In Maria Witjaksono’s experience, drawing is one of the most enjoyable activities for children who await cancer treatment. Photo courtesy of Maria Witjaksono; used with permission.

Project ECHO Holds Hope for Progress of Palliative Care in Indonesia

By IAHPC Member Maria Witjaksono
Palliative care physician, Dharmais Cancer Hospital; and
Vice-President, Indonesian Palliative Care Society

An intensive basic palliative care training program in Indonesia the past few years has educated 1,500 healthcare professionals. Observation and informal interviews with many trainees revealed significant barriers to initiate palliative care exist in all levels of healthcare services. In March 2025 the Dharmais National Cancer Center (NCC) launched Project ECHO, a yearlong program to formally monitor and evaluate the development of palliative care in the trainees’ institution and to support clinical practice. The results are now being assessed. 

Project ECHO (Extension for Community Health Care Outcomes) is a collaborative medical education model that aims to build workforce capacity in rural and underserved areas; it addresses managerial levels of response and support, availability of opioids, response from the community, and clinical challenges in delivering palliative care. 

A decree is not a plan

Project ECHO is a crucial step to ensure that Indonesia’s program of palliative care integration in national health services can be delivered in accordance with a 2023 amendment to the health law. The law now states the government’s commitment to providing high-quality palliative care throughout the country—including identifying sources of funding—but lacks an implementation plan or timeline to provide it. 

Although palliative care is included in the national insurance program, reimbursement rates fall short of actual care costs and excludes home care, impeding institutions from setting up palliative care services.

As a national cancer center under the wing of the Ministry of Health, Dharmais NCC has a responsibility to develop and to improve the country’s coverage and quality of palliative services. It has aided in development of training modules coordinated by the Ministry of Health and Balai Pelatihan Kesehatan/Bapelkes health training centers. Indonesia’s 2024 ImPACT study noted that Dharmais Cancer Hospital had the country’s only fully operational palliative care unit. 

Dr. Withaksono prepares a young mother for her return home after a lengthy cancer treatment. Although response to the treatment was poor, she accepted the outcome and wanted to spend her remaining days with her 10-year-old daughter.  Photo courtesy of Maria Witjaksono; used with permission.

40,000+ need training in basic care

The imPACT study outlined a significant need for capacity building, calculating that over 20,000 doctors and an equal number of nurses providing primary healthcare require basic training, and palliative care teams in over 2,500 hospitals need at least intermediate-level training.

Indonesia was one of the founders of the Asia Pacific and Palliative Care Network, and the Indonesian Palliative Society was established in 1999 but only two of its 17 branches are active and palliative care here remains scarce, disproportionally distributed, and of an uncertain quality. 

Use of pain meds hampered

Opioids were included in the National Formularies in 2009, but availability and accessibility have been major issues. A complicated regulation and report system contributes to low usage, as well as the lack of education about opioids among healthcare professionals. Only codeine is included in the 2023 formulary for primary healthcare services, and the requirement of biometric verification to get refills from hospitals obliges patients to travel long distances.

Educate, educate, educate!

Indonesians have historically rejected palliative care because of misconceptions about its purpose, as well as a fear of opioids and the perception that palliative care severs a patient’s access to hospitals. Until recently, a significant barrier has been attitudes by oncologists that impede referrals due to the dilemma of palliative care being negatively viewed. 

Pressure from peers, patients and their families make doctors hesitant to refer their patients to palliative care. Referrals are gradually improving, but remain a challenge. Educating religion leaders and family members, who are essential to decision making (Martina, 2023), could improve the implementation of palliative care.

In summary

Education and training are essential pillars of palliative care development. Despite recent intensive training, palliative care in Indonesia is still underdeveloped. Robust data about the barriers and a post-training monitoring system can help support a concrete plan for future development. The ECHO program is expected to facilitate the needed supports to ensure faster development of palliative care.

References

1. Kumar S. imPACT Mission Indonesia Review Report, 2024.
2. Martina D, Witjaksono MA, Putranto R. Advance Care Planning in Indonesia: Current state and future prospects. ScienceDirect 2023; 180: 94-98.
3. Witjaksono M. Criteria for the Need of Palliative Care in Cancer Patient Management in Indonesia: A multidisciplinary study (doctoral dissertation). Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada, 2021.

Maria Witjaksono was head of the palliative care unit at Dharmais Cancer Hospital, and is currently on staff at the Palliative Care Installation. She is Indonesia Palliative Care Association’s vice-president responsible for education, research, and international relations, and is a member of the advisory board of Indonesia’s National Cancer Program for the development of palliative care.