RECENTLY, INDONESIA WAS ranked as the fourth

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1 Digestive Endoscopy 2014; 26 (Suppl. 2): 2 9 doi: /den Special Lecture Present status of endoscopy, therapeutic endoscopy and the endoscopy training system in Indonesia Dadang Makmun Division of Gastroenterology, Department of Internal Medicine, Medical Faculty, University of Indonesia/Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia Recently, Indonesia was ranked as the fourth most populous country in the world. Based on 2012 data, general practitioners and specialists are in service around the country. Gastrointestinal (GI) disease remains the most common finding in daily practise, in both outpatient and inpatient settings, and ranks fifth in causing mortality in Indonesia. Management of patients with GI disease involves all health-care levels with the main portion in primary health care. Some are managed by specialists in secondary health care or are referred to tertiary health care. GI endoscopy is one of the main diagnostic and therapeutic modalities in the management of GI disease. Development of GI endoscopy in Indonesia started before World War II and, today, many GI endoscopy procedures are conducted in Indonesia, both diagnostic and therapeutic. Based on August 2013 data, there are 515 GI endoscopists in Indonesia. Most GI endoscopists are competent in carrying out basic endoscopy procedures, whereas only a few carry out advanced endoscopy procedures, including therapeutic endoscopy. Recently, the GI endoscopy training system in Indonesia consists of basic GI endoscopy training of 3 6 months held at 10 GI endoscopy training centers. GI endoscopy training is also eligible as part of a fellowship program of consultant gastroenterologists held at six accredited fellowship centers in Indonesia. Indonesian Society for Digestive Endoscopy in collaboration with GI endoscopy training centers in Indonesia and overseas has been working to increase quality and number of GI endoscopists, covering both basic and advanced GI endoscopy procedures. Key words: present status, diagnostic endoscopy, endoscopy training system, GI disease, therapeutic endoscopy Corresponding: Dadang Makmun, Division of Gastroenterology, Department of Internal Medicine, Medical Faculty, University of Indonesia/Cipto Mangunkusumo National General Hospital, Jl. Diponegoro no. 71, Jakarta 10320, Indonesia. Received 28 November 2013; accepted 8 January INTRODUCTION RECENTLY, INDONESIA WAS ranked as the fourth most populous country in the world following China, India and the USA. Based on new statistical data launched by the Indonesian Central Statistical Bureau in July 2012, people are estimated to inhabit Indonesia s islands with a mean age of 28.5 years and an average life expectancy of years (average male life expectancy, years; average female life expectancy, years). Indonesia is well known as the largest archipelago country in South-East Asia, comprising islands that are located between the two continents of Asia and Australia. Administratively, Indonesia consists of 33 provinces and 497 cities. 1 Countrywide statistics show a 1.49% population growth rate with a density of 121 people/km 2. Highly dense provinces are dominantly located on Java island with Jakarta as the most densely populated city ( people/km 2 ). 1 Based on current statistics data from the Ministry of Health Republic of Indonesia in 2012, general practitioners and specialists are distributed throughout Indonesia s provinces. Using a 1:3000 doctor-to-population ratio, those numbers are almost proportionate with Indonesia s current population; however, the conspicuous problem seemingly concerns its distribution system. Based on data launched in March 2013, Indonesian doctors are in service in 9510 primary health-care centers and in 2083 hospitals in Indonesia, including government and private-owned hospitals. 2 Referring to data from the Ministry of Health Republic of Indonesia in 2009, upper respiratory tract infection was the most common diagnosis of Indonesia s 10 most prevalent outpatient diseases, followed by hypertension, dermatological disease, fever, diarrhea and dyspepsia, respectively (Table 1). Gastrointestinal (GI) disease remains the most common finding encountered in daily practice, both in outpatient and inpatient settings. Diarrhea placed second after pneumonia in the 10 most prevalent inpatient diseases in Indonesia s hospitals, followed, respectively, by typhoid fever, bs_bs_banner 2

