Articles

Indonesia

Jamu in Healthcare

Background

In the last two decades, Traditional Medicine (TM) development program in Indonesia has been established but has not been well implemented because it does not formed synergism of upstream and downstream sectors, although it has many of the underlying regulations. In addition, the utilization of TM as a preventive and curative still is empirical, not based on the evidence base yet. Scientific data on safety, efficacy and quality of herbal medicine are very limited, while that public demand on Jamu continues to increase.

Anthropologically, health care system in any country consists of three sub-systems, namely: formal health care system, indigenous health care system, and folk health care system. Formal health care system is inherent with western health care model - in which health providers are trained and educated using western medical approach-emphasizing Evidence Based Medicine (EBM) approach. Whereas indigenous health care system is inherent with traditional medicine approach which have been established indigenously in the community such as the use of Jamu or the practice of traditional bone setters. Meanwhile, folk health care system is a kind of self care or self treatment practiced in the community, for example: the use of spider web for wound treatment.

TM in Indonesia commonly divided into two kinds of medication namely herbs base medication (Jamu) and skill base medication (manual: bone setter, massage, acupressure, reflexy, using tools/technology: acupunture, cupping and mind/spirit: hypnotherapy, spiritual, and praying).

In developing TM which includes Jamu, the techniques and the materials used to prepare it should be studied. In terms of its safety and efficacy in maintaining health and curing diseases, interaction across the systems need the synchronization with mutual symbiosis whereby the formal health care system can strengthen and improve the quality of indigenous health care system and folk health care system.

Since Jamu Brand Indonesia launched by President Susilo Bambang Yudhoyono in 2008, then all relevant ministries such as the Ministry of Health, Ministry of Agriculture, Ministry Forestry and Ministry of Education and Culture simultaneously arranged programs and activities to support development of Indonesia traditional medicine, which is known as Jamu.

Utilization of Evidence-base of Traditional Medicine in Health Care

Initial step

Recently, research in the field of TM should be the basic for using Jamu by the physician prescription in formal health care absolutely. Inevitably, if Jamu is used into the health care system, the safety, efficacy and quality must be met to appropriate methodology and ethics.

Since October 2007, the Ministry of Health c.q. National Institutes of Health Research and Development established Herbs Research Clinic "Hortus Medicus" in Tawangmangu to prove that the Jamu is safe and can be used as an alternative in seeking of treatment options for community.

The following figure is increasing of number of patient visits. Uniquely, they are choosing Jamu as an alternative medicine rather than complementary medicine.

graft jamu

To provide the evidence base of jamu, the Ministry of Health have a breakthrough TM development program namely Scientification of Jamu, launched on January 6, 2010, by Decree Number 003 year 2010. Scientification of Jamu is a research based health services. It consists of two terms; formula Jamu and health personnel (medical doctor, pharmacist, nurse, etc) that should be pushed toward to be TM scientifically, which is supported by appropriate regulations/policies.

In line with Decree of the Minister of Health Number 003 year 2010 on Scientification of Jamu the programs has the following objectives:

  1. To provide scientific basis (evidence based) regarding the use of Jamu for health services empirically
  2. To develop the formation of network of "dual system of health providers" who acts as "Jamu services" and "Jamu research" in promotion, prevention, treatment, and rehabilitation
  3. To improve the provision of safe, quality and effective Jamu

By having this program the infrastructure of health providers with the characteristic of "services providers" and "research doers" can be developed.

Progress and Achievement

Strengthening the Capacity of Human Resources

During the year 2010-2011 has been carried out 4 classes training on Scientification of Jamu that graduated 120 doctors who are ready to conduct the research of Jamu based on health services at 35 public health centers and one hospital located in Central Java province. In line with the related training it will be formulated the curricula in order to conduct training for Pharmacist and Farmers.

To increase awareness of community regarding utilization of Jamu need promotion and education about safety and efficacy of Jamu periodically.

Ensuring the Provision of Good Quality Raw Materials

Upstream side cannot be separated from the downstream side, which means that raw materials must be obtained through the Good Agricultural Practices (GAP), Good Agricultural and Collection Practices (GACP) guidelines and national regulations. It needs collaboration with Ministry of Agriculture to standardize raw material process (planting, harvesting, and post harvesting process); training and education for farmers in planting, harvesting, and post harvesting process; and farmer empowerment in medicinal plants for family economic improvement. To meet the qualified of raw materials and its sustainability, Ministry of Agriculture have published the Guidelines of Medicinal Plants Cultivation to support the program of Scientification of Jamu. At amount of 14 medicinal plants have been successfully standardized such as Curcuma xanthorriza, Zingiber officinale, Curcuma domestica, Kaempferia galanga; Andrographis paniculata; Centella asiatica; Guazuma ulmifolia; Morinda citrifolia; Apium graveolens; Piper retrofractum; Ammomum cardamomum; Alpinia galanga, Acorus calamus, and Curcuma aeruginosa.

In the year 2012, MoH will conduct National Survey on medicinal plants and folk medicine formula to gain the data base and mapping of ethnomedicine in Indonesia tribes. This survey will cover 33 provinces, around 450 districts and 1,128 sub-tribes.

Ensuring Safety, Quality and Efficacy

To assure the safety, quality and efficacy of Jamu, Scientification of Jamu is a tool for providing "a label" that certain Jamu or certain Jamu formula is effective and safe for maintaining health or curing diseases. For this reasons, Research and development (R&D) in safety, quality and efficacy of Jamu (clinical observation, clinical trials) and R&D in sociocultural aspects regarding the use of Jamu in the community absolutely have to do.

