Long-Term Care in Indonesia: The Role of Integrated Service Post for Elderly

Abstract

Objective: This article aims to examine community long-term care (LTC) in Indonesia by drawing upon the five principles of human right provision: availability, accessibility, acceptability, quality, and universality. Method: We used a qualitative approach with exploratory multiple case studies in three different areas in East Java Province, Indonesia. This study gathered the initial evidence using a report card approach with self-report questionnaires. In-depth interviews and focus group discussions were carried out to understand factors that affect the efficacy of LTC services. Results: The Indonesia Government imposed a regulation that required each local community to make community health services available for the elderly. By managing the integrated post, the community provided LTC service for the elderly. Community leadership played a pivotal role to make LTC services available. Improving the services with religious activities was essential to improving the acceptability, but it also needed to take into consideration universality and nondiscrimination principles. Results show that LTC services are difficult to expand and quality standards are difficult to raise, due to challenges such as few community members volunteering their services, lack of support from religious leaders, limited resources, and inadequate volunteer training. Discussion: This study highlights the role of community engagement in LTC services and shows that it is difficult to succeed without adequate government support. Improving services with creative and culturally acceptable activities is necessary.

Keywords

Indonesia long-term care services community engagement human rights

Introduction

Indonesia is the third most populated country in Asia and is a rapidly aging society. The Indonesian Statistics Bureau estimated that the aged population would increase from 20.24 million in 2014 to 36 million by 2025 (Statistics Indonesia, 2015), while the United Nations (UN) estimated that the number would reach 25% of the population by 2050 or nearly 4 times higher than in 2014 (UN, 2015). In response to population aging, the Government of Indonesia ratified the International Covenant on Economic, Social and Cultural Rights (ICESCR) in 2006. The covenant stipulates that the country fulfills basic rights by providing social security, an adequate standard of living, and the highest attainable level of physical and mental health, and education (Adroff, 2015). In regard to long-term care (LTC), General Comment No. 14 outlines rigorous standards based on principles of availability, accessibility, acceptability, quality, nondiscrimination, and universality (World Health Organization [WHO], 2015).

In Indonesia, the responsibility for LTC comes under the coordination of the Ministry of Health. Through Regulation No. 25/2016, the country launched the National Strategic Plan for elderly, which made Puskesmas, a state-funded clinic, the frontline provider of health care and LTC. At the grassroots level, the government encourages local communities to promote the integrated service pos (Posyandu). This service initially aimed to identify early malnutrition and other health problems by involving volunteers in managing a monthly check-up and health education. Thus, providing LTC and fulfilling the needs of older adults has become an obligation of the government following the ratification of the ICESCR.

This article aims to examine community LTC in Indonesia by adopting the principles of human rights provision, including the availability, accessibility, adaptability, quality, and universality. This study extends the central question into four subresearch questions:

Research Question 1: How did the Posyandu help the elderly gain access to LTC services?

Research Question 2: How were the services adapted to suit elderly needs?

Research Question 3: How did the community make the services acceptable?

Research Question 4: Do senior citizens enjoy the LTC services?

Participation and Quality of Public Service

LTC refers to the provision of daily service and formal and informal support to individuals with physical or cognitive limitations (Broyles, Sperber, & Voils, 2015). LTC has become a concern of the international and regional human rights treaties as well as national constitutions, including the 1966 ICESCR and the 1979 Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). Every state is mandated to attend to the rights of the citizens to attain optimal public health services, which involve medical services, food, decent housing, sanitation, and clean environment.

This study makes reference to the work of the UN. To clarify and operationalize the above provisions, the UN Committee on Economic, Social and Cultural Rights monitors compliance with the ICESCR and adopted the General Comment No. 14 on the Right to the Highest Attainable Standard of Health in 2000 (De Schutter & Kedzia, 2017). To ensure the right to health for all people, General Comment No. 14 outlines rigorous standards that fall into seven principles: nondiscrimination, availability, accessibility, acceptability, quality, accountability, and universality (WHO, 2015).