2 Digestive Endoscopy 2014; 26 (Suppl. 2): 2 9 Present endoscopy status in Indonesia 3 Table 1 Most common diseases in the outpatient setting of Indonesian hospitals as estimated in 2009 Rank Disease Sex Total case findings Male Female No. patient visits 1 Upper respiratory tract infection Fever of unknown origin Dermatoses and other subcutaneous tissue disease Diarrhea and gastroenteritis caused by certain infectious agents (infection-associated colitis) 5 Refraction and accommodation-related disorders Dyspepsia Essential hypertension Pulpal and periapical disease Ear disease and mastoid process-related disorders Conjunctivitis and other conjunctiva-related disorders Cited from Indonesian Health Profile 2009, Ministry of Health Republic of Indonesia. 2 Table 2 Most common diseases in the inpatient setting of Indonesian hospitals as estimated in 2009 Rank Disease Sex Total case findings Male Female No. deaths CFR (%) 1 Diarrhea and gastroenteritis caused by certain infectious agents (infection-associated colitis) 2 Dengue hemorrhagic fever Typhoid and paratyphoid fever Fever of unknown origin Dyspepsia Essential hypertension Upper respiratory tract infection Pneumonia Appendiceal disorders Gastritis and duodenitis * CFR : Case Fatality Rate. Cited from Indonesian Health Profile 2009, Ministry of Health Republic of Indonesia. 2 hypertension, dengue hemorrhagic fever, fever with unknown origin and dyspepsia (Table 2). However, GI disease is in fifth place regarding mortality-causing disease in Indonesia, following vascular disease, infectious disease and certain parasitic disorders, certain conditions of the perinatal period and respiratory system disease (Table 3). As a developing country, Indonesia s health-care system is designed as a three-level system comprising primary health care by general practitioners or family physicians, secondary health care by specialists, and tertiary health care by subspecialists. Each level requires accredited competence and supporting facilities based on requirements. 2 Management of patients with GI disease involves all the health-care levels with the main portion of its management expected to be carried out in primary health care. With the advancement of a referral health system, the number of patients with GI diseases are managed by specialists in secondary health care or further referred to tertiary health care. DEVELOPMENT OF GI ENDOSCOPY IN INDONESIA GASTROINTESTINAL ENDOSCOPY HAS been used worldwide as one of the main diagnostic, as well as therapeutic, modalities in the management of GI disease. Development of GI endoscopy in Indonesia was almost similar to other countries in which a rigid endoscope was used before World War II. This rigid endoscope took the form of a rectosigmoidoscope that was specifically used by

3 4 D. Makmun Digestive Endoscopy 2014; 26 (Suppl. 2): 2 9 Table 3 Most common causes of death in Indonesian hospitals as estimated in 2008 Rank Cause of death No. deaths CFR (%) 1 Vascular disease Infectious disease and certain parasitic disorders 3 Certain conditions of the perinatal period 4 Respiratory system disease Gastrointestinal disease Injuries, intoxications, and other external causes 7 Endocrine, nutrition, and metabolic disease 8 Urinary tract disease Neoplasm Unknown signs, symptoms, and abnormal laboratory findings * CFR : Case Fatality Rate. Cited from Indonesian Health Profile 2009, Ministry of Health Republic of Indonesia. 2 surgeons. In 1958, Pang reported the use of the first laparoscope without a camera in Indonesia. 3 Semi-flexible endoscopy was first introduced in Indonesia as a semi-flexible gastroscope by Simadibrata in In 1971, flexible gastroscopes were widely used (Olympus GTFA, Olympus Co., Japan). Ever since, more reports on the use of flexible endoscopes have been published in Indonesia, especially after the establishment of the Indonesian Society for Digestive Endoscopy (ISGE) in 1974, chaired by Pang. 4,5 The flexible colonoscope was first used in Indonesia by Hilmy in 1973 with its first therapeutic use in the colon reported in Henceforth, more endoscopic polypectomies were reported in the main hospitals in Indonesia. In 1984, endoscopic sclerotherapy was pronounced for the first time by Hilmy and colleagues by ethoxysclerol injections in patients with esophageal varices related to liver cirrhosis. Endoscopic cauterizations were first reported by Aziz Rani in 1984, using an Olympus electro-surgical unit in patients with post-esophageal transection strictures. 3,6,7 Nowadays, more GI endoscopy procedures are conducted in Indonesia, both for diagnostic and therapeutic purposes. Currently, medical technology advancements contribute voluminous innovations in health-care trends, especially in GI endoscopy, with the distribution of more advanced GI endoscopes and accessories. Recently, diagnostic endoscopy modalities in Indonesia were commonly categorized as esophagogastroduodenoscopy, colonoscopy, capsule endoscopy, enteroscopy, and endoscopic ultrasonography. Most endoscopists are competent in carrying out diagnostic endoscopy procedures (esophagogastroduodenoscopy and colonoscopy) whereas only a few carry out enteroscopy or endoscopic ultrasonography. This discrepancy is caused by the limited provision of both diagnostic modalities in Indonesia. In contrast, GI endoscopy is economically costly as a result of the high cost of the GI endoscope and its accessories. In March 2013, there were only 313 hospitals currently providing GI endoscopy services, distributed in 33 provinces around the country (Table 4). 8 Unlike diagnostic endoscopy procedures which are commonly carried out by all GI endoscopists, therapeutic endoscopy, especially advanced endoscopy procedures, is not routinely done by all endoscopists. This has been argued to be related to the limitations of endoscopy facilities and accessories, endoscopist competency, poor distribution of patients with complicated GI diseases requiring advanced endoscopy procedures and the courage of the endoscopist to carry out advanced endoscopy procedures with all the risks contained therein. Today, therapeutic endoscopy procedures that are routinely done in Indonesia comprise the following. 1. Upper gastrointestinal endoscopy: Sclerotherapy and esophageal varices ligation Histoacryl injection in gastric varices Polypectomy Esophageal/pyloric dilatations Percutaneous endoscopic gastrostomy (PEG) Foreign body extractions Endoscopic hemostasis (clips, adrenaline injection, coagulation) Esophageal stenting 2. Lower gastrointestinal endoscopy: Polypectomy Endoscopic hemostasis (clips, coagulation) Colonic stenting 3. Endoscopic retrograde cholangiopancreatography (ERCP): Biliary stone extraction Biliary and pancreatic stenting Biliary dilatation 4. Enteroscopy: Enteroscopic hemostasis Foreign-body extraction 5. Endoscopic ultrasonography: Pancreatic cyst/pancreatic pseudocyst drainage Biliary drainage In Indonesia, competency in GI endoscopy comprises a three-level grading: basic, first-level advanced, and secondlevel advanced competency. Basic endoscopy competency includes esophagogastroduodenoscopy, colonoscopy, esophageal varices sclerotherapy, esophageal varices ligation and adrenaline-injection endoscopic hemostasis. First-level advanced endoscopy competency allows the endoscopist to

