Indonesian National Suicide Prevention Strategy 2022: A Preliminary Report

Sandersan Onie1 Ashra Daswin2,3, Kezia Taufik2, Juneman Abraham4,5, Diana Setiyawati 6,
Erminia Colucci 7, Jessica F. Nilam2, Stephanie Onie2, Mark E. Larsen1, Aliza Hunt 8, Arif Fajar
9
, Nurul E. Hidayati 10 , Christine, Damba Bestari 11, Nalini Mudhi 12, Alegra Wolter, Andrian
Liem 13, Ida Rochmawati 14, Jiemi Ardian 15, Radityo Eko Prasojo 16, Yohanes Aristanto Heri
Setiawan 17, Grace Heny 18, Halim Purnawan 19, Indria Laksmi Gamayanti 20, Herwindra Aiko
Senosoenoto 21, Marthen Jenarut 22, Benny Prawira Siauw 23, Cahyo Trianggoro 24, Edberg
Warbung 25, Catherine Lily Novita Mudjianto 26, Anna Surti Ariani 20, Irmansyah 24, Musdah
Mulia 27, Jussar Badudu 28, Maranatha Badudu 28, Retno Kumolohadi 20, Rizqy Amelia Zein 29,
Sidney Mohede28 ,Stephanie Mahadi 31, Turro Wongkaren 31, Leon Muhammad32, Luki
Hartanti32, Herbet Sidabutar32, Edduwar Idul Riyadi32, Bambang Tri Wahono32, Lucia Maya
Savitri32, Vensya Sitohang 32

1
Black Dog Institute, University of New South Wales, 2 Emotional Health for All Foundation, 3
World Health Organization Indonesia, 4 Bina Nusantara University, 5 Indonesian Psychological
Association, 6 Universitas Gajah Mada, 7 Middlesex University London, 8 Australia National
University, 9 Ibunda.id, 10 Indonesian Association of Social Workers, 11 Universitas Airlangga, 12
International Association for Suicide Prevention, 13 Monash University Malaysia, 14 RSUD
Wonosari GK-DIY, 15 Siloam Hospitals, 16 Kata.ai, 17 Konferensi Waligereja Indonesia, 18 168
Solution, 19 Manusia Indonesia Baru, 20 Ikatan Psikolog Klinis Indonesia, 21 Majelis Niciren
Shoshu Buddha Dharma Indonesia, 22 JPIC Keuskupan Ruteng, 23 Into the Light Indonesia, 24
Badan Riset dan Inovasi Nasional, 25 Tunas Bangsa School, 26 Sekolah Lentera Indonesia, 27
Religions for Peace Asia, 28 Jakarta Praise Community Church, 29 Open Science Indonesia, 30
Bisnis.com, 31 Universitas Indonesia, 32 Directorate of Mental Health, Indonesian Ministry of
Health

Corresponding Author:
Dr. Sandersan Onie
Email: sandy.onie@gmail.com
Ph: +61 432 359 134
Black Dog Institute, Australia

To cite, please cite the below:

Onie et al., (under review). Indonesian National Suicide Prevention Strategy 2022: A
Preliminary Report. DOI: 10.31234/osf.io/xhqgm
The reduction of suicide is a priority with the United Nations’ Sustainable Development
Goals (SDG 3.4). However, Indonesia – a country with a population of 273 million and over
300 ethnic groups – does not have a national suicide prevention strategy. Thus, in 2021, we
began developing such a strategy, starting with a situational analysis as recommended by
the WHO LIVE-LIFE framework1. This massive nationwide effort was led by a leadership
committee advised by the Ministry of Health and WHO Indonesia.

During the situational analysis, we investigated risk, protective and unique cultural factors;
registry infrastructure; government legislation and processes; healthcare systems and roles;
suicide research infrastructure and capacity; current efforts; situational heterogeneity; data
needs; and how these factors interact. We applied a wide range of methods including
studying non-public historical records, case studies, field interviews and service mapping.

