cisdi health outlook 2021

CISDI HEALTH OUTLOOK 2021The Disruption of Covid-19 to Essential Health Services, Its Impact and the Way to Rebuild Indonesia’s Health Sector

Published in Indonesia in December 2020 byCenter for Indonesia’s Strategic Development Initiatives

Probo Office ParkJl. Probolinggo No. 40C Menteng, Jakarta Pusat 10350

www.cisdi.org

Cover design by Dedi Suhendi, all rights reserved.

Translated and edited by Dwitri Amalia.

Unless otherwise stated, this report is licensed underCreative Commons Attribution-NonCommercial 4.0 International License.

Some rights reserved.

How to quote this report:(CISDI, 2020)Center for Indonesia’s Strategic Development Initiatives. 2020. Health Outlook 2021: The

Disruption of Covid-19 to Essential Health Services, Its Impact and the Way to Rebuild

Indonesia’s Health Sector. Jakarta: Center for Indonesia’s Strategic Development Initiatives.

1Indonesia’s Health Outlook 2021:

The Disruption of Covid-19 to Essential Health Services, Its Impact and the Way to Rebuild Indonesia’s Health Sector

Chapter 2Reflection: Vicious Cycle of COVID-19 Pandemic .............................................

Chapter 3Rethinking the Future of Indonesia’s Health System 2021: Some Plausible Scenarios ........................................................................................................

Closing...........................................................................................................

List of Abbreviations .......................................................................................

Glossary ..........................................................................................................

Introduction ....................................................................................................

Executive Summary ........................................................................................

Chapter 1At a Glance: Indonesian Health System 2020 ..................................................

The Journey of COVID-19 Pandemic in Indonesia ....................................

The Impact of COVID-19 to the Pillars of National Health System .............

1.1

1.2

Vicious cycle of covid-19 in the health, economic, political, and social

systems................................................................................................

1.3

Healthcare ..................................................................................

Health Workers ...........................................................................

Health Information System ..........................................................

Health Funding ............................................................................

Leadership ..................................................................................

Governance .................................................................................

1.2.1

1.2.2

1.2.3

1.2.4

1.2.5

1.2.6



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6

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Table of Contents

ADAPTT Surge Planning Support ToolADE Antibody Dependent EnhancementAKI Angka Kematian Ibu

APBN Anggaran Pendapatan Belanja Negara

APBD Anggaran Pendapatan Belanja Daerah

ASKES Asuransi Kesehatan

ASKESKIN Asuransi Kesehatan Bagi Masyarakat Miskin

BBLR Berat Badan Lahir Rendah

BIN Badan Intelijen NegaraBLC Bersatu Lawan COVID

BNPB Badan Nasional Penanggulangan Bencana

BOK Bantuan Operasional Kesehatan

BOR Bed Occupancy RateBPJS Badan Penyelenggara Jaminan Sosial Kesehatan

BPNT Bantuan Pangan Non Tunai

BPOM Badan Pengawas Obat dan Makanan

BPPSDM Badan Pengembangan dan Pemberdayaan Sumber Daya Manusia

Kesehatan

BPS Badan Pusat Statistik

CISDI Center for Indonesia’s Strategic Development InitiativesCOVID Corona Virus DiseaseDAK Dana Alokasi Khusus

DKI Daerah Khusus Ibukota

DNA Deoxyribonucleic AcidERD Enhanced Respiratory DiseaseESFT Essential Supplies Forecasting ToolEUA Emergency Use AuthorizationFKTL Fasilitas Kesehatan Tingkat Lanjut

FKTP Fasilitas Kesehatan Tingkat Pertama

GAVI Global Alliance for Vaccine and ImmunizationGDP Gross Domestic ProductICU Intensive Care UnitICT Information and Communication TechnologyIHME Institute for Health Metrics and EvaluationIHR International Health RegulationIPM Indeks Pembangunan Manusia

INA-CBGs Indonesia Case Base GroupsITAGI Indonesian Technical Advisory Group on ImmunizationJKN Jaminan Kesehatan Nasional

KEK Kurang Energi Kronik

Kemenag Kementerian Agama

Kemendikbud Kementerian Pendidikan dan Kebudayaan

Kemenhub Kementerian Perhubungan

Kemenkeu Kementerian Keuangan

KMP Kemitraan Multipihak

KOMDAT Komunikasi Data

KOMDA PP Komisi Daerah Pengkajian dan Penanggulangan



List of Abbreviations

KOMNAS PT Komite Nasional Pengendalian Tembakau

Litbangkes Badan Penelitian dan Pengembangan Kesehatan

Menko Menteri Koordinator

NHA National Health Account

NSPK Norma, Standar, Prosedur, dan Kriteria

ODP Orang Dalam Pemantauan

OECD Organization for Economic Co-Operation and Development

PAUD Pendidikan Anak Usia Dini

PBI APBN Penerima Bantuan Iuran Anggaran Pendapatan dan Belanja Negara

PBI APBD Penerima Bantuan Iuran Anggaran Pendapatan dan Belanja Daerah

PBPU Pekerja Bukan Penerima Upah

PCR Polymerase Chain Reaction

PDB Produk Domestik Bruto

PDP Pasien Dalam Pengawasan

Perpres Peraturan Presiden

Perkeni Perkumpulan Endokrinologi Indonesia

PHEIC Public Health Emergency of International Concern

PHEOC Public Health Emergency Operating Centre

PHK Pemutusan Hubungan Kerja

PHR Personal Health Record

PIS-PK Program Indonesia Sehat dengan Pendekatan Keluarga

PKH Program Keluarga Harapan

PONEK Pelayanan Obstetrik Neonatal Emergency Komprehensif

Posyandu Pos Pelayanan Terpadu

PP Permenkes Pelaksanaan

PPDS Peserta Pendidikan Dokter Spesialis

PPE Personal Protect Equipment

PPNI Persatuan Perawat Nasional Indonesia

PPOK Penyakit Paru Obstruktif Kronis

PPU Pekerja Penerima Upah

Prolegkes Prioritas Legislasi Kesehatan

PSBB Pembatasan Sosial Berskala Besar

PT Perseroan Terbatas

PTM Penyakit Tidak Menular

PUPR Pekerjaan Umum dan Perumahan Rakyat

Pusdatin Pusat Data dan Informasi

Puskesmas Pusat Kesehatan Masyarakat

RAPBN Rancangan Anggaran Pendapatan dan Belanja Negara

Risfaskes Riset Fasilitas Kesehatan

Riskesdas Riset Kesehatan Dasar

RKO Rencana Kebutuhan Obat

RKP Rencana Kerja Pemerintah

RLI Rasio Lacak Isolasi

RPJMN Rencana Pembangunan Jangka Menengah Nasional

RS Rumah Sakit

RSMTH Royal Society of Tropical Medicine and Hygiene

RSUD Rumah Sakit Umum Daerah

RT Rukun Tetangga

RW Rukun Warga

SARI Severe Acute Respiratory Infection



SD Sekolah Dasar

SDGs Sustainable Development GoalsSDKI Survei Demografi dan Kesehatan Indonesia SDM Sumber Daya Manusia

Sembako Sembilan bahan pokok

SIHA Sistem Informasi HIV/AIDS

SIK Sistem Informasi Kesehatan

SIP Sistem Informasi Puskesmas

SISRUTE Sistem Rujukan Terintegrasi

SITT Sistem Informasi Tuberkulosis Terpadu

SJSN Sistem Jaminan Sosial Nasional

SMA Sekolah Menengah Atas

SMP Sekolah Menengah Pertama

SPM Standar Pelayanan Minimum

TBC TuberculosisTK Taman Kanak-kanak

TNI Tentara Nasional Indonesia

TPB Tujuan Pembangunan Berkelanjutan

UNAIR Universitas AirlanggaUNICEF United Nations International Children’s Emergency FundUU Undang-Undang

UKBM Upaya Kesehatan Berbasis Masyarakat

UKM Upaya Kesehatan Masyarakat

UKP Upaya Kesehatan Perorangan

VAERD Vaccine Associated Enhanced Respiratory DiseaseVAERS Vaccine Adverse Events Reporting SystemWHO World Health Organization



Ad hoc

Bed Occupancy Rate

Building castles in the air

Bureaucracy

Clinical pathway

Comprehensive

Cost-benefit analysis

COVAX

Crowding out effect

Direct medical cost

Direct mortality

E-catalog

Epidemiology

Emergency Use Authorization

Temporary or impermanent.

The number of beds effectively occupied.

To make plans that have very little chance of happening.

A system of government in which most of the important decisions are taken by state officials rather than by elected representatives.

One of the main tools used to manage the quality in healthcare concerning the standardization of care processes.

Able to be understood; intelligible.

Relating to or denoting a process that assesses the relation between the cost of an undertaking and the value of the resulting benefits.

International consortium; comprised of GAVI, the Vaccine Alliance, the Coalition for Epidemic Preparedness Innovations (CEPI), and WHO, who are responsible to accelerate efforts in research, development, and production of COVID-19 vaccine candidates.