4 Digestive Endoscopy 2014; 26 (Suppl. 2): 2 9 Present endoscopy status in Indonesia 5 Table 4 Hospitals currently providing gastrointestinal endoscopy service in Indonesia No. Province No. hospitals July 2008 September 2010 July 2011 July 2012 March 2013 Java 1 Jakarta Banten West Java Yogyakarta Central Java East Java Nusa Tenggara 7 Bali West Nusa Tenggara East Nusa Tenggara Sumatra 10 Lampung South Sumatra Bangka Belitung Bengkulu Jambi Riau Riau Islands West Sumatra North Sumatra Nanggroe Aceh Darussalam Kalimantan 20 West Kalimantan East Kalimantan South Kalimantan Central Kalimantan Sulawesi 24 West Sulawesi South Sulawesi North Sulawesi Central Sulawesi South East Sulawesi Gorontalo Maluku Islands and Papua 30 Maluku North Maluku Papua West Papua Total Cited from Indonesian Society for Digestive Endoscopy Report, August carry out basic endoscopy competency and esophageal dilatations. Second-level advanced endoscopy competency consists of basic endoscopy competency and all therapeutic endoscopy procedures and advanced endoscopy procedures (i.e. enteroscopy and endoscopic ultrasonography). Currently, an estimated 515 endoscopists carry out GI endoscopy in Indonesia (Table 5). Almost 80% of the 515 endoscopists are accredited in basic endoscopy competency only, the rest are accredited in first-level and second-level advanced endoscopist competencies. 8

