Country context

Indonesia is the largest archipelago in the world, with approximately 17,000 islands, and a population of 275.5 million people as of 2022. In the past decade, Indonesia has made significant economic and demographic advances, improving life expectancy from 68.68 years in 2010 to 72.32 years in 2023, and graduating to an upper-middle-income country in 2021. These factors have contributed to a change in Indonesia’s disease burden. Although historically infectious diseases—particularly tuberculosis—remain a significant challenge, their prevalence has receded in recent decades while non-communicable diseases (NCDs) now represent the leading driver of mortality. Lung cancer is the leading cancer cause of mortality, responsible for 12.6 percent of cancer deaths in Indonesia.

In 2022, overall lung cancer incidence was 13.4 cases per 100,000 people, while mortality was 11.9 cases per 100,000 but these statistics are suspected to be under-estimated due to gaps in health data collection across the archipelago, and additionally hide a significant gender disparity. Among Indonesian men, the incidence rate is 21.3 cases per 100,000, compared to 6.4 cases per 100,000 among women. This disparity may be due to significant gender disparities in smoking rates, and the gendered nature of certain professions such as mining and construction, which involve a high risk of exposure to carcinogens such as asbestos. Indonesia has the highest male smoking prevalence in the world, at over 70 percent, although female smoking rates are just 3.6 percent. Indonesia is the only country in the Asia Pacific region not to become a signatory to the WHO Framework Convention on Tobacco Control. Smoking is extremely common among young males, with around 28.6 percent of males aged 10 to 24 smoking, as of 2016, a trend that could indicate higher rates of lung cancer in the future. Indeed, annual lung cancer cases are predicted to almost double between 2018 and 2040, and in 2021 tobacco use was estimated to cause more than 225,700 premature deaths and cost the economy USD 44,626 million (IDR 7.02 trillion) in direct and indirect costs.

One significant challenge for Indonesia is the late stage at which most lung cancer patients present to doctors, leading to delayed diagnosis, higher medical costs, and a lower chance of survival. Around 70 percent of lung cancer patients present in the higher stages, when their symptoms become obvious and after the window of opportunity for early intervention has passed. As a result, in 2019–2020 (the year in which universal health coverage was introduced in Indonesia), cancer treatment cost the Ministry of Health (BPJS) approximately IDR 7.6 trillion (USD 490 million).

Assessing policies and programs

Indonesia’s cancer response is predominantly guided by two strategies—the Action Plan for Control of Non-Communicable Diseases 2020–2024 and the National Cancer Control Plan 2020–2024 (NCCP). The NCCP has the overall goal of reducing the number of Indonesians living with cancer and increasing the survival rate and quality of life of those persons. It is implemented and administered by the National Cancer Prevention Committee (KPKN), which also conducts monitoring and evaluation, and carries out critical reviews of new health technology. Neither plan is specific to lung cancer—and the NCCP in fact focuses largely on breast and cervical cancer, and childhood leukemia—but both outline general cancer control measures being taken, including many that are relevant to lung cancer. The NCCP, for example, outlines 13 priority areas, including increasing healthy lifestyles through smoking cessation, increasing the public recognition of common cancer symptoms, and increasing national cancer research. Both the NCCP and the NCD Plan also highlight the need for increasing the numbers and improving the training of health care personnel; expanding access to health care facilities and standardizing quality of care across the country; and increasing local and regional ownership of health care policies, including through participatory processes. These goals address weaknesses in the health system identified by the Ministry of Health and independent experts, particularly in the wake of COVID-19, which disproportionately affected underserved communities in remote areas with inadequate access to quality health care.

Indonesia’s Ministry of Health and other bodies have identified prevention and early detection policies as key to reducing health care spending, and the number of patients presenting with late-stage cancers. Prevention activities include national education campaigns and a renewed focus on tobacco control and anti-smoking activities. The NCD Plan lays out clear goals for 80 percent of districts to implement no-smoking zones in offices, schools, restaurants, bars, and cafes, and to increase access to counselling and quitting services, including via primary health care services. In addition, the Health Minister Regulation No. 40/2013 on the Tobacco Control Roadmap outlines the goal of reducing smoking prevalence by 10 percent by 2024, from a 2020 prevalence of 37.6 percent. Measures to reduce smoking laid out in the Roadmap include limiting tobacco advertising on television and radio, banning sales of tobacco to people under the age of 18, and increasing the size and number of health warnings on tobacco packaging. While this regulation has been in place since 2013, the NCD Plan acknowledges that the creation and enforcement of non-smoking zones has not been a priority area for most districts in Indonesia, and that public understanding of the risks of cigarette consumption remains low.