A phenomenon that occurs when increased government involvement in a sector of the market economy substantially affects the remainder of the market, either on the supply or demand side of the market.

Costs that are directly attributable to patient care.

Death due to SARS-COV-2 virus or its comorbidity that is borne by a suspect patient.

Electronic information system that contains list, type, and technical specifications and prices of certain goods/services from the government’s vendors list.

The branch of medicine which deals with the incidence, distribution, and possible control of diseases and other factors relating to health.

A mechanism to facilitate the availability and use of medical countermeasures, including vaccines, during public health emergencies, such as the current COVID-19 pandemic.

Glossary



A mild or indirect word or expression substituted for one considered to be too harsh or blunt when referring to something unpleasant or embarrassing.

A situation in which two alternative points of view are presented as the only options, when others are available.

Relating to or encompassing the whole of something, or of a group of things.

Costs incurred indirectly due to a health service for example insurance, taxes, floor space, facility and administration.

Illnesses that have symptoms similar to influenza.

Targeting intervention on places that needed it the most and exercising social distancing.

An organization or institution that leads a process of activity that is related to undertaking a program or solving a problem.

A number of deaths per total population.

List of medicines that are listed based on the latest scientific evidence by the National Formulary Committee.

Change in behaviors to maintain normal activities but with added health protocols to prevent the spread of COVID-19 virus.

The direct payment of money that may or may not be later reimbursed from a third-party source.

(Of a disease) prevalent over a whole country or the world.

A principle in a partnership that is equal between related parties in said partnership.

A protocol for keeping distance physically.

Pelayanan Obstetri Neonatal Emergensi Komprehensif (PONEK) is a referred hospital that gives a 24-hour emergency care for mothers and newly born babies.

A state or place of isolation in which people that have arrived from elsewhere or been exposed to infectious or contagious disease are placed.

Relating to a region.



Euphemism

False dichotomy

Global

Indirect medical cost

Influenza-like illness

Intermittent suppression

Leading Agency

Mortality ratio

National Formulary

New Normal

O u t - o f - p o c k e t spending (OOP)

Pandemic

Partnership among equal

Physical distancing PONEK

Quarantine

Regional

Severe Acute Respiratory

Single pool

Social prescribing

Street-level bureaucrats

Stunting

Sub-national

Surge capacity

Surveillance

Swoosh shape

Telemedicine

Tobacco-attributable disease

Undernutrition

Underreporting

Unpaid care work

Wasting

Whole of government

Infection that is caused by SARS-Associated Corona Virus.Infection

Placing all types of insurances under one pool, which is then distributed between members proportionately as mutually agreed regarding to loss, fee, or profits.

Community referral: a means of enabling health professionals to refer people to a range of local, non-clinical services.

Bureaucrats who deal directly with people, especially in public service.

Impaired growth and development that children experience from poor nutrition for a long period of time. Parts of local government in a country; province/regency.

Measurable representation of ability to manage a sudden influx of patients.

Close observation.

Economic growth reaches its lowest point in a very short period of time, and then takes a long to return to a positive growth; similar to Nike brand logo.

The remote diagnosis and treatment of patients by means of telecommunications technology.

A disease that is caused by tobacco consumption.

Lack of sufficient nutrients in the body.

Usually refers to some issue, incident, statistic, etc., that individuals have not reported, or have reported as less than the actual level or amount.

Refers to all non-market, unpaid activities carried out in households.

Sometimes referred to as "acute malnutrition" because it is believed that episodes of wasting have a short duration, in contrast to stunting, which is regarded as chronic malnutrition.

Refers to the joint activities performed by diverse ministries, public administrations and public agencies in order to provide a common solution to particular problems





Whole of society

Vaccine hesitancy

Zoning

Refers to an approach that unites collaborative efforts from the community from across the sectors in a wider scope to achieve development goals and public service.

Delay in acceptance or refusal of vaccines despite availability of vaccine services.

The classification of land according to restrictions placed on its use and development.

Introduction

Center for Indonesia’s Strategic Development Initiatives (CISDI) published the 2021 Health Outlook to give direction and recommendation to the government as a reference for other stakeholders to determine the priority in Indonesia’s health policy improvement. This report measures the Indonesian health system in 2020 in the midst of COVID-19 pandemic based on World Health Organization’s framework on pandemic preparedness.

After mapping a handful of events and reflecting on the driving factors, tendencies, and main challenges that have significantly marked Indonesia’s health environment throughout 2020, CISDI developed four simple scenarios. These four scenarios are built to anticipate the approach and direction for the health policy in 2021. Each scenario has underlying characteristics that have the same chance to be equally plausible.

CISDI formulate this recommendation to improve policies, based on the implementation challenges from the aforementioned four alternative scenarios. This recommendation is arranged based on the explicit and implicit knowledge gathered from our experience working at the grassroot level to help Puskesmas in North Jakarta and Bandung City to curb the COVID-19 infection rate, and to maintain the integrity of essential health service.

This report is prepared by a team led by Gatot Suarman, comprised of Yurdhina Meilissa, Olivia Herlinda, Yenuarizki, Adrianna Bella, Egi Abdul Wahid, and Lara Rizka. Diah Satyani Saminarsih directed the breadth and depth of the report. Dedi Suhendi and Rudra Ardiyase were responsible for the layout of this report.

We received many feedback and guidance from the expertise of CISDI’s Board of Advisor consisted of Akmal Taher, Wicaksono Sarosa, Christian P. Somali, Ani Rahardjo, Anindita Sitepu, and Fasli Jalal. Special feedback about the governance of our Central and Regional Government, primary and institutional healthcare were received from Yudhi Prayudha Ishak Djuarsa.

CISDI is fully responsible for the findings, conclusions, and recommendations written in this report.





There is no transparent risk communication. The government seems to rush into re-opening economic activities without working on two big tasks: (1) to accurately, quickly, and consistently measure the pandemic situation through testing and tracing and (2) to act in handling cases (treat, isolation, and quarantine). This remiss in assessing situation is a driving force to the ‘new normal’ policy. The ‘new normal’ policy was applied too early, and too quickly responded by regional governments, who had not yet full understanding that the pandemic does not happen simultaneously across the country. Instead of aggressively doing the testing and tracing to identify red zones, or targeting intervention to places most needed, or applying intermittent suppression, the government turned to eliminate public’s vigilance to give them illusion that the pandemic will soon be over. This drives those who abide the lockdown recommendations feel imprisoned at home without any certainty.

The government’s commitment to protect the people are only limited to those who are poor, who are sick, and towards essential public service. Whereas in pandemic situation, the definition of vulnerability expands. The already vulnerable groups become more vulnerable, and the non-vulnerable groups become vulnerable. The socially and economically vulnerable groups have lower ability to do preventive care consistently. While social distancing

For us, 2020 felt very gloomy. All throughout the year we witnessed the Government of Indonesia forcing the people to live with SARS-CoV-2¹, without a clear strategy in handling the pandemic and without providing us the public health intervention package according to the standard set by the World Health Organization (WHO)².

The Government chose the road that leads to the uncontainable pandemic and loss of many human lives. The public communication pattern that keeps publishing belittling statements about the impact of the pandemic are contradictory to the scientific credo. In reality, COVID-19 has the capability to spread many long-term health complications, even for those who are already recovered3,4. The chance for the SARS-CoV-2 virus to mutate is huge because the high transmission rate that affects the immunity of the patient post-infection may not prevent reinfection⁵. The combination of both is proven deadly. Health facilities are overwhelmed to manage the jump in COVD-19 cases, causing them to sacrifice the non-COVID-19 health service.

The crowding out effect could not be contained, which results to an excess death from mortality displacement. The loss of human lives obviously reduced welfare, countering the objective function of an economy. Income without health is not welfare. Income without a life, a soul, cannot be called welfare either.

1

2

3

4

5

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that causes coronavirus disease 2019 (COVID-19).In August 2020, the result from WHO’s Intra-Action Review (IAR) supported by the Indonesian Ministry of Health to assess COVID-19 response di Indonesia showed that the Indonesian government still needs to improve their initiatives. Tenforde MW, Kim SS, Lindsell CJ, et al. Symptom Duration and Risk Factors for Delayed Return to Usual Health Among Outpatients with COVID-19 in a Multistate Health Care Systems Network — United States, March–June 2020. MMWR Morb Mortal Wkly Rep 2020;69:993-998. DOI: http://dx.-doi.org/10.15585/mmwr.mm6930e1WHO, EPI Win, Infodemic Management. 2020. What we know about long-term effect of COVID-19: The latest on the COVID-19 global situation and long-term sequelae. [PowerPoint slides]. Retrieved from: https://www.who.int/docs/default-source/coronaviruse/risk-com-ms-updates/update-36-long-term-symptoms.pdf?sfvrsn=5d3789a6_2Tillett, R. L., Sevinsky, J. R., Hartley, P. D., Kerwin, H., Crawford, N., Gorzalski, A., Laverdure, C., Verma, S. C., Rossetto, C. C., Jackson, D., Farrell, M. J., Van Hooser, S., & Pandori, M. (2021). Genomic evidence for reinfection with SARS-CoV-2: a case study. The Lancet Infectious Diseases, 21(1), 52–58. https://doi.org/10.1016/s1473-3099(20)30764-7

EXECUTIVE SUMMARY



(prolonged or intermittent) would likely be maintained until the end of 2022. SARS-CoV-2 surveillance has to be maintained because the jump in infection rate can still happen until 2024⁶. Protection to vulnerable population, especially women and children, should be inherent in all aspects of pandemic control. The low protection of women and children results to the worsening of domestic and gender-based violence.