A better appreciation of key stakeholders’ perspectives is essential to understanding the impact of community participation and the complex debate about LTC (Nathan, Braithwaite, & Stephenson, 2014). LTC calls for a cross-cutting policy with an aim to provide services to older people who are incapable of long-term self-care with the highest possible degree of independence, participation, and human dignity (Organisation for Economic Co-operation and Development, 2005). The elderly become vulnerable as they age with low education, low socioeconomic status, and, often without a marital partner (Ng, Hakimi, Byass, Wilopo, & Wall, 2010). The elderly are often stereotyped as a burden, especially when they become vulnerable by low income after retirement (Zaidi, 2014).

Shifting relationships between state and citizens imply a complicated issue on the initiative to promote healthy and productive aging, including political and societal norms. Countries with earlier transition societies experienced the higher level of older people living alone with low levels of coresidence with their married children (Glaeser et al., 2006). In transition economies, the government has traditionally provided more limited support than in other parts of the world, while traditional values highlight the role of families and other social networks, including local leaders and communities, for providing care to older adults (WHO, 2015).

The welfare triangle theory suggests that the economy includes various forms of exchange, involving the state (the government), the private sector (the market), and civil societies, while the third sector emerges from the interaction among these three main stakeholders (Evers, Liebig, & Laville, 2004). Community participation involves various interests, which results from an exchange between community members and implies long-term relationships (Slack, Corlett, & Morris, 2015).

Government intervention may imply inefficient allocation of resources as preferences for redistribution coming from the decision makers could be different from those which arise from grassroots communities (Guillaud, 2013). Government intervention may also imply coercive resource distribution or alternative financial resources, such as mandatory or voluntary insurance for various welfare services like home care for the elderly (Pestoff, 2008).

Social support from the neighborhood is associated with greater social cohesion, the availability of health facilities, and perceived neighborhood safety (Li, Kao, & Dinh, 2014). Community engagement in LTC is expected to improve the quality of public services and to help forge strong social ties, which contributes to better quality of life (Kehyayan, Hirdes, Tyas, & Stolee, 2015). Given the positive impact of community engagement, the gap between policy intervention and needs comes from the poor assessment from not covering the dimension of community participation and complex needs of the elderly (Levasseur et al., 2014).

To avoid community failure in public services such as LTC, the complex debate on the project calls for fair negotiation from different players (Nathan et al., 2014). Policy assessment needs to be carried out regularly prior to resource acquisition to redefine the innovation policy to improve social benefit for the target group by integrating between the assessment and transfer of power to stakeholders (Nicholls, 2014; Pratono, Suyanto Marciano, & Zurbrügg, 2017)

Research Method

To understand LTC in Indonesia, this study undertook a case study for examining community-based services with interpretive analysis. We first gathered evidence by adopting the report card approach with self-report questionnaires to collect information regarding the availability, accessibility, adaptability, and quality of LTC. We then carried out an in-depth study of factors that played a part in fulfilling basic rights by conducting interviews and focus group discussions. Multiple case studies were used to explore the complexity of LTC services (Rittenhofer, 2015). The focus group discussion was conducted before the report card survey and was followed by the presentation of the results from report card survey to validate the result. The discussions aim to assess the perceptions of local leaders, volunteers, midwives, and medical staff. Respondents may perceive that the quality of services is excellent, while the government report highlighted the limited capability of service. The combination of these techniques was expected to support the findings and did not contradict the categorizations (Jonsen & Jehn, 2009).

The in-depth interviews were conducted with three different groups of respondents: Persons aged 60 years and older (n = 30), village midwives (n = 15; who are primarily responsible for maternity and health needs of children as well as for providing basic health services for all residents, including elderly people), and volunteers (n = 30), who are family welfare programs (Program Kesejahteraan Keluarga or PKK) cadres with the special mission of promoting health and well-being of individuals by offering accessible, integrated, continuous, and high-quality health care information.

Research Site

This study was conducted in East Java, which is one of the most populous provinces in Indonesia with 38 million inhabitants in 2014 and around 10% of them (4.3 million) aged 60 and above. More than half of these (54%) are women, while the rise of the aged population expected to be almost a quarter higher than that of the total population from 2010 to 2035 (Indonesia Ministry of Health, 2015). Life expectancy was 71 years in 2016, which is similar to the global life expectancy. The number of respondents in The Indonesia Basic Health Survey 2013 (Riset Kesehatan Dasar or Riskesdas) with coronary heart disease (CHD) is highest in East Java Province with as many as 375,127 people (1.3% of all respondents in East Java).