In the year 2011, Jamu formulas that have been investigated are for diabetes mellitus, hypertension, hyperuricemia and hyperlipidemia. The results showed good and effective so it can be used in health care. In the coming years the similar research will be conducted with a different formulas by randomized control trial methodology.

Traditional Medicine Health Service Facilities

Service hospital which implement complementary-alternative traditional medicine i.e. Jamu, acupuncture, acupressure, hyperbaric, hypnotherapy, yoga, chiropractic, massage, etc are 12 hospitals (A Class), such as Dr Soetomo Hospital, East Java; Sjaiful Anwar Hospital, Malang, East Java; Herbal Clinic, Dr. Sarjito Hospital, Yogjakarta; Dharmais Cancer Hospital, Jakarta; Persahabatan Hospital, Jakarta; Sanglah Hospital, Denpasar Bali; Pirngadie Hospital, Medan, North Sumatra; Suharso Orthopedic Hospital, Solo, Central Java and Soeradji Hospital, Klaten, Central Java. Kandouw Hospital, North Sulawesi (hyperbaric); Wahidin Sudirohusodo, Makassar, South Sulawesi, and Mintohardjo Navy Hospital, Jakarta.

The capacity of 13 Centers for Development and Application on TM (SP3T) were located in 13 provinces such as Medan, Palembang, Jakarta, Bandung, Yogyakarta, Semarang, Surabaya, Denpasar, Makassar, Kendari, Manado, Mataram and Ambon have been strengthened by participating courses and technical assistance regularly.

In order that the community can have an access to good quality, safe and effective of Jamu, health providers (doctors, pharmacist and traditional healers) have to provide Jamu preparation or Jamu formula/prescription that is rational. To reach this objective, the following programs should be taken into considerations:

  1. The use of good quality Jamu is mandatory for health providers.
  2. The development of Vademecum Herbal and Jamu Formularium.
  3. Vademecum volume 1 and 2 has already published in 2011. A number of 4 formulas of Jamu have proven safe, efficacious and quality, while about 60 pre-formulary ready to do clinical trials. Training and education for specialists, general physicians, health center doctors and pharmacist concerning traditional medicine (Jamu). Some training will be done per year simultaneously.
  4. Training and education for traditional healers and community regarding the use of Jamu for health promotion, prevention, treatment of early symptoms, and rehabilitation.
  5. Training for medicinal plants farmers.

In the context of health services, to assure the community access to good quality, safe and effective, the following programs should be implemented:

  1. The development "Jamu Clinics" in both governmental and private hospitals
  2. The development of "Jamu Corners" in Health Centers
  3. The development of medicinal plant garden for first aid of common diseases at household level
  4. The supervision of jamu producers in practicing Good Manufacturing Process (GMP)
  5. The establishment model of "Jamu Kit" in order to enhance health community. In this matter, Nippon Foundation will support such it funds

The target on 2014, MoH will increase the number of public health centre from 35 in 2011 to 500 PHC which have Jamu services, and 12 hospitals in 2011 to be 200 hospitals.

Integration of Jamu into Formal Health Care System

In order to integrate Jamu into the formal health care system, Jamu needs to be accepted by doctors as formal health care providers. Towards that, they need evidence of Jamu that are safe, effective, and fulfilling the standard of quality. At the community level, the integration of TM in the health care system started when the people themselves who choose Jamu for preventive efforts, curative and rehabilitative.

In line with the result of the anthropology study, there are three health care systems which are formal health care system, indigenous health care system, and "folk health care system". It is impossible to avoid "indigenous health care system" or "folk health care system" in community,

Therefore, in order that TM (indigenous heath care system and folk health care system) to be safe and effective, it needs synchronization between folk health care system, indigenous health care system, and formal health care system. If possible, a hierarchical referral system between folk health care system, indigenous health care system, and formal health care system should be established.

In order that each system works in line with its own task and functions, guideline on the use of Jamu at household level, the use of Jamu at traditional healers level, and the use of Jamu at formal health providers level (Doctors) should be developed.

In the development of Jamu, there are some issues to be given special attention, such as: (i) National policy, including regulation, (ii) provision of good quality raw materials, (iii) safety, quality and efficacy of Jamu, (iv) access to good quality, safe, and effective Jamu, and (v) rational use of Jamu.

In the context of national policy, the issues are 1) the weakness of inter-sector collaboration, 2) Jamu has not been incorporated into the national health care system, 3) reluctance of doctors to use Jamu, 4) lack of empirical evidence, and 5) inadequate regulatory framework.

The Role of Academy and Industries

By the time being there are several universities emphasized their curricula development regarding to provide human resources on TM. Lately, there are graduate program of herbal medicine (University of Indonesia), Jamu diploma (POLTEKKES, MoH), herbal medicine diploma (University of Airlangga), Diploma of Biopharmaca (University of Sebelas Maret) and will followed by Diploma of Jamu Pharmaceutical (Bogor Institute of Agriculture).

Presently, there are 79 big scale TM Industries (lOT) and 1,149 small scale TM Industries. Several industries have been collaborating with medicinal plants farmers on providing raw materials. In the next coming year, the government will develop Jamu trading system to regulate the supply chain of Jamu materials.

Publication

Many research result of TM and medicinal plant have been publish regularly by related stakeholders i.e. Scientific Journals, books, guidelines, and popular magazines. A lot of seminars, workshops and conferences are held to disseminate information and as media of experiences sharing.

Policy and Regulation

Many regulations, policies and guidelines have been endorsed such as roadmap of Jamu development which formulated in 2011 under coordination by coordinating Ministry of Economic and government and non-government Bodies.

Regulation is being formulated is the law of Jamu, standardization of traditional services in hospitals and health centers, guidance cultivation of medicinal plants, Jamu clinical trial guidelines, ethical guidelines for herbal medicine, etc.