On the other hand, the weak civic engagement pushes some people who don’t understand about the urgency of the situation to be reluctant in accepting policy consequences that the government takes. The law enforcement seems discriminative in several cases. The government doesn’t give good example, and is free from firm sanctions when they made reckless endangerment. The absence of this accountability system makes people not feel embarrassed or guilty when they violate health protocols. In actual reality, if the national strategy and the risk communication becomes a crucial part of pandemic control strategy, it will not make people afraid if the government explains them the whole impact of the pandemic. In contrary, it will encourage them to realize the severity of the pandemic fully, so they can discipline themselves to follow government rules to prevent infection. Because without open information, it is difficult to build an ecosystem that can support the people to follow the 3M rules (wearing mask, washing hands, and physical distancing).

The tendency to centralize the COVID-19 infection prevention policy to ad-hoc institutions in national level is truly felt. The formation of ad-hoc institutions in central government level can be read from at least two perspectives. First, the pandemic is seen as a very serious threat, so they need an addition to complete the three-party bureaucratic standard that is

6 https://science.sciencemag.org/content/early/2020/05/11/science.abb5793

regulation, institution, and budgeting framework. However, from another perspective, especially after a few months, in reality the ad-hoc institutions are not successful in delivering the pandemic control. It is clear to see there are many governance aspects that are guaranteeing the interweaving and partnership between ad-hoc institutions with technical Ministries that are actually depending on subjective factors outside of official regulations. The President failed to take back control, making the pandemic control a leaderless pursuit. The Minister of Health does not have a comprehensive understanding about health system, disinclined to deliver investment case to the President that the comprehensive solution to public health sector is the best response to COVID-19, and reluctant to do political bargaining process towards groups that are representing vested interests.

The experts and scientists in health and medical sectors do not get the visibility or legitimation to give their perspectives and recommendations on evidence- based policymaking. Ultimately, the empty rooms from many sides of leadership are filled with opinions that are not based in science from public figures or officials who are fighting for the spotlight. This aggravates the information chaos in public space.

The policies between central and regional governments are overlapping and inconsistent, and sometimes negating one another. With an argument to protect the information chain and domestic stability, the central government often criticize proactive efforts of regional governments that are opposing the prescription from Jakarta. Regional government’s policy is narrated as uneducated decisions and not based on evidence, or as a tool to increase popularity, or have potential to create



panic in people. This generally discourages regional government to formulate best policies based on regional decision, prevention of COVID-19 based on potential risk, and attempting to ensure local capacity is increased to match the infection rate.

No country is prepared for COVID-19 and since the beginning there is no universal recipe to handle COVID-19 pandemic that can be applied in every country in the world. However, many countries succeed in learning from the dynamic and approach of COVID-19 pandemic or from previous pandemics. Below is at least six points of effort to manage a pandemic, that should be done by the Indonesian government:

Although many things are irrevocable because the momentum has passed, next year the government’s mindset should change. COVID-19 case management should be built with a mindset to tackle the current jump in cases as efficient as possible, while preparing to face the next infection wave.

Indonesia should also be prepared to face a new world. Public service and economic activity should go on under the COVID-19 case jump threat that can happen anytime until herd immunity is achieved.

At its core, COVID-19 pandemic is a health emergency, which damaging effect can be controlled as long as the policies are based on science, and scientists from national science institutions are listened to, pentahelix collaboration is not a jargon per se, and strategy, leadership, solidarity, and transparency are in place. From our point of view, if the COVID-19 pandemic was correctly managed in the beginning, it has the perfect window of opportunity to establish a solid health system across Indonesia. The government at least should be savvy enough to see opportunity in youth involvement as a whole in terms of handling the pandemic, given the fact that the young health professionals are the spearhead of the health system in Indonesia right now. We agree that we have to leave the social distancing mode as soon as possible because not everyone is privileged enough to survive under this pressure.

6.

the feedback to renew strategy is readily available.

Cost and benefit assessment in managing the pandemic places health and economy as false dichotomy that costs thousands of lives. Meanwhile, the broken health system will result to the vicious circle affecting the economy, politics, social systems.

1.

2.

3.

4.

5.

Response in COVID-19, especially testing, tracing, treatment (3T), requires a strong primary healthcare, especially in primary healthcare and public health, epidemiology tracing, community empowerment, and cross-sector involvement.

Campaigning for behavior change: consistent handwashing, avoiding crowds, and wearing face mask (3M). This can only be achieved through supportive environment, for example public policy and communication, education, and infrastructure.

A holistic strategy to ensure quick handling; taking drastic measures as a key for success.

Coordination, communication, openness, and trust-building between the central and regional government are essential to implement COVID-19 management in micro level.

The agility to adapting strategy can only be done if evaluations are conducted to the same indicator and



However, we need to remember that to relax social distancing without calculating and investing massively in the public health infrastructure, will further jeopardize people’s lives especially the health workers.

Having said that, they can only happen if the Ministry of Health functions well as the leading agency of pandemic handling, not just as an entity that is responsible to achieve case-finding targets. The Ministry of Health should be giving a comprehensive strategy to respond short-term target, such as the increase in recovery rate and the decrease in case fatality for confirmed and suspected cases. In the middle-term, Ministry of Health should invest in logistical preparation, guaranteeing immunization access, and intervene behavior change to warrant vaccine recipients and equal access to groups from various economic and social backgrounds.

There are some scenarios on how this pandemic can end but it will not go back to “normal” anytime soon, as what we would imagine. From the few scenarios below, CISDI takes position that the first scenario should not be an option anymore. This is our landing point as a nation that has fought through this pandemic.

First scenario: Imagined Nation.

In this scenario, single-dose vaccines are readily available with high efficacy and the country does not face significant chal-lenge in terms of resources to ensure that 60-70% of the population are covered, as recommended by WHO. The strong health diplomacy through multilateralism pushes access to vaccine to cover 20% of the population gradually until end of 2021. National Health System Reformation hap-pens across the country and the priority is set to primary healthcare to maintain the health of the 85% population. Combined with vaccine acquisition from various

sources, the strength in surveillance (test and trace) and integrated data platform; Indonesia will survive the pandemic and the economy will improve.

Second Scenario:Building Castles in the Air.

Vaccines are available but the country has limitations in buying and distributing it to the rural areas because of logistical reasons, while the economy is not getting better. On the other hand, the pressure to immediately open social restrictions that will lead to economic pressure also results in further social restrictions that are not favorable by people, especially that it becomes a policy option by the government.

Third Scenario: Bad Dream.

Vaccine fails to be available. The government tries to eradicate SARS-CoV-2 as soon as possible, but it needs an extra effort to do an aggressive test and trace – something that needs an extensive resource in the middle of economic recession, because no more resources/budget support remain. The business world can no longer give support in extra resources because the business turnover is not enough to cover income. Meanwhile, because of the weak health diplomacy, foreign aid through multilateralism is difficult to secure.

Fourth Scenario: Would It Return?

Vaccine is not available in decent quantity to build herd immunity. The government is doing test and trace on a mediocre level. The government guarantees the availability of antiviral therapy to combat COVID-19. The population is able to reach herd immunity gradually. This means that, 60-70% of the population will fall sick before getting the immunity. The implication is that, the health system will always be on the brink of collapse. The economy can improve but it takes a very



long time, which will end in the increase of unemployment and poverty rate and the worsening of the profile in population health. All of them require a long-term effort that can only be achieved through cross-ministry policies.

Indonesia should be prepared for whatever scenario. Every scenario has their own challenges and consequences in tow.

We do not wish for the COVID-19 pandemic in Indonesia to end in disaster. Social distancing without a solid public health infrastructure will result in the spread of COVID-19 across population, uncontainably. This can lead to the elder and vulnerable population through Darwin’s natural selection. This should be avoided at all cost because to live and be healthy, even in the midst of pandemic, is a human right.

Chapter 1.

8

History,in general,

only informs us what bad

government is.Thomas Jefferson

IHR Emergency Committee. At that time there were 89 cases without death in 18 countries outside of China. The four countries (8 cases) had evidence of human-to-human transmission (Germany, Japan, the United States, and Vietnam).

