victims of restraints. 2. Collaborative service by engaging all stakeholders including the executive, the legislative, private sector and community, among them are Provincial Parliament or DPRD, Provincial, Municipal, Regency Government, Corporate Social Responsibilities (CSR), the Indonesian Community Care for Schizophrenia (KPSI), mental healthcare personnel, NGOs, volunteers from education institutions, Community Mental Health Nursing, and other stakeholders. 3. The MLM-Pasung was able to change the reference service pattern into family and community-based inclusive service pattern. 4. The leveling of stakeholders based on their tasks and responsibilities made the innovation unique and innovative.

The Governor who is responsible for mental healthcare services in East Java received the information from mass media regarding the “Crazy Village” whereby many people with mental disorders were restrained. The Governor then instructed the Health Office of East Java Province to prepare a strategy for handling the restraint victims. The existing restraint management system coordinated by the Steering/Executing Team for Public Mental Health (TPKJM) was not optimal yet due to hierarchical and long bureaucracy and inaccurate record process. In addition to that, the budget for handling of victims was still unclear while competent personnel were still limited. Realizing these, Menur Mental Hospital came up with an innovative breakthrough “The MLM-Pasung” which adopts the Multi-level Marketing system in product-selling whereby an upline drives the downline while in MLM-Pasung, the tertiary level drives the lower-level stakeholders. Therefore, MLM-Pasung innovation is an original idea initiated from the dilemma of restraint victims with mental disorders in East Java.

Stakeholders provide assistance, such as: 1. Financial resources a. Provincial Government allocated budget of IDR 15,000,000,000 in 2014 through Local Development Working Plan. b. Health Office of Ponorogo Regency allocated IDR 14,400,000 in 2014 for integrated mental health services provided by Puskesmas. c. Menur Hospital received Local Budget Allocation up to IDR 571,000,000 in 2015, IDR 271,200,000 in 2016 and IDR 224,850,000 in 2017 for improving the accessibility of victims of restraints also inclusive service. d. Provincial Social Welfare Office received IDR 1,400,000,000 for family-based victim handling programs. e. The private sector provide CSR (corporate social responsibility) for example to hire the ex-pasung as employee at carwash, food home industry, cleaning service, and also fascilitate handycrafts materials. 2. Facilities Four vehicles for pickup service unit and shelters for Social Office of Provincial Government and in each regency. 3. Human resources include: -Governor of East Java Province -Director of Menur Hospital whom prepared 4 psychiatrists and 10 nurses. -Chief of Health Offices of Provincial and Regency/Municipal Government. -Chief of Social Welfare Offices of Provincial and Regency/Municipal Government. -Local Parliament at Provincial and Regency/Municipal Levels. -Head of Puskesmas. -Babinsa and Babinkamtibmas. -Al-Hafizh Foundation for Mental Rehabilitation. -Village personnel. -Public Figures.

Yes

Yes. In 2016, the Provincial Social Welfare Office has developed an innovation called Integrated Administration Management (ATM-Pasung) “Free from Restraint without Re-restraint”. It is a continuation of restraint victims handling management. The ATM-Pasung is a data-based program using E-Pasung Application to record the actual number of restraint victims in East Java. Several government institutions from other provinces and regencies have carried out study visits and showed their interests to replicate the restraint handling system applied in East Java. Among these governments are Provinces of West Java, East Kalimantan, and South Kalimantan. They are concerned on the policies of Provincial Governments related to the treatment of victims of restraints, financing, reference system, provision of resources including regulations of medication provision, the enhancement of human resource competencies, treatment of the victims in Menur Hospital, and post-treatment rehabilitation programs in Menur Hospital.

This innovation has successfully drove all stakeholders to engage in handling the practices of restraints whereby its sustainability is reached through 1. Social aspect. a. Socialization and publication of MLM-Pasung Innovation through printed and electronic media. The socialization also includes the testimony session of the victims of restraints in the annual Mental Health Jamboree organized by Provincial Government of East Java. These activities will raise people’s awareness of proper treatment for victims of restraints, eliminate negative stigma and build people’s faith that People with Mental Disorders can be cured. b. Re-socializing efforts under the coordination of Provincial Social Welfare Office. 1) To prepare the family and community to welcome the victims through outreach training programs, counsellings and persuasive activities. 2) Social rehabilitation for ex-mentally disordered people. 2. Economic aspect. a. Provincial Government prioritized this innovation by providing financial assistance up to IDR 4,000,000/family for victims’ family through Productive Economy Entrepreneurship program. b. The engagement of private sector through CSR. Several automotive companies distributed raw materials for handmade crafting through Community Mental Health Nursing. c. Stimulant assistance and basic needs support for victim post-treatment period provided by Provincial Social Welfare Office. 3. Environmental aspect coordinated by tertiary level a. Socialization of Governor’s Circular Letter No. 460/11166/031/2014 on Releasing the people with schizophrenia from the restraints. b. Declaration of East Java Free from Restraints by the Governor on June 20, 2014 and later followed by all Regents/Mayors. c. Referral to treatment and medication in Menur Mental Hospital. d. Family gathering in village halls to accommodate sharing session among victims’ families during the treatment process. The session is guided by personnel from sub-district Social Welfare office.