The Government of Indonesia has issued some regulations to encourage LTC, such as Law No. 4/1965 on livelihood assistance for the elderly, Law. No. 23/1992 on health services, Law No. 13 1998 on elderly welfare, Law No. 39/1999 on human rights, and Law No. 52/2009 on population growth and family development. In East Java, the Local Regulation (Perda) No. 6/2007 mandates that the local government in East Java should establish hospitals, geriatric clinics, and community health centers (Puskesmas). In East Java Province, a geriatric clinic is available at the Dr. Soetomo Hospital in Surabaya and the Syaiful Anwar Hospital in Malang City. In rural areas, the Malang Municipality Government provides regular geriatric services at Kepanjen Hospital. The East Java Provincial Government manages 960 Puskesmas, of which 130 provide special health services for the elderly (Statistics Indonesia, 2015).

Posyandu is a community-based clinic at the village level initially providing basic health services for children and pregnant women (Posyandu Balita), and late services expanding to provide senior citizens (Posyandu Lansia). The Posyandu was operated solely by volunteers. In 1990, the Ministry of Home Affairs published the Instruction Letter No. 9, which stipulated that local leaders be responsible for the quality of Posyandu in their service area. The volunteers worked for the Family Welfare Program (PKK). The national government initially established the PKK program in 1962 with the aim of improving the quality of primary education and providing family life education for young women who were out of school.

The City Government of Surabaya provided IDR5,000 per person per week to support 46,577 elderly living in abject poverty (City Government of Surabaya, 2011). In Surabaya, there are 9,271 Rukun Tetangga or community groups in the grass-root level that manages Posyandu. Table 1 shows that there are only 2,819 Posyandu in Surabaya, 656 Posyandu in Malang City, and 2,816 Posyandu in Malang Regency. Each Posyandu provides service for a population of 922 in Surabaya, 1,250 in Malang City, and 868 in Malang Regency. As the elderly make up 10% of the population, each Posyandu serves nine to 12 seniors. The City Government of Malang manages gerontology service centers in 15 Puskesmas and provides support for health services for elderly at 299 Posyandu centers. In Surabaya City, there are 2,819 Posyandu, out of which nearly 600 applied for financial aid for their LTC services from the local government in 2015. According to Local Regulation No 19/2016, the City Government of Surabaya would allocate a budget of IDR120 million in 2017 for the elderly, orphans, and the disabled. In Malang Regency, the government provided financial support of around IDR600,000 (US$45.96) to the Posyandu volunteers. In 2013, the City Government of Malang (2013) offered public gerontology health services, but the service was accessible by only 8,950 out of approximately 24,000 older people.

Table 1.

Demographics and LTC Service Centers in Surabaya City, Malang City, and Malang Regency.

	Surabaya City	Malang City	Malang Regency
Population	2,599,796	820,243	2,446,218
Coverage area, mile²	144.7 mile²	97.35 mile²	1,365 mile²
Number subdistricts	31	5	33
Number of villages	154	57	378
Elderly population	9%	8.5%	10%
LTC service providers
Puskesmas	53	15	39
Pustu	69	33	93
Mobile centers	NA	15	72
Posyandu	2,819	656	2,816

Source. Statistics Indonesia (2015).

Note. LTC = long-term care.

The first step of data collection involved identifying the target sample of the elderly using the PKK database obtained from the City of Surabaya, the City of Malang, and the Regency of Malang. According to the 2014 PKK directory, there were 6,291 villages, which provided Posyandu in the observed areas. However, specific data about the elderly, such as name and address, were not available. Thus, a random sample of 600 villages was drawn. From the selected 600 villages, the survey obtained support from local leaders in 589 villages, who agreed to participate by providing lists of senior citizens.

The fieldwork was carried out between 2014 and 2015 involving case studies of LTC in Surabaya City, Malang City, and Malang Regency. The survey used a self-administered approach. Primary data collection with this approach has challenging issues of low response rate. Research assistants distributed the 3,000 questionnaires to respondents in the villages. A total of 439 respondents completed the survey yielding a response rate of 14.9%, which is not unusual for self-administered surveys (Cooper & Schindler, 2013).