WHO announced the COVID-19 as pandemic in March 11th 2020 because of the high infection and severity rates, and the fear that many countries will respond slowly. In the press conference led directly by the General Director, WHO asked for every country to take an aggressive emergency measure. Further stressing that through the whole-of- government and whole-of-society approach, the strategy will be comprehensive. Every country can still contain the pandemic if they put in place the effort to detect, test, medicate, isolate, trace, and involving the public within the response.


Disrupsi Covid-19 pada Layanan Kesehatan Esensial, Dampak yang Ditimbulkan dan Jalan Membangun Kembali Sektor Kesehatan Indonesia

The wave of COVID-19 pandemic at the start of 2020 hit the world’s order abruptly. For Indonesia, the pandemic reveals the list of problems of the six pillars of the national health system. The broken health system sends a shockwave to the political, economic, and social systems.

The Chinese government gave warning about the discovery of new type of Coronavirus in Wuhan since December 30th 20197. On January 7th 2020, the virus was named 2019-nCoV. Not long after that, on January 13th, the first case outside of China was confirmed in Thailand. Scientists in Hong Kong claimed that the virus was infectious via human-to-human transmission.

In an interconnected world, the pandemic spreads through the world’s borders in high speed. WHO declared the 2019-nCoV as a Public Health Emergency of International Concern (PHEIC) on January 30th 2020 as recommended by

WHO. (2020, December 17). Timeline: WHO’s COVID-19 response.

https://www.who.int/emergencies/diseases/novel-coronavirus-2019/interactive-timeline.

7

The first part of this analysis is written to give you a glace of COVID-19 pandemic throughout 2020. Following that, we will offer you some critical perspectives about the steps that the Indonesian government took to overcome the pandemic. By the end, we will analyze how those decisions changed the face of Indonesian health system as a whole and how they affected non-health sectors significantly.

Indonesia only announced the first case on March 2nd 2020. Meanwhile, the positive case in Malaysia⁸ and Singapore⁹ in early March had already showed a patient with travel history from Indonesia in February.

All throughout 2020 it was almost impossible to digest the handling strategy chosen by the Government of Indonesia. The mitigation strategy by the Government of Indonesia always relied on large-scale social distancing (PSBB,

pembatasan sosial sekala besar), without proper enforcement, which proved to be ineffective. Laxing the PSBB was not accompanied by an aggressive test and tracing actions either. The emergence of isolation centers in the capital city unsystematically encourages the emergence of smaller-scale isolation centers in sub-national and community levels. As a result, until December 2020 Indonesia still has not seen the peak of pandemic curve, and the rate of infection is increasing rapidly.



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https://www.kompas.com/tren/read/2020/03/02/112349465/dua-ka-

sus-baru-corona-covid-19-di-singapura-pasien-punya-riwayat-perjalanan?page=all.

Satgas Covid-19. (n.d.). Peta Sebaran Covid-19. https://Covid19.Go.Id/. https://covid19.go.id/peta-sebaran

Roser, M., Hannah Ritchie, E. O.-O., & Hasell, J. (2020). Coronavirus Pandemic (COVID-19). Our World in Data. https://ourworldindata.org/coro-

navirus

Since the announcement of the first COVID-19 case in Indonesia in March 2020, there has been 643,508 confirmed cases and 19,390 death cases from COVID-19 until December 17th 202010. In the last one week (December 7th - 13th 2020), the incidents rate of COVID-19 in Indonesia is 15.5 per 100,000 people, increasing from 15.3 per 100,000 people in the previous week. This is the highest incident since the first case was reported in Indonesia. Compared to Australia and several other Southeast Asian countries (Malaysia, Philippines, Singapore, Vietnam, and Thailand) who have seen a reduction in their daily cases, the increase in COVID-19 cases in Indonesia is the worst in the region with (1) the highest confirmed cases and death tolls, (2) the consistently increasing daily cases, and (3) the lowest rate of test per confirmed cases11.

The unpreparedness of disaster management system in Indonesia is evident from the outdated and overlapping regulation framework of disaster management and communicable diseases. Referring to the President Decree Number 7 Year 2020 about the COVID-19 Response Acceleration of Task Force, at least there are four Articles that can be referred, namely Article Number 7 Year 1984 about Disease Outbreak, Article Number 24 Year 2007 about Disaster Management, Article Number 36 Year 2009 about Health, and Article Number 6 Year 2018 about Health Quarantine.

Article Number 4 Year 1984 about Disease Outbreak is obsolete and not up to date with the newest guideline of International Health Regulation, so it bears little relevance.

1.1 The Journey of COVID-19 Pandemic in Indonesia

Restriction was issued on April 1st 2020 or 2 weeks after the pandemic was announced by WHO and national disaster by the President. At that time, the total COVID-19 case was 1,677 with 157 death counts. The Minister of Health only issued the Health Regulation PS PSBB on April 4th 2020 when the COVID-19 rate had increased to 2,092 with 191 death tolls.

The Regional Government, for example DKI Jakarta, although they have recommended to work and study from home, and close down several mass gatherings since March 14th, only officially imposed PSBB per April 10th 202016. This lateness was caused by the delay in securing permission from the Ministry of Health. In the same period, the request of several regions to impose PSBB were rejected because the reasons were thought to be insufficient17. Consequently, the public health intervention ran out of breath in holding the community transmission in 514 regencies/cities in Indonesia.

Different with the other three Articles, Article Number 6 Year 2018 about Health Quarantine mandated the central government’s role instead of decentralization. This Article seems as though they erase the main political-legal power of Regional Government (Pemda, Pemerintah Daerah) to do the needed corrective actions when a pandemic hits their regions12, setting an emergency disaster status according to their administrative scale13, and to regularly inform the public about the type and spread of disease that are potentially infectious within a short amount of time together with the originating areas of infection14.

Indonesia wasted the golden period of pandemic handling because the bureaucracy moves slower than the transmission rate of SARS-CoV215. The temperature and risk screening, together with quarantine in 304 points are only formality and loosely enforced. The Government Regulation (PP, Peraturan Pemerintah) about Large-Scale Social

Figure 1 Graphic of Covid-19 daily case from the first case (2 March 2020) until 4 December 2020.

12

13

14

15

16

17

See Article 12 clause 1 Article Number 7 Year 1984 in “Article Number 4 Year 1984 about Disease Outbreak,” Hukum Online, https://www.hukumon-

line.com/pusatdata/detail/415/undangundang-nomor-4-tahun-1984#

See Article 51 clause 2 Article Number 24 Year 2007 in “Article Number 24 Year 2007 about Disaster Management,” Hukum Online, https://ww-

w.hukumonline.com/pusatdata/detail/26595/undangundang-nomor-24-tahun-2007

See Article 155 clause 1 Article Number 36 Year 2007 in “Article Number 36 Year 2009 about Health,” Hukum Online, https://www.hukumon-

line.com/js/pdfjs/web/viewer.html?file=/pusatdata/viewfile/lt5b5fdd8147604/parent/lt4af3c27570c04Partly adapted from https://www.cnnindonesia.com/longform/nasional/20200817/longform-jejak-pandemi-di-tangan-jokowi/index.html

Permatasari, A. N. (2021, April 8). Mulai 10 April 2020 DKI Jakarta Terapkan PSBB, Berikut Info Lengkapnya. Kompas TV. https://www.kom-

pas.tv/article/75109/mulai-10-april-2020-dki-jakarta-terapkan -psbb-berikut-info-selengkapnya#:~:text=JAKARTA%2C%20

KOMPAS.TV%20%2D%20Mulai,jarak%20sosial%20selama%20kebijakan%20berlaku. https://www.cnbcindone-

sia.com/news/20200416114929-4-152340/daftar-daerah-yang-ditolak-terawan-untuk-lakukan-psbb



The limited resources made it impossible for the intervention in test, trace, and isolation to be at the ideal proportion. The increase in test capacity went very slow and fluctuated. With total population of 270 million, Indonesia needs to test at least 40,000 people every day to reach the minimum standard of 1 test per 1,000 population per week. At the second week of December, the amount of test only reached 0.84 test per 1,000 population per week, which shows there is still a lot of disparity in lab capacity between provinces.

DKI Jakarta donated 20-30% of test capacity from the total amount every day. Until the first week of December, the Special Task Force reported only 11 provinces that have met the minimum WHO standard; 13 provinces reached 50% target; and 10 provinces are still below 50%.

National guideline to COVID-19 case testing with RT-PCR recommends doing two tests consecutively within 24 hours for suspect cases. This means, if the laboratorial protocol is followed properly and the PCR test is available, the amount of specimen tested every day is at least two times the amount of people tested. However, on December 17th 2020 for example, 43,461 people have been tested RT-PCR but the amount of specimen tested was 60,629.

With the limited access to testing, the new guideline recommends priority test to people with symptoms. If one is in direct contact but has no symptoms, they are only recommended to quarantine. Following those criteria, added with limited facility and the loose surveillance of home isolation, the case infection rate is hard to contain.

