The policy framework for palliative care in Indonesia has undergone a significant evolution over the past two decades. Initially, the foundation was laid by the Minister of Health Decree (KMK) No. 812/Menkes/SK/VII/2007, which was a pioneering step in recognizing the importance of palliative care ( Kemenkes, 2007). However, this decree served more as a guideline and lacked full legal binding force, resulting in sporadic implementation dependent on the initiatives of individual health facilities.

A fundamental turning point occurred with the enactment of Law No. 17 of 2023 concerning Health. For the first time in Indonesia’s health legislation history, palliative services were explicitly recognized as one of the pillars of health services that must be provided by the central and regional governments, on par with promotive, preventive, curative, and rehabilitative services ( Kemenkes, 2023). This change elevated the status of palliative care from a mere “option” to a legal “mandate.”

This mandate was further strengthened by KMK No. HK.01.07/MENKES/2180/2023 concerning Guidelines for the Provision of Palliative Services, which replaced the 2007 guidelines ( Kemenkes, 2023). This new guideline is far more comprehensive, detailing the principles of service provision, patient eligibility criteria, and, most importantly, expanding the scope of service delivery to the community level through the concept of “Palliative Homes” as a network of primary health facilities ( Kemenkes, 2022, 2023). This paradigm shift creates a strong legal foundation for the development of structured and equitable palliative services throughout Indonesia, as summarized in Table 1.

Despite a robust legal framework, a wide gap exists between the policy mandate and the reality on the ground. This situation can be described as a “mandate without a mechanism” there is a clear legal order, but the structured implementation pathway, especially in terms of financing and human resource development, has not yet been established. This gap manifests in several systemic barriers.

Access to palliative services remains highly unequal. These services are concentrated in a handful of major cities such as Jakarta, Yogyakarta, Surabaya, Denpasar, and Makassar ( Putranto et al., 2017, 2023). This condition creates “palliative care deserts” in most parts of Indonesia, especially in rural and remote areas, where patients and families are left to bear the burden of suffering alone. This disparity is a fundamental obstacle to achieving health equity ( Hidayah, 2024).

The root cause of the difficulty in developing palliative services is a human resources capacity crisis, especially among nurses, who are the backbone of palliative care. Various studies show inadequate levels of knowledge and attitude; one study reported that 64.8% of nurses had poor knowledge of palliative care ( Wahyuni et al., 2025). This crisis reflects a deeper systemic failure: a.

Failure of the Education System: To date, there is no specialist palliative nursing education program in Indonesia ( Wahyuni et al., 2025). Palliative care modules have not been systematically integrated and mandated in the basic medical and nursing curricula ( Agustina et al., 2025). Consequently, graduating health professionals are not equipped with the basic competencies to provide palliative care.

The ambiguity in JKN financing is the most strategic and crippling upstream barrier. Although the 2023 Health Law mandates palliative services, derivative JKN regulations, including Presidential Regulation No. 59 of 2024, have not explicitly defined the benefits package, eligibility criteria, and tariff schemes for these services ( Susanti & Syofyan, 2025). This “legal ambiguity” creates a negative domino effect: health facilities are hesitant to provide services due to claim uncertainty, and as a result, patients continue to bear significant out-of-pocket costs ( Prasetya et al., 2023). The current policy, which only allows claims with a specific “palliative care” diagnosis, often leads to late referrals when a crisis has already occurred ( Prasetya et al., 2023).

The final challenge is the low public awareness, and even among some health professionals, of the true concept of palliative care ( Komite Penanggulangan Kanker Nasional, 2019). The persistent stigma that palliative care is synonymous with “giving up” or is only for those nearing death is a major barrier to early referral ( Putranto et al., 2017). Cultural factors, such as the taboo of discussing prognosis and death and a family-centered decision-making model, also require a sensitive and skilled communication approach from the palliative team ( Tampubolon et al., 2021).

To bridge the gap between policy mandate and implementation, a comprehensive approach touching on four strategic pillars is necessary. These four pillars are designed as a mutually reinforcing ecosystem; the success of one pillar will support the others, and failure in one will weaken the entire system.

Recommendation 1: Formalize and standardize palliative services within the JKN benefits package

Addressing the JKN financing ambiguity is the most strategic leverage point. If JKN provides a clear and adequate financing scheme, it will create an economic incentive for health facilities to develop services, which in turn will drive demand for trained health professionals and trigger system-wide change.

Action : The Ministry of Health, together with BPJS Kesehatan, must immediately formulate and enact a derivative Minister of Health Regulation (Permenkes) that explicitly defines the scope, criteria, and tariffs for palliative services under the JKN scheme.

Details: a.

Scope of Services : The benefits package must be comprehensive, covering interdisciplinary team consultations, management of pain and complex symptoms, psychosocial and spiritual support for patients and families, and home-based care services.

Recommendation 2: Develop a National competency-Based palliative education and training strategy

A supply of competent health professionals is an absolute prerequisite for quality services. A coordinated national strategy is needed, not just sporadic training sessions.

Action: The Ministry of Health, in collaboration with the Ministry of Education, Culture, Research, and Technology and professional organizations (PPNI, IDI), must develop and implement a national strategy for palliative education and training.

Details: a.

Curriculum Integration : Mandate a competency-based palliative care module as part of the core curriculum for undergraduate medical and nursing programs throughout Indonesia.

Recommendation 3: Implement a decentralized and tiered palliative care delivery model with a focus on primary care

To address geographical disparities, the service delivery model must be decentralized, leveraging existing health infrastructure down to the most basic level. Placing Puskesmas and nurses at the center of this model is the most strategic and realistic step, in line with the primary care transformation program being promoted by the Ministry of Health.

Action: Regional Governments (Provincial and District/City Health Offices) must adopt and implement a structured, tiered service model to ensure equitable access, consistent with the referral system outlined in national guidelines.

Details: This model can be outlined as in Table 2, which adapts best practices from other developing countries that have successfully implemented community-based palliative care ( Kemenkes, 2023).

Recommendation 4: Launch a National public education and destigmatization campaign

Social acceptance and demand for early services can only be realized through massive and sustained public literacy improvement.

Action: The Ministry of Health, through the Directorate of Health Promotion and Germas, must design and launch a comprehensive national campaign to increase understanding and change public perception of palliative care.

Details: a.

Key Messaging : Consistently shift the narrative from “end-of-life care” to “support for the best quality of life at every stage of a serious illness”.