5 6 D. Makmun Digestive Endoscopy 2014; 26 (Suppl. 2): 2 9 Table 5 Distribution of doctors carrying out GI endoscopy procedures in Indonesia No. Province Specialization Total Internist Pediatrician Surgeon General Practitioner 1 Jakarta and Banten East Java North Sumatra and Jambi West Java South Sulawesi West Sumatra North Sumatra Yogyakarta Surakarta Central Java West Nusa Tenggara Malang Bali North Sulawesi, West Sulawesi, Central Sulawesi, Gorontalo, Maluku and Papua 15 South Kalimantan East Kalimantan, West Kalimantan and Central Kalimantan Lampung Riau Banda Aceh Total Cited from Indonesian Society for Digestive Endoscopy Report, August ENDOSCOPY TRAINING SYSTEM IN INDONESIA IN THE FIRST years of GI endoscopy development in Indonesia, doctors were studying endoscopy-related skills in several countries, such as Japan, Germany, and The Netherlands. Right after the establishment of the Indonesian Society for Digestive Endoscopy in 1974, endoscopy training was introduced to several main hospitals, such as Cipto Mangunkusumo National General Hospital in Jakarta, Sutomo General Hospital in Surabaya, Adam Malik Hospital in Medan and Hasan Sadikin General Hospital in Bandung. The mission of the Indonesian Society for Digestive Endoscopy is to maintain and to enhance the quality of GI endoscopy services in Indonesia professionally. Considering the number of GI endoscopists in Indonesia (515 doctors) who are in service all around the country, it is still far from ideal. For this reason, the Indonesian Society for Digestive Endoscopy keeps increasing the number of endoscopy training centers with the vision of enhancing the quality and quantity of endoscopists in Indonesia. Evidence is lacking on the ideal endoscopist-to-population ratio, but in the USA in 2003, the ratio between consultant gastroenterologist and population is 1:37 037, whereas in England in 2007, the ratio ranged between 1: and 1: In Indonesia, the ideal number should be one gastroenterologist per one district (capable of carrying out GI endoscopy services). As the total population of Indonesia is assumed to be approximately 250 million and the average number of citizens per district is , therefore, ideally, 2500 consultant gastroenterologists are required. In recent years, only 10 gastrointestinal endoscopy training centers were established (Table 6). Thus, further development of well-distributed centers is in demand In recent times, gastrointestinal endoscopy training in Indonesia consists of basic gastrointestinal endoscopy training which trainees are internists, surgeons, or pediatricians and further endoscopy training as part of fellowship for consultant gastroenterologists. 8 Basic GI endoscopy training is under way in all GI endoscopy training centers in Indonesia with 3 6 months duration of training. Besides lectures on GI endoscopy, trainees are practically trained, starting from observational studies, followed by endoscopy under supervision and, finally, unsupervised endoscopy. During the training, trainees are expected to independently carry out esophagogastroduodenoscopies and colonoscopies. Trainees are also expected to undergo five to 10 unsupervised

Digestive Endoscopy 2014; 26 (Suppl. 2): 2 9 Present endoscopy status in Indonesia 7 Table 6 Development of endoscopy training centers in Indonesia (2002-2012) No. Endoscopy training center No.

6 Digestive Endoscopy 2014; 26 (Suppl. 2): 2 9 Present endoscopy status in Indonesia 7 Table 6 Development of endoscopy training centers in Indonesia ( ) No. Endoscopy training center No. trainees Total Jakarta (Cipto Mangunkusumo National General Hospital) Surabaya (Dr Soetomo General Hospital) Medan (H. Adam Malik General Hospital) Bandung (Dr Hasan Sadikin General Hospital) Semarang (Dr Kariadi General Hospital) Yogyakarta (Dr Sardjito General Hospital) Denpasar (Sanglah General Hospital) Surakarta (Dr Moewardi General Hospital) Malang (Dr Saiful Anwar General Hospital) Makassar (Dr Wahidin Sudiro Husodo General Hospital) 1 1 No. trainees Cited from Indonesian Society for Digestive Endoscopy Report, August Figure 1 Endoscopy training centers in Indonesia. Source: Indonesian Society for Digestive Endoscopy report, August esophageal varices ligations and esophageal varices sclerotherapy. Upon completion of the training, trainees should be prepared to appropriately recommend endoscopic procedures, as indicated, with explicit understanding of specific indications, contraindications, and diagnostic/therapeutic alternatives, carry out the procedures safely, including principles of conscious sedation and the use of anesthesiaassisted sedation where appropriate. They are also expected to have explicit understanding of pre-procedure clinical assessment and patient monitoring, interpret endoscopic findings and integrate them into medical or endoscopic therapy, identify risk factors for each procedure and appropriately manage complications when they occur and acknowledge the limitations of endoscopic procedures and personal skills and when to request help. Henceforth, they should periodically report endoscopy activities in their institution. Trainees are encouraged to continuously attend continuing medical education (CME), especially in the field of gastroenterology and GI endoscopy in Indonesia and overseas 8,11 (Fig. 1). Gastrointestinal endoscopy training is also eligible as a part of a fellowship program for consultant gastroenterologists in Indonesia. During 3 4 years of fellowship, fellows also attain endoscopy modules according to the facilities