Results

Table 2 shows the demographic background of the research participants from the report card. The average age of the respondents was 68 in Surabaya City, 72 in Malang City, and 74 in Malang Regency. It is essential to mention that during the interview, the research participants found it difficult to provide the exact date of their birth. For example, many of them just said that they were born during World War II, while some said during the Japanese occupation. Most of the respondents (72%) stated that they graduated from primary school, while 16% never went to school and 12% of respondents indicated that they went to high school. Some of them found it difficult to answer the simple questions on the report card. Researchers and family members often helped the respondents to provide answers.

Table 2.

The Profile of Report Card Respondents.

	Surabaya City	Malang City	Malang Regency
M age	72	75	80
Male, %	42	38	39
Single, %	28	25	18
Education
Primary, %	60.3	68.4	78.3
Secondary, %	29.1	22.8	16.1
College and higher, %	10.7	8.7	5.7

Making LTC Available by Community Engagement

The regulation required each local community in Indonesia to establish community health services available for the elderly. According to the Regulation of National Ministry of Home Affair No. 7/2007, the community group should consist of 30 to 50 households. The regulation also stated that there should be five to 10 volunteers in charge at each service area. During the observation, the wife of the community leader was responsible for managing the integrated post (Posyandu). Volunteers were expected to ensure that LTC was available on a given day in a month. They were also supposed to make an effort to invite the elderly to visit the Posyandu. At the observed communities, the local government issued the instruction letters to the medical staffs at the Community Health Center (Puskesmas) to support the integrated post (Posyandu).

Table 3 shows that all respondents in Malang City patronized the services provided by the Posyandu Lansia. In Malang Regency, 92% of respondents stated that they used the services of the Posyandu. Conversely, 13% of respondents in Surabaya reported that they had never used the services. These disparate rates suggest that not all communities could manage the Posyandu. In rural areas, the typical problem was a shortage of medical doctors. In urban areas, the service had to compete with private health clinics in the downtown area and many older people expressed a clear preference for private clinics. Table 4 provides the exemplary quotations on the LTV services in Posyandu. These were some responses from the elderly and local leaders that reveal some of the challenges:

“There is Posyandu Lansia, but it does not provide regular services. Sometimes it was once a month, while the last service was available two months ago . . .”

“There was no transportation service, so I had to walk to the Posyandu . . .”

“I prefer to go to private clinics. The doctor provides good medicine, which quickly eases my severe headache . . .”

“Those who work as volunteers are mostly senior citizens as well. Young people seem to not be interested . . .”

“.. We find it difficult to get volunteers for Posyandu Lansia. In the past, women preferred to be housewives. Now they prefer to work following the growing opportunities and increasing living costs . . .”

“In my village, no one is interested in initiating the service. It involves much time and high-stress level . . .”

Table 3.

Respondents’ Views of LTC Services.

	Major questions	Surabaya City (%)	Malang City (%)	Malang Regency (%)
1	Do you use the services of Posyandu Lansia?	87	100	92
2	Do the services meet your needs?	85	53	75
3	Are the services affordable?	79	47	71
4	Are the services accessible?	74	63	77
5	Do you get excellent services?	82	74	75

Note. LTC = long-term care.

Table 4.

The LTC Services in Posyandu.

Axial coding	Open coding	Exemplary quotations
Availability	Policy	The elderly have become subject of the law and regulation, which mandated that the Posyandu Lansia should be available at the lowest community group (Rukun Tetangga). By the law, the post should provide the basic regular health check-up, organized peer groups, and social activities for elderly.
Availability	Resources	The posts relied on financial support from the local government. The posts highly depended on volunteers and local leaders.
Accessibility	Transportation	Transportation was a problem in rural areas. The elderly highly depended on support from their family.
Accessibility	Affordability	The post provided free health services and food supplements. The post encouraged the members to save money for the annual recreation.
Acceptability	Cultural issue	The post provided service in the local dialect. There was fear of the medical system, which became a challenge at a village level. The elderly had the problem to understand some medical terminologies.
Acceptability	Religious	Use of the religious approach to promoting LTC increased the acceptability.
Quality	Standard quality	The objective measures indicate that the post was expected to regularly provide services (at least 8 times in a year) with at least five volunteers in each post, which offered basic medical check-up.
	Standard quality	The subjective measures show that the grateful became the way of life in which targeted groups began to think that anything they had to be thankful.
	Health professional	The post relied on support from medical staff from health centers at the district level (Puskesmas). There was no specific qualification required for the volunteers.
Universality	Gender equality	As female groups volunteered in Posyandu, male elderly were more interested in religious activities.
Universality	Religion	Targeting elderly beneficiaries based on the religious group was effective but raised issues of discrimination.