A core component of our investigation was over 60 in-depth semi-structured interviews in

Indonesian representing different regions and facets of suicide In Indonesia. To ensure our
strategy is comprehensive, we included a range of expertise beyond policymakers, clinicians,
researchers, and those with lived experience, including individuals in education, drug and
alcohol rehabilitation, media, arts, religion, research infrastructure, technology and
innovation, sociology, economics, and minority representation. Below we outline the
preliminary findings and key recommendations.

While Indonesia does not officially report a national suicide rate, the WHO estimates a low
suicide rate (an age-standardised rate of 2.6 per 100,000 population); however, the WHO
has classified the data quality as low2. There are myriad sources of suicide data including
police data, regional administrative surveys, and a death registry, with police data
traditionally being accepted as the official source3. However, how well these data capture
true rates, and how they interact is uncertain. There was consensus among respondents
that there is tremendous underreporting.

Our investigation revealed that families will often ask police not to report a suicide, and the
police are only called when unavoidable due to severe suicide stigma. A death registry is
being piloted; however, several issues were reported. The death registry is based on death
certificates; however, the family of the deceased are responsible for applying for the death
certificate and application is not mandatory. Death certificates are typically used to claim
universal healthcare or for managing inheritance issues, thus the registry may not have
accurate or timely reporting of suicides. Families will often go to great lengths to prevent a
suicide being known, and hospitals have no mandate nor standardized pipeline to report
suicides. It was also found that among health professionals, even in the absence of any
request, there is an unwritten rule to not to not mention suicide, a phenomenon we dub
reporting taboo. Furthermore, an analysis of the police and death registry data suggest that
these registries may partly capture different incidents4. Due to a lack of data quality control,
we cannot confidently quantify the true rates of suicide.

Suicide in Indonesia is not criminalised; however, individuals who attempt suicide face
myriad challenges. Among them is not being able to claim universal insurance (BPJS)5 – on
which 225 million individuals are reliant on – if any suicidality is known about. This is due to
suicide still being perceived as an individual’s free choice to burden society and themselves 5.
Thus, we found that doctors will remove any indication of suicidal intent to allow patients to
access universal insurance.

There is a severe lack of continuity, coordination, and rigorous adaptation of most suicide
prevention efforts. Consistent funding for suicide prevention is sparse and several suicide
hotlines have come and gone. Non-government efforts are siloed with a high rate of
repetition and low innovation. Most efforts simply imitate those done overseas without
cultural adaptation or research evaluation. Research is sparse, and without proper indexing
and meta-data of local journals, reviews of existing local literature are incredibly
challenging. Important context specific knowledge is either missing or difficult to access.
Clinical help is difficult to access with 4,401 psychologists and psychiatrists for the entire
population of 273 million6, with few trained in suicide prevention.

Our investigation found that family and religion play a critical role in both suicide risk and
prevention. Lived experience interviews suggest that poor family dynamics are common risk
factors; however, thinking of loved ones often prevent an attempt. Individuals who attempt
or died by suicide have often been disowned from their family, or families have not held
funerals due to deep family shame and stigma by association. Religion is another commonly
reported factor, where held religious beliefs have both stopped individuals from attempting
suicide and stopped individuals from seeking help.

Our investigation suggested that suicide is commonly classified as aib, which is a shame so
deep, such that there is no English equivalent for the term. It is to be hidden, regarded as a
source of moral failing. The mention of suicide results in a visceral reaction, leading to an
aversion of the issue. Further investigation revealed that this is likely due to religion-based
moralisation of suicide given that suicide is considered a deadly sin 7, and religion holding a
central role in Indonesia’s society.

To address the challenges described above, several action plans are proposed. First,
development and validation of a suicide registry is paramount, involving collating raw data
(e.g., coronial reports, hospital reports, etc.) from the myriad data stewards and ensuring
data comprehensiveness and timeliness. Given that different data sources may cover
different incidents and the data stewards’ processes are largely governed by priorities
outside of suicide, we propose a new registry that collates and investigates police coronial
data and hospital records. Studies need to be conducted to quantify suspect underreporting
and investigate the causes.

