Family’s Health Cadre Empowerment Program; an Innovation for Chronic Disease Management during COVID-19 Pandemic in Low- and Middle- Income Countries (LMICs)


Tuesday, October 26th 2021
16.00 – 17,30 WIB


The pandemic of COVID-19 has taken its toll on the healthcare system worldwide. As countries focus more on outbreak management, chronic disease has somehow been neglected. Due to social distancing measurement, healthcare workers, including family doctors, try to minimize contact with patients, results in reduced services for people with chronic disease [1]. Moreover, chronic diseases such as diabetes, hypertension, and heart disease are usually found on people above 40s, who are classified as a high-risk group of getting infected with COVID-19[2], making them feel scared to go out and visit the health centers. These circumstances affect the condition of people with chronic diseases who need long-term management and continuous care.

Chronic diseases such as cardiovascular and respiratory diseases, cancer, and diabetes, kill 41 million people annually, contribute to 71% of all deaths worldwide[3]. Stroke, Ischemic heart disease, diabetes, tuberculosis, and cirrhosis has become the top five leading cause of death in Indonesia within the past few years[4]. According to the National Basic Health Survey of Indonesia (Riskesdas) 2018, the prevalence of people with cancer, stroke, chronic kidney disease, diabetes, hypertension increased compare to the previous survey in 2013[5]. In Aceh, the prevalence of cancer, chronic kidney disease, diabetes, and hypertension were above the national level[5].

Family physicians play an essential role in chronic disease management, especially in Indonesia, where diabetes, hypertension, and tuberculosis are being treated at the primary health care due to the national health insurance’s regulation[6]. General physicians who act as family doctors in the country have to provide care to monitor, maintain, and treat people with chronic disease through promotive, preventive, curative, and rehabilitative programs. Not only in the primary health centers, doctors also provide community and home visits to check upon chronic disease patients as well as to ensure that they get the medication[6]. A chronic disease club is another program that primary health care provides as a support group for people with chronic disease. However, none of the programs can be carried out during the pandemic.

Some research suggested telemedicine or e-health as a solution for chronic disease management during outbreaks[7]. Through electronic platforms, health workers, especially family doctors, can still keep their patients monitored. On the other hand, patients could still talk to their doctors about their symptoms and disease. However, the use of electronic or online platform for low- and middle-income countries like Indonesia is challenging. Most of elderly population in Indonesia are not familiar with technology. Moreover, due to a challenging of geographical condition, internet or even electricity are still a luxury for many people living in rural area of Indonesia. Thus, this approach is not ideal to be implemented as a solution for chronic disease management.

In order to bridge the gap between family doctors and chronic disease patients, we proposed to go back to the family and community through the “Family’s Health Cadre Program.” As the same as cadres for vaccination and nutritional programs for children, these cadres are in charge of filling in the gap between family physicians and chronic disease patients with diabetes, hypertension, and tuberculosis. Doctors will first choose a coordinator for cadres, where one coordinator is responsible for ten households. These coordinators will later find a potential family to be assigned as the “Family’s Health Cadre.” The Family’s Health cadres will communicate with the family doctor through “E-health,” a telecommunication program established by the Indonesian Family Doctors’ Association following the Covid-19 pandemic.


Introducing & sharing the project goal; Establishing the new model of chronic diseases management through Family Medicine cadre empowerment

Targeted Audiences

Medical students, Nursing students, Doctors, Nurses, Health work force, Health volunteer

Program Design

Presentation, Discussion, Sharing Project preliminary output (chronic disease educational tools: video, booklet and flyers), role play.

Moderator: Shabrina Masturah
Speaker: dr. Ichsan, M.Sc., SpKKLP
Fasilitator: dr. Amanda Yufika, M.Sc.

Organize by

Universitas Syiah Kuala

Supported by

Besrour Center of Family Medicine Canada

Foundation for Advancing Family Medicine (FAFM)

If you are interested to join, please click here