7 8 D. Makmun Digestive Endoscopy 2014; 26 (Suppl. 2): 2 9 Table 7 No. consultant gastroenterologists in Indonesia No. Province No. consultant gastroenterologists Jakarta and Banten West Java North Sumatra and Jambi West Java South Sulawesi West Sumatra South Sumatra Yogyakarta Surakarta Central Java East Nusa Tenggara Malang Bali North Sulawesi South Kalimantan West Kalimantan Lampung Riau Banda Aceh Total Cited from: Indonesian Society for Digestive Endoscopy Report, August provided in each center. Today, there are only six accredited consultant gastroenterologist fellowship centers in Indonesia (Jakarta, Surabaya, Medan, Yogyakarta, Semarang, and Bandung). As a result of the lack of facilities, there are limitations in the capacity to train fellow consultant gastroenterologists. As of July 2013, the number of consultant gastroenterologists in Indonesia was 113 doctors only (Table 7). This number is lacking considering the size of the Indonesian population and its health problems, especially GI disease. Problems regarding training at advanced GI endoscopy level are due to the limited number of competent doctors able to carry out advanced GI endoscopy and the poorly distributed facilities of advanced GI endoscopy among the centers. In daily practice, not all consultant gastroenterologists in Indonesia carry out advanced GI endoscopy procedures because of the poor distribution of patients with complicated GI disease requiring advanced GI endoscopy procedures. 8 CONCLUSIONS GASTROINTESTINAL DISEASE REMAINS one of the main health problems in Indonesia, both for outpa tients and inpatients, and is the fifth major cause of death nationwide. In contrast, GI endoscopy facilities, one of the main diagnostic and therapeutic modalities in the management of GI disease, are still limited. The number of hospitals equipped with GI endoscopy facilities and doctors that are competent to carry out diagnostic and therapeutic GI endoscopy are prominently limited. Today, GI endoscopy remains a high-cost health-care service that is unaffordable for most citizens. Now and in the future, the government plans to broaden health-care coverage including GI endoscopy procedures, and to provide GI endoscopy facilities especially in government-owned hospitals. Concurrently, the Indonesian Society for Digestive Endoscopy has been collaboratively working with existing GI endoscopy training centers in Indonesia to increase both the quality and number of GI endoscopists, covering both basic and advanced GI endoscopy levels. The Indonesian Society for Digestive Endoscopy also plans to send potential members to enhance their skills and knowledge in international GI endoscopy training centers worldwide. In the coming years, the GI endoscopy service in Indonesia is envisioned to equal that of international standards and, specifically, to fulfil the standard of health care in the Asia Pacific region. ACKNOWLEDGMENTS THE AUTHORS THANK Dr Jeffri A. Gunawan and Ms Shinta Lestiani for their editorial assistance.

8 Digestive Endoscopy 2014; 26 (Suppl. 2): 2 9 Present endoscopy status in Indonesia 9 CONFLICT OF INTERESTS THE AUTHORS DECLARE no conflict of interests for this article. REFERENCES 1 Indonesian Central Statistical Bureau. Indonesian demographic profile Cited on July 29th Available from URL: 2 Ministry of Health Republic of Indonesia. Indonesia health profile Cited on July 29th Available from URL: 3 Pang, RTP. Observation with peritoneoscopy in liver disease in Indonesia. PhD [dissertation]. Jakarta: Universitas Indonesia; Hadi, S. The development of gastrointestinal endoscopy in Indonesia and overseas. In: Endoscopy in Gastroenterohepatology p Simadibrata, S. The use of gastroscopy in stomach disorder. In: Proceeding book of national congress of Indonesian Association of Internal Medicine p Hilmy FA, Tilaar PC, Daldiyono, et al. Colonoscopy and sigmoidoscopy in Cipto Mangunkusumo National General Hospital Jakarta. In: Proceeding book of national congress of Indonesian Association of Internal Medicine p Rani AA, Ali I, Daldiyono, et al. Endoscopic therapy in patient with post esophageal transection stricture. In: Proceeding book of national congress of Indonesian Association of Internal Medicine p Makmun D, Syafruddin ARL. Indonesian Society for Digestive Endoscopy report. Center for information and publishing; Jakarta: Graduate Medical Education National Advisory Committee. Target Physician to population ratio Cited on July 29th, Available from URL: 10 Thompson, N, Romaya, C. Gastroenterology workforce report Cited on July 29th Available from URL: gsg.org.uk 11 American Society for Gastrointestinal Endoscopy. Principles of training in GI endoscopy. Gastrointest. Endosc. 2012; 75:

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