Second, given the nation-wide aversion to the topic of suicide, a non-typical, religious
approach to destigmatisation of the topic of suicide is needed which will permit further
efforts to grow, such as lobbying for universal health coverage for suicide attempts and
increased research and funding.

Third, given the lack of continuity, coordination and research in suicide prevention activities
a body responsible for overseeing the implementation and evaluation of these action points
and coordinating future efforts is needed.
Further recommendations include adapted suicide prevention training for clinicians and
laypersons, integrating lived experience perspectives into all areas of suicide prevention,
and an emphasis on family and community-based approaches. Given the strong cultural
influences noted above, research must focus on understanding Indonesia’s unique context
and evaluating interventions locally. All efforts must be adapted and evaluated given that
interventions common in the Global North have failed in the past9, and there is an
imperative to ensure the limited resources available are judiciously used to reduce suicides
in the Indonesian community.

References

1. World Health Organization (2021) LIVE LIFE: An implementation guide for suicide
prevention in countries. Retrieved from:
https://www.who.int/publications/i/item/9789240026629
2. World Health Organisation (2019) Suicide Worldwide in 2019. Retrieved from:
https://www.who.int/teams/mental-health-and-substance-use/data-research/
suicide-data
3. Pusat Data dan Teknologi Informasi (2019) Situasi dan Penceghan Bunuh Diri.
Retrieved from:
https://pusdatin.kemkes.go.id/download.php?file=download/pusdatin/infodatin/
infodatin-Situasi-dan-Pencegahan-Bunuh-Diri.pdf
4. Onie, S., Daswin, A.V., et al. (in prep). Suicide in Indonesia in 2022: Underreporting,
Provincial Rates, and Means. DOI: psyarxiv.com/amnhw
5. detikNews (2014) Biaya Rawat Pasien Korban Upaya Bunuh Diri Tak Ditanggung BPJS.
Retrieved from: https://news.detik.com/berita/d-2494611/biaya-rawat-pasien-
korban-upaya-bunuh-diri-tak-ditanggung-bpjs
6. Ramdlan, MM (2017) Dosa Pelaku Bunuh Diri, Apakah Kekal di Neraka?. Retrieved
from: https://islam.nu.or.id/bahtsul-masail/dosa-pelaku-bunuh-diri-apakah-kekal-di-
neraka-1-Edo0U
7. Najlawati F., Purwaningsih, I.E. (2019). Kesejahteraan psikologis keluarga penyintas
bunuh diri. Jurnal Spirits. Retrieved from:
https://jurnal.ustjogja.ac.id/index.php/spirit/article/view/6531
8. Simon, S., et al. (2021) Participation of Religious Leaders in Helping the Success of
the Government's COVID-19 Vaccination Program. Retrieved from:
https://journal.sttsimpson.ac.id/index.php/EJTI/article/view/405/0
9. Onie, S. & Daswin, A. (2021) The lesson of talk over tea and cakes? Local research
matters. Nature 598 (405)

Contributorship

Sandersan Onie, Ashra Daswin, Juneman Abraham, Diana Setiyawati, Erminia Colucci, Jessica
F. Nilam, Stephanie Onie, and Kezia Taufik are part of the leadership committee, led by
Sandersan Onie and advised by the Indonesian Ministry of Health. The leadership
committee and Mark E. Larsen were involved in the conceptualization, study design and
methodology. Mark E. Larsen provided supervisory role. The rest of the authors were
interviewed as part of the expert panel and have equal contributorship. Sandersan Onie and
Kezia Taufik were involved in the data collection, formal analysis, and administration.
Sandersan Onie wrote the original draft, with the rest of the authors reviewing and editing
the manuscript. Apart from the leadership committee, authors with supervisory roles, and
final authors with the Ministry of Health, names are arranged in chronological order of
engagement. The views of this paper do not represent the view of the Indonesian Ministry
of Health.