FIGURE 2

GRIP: Gains, Risks, Innovations, Prospects in Policies and Programs

A screening program for lung cancer appears to have been introduced by the Ministry of Health in 2023, based on recommendations from professional medical associations. Two high-risk groups will now be referred for screening once identified in a primary health care setting: any individual aged over 45 years who has been a smoker or passive smoker within the last 10 years, and any individual aged over 40 years with a genetic predisposition to, or immediate family history of, lung disease. More broadly, government-led cancer prevention efforts include strengthening primary health care facilities, improving referral time to oncology units, and increasing screening for all NCDs in health centers across the country.

Treatment of lung cancer patients in Indonesia is beset with challenges. One major issue is access to relevant treatments and drugs. An estimated 90 percent of Indonesians with cancer are unable to access radiotherapy, as large parts of the country do not have a tertiary hospital facility with the relevant equipment, and very few cancer drugs are currently reimbursed through the national and regional health insurance schemes. Delays in reimbursement also create cost burdens on patients or discourage them from seeking further treatment at all. In addition, Indonesia lacks trained medical personnel, with only around 140 medical oncologists and 200 surgical oncologists serving the entire country. While telemedicine services may help to bridge access gaps, broadband penetration is not complete across the archipelago—around 66 percent of the population had internet access in 2022.

Despite these barriers, the Ministry of Health is pursuing some innovative, tech-enabled approaches to diagnostics and treatment, including the use of genomic sequencing. Launched in 2022, the Biomedical Genome Science Initiative—a multi-stakeholder, cross-sectoral partnership—is focused on eight disease areas, including cancers, to better understand how they manifest in Indonesians, and identify relevant biomarkers for faster diagnosis and treatment. While the BGSi cancer program currently focuses on breast, ovarian, and colorectal cancers, if proven effective, it could be expanded to include lung and other cancers. One stated goal of the program is to demonstrate the value and returns on investment in cancer treatments, to facilitate their coverage by the government-backed insurance program.

Palliative care has become a priority in both the NCD Plans and NCCPs of recent years, with both acknowledging the need for expanded palliative care facilities and access to palliative radiotherapy. While palliative care is not well-integrated into the broader health care system, Indonesia benefits from a well-developed tradition of family- and community-based care, and the establishment of several non-governmental organizations focused on patient care, including palliative care. The Indonesian Cancer Foundation (ICF), for example, has operated home hospice care programs since 1995, conducted palliative care training for community caregivers and volunteers since 2015, and established hospice facilities in South Jakarta. However, like much of the continuum of cancer care in Indonesia, these and other formal palliative care services are largely available in urban centers.

Opportunities ahead

While Indonesia has begun to address its significant lung cancer burden, major obstacles remain to reducing incidence and mortality. Strengthening tobacco control policy enforcement and improving education around risk factors and symptoms for lung cancer, particularly smoking, will be important first steps to improving lung cancer prevention. In addition, a key strategy to control lung cancer and meet SDG targets relating to cancer and other NCDs will be increasing the number of health care facilities and health care workers, both generally and specifically trained in oncology. In particular, health care expansion activities will be impactful if focused in remote regions such as eastern Indonesia, where there are currently no oncology facilities, and the remote islands. Additionally, the Indonesian government can signify its commitment to controlling lung cancer by including it as a priority disease in the updated NCCP and NCD Plans expected to be published in early 2025, and likely to cover the period leading up to the SDG deadline.

Private-sector actors are also beginning to play a role in strengthening Indonesia’s lung cancer care and control. Project ECHO, for example, is a public-private partnership intended to improve telemedicine services by connecting oncologists and other expert medical personnel with patients in remote regions to monitor and inform diagnosis and treatment. Remote and internet-based services can also be used to train health care workers, including community and primary health care workers, to identify early signs and risk factors for lung cancer, and to utilize new treatment techniques or drugs. Innovative new areas of research and treatment—such as next-generation sequencing—also represent an opportunity for regional and global private health companies to build partnerships with the Ministry of Health and local health care actors to better address lung cancer. An additional area for public-private partnership could be through the establishment of patient assistance programs, to support patients who are unable to cover the cost of necessary or innovative cancer treatments that may not be currently covered by public health insurance.

Beyond these interventions, one critical area for improvement will be in closing data gaps, and facilitating the collection of high-quality, gender- and age-disaggregated data, particularly relating to lung cancer, which is suspected to be under-reported. The Ministry of Health has identified the expansion of data registries as a key priority and will likely benefit from working with primary and community health care workers to collect data in the most remote regions and islands.