Note. LTC = long-term care.

Increasing Accessibility by Family Support

When services were available, the volunteers had to deal with the main factors that affected accessibility, including physical, quality, and affordability of transportation options. In Surabaya City, there were 19 Posyandu per square mile and six Posyandu per square mile in Malang City. In rural areas of Malang Regency, there were two Posyandus in each one-square mile, which means one Posyandu provided services to four older people. The figure indicates a larger coverage area in rural than in urban areas, which may imply less accessibility. The survey reveals that 77% of the respondents in Malang Regency mentioned that the services were easy to access. This is the highest accessibility rate compared with that in the other two observed areas—74% in Surabaya City and 63% in Malang City.

Family support played a pivotal role in helping the elderly gain access to the Posyandu. In Surabaya City, limited social support and physical impairment became significant issues affecting accessibility. The elderly were very dependent on their families. Many elderly did not want to burden their family by asking for rides. Ridesharing was an alternative. In some cases, the older people had to take care of their grandchildren whose parents worked from early morning to evening. In these cases, they expected the Posyandu Lansia to visit them to provide medical check-up.

“. . . My son gives me a ride to the Posyandu whenever he is available . . .”

“. . . I cannot pay a visit to the Posyandu, because I have to take care of my grandchildren . . .”

“. . . I will go to the Posyandu if the weather is good and my leg is not in great pain . . .”

The case is different in Malang City and Malang Regency. Most of the observed families relied on farming activities and they spent more time with older family members. During the observation, it was possible to find three generations of the family spending time together. In some cases, young people had gone to the cities to work or study, and the elderly managed the household and took care of the grandchildren, with the expectation that the family would stay together in the future. Hence, inadequate transportation was a significant obstacle to the accessibility of rural areas. The road conditions were severe, especially during the raining season. The Posyandu was available at the village center, but the interviews indicated that the use of its services was hampered by the lack of transportation, health problems, and family issues, as shared by some elderly respondents:

“The integrated services are for elderly, but only a few of them can access the services. Those who stay nearby will be able to join the activities that the Posyandu provides . . .”

“The Posyandu is only accessible on foot. When the rainy season comes, it is almost impossible to visit the Posyandu . . .”

In terms of affordability, the Posyandu Lansia provided free services for the medical check-up or other health care services. However, only 47% of respondents in Malang City mentioned that LTC services were affordable. The respondents said that although Posyandu Lansia provided free services, they had to bear the cost of social events. Not everyone could afford the fee for joining the events.

“The Posyandu in my village is very active. The volunteers organize various activities for the elderly, such as weekly dance exercises, congregation prayer, and recreation. However, I do not feel comfortable because I cannot afford to buy the uniform or contribute financially to such activities . . .”

“I believe that the cost for recreation is reasonable, but I still cannot afford it . . .”

Increasing Acceptability of LTC by Local Culture and Religious Support

There were other challenges related to local cultures. The first challenge was the language barrier. The predominant ethnic groups in Surabaya and Malang were Javanese and Madurese. The elderly spoke the local dialects, while the official language used by medical doctors was Bahasa Indonesia. The Madurese elderly were Muslim and fluent Arabic readers but could not read the alphabet and had difficulty speaking the official language. As health services were expected to uphold medical ethics and to be culturally appropriate as well as sensitive to gender and life cycle requirements, volunteers often had to fill the cultural gap between the medical doctor and the elderly.

The service was about not only translating the official language into local dialects but also building the confidence of the elderly. The report cards showed that all respondents in Malang City gained accessed to Posyandu Lansia and 74% of respondents in Malang City enjoyed good quality services. This figure is lower than in Surabaya City (82%) and Malang Regency (75%). Many older adults agreed the services are beneficial to them.