The sustainability of MLM-Pasung Innovation can be guaranteed through: a. Legal aspect - Governor’s Circular Letter No. 460/11166/031/2014 on Releasing the people with schizophrenia from the restraints. - The Regulation of East Java Governor No. 41/2016 on Referral System in Health Care whereby the article 23 explained about the Referral Facilities for Mental Illness case - The Regulation of the Health Minister No. 54/2017 on The Elimination of Restraints for People with Mental Disorders. - The Regulation of East Java Governor No. 87/2017 on Financing Health Care Service for Poor People in East Java Province. - The availability of Technical Guidance for Restraints Release. - Provincial Budget included in the Budget Execution Documents of Provincial Social Welfare Office, Health Office and Community Welfare Bureau. b. Facilities - The provision of treatment facilities for ex-victims of restraints in Menur Hospital. - Increased number of Puskesmas with mental health care services. c. Human resources - Skillful mental health personnel. - Active roles from Community Mental Health Nursing, Association of Indonesian Psychiatry, Indonesian Community Care for Schizophrenia. d. Strengthening Inclusive Service - Implementation of Integrated Mental Health Care Services. - Providing assistance and guidance to the health care personnel at primary level.

Yes

Provincial Government conducts annual evaluation of activities in a year. This will be a reference for follow-up plan and preparation for next year’s plan. The evaluation activities include: - Preparing annual report of MLM-Pasung Service Performance. - For the victims of restraints in each Regency/City: 1) Coordination meetings are held among the stakeholders represented by TPKJM (Steering/Executing Team for Public Mental Health). 2) Hearing meetings are held to discuss and evaluate the results of health care toward victims of restraints in East Java. 3) Cross-sectoral coordination meetings in Menur Mental Hospital. The meeting’s results will be reported to the Governor and later formalized into a policy.

Based on the monthly monitoring and evaluation by MLM-Pasung Team, the real impacts are as follow: a. Impact on service quality - A number of restraint cases in East Java decreased to 80% (from 3451 cases in 2015 to 749 in 2017). - The primary mental health care services are improved through the establishment of 14 Supporting Puskesmas with Mental Health Care Service in several regencies/cities. - Increased community awareness of the mental health treatment, shown by the increased number of patients visiting the outpatient clinic in Menur Mental Hospital from 33,975 in 2014 to 39,332 in 2017. - With the simplification of bureaucratic procedures in MLM-Pasung system, early detection, prevention and treatment of patients with mental disorders are much faster and better. b. Impact on health care policy - The stipulation of Governor’s Regulation on financing the Jamkesda (regional health insurance) claim improves the ability of Ponorogo people to access health facilities. - The establishment of integrated Restraints Handling System in East Java that engaged different levels of government in accordance with their scopes and working areas. - MLM-Pasung system is applicable to all regions in Indonesia. - Restraints handling networks are established.

The indicators to measure the innovation’s achievements are as follow: 1. The decreased number of victims of restraints in East Java. Provincial Health Office’s report showed 80% decrease in restraint cases. 2. The increased number of trained mental health personnel and volunteers. Provincial Health Office’s report showed 21% increase in number of mental health personnel. 3. The increased number of patient visits at the Menur Hospital which reached up to 15%. 4. Socio-economic improvement for restraint victims’ families. After the implementation of MLM-Pasung, Provincial Health Office provides financial assistance up to IDR 4,000,000/family/year through Productive Economic Entrepreneurship program.

A voluntary group named Community Mental Health Nursing (CMHN) consists of mental health care nurses who care for the victims of restraints. They provide public health care services by collaborating, coordinating and synergizing with Health Office in the planning, implementation and evaluation of treatment toward victims of restraints. Planning activities include preparing monthly and annual activities plan for supervisory nurses, puskesmas nurses and mental health care personnel. Implementation activities include personnel supervision, monthly meeting, foster care for psychosocial-risk group and victims’ family, and rehabilitation for patients with mental disorders. Working stages of CMHN: 1. Social Planning: program decision is made based on the facts in the field. 2. Local Action Movement: Providing foster care for victims of restraint. 3. Community development: Emphasizing the roles of mental health care personnel and empowering communities in solving their problems. 4. Application: Identifying the existing problems, needs, and resources as well as classifying the data, planning and implementing mental health care. Other stakeholders involved in MLM-Pasung are as follow: 1. Tertiary level stakeholders include Provincial Secretary, Regional Development Planning Agency, Provincial Social Welfare Office and Health Office, Menur Mental Hospital, Jiwa Lawang Mental Hospital, Soetomo General Hospital, Saiful Anwar General Hospital, Community Welfare Bureau, Police, Military, and Village apparatus. At this level, stakeholders serve to stipulate policies/regulations, strengthen human resource capacity, provision of facilities, and are responsible for the shared commitment. 2. Secondary level stakeholders’ main task is to implement the activities of restraint handling program. 3. Primary level stakeholders are those whom directly and collaboratively handle the victims of restraints, for example the Community Mental Health Nursing (CMHN), mental health volunteers from the education field.

Lessons learned from the MLM-Pasung are: 1. MLM-Pasung is able to curb the bureaucratic line. This makes the problems faced by the victims of restraints, their families and surrounding community can be handled in an effective and efficient way. 2. The roles of local government in providing regulation, budget and cross-sectoral coordination are required to encourage community participation in accelerating the target achievement of free from restraints program. 3. With the additional number of personnel and volunteers trained by professionals, the re-restraint practices can be prevented.