Indonesia failed to identify those who have been infected with COVID-19 and those who have not. The tracing-isolation

ratio (RLI) for Indonesia as per December 9th 2020 was 1.62, which means that for 1 case confirmed, only 1-2 people are traced. Sixteen provinces in Indonesia have RLI>1, and three provinces had a 0 RLI. As a consequence, the people who are tested positive have the potential to infect other people without knowing. Apart from that, the low testing capacity has the potential of underreporting, compared to the real case on the ground. This results to the government not having credible data to guide the next improvement steps. The increase in tracing capacity was very slow in Puskesmas, as rejection and misinformation in the public have sustained for a long time.

An accurate COVID-19 epidemic curve is not available, either on the national scale or sub-national scale. The number of additional confirmed cases announced to the public every day does not reflect the number of daily new cases. This is caused by at least four things; (1) the low coverage of PCR test that is used to find new cases, (2) the weak epidemiology investigation so that the estimated date of anyone getting infected or starting to have symptoms are not able to determined, (3) average testing sample from 426 laboratories were rejected, and (4) there was a backlog in data input in the lab, and because the central government has the ultimate authority to analyze and report the case reporting, the regional government could not analyze their own epidemic curve.

The success of pandemic handling relies on a robust data collection system. But due to the overlapping system from the sub-district to central level, it lacks the interoperability between various platforms and applications, which results to National Response to COVID-19 as a whole not being able to be categorized as something that is based on data. According to Center for Disease Control,



8

Policymaking based on zoning system without a complete data can be misleading and dangerous. This problem with data has been an issue since the beginning. The government uses zoning system that was determined based on several important indicators in epidemiology, surveillance, and health service. But in reality the data was not collected in sub-national level, or even if it was available, it was not accurate or reliable. For example, the re-opening of schools was based on zoning system. The number of tests that was carried out by the regional government was also affecting the number of cases found. The indicator of the number of positive cases cannot be an independent indicator. As a consequence, although the policymaking was based on data, in reality it was endangering public health.

The monitoring to assess the threshold level of service capacity moved slower than the transmission rate. These three indicators were only gathered in Indonesia in May 2020: (1) WHO Oxygen Capacity Survey that assesses the distribution and management of oxygen, (2) Essential Supplies Forecasting Tool (ESFT) dashboard, and (3) Surge Planning Support Tool (ADAPTT) that can count estimate on the number of hospital beds and ICUs. This caused logistical delivery from BNPB to be based on ad hoc request, rather than be based on the need assessment according to the epidemic curve.

COVID-19 handling was not based on the foundations of health system: too hospital-centric and does not place primary health service as a main guard of population health. Currently Indonesia relies on 132 level-2 referral hospitals to handle acute and critical cases, and 171 level-1 referral hospitals in province-level to handle light to mild cases. This approach forces people to travel far to



there are two independent curves that should be monitored in sub-national scale openly: the epidemic curve and the threshold line of service capacity. These two data are not available in reliable or actual manner, so Indonesia does not have a scientific base to measure the effectiveness of control efforts, including the peak of pandemic, let alone to predict the end of pandemic.

In May 9th 2020, the Task Force introduced a one-data platform called Bersatu Lawan COVID (BLC/Together Fighting COVID) to be utilized by the health offices in the province and district level, for health service, and for hospitals. BLC shows the data of COVID-19 cases (confirmed cases, Person Under Supervision, Patient Under Supervision, contact with symptoms) together with logistical data, for example the PPE availability and laboratory equipment. BLC was hoped to cut the reporting path between the sub-national level and national level.

However, it is unclear how this platform connects the data from many surveillance systems available in real time. Until December 2020, there seems no improvement and synchronization between reporting and data. Since November 2020 the contact recording report has been done by Puskesmas through Silacak application from the Ministry of Health. However, Silacak is not integrated with the New All-Record (NAR) platform, so we cannot see how many cases are confirmed on a particular day that are successfully traced. The Ministry of Health also does not receive report about the tracing indications of contact and home quarantine surveillance although the two indicators should be monitored based on COVID-19 Handling Guide revision 5.

attain care, making them susceptible to spread infection or be infected through nosocomial infection in the referral hospital that could be a new epicenter. On the other hand, there is actually an untapped potential in primary healthcare that is closer to communities. Primary healthcare does not only consist of the government-owned Puskesmas, but also private and independent clinics that are available in provinces with high density. The government approach that does not see the triangle in national health system also creates a burden such as a huge direct medical cost in the national budget, or indirect medical cost for the patients and their family. The pandemic handling that is overly concentrated in hospitals also makes the 3T interventions (test, trace, treat) to stand on a fragile ground. The response in handling COVID-19, especially 3T, needs a strong primary healthcare, especially in the aspects of epidemiological investigation, surveillance, community empowerment, and the cross-sectoral partnership in order to cut the infection chain in community level. Puskesmas’ role is also important to enforce compliance towards 3M in the society through efforts such as raising awareness or public literacy related to COVID-19. Mild cases and those without symptoms should be handled in puskesmas level and local actors, to avoid overcrowding at the hospitals.

Some experts and scientists in health or medical sectors did not get enough visibility or legitimizing power to give perspectives and recommendations to the policymakers based on scientific evidence. And some other experts and scientists, instead of enlightening or siding with science, were busy serving decisions based on political interests. At the end, the empty room in leadership intelligence is served with opinions that are not based on science by public officials who are fighting for spotlight,



which further aggravates the information chaos in public sphere.

One of the main examples of policymaking mistake is the COVID-19 “medicine” based on research from UNAIR, BIN, and TNI, which were urged to be taken up immediately without a valid clinical trial. The eucalyptus necklace from the Ministry of Agriculture to prevent COVID-19 also became a public discussion, which added confusion to the public who since the beginning had not received complete, credible, and transparent information about COVID-19 and its implications on everyday life.

Another one is the zoning system that was carried out by COVID-19 Task Force, without using any real-time or accurate data of the increase in daily cases. This is truly dangerous, to base the zoning system as the foundation of re-opening schools. Because this means that there is an added risk in infection that can happen in schools. We hope the decisionmaking process for vaccine provision and distribution does not repeat the same pattern. In-depth analysis based on various scientific reference can be carried out prior to making decisions. And the experts in medical and health sectors should be the main scientific reference.

The world was actually on a positive path to give healthcare access to all through the universal health coverage in 2030, before COVID-19 fundamentally destroyed the global health system. Within 25 weeks, the pandemic eroded the massive achievement in immunization program of the past 25 years18.

We can end COVID-19. Together. (n.d.). https://www.gatesfoundation.org/goalkeepers/report/2020-report/?download=false#GlobalPerspective18

1.2 The Impact of Covid-19 to The Pillars of National Health System

14

Although the death record is incomplete, the WHO Situation Report as per December 2nd 2020 stated that Indonesia’s mortality rate, 3.4%, is higher than the world average (2.39%). As of December 16th 2020, the death count in DKI Jakarta hit 281 deaths per 1 million people (the highest in Indonesia), followed by East Kalimantan, South Kalimantan, East Java, North Sulawesi, and Bali. For the past one week, the number of death due to COVID-19 in Indonesia was 0.40 per 100,000 people—the highest since the first case was reported.

There is an inexplicable spike in burials in DKI Jakarta throughout 202019. Between 2015-2019, the average burial rate in DKI Jakarta was 600/week and that was on the same range until March 2020. Since then, the number jumped to 1,000/week, and then 1,400/week in September 2020. In total, there is 61% increase in burials in 2020 compared to the previous 5-year trend. Applying the same pattern, in March-November 2020 period there were 16,118 burials, where 48% of them were done with COVID-19 protocols.

COVID-19 exposed the gap and vulnerability of Indonesia’s health system. Although the global scientific knowledge about how to handle COVID-19 grew rapidly, unfortunately it was not matched with a strong national health system to help remedy those in need; be it comprehensively or in a large scale. We saw the most contributing pillar in ensuring that the national health system is still safe and strong rattled: healthcare is not ready, health workers are overwhelmed and unprotected, the COVID-19 one-data system is not available up to the household level, health funding is suppressed, governance is in chaos, and leadership is incompetent and has failed.

World Declaration to Universal Health Coverage that was signed on the day of the UN General Assembly in 2018 explicitly states that a transformative primary healthcare is the way to ensure the success of Universal Health Coverage. With this modality, the world should be able to move towards these Universal Health Coverage principals and the primary care as a gate for health workers who should be the most empowered in controlling the pandemic. Several countries in Asia such as Thailand and Vietnam who already have a solid primary healthcare prove that the pandemic can be contained with activating the principles and pillars of public health within the primary healthcare infrastructure.

When the health system is overwhelmed, direct mortality caused by pandemic and indirect mortality caused by other diseases preventable by vaccines or medicines increased dramatically. Every country needs to make difficult decisions to intervene the outbreak while providing other health services and continuing to develop the health sector as best as possible. Hence, there needs to be a planning and coordination to mitigate the risk of a collapsing health system.