“. . . I agree that Posyandu provides benefits for us, such as medical check-up, and it allows me to meet friends. So, I can share information with other elder people . . .”

“Belonging to the community provides benefits, such as health services once a month, religious activities, dancing, and recreation once a year . . .”

Second, religious communities are essential sources of participation that have implication for the acceptability of the LTC. It seemed that the elderly were interested in accessing the services, but the volunteers and health workers could not meet the expectation of targeted groups. In villages of Malang Regency, many seniors still preferred traditional medicine or traditional healers to modern health care. If they had problems, including health problems, they went to local religious leaders who would say a prayer for their house, for water, and for food. Some elderly were also averse to medical treatment:

“. . . I am afraid of visiting the doctor at Posyandu. I am afraid that the doctor might diagnose me with complicated health problems. So, I prefer to consume traditional medicine or go to a traditional healer . . .”

In Malang Regency, some respondents mentioned the acceptability issue:

“We can find most of the elderly involved in religious activities, such as Quran recitals. Here, we announced and gained support from the community for activities of Posyandu . . .”

“All women in my village are familiar with voluntareer work. They are involved in various religious activities. It is not difficult to ask them to participate for Posyandu Lansia as well as Posyandu Balita . . .”

“Our village leader is very charismatic and powerful. We follow, especially when the Posyandu provided health information during the religious speech and she encouraged all of us to participate in it . . .”

Measuring Quality of LTC by Objective and Subjective Approaches

The minimum service standard of Posyandu at Surabaya City and Malang Regency provided on health services for young mothers and children. Although the Ministry of Health passed Regulation No. 25/2016, stating the National Health Strategic Plan for elderly focusing on Puskesmas and hospitals, there was no specific action plan for Posyandu Lansia. It was optional for Posyandu to expand the services to Posyandu Lansia. According to the National Ministry of Health (2015), only 9.68% of Posyandu services in East Java Province met the minimum service standard, which included providing services 8 times per annum, managing at least five volunteers, providing high accessibility to the community, and having capability to manage five main health programs (family planning, prenatal and child health services, and immunization). The report revealed that only 1.2% of Posyandu was considered to have met the highest quality service standards with the capability to manage community-based financial resources. Many Posyandu services were of low standards because of lack of volunteers (less than five volunteers) and lack of capability to provide regular activities.

From the target group’s point of view, the majority of the respondents stated that the quality of LTC services that Posyandu provided was excellent—74% in Malang City and 75% in Malang Regency (75%). In urban areas, like Surabaya City and Malang City, many Posyandu Lansia centers provided creative and fun activities, such as health and nutrition counseling as well as yoga and gym competition for senior citizens. In urban areas, the Posyandu provided more events than in rural areas, including consultation on healthy living. In Surabaya City, senior citizens could visit the Garden for Elderly (Taman Lansia) for foot reflexology and yoga club activities:

“I am happy that there is a public space and a city garden nearby my home. I visit that place almost every day to meet friends and do some simple exercises . . .”

“I really enjoy the yoga. The elderly community conducts the activity every Sunday morning . . .”

LTC services in Posyandu Lansia also faced some challenging issues. The midwife provided guidance on preventive measures such as early detection of diseases, hypercholesterolemia and hypertension, as well as health and psychological counseling. However, many of them found it challenging to provide the services due to the limited resources, especially when fatal accidents occurred. Knowledge transfer was also quite difficult.

“I experienced delayed services and long waiting time. Sometimes, there was no paramedic and only some volunteers . . .”

“The service standard covers registration, recording, check-up, and consultation. There is no specific standard on how the volunteers work, interact and address step-by-step care procedures . . .”

“I was so tired to listen to the lecture on healthy living. It seemed to take hours. I preferred to go to another Posyandu or a private clinic . . .”

In rural areas, Posyandu Lansia had limited resources, including medical doctors and midwives. The volunteers focused on registration, recording, and providing food.

“To me, Posyandu merely provided basic health check-up, such as taking my blood pressure, asking some questions and weight to make sure whether they need to send me to the hospital for further tests . . .”

In the Malang Residence, a midwife provided basic medical services and health-related information. The local community expected the midwife and volunteers to provide medical services for all diseases including arthritis, depression, and accidents including falls.

