Diabetes in Bali

Year after year, Bali rises in the ranks not only as one of the world’s top travel destinations, but also as an enviable home for a growing expat community. Surf addicts, yoga masters, and digital nomads argue that this idyllic Indonesian island offers more perks than the frenzied lifestyle of the Western world, and for an unbeatable cost of living.

Yet if you’re a surf addict, yoga master, digital nomad AND a diabetic, the quality of health care might be your most important deciding factor. We wanted to know if Bali could provide the same level of health care that we’re used to in Spain so we did some scouting around. We sent out numerous emails, we cold-called health clinics, and we presented ourselves at a public hospital in Denpasar before we got in touch with BIMC in Nusa Dua.

BIMC is an English-speaking private hospital that specifically caters to tourists. We were able to meet with Dr. Raymond Sebastian Purwanta, Sp. PD, an internal medicine doctor at BIMC, in order to discuss the resources available at his hospital and also to learn a little bit about what the diabetes picture looks like for Indonesians.

From the start, it was clear that we were in good hands. The BIMC hospital is located in Nusa Dua, the heart of the tourist resort zone. You pass through a special security checkpoint in order to reach this area and the change in scenery is immediate. The streets are wider and perfectly paved, the landscape is green and neatly manicured, and traffic flows peacefully around elaborately decorated roundabouts. The BIMC Hospital is clearly marked and easy to find, approximately 2 minutes beyond the security checkpoint.

When we arrived, Oka, the marketing manager, was waiting to give us a tour of the grounds. Apart from its regular ER and hospital care, BIMC also has a dialysis center, a dental clinic, and a cosmetic surgery center.

“BIMC is a pioneer among hospitals in Bali,” Dr. Raymond explained. “It is the first hospital in Indonesia with accreditation from the Australian Council on Health Care Standards – International. We are also the first ones to establish medical tourism in Bali. We are an English-speaking hospital designed to work with tourists. In other hospitals, they may be able to speak some English, but not all the staff can do so fluently. At our hospital, you won’t have any problems with communication.”

Dr. Raymond is an internist, or internal medicine doctor, who handles adults and geriatric medicine and in Indonesia, an internist would be the primary contact for a diabetic patient as well. “We also have endocrinologists in Indonesia, but a diabetic patient is usually handled by an internal medicine doctor since we don’t have as many endocrinologists,” he explained. “If a second opinion is needed or there is a kind of special emergency, of course, we would refer the patient to an endocrinologist.”

Approximately 85% of BIMC patients are tourists while 15% are locals. Roughly 60-70% of those tourists are Australians, given Bali’s proximity to the country. The rest come from all over. In fact, we were startled to find the Emergency Room in pristine condition and void of activity when we were there in June.

“That’s because we’re in the low season right now,” the ER doctor said. “The Australians usually start coming around Christmas and New Year’s. Then we are full.”

We asked what kind of injuries they usually see in the ER and the answers were as we predicted: surfers with nasty gashes from reef wipeouts and more than a few drunken motorbike accidents.

“We don’t see a lot of people coming in with diabetes-related issues,” the ER doctor admitted. “But we do see people with diabetes coming in for other reasons. We check their charts so of course we know they have diabetes and we take that into account when we treat them. We make sure they are always stable.”

The dialysis center is a department that works more often with diabetic patients. Someone who needs dialysis treatment during their time in Bali would have to contact the hospital a few months in advance to make the appropriate arrangements, but the service is available, making travel possible for people who otherwise might not consider it.

Of course, all of this comes with a price tag or a very good insurance plan. We were impressed with the quality of the facilities and services provided at BIMC and we were very glad to know that places like this exist in Bali. However, we worry about how accessible a place like BIMC is for the budget backpacker or long-term expat. We also found the empty ER to be an eerie scene. It made us wonder what things were like in a public hospital.

In our conversation, Dr. Raymond provided us with a little background to the health care situation for Indonesian citizens as well.

The current president, Joko Widodo, came to power in 2014 and made health care one of his first concerns. Widodo established a compulsory national health care system, known as Badan Penvelenggara Jaminan Sosial Kesehatan (BPJSK), with the goal of closing the gap in access to basic health care for its approximately 250 million citizens by 2019.

Previously in Indonesia, private insurance was available to those who could afford it, the poorest of the poor received government help, and a smattering of NGOs did what they could to help those in between.

Now, citizens can access a variety of health services provided by public facilities and even by some private organizations who have chosen to participate in the program. (BIMC is not currently enrolled in the program). In exchange, those in the formal employment sector pay a premium of 5% of the salary, 4% payable by employers and 1% by employees. For other situations, a monthly premium is paid in a tiered system of first, second, and third-rate care.

The health care system is a huge undertaking and even in 2017, many parts of the program are still in their infancy and working out growing pains. Lack of communication and infrastructure make it difficult for Indonesians to use the service, especially in remote areas.

“Well, I do think there is a difference in awareness,” Dr. Raymond assured. “Before the BPJKS era, not everybody knew about what health care was available, if any, and how to get benefits. But now with the new program, most people have information on BPJKS and it’s easier for them to get their medication.”

In theory, a patient with diabetes would have their medicine covered under the national insurance plan, as long as they paid their monthly premium. (Blood glucose testing equipment is not included. Glucose strips = $ .50 cents USD, ketone strips $3 USD, which could be prohibitively expensive for some families). And like most things, it’s not as simple as if you build it, they will come.

“There is still a lot of work today in educating people about the dangers of diabetes,” Dr. Raymond acknowledged. “Most of our diabetes patients are in urban areas and it’s because of the lifestyle. Nobody walks here; everyone goes by motorbike. We have a lot of Western food and our food is a lot sweeter now. Stress, smoking, people think it’s cool to eat at McDonald’s – there are many factors.”

Indonesia’s story is no different from other developing countries with a growing middle class. This trend usually corresponds with a higher calorie intake and more sedentary behavior. As of 2016, about 7% of Indonesia’s population suffered from diabetes according to official registries, but those are only registered cases. In rural areas, undiagnosed diabetes may be as high as 70%.

“So now, yes, we need more education,” Dr. Raymond said. “I think well-educated people know a lot about diabetes – what it is, how to prevent it – but we still have to do more work to make sure that everybody knows.” WHO reports that clinics can suffer shortages of important diabetes supplies and insulin as well.

We also asked Dr. Raymond what would happen if a tourist came to BIMC and needed to buy insulin.

“We have insulin here,” he explained. “The patient would need to set up an appointment with our doctor first. We can’t just sell you the insulin, but you can get it the same day of the appointment. We just need to see your prescription from your home country and do a small check-up. We have long acting, we have short acting, and we have the mixed. Indonesia does not have insulin pumps, however, so please keep that in mind when you travel here. Make sure you bring a back-up.”

Overall, we concluded that it’s not an issue to travel to Bali with diabetes. If you are traveling with good travel insurance or a long-term expat health care plan, there is a high possibility that you would be directed to a private facility like BIMC in Bali. If so, you would be extremely lucky. Their facilities and staff are outstanding. If you need to buy insulin during your stay, it is best to make an appointment at a public or private facility in Denpasar, where they are guaranteed to have a full dispensary. The more remote you are, the less likely it is that clinics will carry what you need.

For Indonesians, the road to comprehensive diabetes care awareness is long. Their basic health care plan is still finding its legs, but it is encouraging to know that the government has made it an important part of their agenda.

We would like to thank Dr. Raymond and Oka for taking the time to speak with us and share their insights on their country and profession. We hope that the next time we visit Bali we will see a country enjoying the fruits of a successful universal health care program and working hard to reverse the diabetes trend.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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