Mortality rate kept increasing although the real infection rate had been predicted to be much higher because the reported data is not up to the WHO standard. The number of dead people who were a suspect and probable were not reported in many Regencies/Cities although they were buried in accordance to the COVID-19 protocol. Because according to WHO definition, death of suspect (having COVID-19 symptoms but not confirmed) counts as COVID-19-related death, which should also be reported.



Elyazar, IRF et.al., 2020. Excess mortality during the first ten months of COVID-19 epidemic at Jakarta, Indonesia.medRxiv 2020.12.14.20248159; doi: https://doi.org/10.1101/2020.12.14.20248159

19

20 UNICEF. 2020. Quick assessment: The Impact of COVID-19 pandemic towards immunization service in Indonesia. https://www.unicef.org/indonesia/-

media/4871/file/Penilaian%20Cepat:%20Dampak%20Pandemi%20COVID-19%20terhadap%20Layanan%20Imunisasi%20di%20Indonesia.pdf

The limited access to nutritious food, loss of family income, and disruption in healthcare sustainability in essential maternal and children healthcare during the COVID-19 pandemic contribute to a threat in children’s nutrition. A UNICEF Quick Survey conducted in April-May 202020 showed that 75% Posyandu were closed and more than 41% home visits were suspended. Almost 86% of Posyandu reported suspension in children growth and development monitoring. 55% reported suspension in immunization service and 46% reported disruption in vitamin A distribution, and 46% reported suspension in antenatal care. The main reasons of these service suspensions are the people’s safety, to comply with social distancing, and also health workers’ anxiety.

The government expanded the support for stunting prevention through protection program undertaken by the Ministry of Social Affairs, for example PKH (Program

Keluarga Harapan) and BPNT (bantuan pangan non tunai, non-cash food support). The government has allocated a total of 695.2 trillion Rupiah (approximately US$47.5 billion) for COVID-19 response and 203.9 trillion Rupiah (approximately US$13.9 million) towards social protection, including PKH and sembako program which is part of BPNT. However, the recent corruption allegation of the Minister of Social Affairs related to the COVID-19 handling signals the ineffectiveness of the social assistance carried out in this institution.

1.2.1 Healthcare There are many indications of fraud during disaster where an elite few takes advantage of the situation. From the book The Shock Doctrine: The Rise of Disaster Capitalism, Naomi Klein explained the tendency of pro-corporation efforts and policies to take advantage of the shock and public disorientation who are faced with disaster. The naming of Minister of Social Affairs as suspect is a strong evidence of that practice in Indonesia. In the beginning of pandemic, we were faced with the news of imported and commercialization of COVID-19 rapid test with uncontrollable pricing limit. This time, the independent vaccine program has a big risk to be a commercialization minefield to many people.

The World Bank (2020) estimated the stunting number for those under three years old will keep decreasing and follow the trend from 30.8% (2018) to 27.6% (2020), but with slower acceleration. In a realistic scenario, the slowdown in stunting rate will hit 3 percentage point, to be 21.0% (not 18.2%) in 2024. This means that the current middle-term 2020-2024 RPJMN target with stunting rate <20% is not predicted to be achieved.

As the second country with the highest TBC cases in the world, the impact of COVID-19 towards TBC is significant. The healthcare that is diverted to handle COVID-19 causes a lot of disruption to many other health services, including TBC. In May 2020 the Ministry of Health recorded a drastic decrease in TBC patients getting health treatment. Stop TB Partnership estimated globally there will be an additional



6.3 million cases and 1.4 million deaths of TBC patients all over the world in 2020-2025 due to COVID-19, assuming a 3-month full lockdown and a 10-month healthcare restoration.

A survey conducted by the National Committee of Tobacco Control (Komnas PT) shows that the majority (49.8%) of respondents who smoke admitted to still spend money to buy cigarettes during the COVID-19 pandemic. From those who smoke, the majority (50.2%) admitted consuming a stable amount of cigarettes during COVID-19, and even 15.2% admitted consuming more cigarettes during the pandemic21.

This finding is contradictory with the scientific analysis indicating that smoking behavior is one of the risk factors of vulnerability and fatality of COVID-19 disease. Based on various systematic reviews22, there is an indication that smokers are more vulnerable to be infected by SARS-COV-2 and when they get infected, smokers have a higher chance to experience a more severe illness. On top of that, smoking has been well known to increase the chance of non-communicable chronic disease, such as coronary heart disease, stroke, and lung cancer, which are also the comorbid conditions of COVID-19.

Surge capacity23 has reached its saturation point. The consistent rise in COVID-19 daily cases resulted in the high bed occupancy rate (BOR) and ICU in several areas in Indonesia. Data from DKI Jakarta

21

22

23

Rahmayanti & Ikhsan, forthcoming

Vardavas & Nikitara 2020; Nugraha et.al 2020; Reddy et.al 2020

Is the ability of the health service to properly add capacity more than the normal service to meet the soaring medical needs. WHO underlined the

importance of four principles in responding surge capacity: availability of rooms, availability of competent and trained health workers, adequacy of

supply facilities, and readiness of management system in responding the surging cases.



Provincial Government as per November 21st 2020 showed that the bed occupancy rate in 98 public hospitals in DKI Jakarta was 78% (172 from 230 public hospitals ICUs) and the occupancy rate of isolation room was 68% (1,055 from 1,554). As per December 1st 2020, the bed occupancy rate in Central Java reached 76.7%.

Puskesmas are not fully ready to help mitigate the prevention and handling of COVID-19 infection. CISDI’s survey showed that 45.4% of Puskesmas have not received training about the infection handling and prevention for services in pandemic. Only 62% of Puskesmas respondents have standard procedures to wear PPE during COVID-19 pandemic. Handwashing and hand-sanitizing facilities are also not provided in 18.5% of Puskesmas. More than 50% Puskesmas modify their environment to avoid infection such as to re-adjust seating arrangement and to install acrylic partition, but only 36% are using information technology such as online registration and queue system and long-distance care. The survey showed that there are a lot of Puskesmas that have limited facilities and are struggling in enforcing health protocols. Without those minimum requirements, there is a big chance for Puskesmas to be an infection hub for COVID-19.

1.2.2 Health Workers



At the 10th month of pandemic, the burden of health workers has not subsided yet and still they are not equipped with protection from risk infection and social stigma. The lack of pandemic control strategy has affected the health workers who are the backbone of national health system. In this situation where the end is nowhere in sight, health workers are expected to keep providing quality healthcare. In the Survey of Puskesmas Needs by CISDI, Kawal COVID-19, and Cek Diri on 647 Puskesmas documented the limited PPE to serve patients with symptoms similar to COVID-19, especially for N95 facemasks (66%), medical gowns (43%), and surgical masks (40%).

The strong stigma faced by the health workers and their families is complicating their work. Health workers are the main target of society’s suspicion because they are seen to bring and spread virus. Based on survey conducted by the Lapor COVID-19 towards 181 respondents in August 7th - 16th 2020, more than half of the respondents felt that other people discuss about them behind their back. Even worse, 33% of respondents are avoided by the society; 25% are dubbed as virus spreader; 10% experienced bullying in social media; and some of their family (7%) was rejected to obtain and use public facilities24.

The unconducive working environment is also faced by groups of PPDS (peserta pendidikan

dokter spesialis, doctors in medical specialty training) who are often caught between their student status and the emergency status

24

25

D. (n.d.). Hentikan Stigma Covid-19. www.laporcovid19.org. https://laporcovid19.org/kajian/hentikan-stigma-covid-19/

Safitri, D. (2020, September 28). Dilema ganda dokter residen di ujung tombak corona. Diakses dari: https://www.cnnindonesia.com/nasion-

al/20200928104017-20-551714/dilema-ganda-dokter-residen-di-ujung-tombak-corona

that requires them to keep working and responding to providing medical care. The global data shows that young professional health workers are on the front line of pandemic handling. They are working in primary and secondary healthcare. MKKI (Majelis Kolegium

Kedokteran Indonesia) estimated that 6,600 teaching staff and PPDS are exposed to COVID-19, spread across 17 education institution. With their high exposure and susceptible levels, 31% from more than 7,000 respondents of President’s Team and the Ministry of Health Survey admitted that they have not received a PCR test25.

Additional incentives for health workers are disbursed late. Until the end of June, only 30% of health workers have received incentives. The Ministry of Health responded to the President’s complaint about this lateness with an excuse of a long bureaucracy process. PPNI (Persatuan Perawat Nasional

Indonesia) recorded as per May 25th 2020 as many as 330 reports declared that the nurse in government or private hospitals experienced cut in their salary and not receive holiday bonus. As many as 65% of them are freelancers.

The mortality rate of health workers in Indonesia per September 2020, 2.3%, is one of the highest in the world. Mitigation Team at Indonesian Medical Association (IDI, Ikatan Dokter Indonesia), stated that at least 342 doctors, dentists, and nurse have passed away due to COVID-19 in the period of March to November 2020. Certainly, this is a huge loss in human resources and further weakening our healthcare.