“Being a midwife in the village is quite challenging. I am an expert in maternal healthcare by training, but local people expect me to provide all kind of medical treatments, including for health problems of elderly people . . .”

“I volunteered for Posyandu, but it was understaffed. It was almost impossible to provide services regularly. It was also difficult to find time to talk to the elderly although I felt that was an important part of the services . . .”

Due to the fact that there was no alternative service, most older adults continued to access the service. They tried to quit from complaining about the quality and continue to access the service. The hardships of their lives made the elderly learn to feel gratitude for everything.

“As an old person, I understand that all these complicated diseases come to me. I was tired of complaining, whining and moaning about the health service that was not as I expected. This can be emotionally draining. So I prefer to accept the Posyandu service, quit complaining and begin to appreciate it . . .”

Promoting Inclusiveness and Nondiscrimination

The observed communities in the urban areas were more heterogeneous than the rural area. As the Posyandu tapped on religious activities and the targeted group was of a specific religion, the elderly who came from different religions could not access the services. The community members may consider forming groups with those following the same faith.

“I joined the elderly community every month for health services only. They also had weekly activities, such as religious activities but I did not attend the second one because I have different religious beliefs. That made me miss information opportunities to be sociable. Sometimes it is quite difficult to be different . . .”

“The service is available at this traditional village. Those who stay at the nearby elite real estate complex never come to our village to access the Posyandu. They prefer to send their old parents to the care house . . .”

A gender division occurred as women and men play different roles in LTC. Most LTC attracts a much higher number of female volunteers accounting for 90% of all volunteers. Men tend to be more indirect in their involvement in LTC, playing roles such as a motivator for participating in religious activities and a worker at the infrastructure to increase the provision of LTC.

Discussion and Conclusion

Despite a favorable legal framework, supply-side factors affected availability of the LTC service, which was highly dependent on community support. The activities became the responsibility of the local leaders, who took up the challenge of organizing the community service. Less than 10% of Posyandu met the minimum standards of activities and volunteers. They had challenges such as a lack of volunteers, poor transportation system, lack of trust from target groups, lack of support from local leaders and religious leaders, and poor skills of the volunteers.

The lack of social support and physical impairment are important challenges for older adults seeking LTC services. Family support was crucial for the elderly to be able to access LTC services, but the conflicting priorities of the family members often prevented them from providing transportation to service providers. Religious activities were quite important to increase the acceptability of the services in the observed communities and to gain support from local volunteers and local leaders. Religious leaders provided key support to LTC through their influence over the people. Those who joined the religious activities gained more spiritual support from the religious community who worship there, which implies a greater sense of belonging in a congregation (Krause & Hayward, 2014).

However, it should be noted that when religion became part of the activities, older adults with different religious background were reluctant to access the services. Similarly, as the services relied on female volunteers, they attracted more female than male participants. Hence, future studies should examine older adults’ spiritual experiences or religious rituals and meanings attributed to them in LTC, how various groups construct their ethnic or group identity, what significance they assign to social roles, and how they cope with multiple obstacles to providing LTC.

Quality of LTC became a challenge for the observed communities, as the perception of quality did not only come from the health experts but also from the target group. According to the health audit report, the LTC services had not yet met the expected level of quality. Only 10% of Posyandu met the minimum standard and only 1% of Posyandu were able to independently manage their financial resources (National Ministry of Health, 2015). However, more than 75% of the observed elderly believed that the LTC provided excellent quality. This was because the target group seemed to be skeptical about the expected services and thought that the available service was better than having nothing at all. Instead of expecting to have more magnificent facilities and services, they came to terms with a more realistic expectation given their physical limitation and limited resources.

This study not only contributes to the knowledge on LTC services in the Asian context but also extends the discourse on human rights. Although the findings provide useful insights, this study has some limitations. First, the study used script data translated from Indonesian into English, which may have subtle interpretation differences during the translation. Second, the survey was carried out in snapshot observations. Some issues such as choice of appropriate quality measures and the adaptation of effective social marketing and capacity building strategies for volunteers need to be addressed in future studies. Finally, this study only included three observed areas in East Java Province, Indonesia. As a result, this raises issues of the generalizability of the conclusions. Further investigations are needed in other parts of Indonesia, which is a very culturally diverse country.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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