Inclusive medical rehabilitation for persons with disability due to leprosy, lymphatic filariasis, and diabetes mellitus: Mapping the gap in three leprosy endemic districts in Indonesia

Medical rehabilitation for person with disability in Indonesia is still an issue. This research aimed to explore Inclusive medical rehabilitation for persons with disability due to leprosy, lymphatic filariasis, and diabetes mellitus in three regions in Indonesia. The qualitative study was employed to gather data from disability patients, health workers in PHCs, medical rehabilitation services for leprosy, DM, and LF in hospitals. The results indicated that the gap on medical rehabilitation for person with disability due to leprosy, lymphatic filariasis and diabetes mellitus in three regions were due to some differences in their geographical aspects, availability of referral hospital for treating leprosy and filariasis, supervision, human resource competencies.


54
Medical rehabilitation in Indonesia remains limited in terms of availability and accessibility 55 to the majority of people needing it [1,2]. There are medical rehabilitation centres in all major 56 cities, and even district hospitals must offer basic rehabilitation services. This however does 57 not mean that all the relevant services are obtainable nationwide, that the professional staff is  The right to receive health services contains the elements of availability, accessibility, 63 acceptability, and appropriateness (or quality) [2]. In Indonesia, people with leprosy often 64 experience barriers in obtaining rehabilitation services [4]. For example, a previous study 65 described barriers to medical rehabilitation services for persons with disability due to leprosy 3 66 [5]. There are seven leprosy hospitals available throughout Indonesia, but only one offers the 67 most relevant medical rehabilitation (e.g. surgery, prosthetics & orthotics, physiotherapy, 68 occupational therapy, including here also guidance to home-based self-care) [3]. Long 69 distance to reach the nearest leprosy hospital limits the access for most leprosy-affected 70 persons. Furthermore, access to general hospitals is often restricted by stigmatising and 71 discriminating attitudes of hospital staff [4]. Furthermore, information accessibility is 72 constrained for many people in remoter areas and with low level of education [6].

74
Many persons affected by leprosy are not members of any insurance scheme as they do not 75 have valid identity cards [7]. Additionally, economical access or affordability is often not 76 ensured when people have to stay for prolonged times in leprosy hospitals waiting for 77 services, or have to bring family members to care for them, both reducing family income [8].

78
Acceptability of medical services is low in some leprosy hospitals where facilities and 79 services hardly respect human dignity, as clearly evident when visiting these hospitals.

80
Appropriateness or quality for services differs and may only benefit those who have the 81 resources.

83
Other diseases such as lymphatic filariasis (LF) and diabetes mellitus (DM) can cause 84 disabilities similar to leprosy in several aspects [9-11]. All require care and self-care to deal 85 with chronic impairments especially to lower limbs [12][13][14]. Both in leprosy and DM, 86 peripheral neuropathy is common, which may lead to wounds when pain is not felt, and 87 ultimately to amputations [9,11]. Simple interventions such as wearing protective footwear 88 may prevent worsening of impairments for people with insensitive feet caused by neuropathy, 89 while tendon transfers in leprosy restore function and mobility [12]. This was a qualitative study designed as baseline data to map the gap of inclusive medical 105 rehabilitation for leprosy, LF, and DM. The aim of this study is to systematically and        In this study, experts consisted of physiotherapist (22.2%), internist (22.2%), dermatologist 166 (11.1%), surgeon (22.2%), general practitioner (11.1%), and professional nurses (11.1%).

167
The majority of experts were male (55.6%). The average age of respondents is 47 years old 168 with the youngest is 45 years old and the oldest is 51 years old. 4 of 9 respondents are known 169 to have studied the disease for an average of 15 years, with the shortest time to explore the 170 field of disease is 2 years and the longest is 24 years.  Health workers reported that the building condition had been a major concern for the health 183 management, which was addressed by continuous effort to improve the condition. However, 184 there were occassions when examinations were conducted where the health workers were on 185 duty, for example, if the health worker is responsible for treating the leprosy and also TB, 186 then the examination for both diseases will be conducted in the same room. It was also 187 known that the total building area in the PHCs affected the availability of examination rooms.  The availability of basic equipment for the diagnosis and therapeutic is presented in Table 1. The result indicated the availability of generic and supporting drugs for leprosy is more 232 complete than DM and LF. However, it should be taken into account that some types of drugs 233 were not available at PHC. There were significant differences between the percentages gap 234 with LF (29.3%) and with DM (64.2%). It can also be seen that the drugs availability in PALI

235
District were more complete than in Pekalongan and Bima Districts. However, there was only 236 a small gap found between the three districts.

238
The Government of Indonesia is organizing programs to provide medicines for leprosy, DM, nurses, a physiotherapist, officers in orthotic prosthetic, and medical rehabilitation doctors.

258
Unfortunately LF expert are not found in these two hospitals. However, an expert from Dr.

259
Rivai Abdullah Hospital, who is a surgeon, stated that he was able to perform surgery for LF 260 patients who already suffered swollen lymph nodes.  This study indicated that in the region there are variations in leprosy referral system 322 implementation inter-regional, especially from the aspect of availability of referral facilities 323 and referral system. Refferal medical rehabilitation was only available in leprosy programs.

324
The best referral system only exists in Java Island. In the research area in Central Java, they 325 have referral hospital with a system to pick up patients who are ready to be rehabilitated by Gap of medical rehabilitation services remains exist between leprosy, diabetes, and filariasis.

351
Medical rehabilitation program of leprosy is better than the other diseases. There was also a 352 gap of medical rehabilitation services between Java and non-Java Islands.