The official COVID-19 website does not give details about the profession or the type of job of the Person Under Supervision/Patient Under Supervision/cases confirmed of COVID-19. Without this open data, Indonesia cannot measure the risk level of health workers. With the doctor-patient ratio of 4 doctors per 10,000 patients, losing 200 doctors because of COVID-19 equals to losing 500,000 people not getting healthcare26.

Puskesmas holds an important role in finding and reporting COVID-19 cases in community level. Puskesmas is expected to do the case-finding and epidemiological investigation to detect the COVID-19 outbreak in community level. The result of the epidemiological investigation is then sent to the Health Department at the regency/city level, province, and PHEOC at the Ministry of Health.

Puskesmas also has a role in doing the testing, tracing, and isolation. Puskesmas has access to fill in the data of people who will receive PCR test including to update the test results. Per November 2020 Puskesmas can report the results through Silacak application managed by the Ministry of Health.

The data on positive cases are reported differently across Puskesmas, regency/city to national levels. Puskesmas has a role in collecting the specimen with rapid test or PCR. Puskesmas sends the PCR specimen to the regional health laboratory (Labkesda, laboratorium kesehatan daerah), andand the puskesmas will then

1.2.3 Health Information System

26 WHO, Global Health Workforce Statistics, OECD, country data

receive result report from the Health Department or the laboratory. The Puskesmas and Labkesda will report the specimen check result to the Ministry of Health through the New All-Record (NAR) platform.

The regency/city department and province also have their own reporting dashboard. The data owned by the Puskesmas sometimes differs from the data published in the regency-level website. In several regions, the data of positive cases are not communicated by puskesmas to the community level such as the Task Force in sub-district or village level. This causes the Task Force team to be unable to help Puskesmas in doing the tracing or monitoring those in home quarantine.

Until November 2020, there is no reporting platform available that can be used to record Important indicators such as contact tracing or people monitoring on those isolating at home. The Silacak application managed by the Ministry of Health was only introduced in November 2020 in several high-priority areas who were receiving volunteers as support tracers from the National Task Force. Before that, reporting was done independently from each Puskesmas, which was then reported to the Health Department. The two important indicators cannot be found in the majority of reporting platforms owned by central or regional offices.

The Ministry of Health also did not accept reports about tracing indicators and home isolation monitoring although the two indicators were mentioned in COVID-19 Handling Guide revision 5.



From supply-side financing, health budget and stimulus in national economic recovery program decreased to 62.5% from 87.55 trillion in 2020 to be 25.40 trillion in 2021. In total the budget for the national economic recovery program does decrease to 48.7% from 695.2 trillion to 356.4 trillion in 2021. The government stated that the health budget will be used to provide anti-viral vaccines, health facilities, laboratories, and pay BPJS premiums for PBPU. Until November 2020, the uptake on the budget health was only 33.1%. Table 1 shows that all clusters show significant decrease, except the Ministry/Institution (K/L) and regional government. The budget will be used primarily to increase tourism, fish and food security, industry zones, ICT development, regional loans, and to anticipate for economic recovery. Business incentives experienced the highest decrease, up to 100 trillion Rupiah. Corporate funding became the smallest budget item in the program, the same with 2020.

1.2.4 Health FundingSilacak application currently is not connected with the New-All Record (NAR) so we cannot see how many people are confirmed on a given day who are successfully contact-traced. Other technical challenges from the Silacak application is the filling-in process that is still relying on the help from the tracer from the Task Force team who are on duty only until December. This will become a problem if the transfer of knowledge is not carried out in time to the local health workers.

The Silacak application can only be viewed in district level. Puskesmas are only made to be a hub of data collection, but they cannot view the input results to measure their success.

The urgency of COVID-19 does not make the reporting mechanism to be simpler. There are many reporting documents that have to be filled in by Puskesmas, and the interoperability issue of COVID-19 data platform wastes health workers’ time. To report a case in Puskesmas, for example, the health workers have to fill in the Silacak application and NAR for the Ministry of Health, and PE form (epidemiological investigation) for the Health Office, while the data are often overlapping.

Especially for NAR application, many puskesmas cannot input it correctly due to the excessive forms to fill in and the application is not user-friendly. This causes misreporting, where many cases are tested but not inputted in NAR so the data is not recorded in the system. Having too many applications also makes puskesmas input the same data on different platforms.



The government’s seriousness in handling the pandemic is not reflected through the APBN posture. Although the national health reformation is one of the main focus in RKP 2021, the budget for health only increased by 7.4% from 78.5 trillion in 2020 to 84.3 trillion in 2021. Meanwhile, the budget for the Ministry of Public Works and Public Housing raised to

98% from 75.6 trillion to 149.8 trillion. The second and third largest budget is allocated to the Ministry of Defense and Indonesian National Police. This certainly sparked a lot of questions about the government’s commitment if they are serious in handling COVID-19 correctly through public health approach and strengthening the health system.

Ministry/Institution

NoNational Budget 2020

(President Decree 72/2020)

Planned National

Budget 2021Difference

Percentage Change

Ministry of Public Works & Public Housing 75.6 T 149.8 T +74.2 T +98.1%

Ministry of Defense 117.9 T 137 T +19.1 T +16.2%

Indonesian National Police

92.6 T 112 T +19.4 T +20.9%

Ministry of Social Affairs 104.4 T 92.8 T -11.6 T -11.11%

Ministry of Health 78.5 T 84.3 T +5.8 T +7.4%

1

2

3

4

Ministry of Education and Culture

70.7 T 81 T +10.3 T +14.6%6

Ministry of Religious Affairs

62.4 T 67 T +4.3 T +6.9%7

Ministry of Transportation

32.7 T 45.7 T +13 T +39.8%8

Ministry of Finance 39 T 43.3 T +4.3 T 11%9

Ministry of Agriculture

14 T 21.8 T +7.8 T 55.7%10

5

Figure 3 Government Budget per Ministry/Institution Year 2020 and 2021Source: Ministry of Finance, 2020



Cluster 2020 (T) 2021 (T) Difference (T) Percentage change

Health 87.55 25.40 -62.15 -71%

Social protection 203.9 110.2 -93.7 -46%

Ministry/Institution (K/L) & Regional Government

106.11 136.7 +30.6 +28,8%

SMEs 123.46 48.8 -74.7 -60.5%

Corporation Funding 53.57 14.9 -38.7 -72.2%

Business Incentives

1

No.

2

3

4

5

6 120.61 20.40 -100.2 -83.1%

Jumlah7 695.2 356.4 -338.8 -48.7%

Figure 2 Budget for National Economic Recovery Program Year 2020 and 2021

In the heavy scenario, COVID-19 caused layoffs of 3.9 million workers in the formal sector and 1.3 million in the informal sector. With this, BPJS-K will lose the potential to receive premium from 8.7 million PPU members and 2.9 million PBPU members. With the composition of PPU members Class II as much as 60% and Class I 40%, COVID-19 will reduce the JKN premium of PPU group as much as 2.92 trillion Rupiah (heavy scenario) and 4.48 trillion Rupiah (very heavy scenario). This premium reduction especially from the PPU segment will highly affect the sustainability of JKN funding because so far the PPU group is the most routine payers and the fewest to claim JKN services because generally they have an additional private healthcare.

The loss of potential in receiving premium from PBPU members is also significant, that is 1.3-1.8 trillion Rupiah, depending on the COVID-19 impact scenario towards the number of layoffs in the informal sector. The projection of the decrease in PBPU premium is caused by several things, such as (1) the non-active members due to COVID-19, (2) the increase in non-active members due to premium adjustment in January 1st 2020 (according to Presidential Decree 75.2019), (3) the reintroduction of the old JKN premium (according to Presidential Decree 82/2018). It is important to know that the Presidential Decree 75.2019 caused 5% in PBPU membership reduction and reduction in PBPU inpatient members. As much as 15.5% of PBPU members who are active in Class I downgraded to Class II and as much as 26.5% active members

The focus and priority of the government depicted through the budget again only focus on the economic recovery. With the potential decrease of income to fund health system, plus the minimal allocation from the National Budget and COVID-10 handling stimulus, the hopes to strengthen health system, to optimize a more massive 3T, and to give free vaccines for all seem a faraway dream.

From demand-side financing, in the short term the BPJS projected a 2.5 trillion Rupiah surplus in cashflow in 2020. This honeymoon period is the result of the premiums as the main significant source of cashflow, especially PBI-APBN and PBI-APBD. On the other hand, the number of hospitals that submitted the INA-CBGs claim decreased drastically because the utilization rate was also reduced especially in post-inpatient care. But once the situation is stable enough, possibly the BPJS-K spending will shoot up because of complications due to delay in healthcare.

The four million registered members of JKN dropping out between December 2019 to end of June 2020 also depicts the possibility in increasing deficit in the future. The persistent slowdown in the economy causes 2,100 businesses to close down, while 29% institutions requested for suspension/removal of premium charge 71%. This number is equal to 401,500 PPU members or 857,000 members (workers and family members). While the number of PBPU members who stopped paying the premium due to financial problem was 780,300 in April 2020.



downgraded from Class I to Class III. This condition further puts pressure in the PBPU group premium.

The contribution of cigarette tax for JKN is predicted to decrease because the increase of excise tax in 2020 was set lower than 2019 and the simplifying policies are not in place. The Ministry of Finance in their press conference stated that these two decisions were made to protect the industry from the double-barrelled impact of COVID-19 towards the industry and workforce. Next year we predict the economic burden that will be borne due to the tobacco-attributable disease will further increase. In 2019 only, Indonesia is estimated to pay 446,73 trillion Rupiah because of the immense level of tobacco consumption, including the cost of sickness (60,28 trillion Rupiah) and the cost of death incurred (368,52 trillion Rupiah) due to the chronic illnesses related to smoking27.

The tendency to centralize the policies to prevent COVID-19 outbreak in ad hoc institutions is very apparent. The prevention control is lacking a strong leadership. The Minister of Health does not comprehend the health system, disinclined to deliver investment case to the President that the comprehensive solution to public health sector is the best response to COVID-19, and reluctant to do political bargaining process towards groups that are representing vested interests. As a consequence, the leading role in COVID-19 is switched to BNPB and Coordinating Ministry of Economic



27

28

29

CISDI, forthcoming

Adam, A., Kresna, M., & Adam, A. (2020, March 11). “The Awkward” Health Minister Terawan Facing COVID-19. Tirto.Id. https://tirto.id/kikuknya-menk-

es-terawan-menghadapi-covid-19-eD3a

BBC News Indonesia. (2020, June 30). Virus corona: Siapa yang diuntungkan, siapa yang dirugikan karena pandemi Covid-19. BBC News Indonesia.

Affairs who does not have the expertise and technical machine needed to handle COVID-19.

The absence of leadership from the Minister of Health in pandemic handling leaves a big question mark to his leadership credibility and capability. There are at least two important indications: (1) President’s reproval of the uptake in health budget that was only 1.53% in June 2020, and (2) President’s reproval about the inequality in COVID checks in Indonesia in the Cabinet Assembly in September 2020. The appointment of the Coordinating Minister of Economic Affairs and the Coordinating Minister of Maritime and Investment Affairs as the spearhead of the pandemic handling further strengthens the suspicion of a strong political-bureaucracy practice and a weak bargaining power from scientists in handling the pandemic. This shows that the government are prioritizing economic recovery over health recovery28,29.

The frequent change in leadership throughout the COVID-19 handling shows that the government failed at political leadership. The determination of national disaster through Presidential Decree Number 12 Year 2020 placed the BNPB in the control room of COVID-19 handling in national level. This also presides against the Minister of Health to be the leading person to combat the pandemic. The Decree assigned BNPB, through the Response Acceleration Task Force of COVID-19, as the central hub of coordination and communication across ministries

1.2.5 Leadership

The policies across central and regional governments are overlapping, inconsistent, and even negating one another. With the argument to maintain information chain and domestic stability, the central government often criticizes regional government’s proactive efforts that are contradictory to what is prescribed from Jakarta. Regional government’s policies are narrated to be some reckless decisions not based on evidence, and only a tool to increase popularity, or seen to potentially create panic among the people. This more or less discourages regional government to formulate policies in handling COVID-19 based on potential risk, or to try to ensure that their local capacity increases as the spread widens.

The synergy and coordination between institutions and governmental bodies in handling the crisis is still weak. This problem illustrates two things: (1) there is still a lack of understanding in policymaking and in publishing public statements between ministries/institutions and officials that are under the President, and (2) the sub-national policies are rarely coordinated with the central government.

involvement of development stakeholders outside of the government Is still blocked by complication regulations and bureaucracy, even in the emergency pandemic situation.



1.2.6 Governance

and institutions, between communities, and the pacemaker for the national pandemic handling. Although so, BNPB does not have a full contextual understanding about pandemic handling, as it is different with the natural disasters that is the DNA of BNPB. The change in priority of pandemic handling from BNPB in March 2020 to the priority in economic recovery by way of leadership of the Coordinating Minister of Economic Affairs in July 2020 gave the impression that every institution and government leader were each taking different steps30.

The pentahelix collaboration is often mentioned as a part of government’s public communication but it has never been truly implemented consistently since the beginning of the pandemic. It is impossible to handle the pandemic using usual approaches with usual groups of people, given its huge magnitude. This is why the WHO strategy document underlined the importance of the whole- of-government and whole-of- society approach. The success in pandemic handling requires involvement from various development stakeholders from global, regional, national, sub-national, and the community level to build together a collective action to handle COVID-19. Unfortunately, the government tends to work in silo using the bureaucracy machine and ways of doing without involving the civil society, business/corporate sectors, experts, or science institutions. Their involvement seemed superficial, done as formality, and often not guided by p a r t n e r s h i p - a m o n g - e q u a l s principle. In practice the

30 Mas’udi, W., & Astrina, A. R. (2020, April). Policy Brief Problematika Kebijakan Krisis Covid-19 di Indonesia. FISIPOL UGM. https://fi-

sipol.ugm.ac.id/wp-content/uploads/sites/1056/2020/04/Policy-Brief-Problematika-Kebijakan-Krisis-COVID-19-di-Indonesia.pdf

30 Mas’udi, W., & Astrina, A. R. (2020, April). Policy Brief Problematika Kebijakan Krisis Covid-19 di Indonesia. FISIPOL UGM. https://fi-

sipol.ugm.ac.id/wp-content/uploads/sites/1056/2020/04/Policy-Brief-Problematika-Kebijakan-Krisis-COVID-19-di-Indonesia.pdf

Regardless of the cross- institutional coordination, the Ministry that has the most experience and understanding of the technical terms in handling disease should be the one coordinating all the related efforts. Instead, the formation of COVID-19 Recovery Acceleration Task Force or the COVID-19 Handling Committee and National Economic Recovery was led by the Ministry/Institution that has limited understanding and technical ability to handle the pandemic. The involvement of BIN in the framework of pandemic handling also raised a question. BIN’s role should be to detect threats and to prevent crisis happening in Indonesia by doing the contact tracing effort. However, the public sees their involvement to fund free PCR tests and COVID-19 medicines. Seeing these events where the ministries and institutions are fighting over spotlight during pandemic, the pandemic handling should have been led directly by the President and helped by the Minister of Health.

The coordination between the central and regional government is key in ensuring the correct steps are taken until the smallest unit of government. With the current dynamics, the regional government has limitations to try out a drastic and quick measures in handling the pandemic in their respective areas. Decisionmaking has to go thought a steep hierarchical route and a long bureaucracy process. This results to a push-and-pull evident in the beginning of pandemic, where the imposition of PSBB and territorial quarantine had to wait for approval of the Minister of Health. Some minister’s rejection of PSBB relayed

to the Jakarta Provincial Government was also an evidence of this situation.

According to the government mandate Number 23 Year 2014 on decentralization, health sector is one of the aspects that falls under the responsibility of the regional government. However, it is also stated that the any governmental issue concerning across provinces or across countries becomes the authority of the central government. So, it is true that the central government holds control in pandemic handling in the national level. But, the central government has many limitations to do the handling until the sub-national level. Through the government’s Circular Letter 440/2622/SJ, the central government appointed regional leaders’ roles as the leader of COVID-19 Recovery Acceleration Task Force for their respective regions. The limited understanding and capacity of the regional government often become a challenge in applying the policies that are set from the central government as they aim to implement the policies consistently across the regions. The coordination chain and communication that is often not optimal between the central and regional government raised question to each leader in sub-national and national levels. The incident in Petamburan that was triggered by 10,000 people further aggravated this problem. This resulted in the Governor of Jakarta and West Java being summoned, and also the Greater Jakarta Metropolitan Regional Police and West Java Regional Police being replaced. An



The COVID-19 pandemic hit the global economy and the majority of countries in the world (The World Bank, 2020). When the government applied policies needed to slow down the virus outbreak, and the public changed their behavior to limit the chance of getting infected, the global supply chain started to close, and the economic disaster expanded. The last time where many countries experience recessions simultaneously was in 1870, around two centuries ago.

The IMF (International Monetary Fund) projected that although US$18 trillion has been spent to stimulate the economy all over the world, the global economy will lose US$12 trillion, or more, by the end of 2021. In terms of global GDP (gross domestic product), the current conditions as the worst since the end of World War II. By the same definition, the financial loss from COVID-10 is twice the size of the Great Recession in 2008.

31

32

33

34

Y-on-y: GDP based on constant price on one quarter compared to the same quarter in the previous year.

Q-to-q: GDP based on constant price on one quarter compared to the previous quarter.

Compared to the previous poverty data, September 2020.

Compared to the same month in the previous year, August 2019.

instruction by the Ministry of Home Affairs Number 6 Year 2020 re-stated that regional leaders who do not abide the Laws can be terminated by the Ministry of Home Affairs.

1.3 Vicious cycle of covid-19 in the health, economic, political, and social systems

Institute of Health Metrix and Evaluation estimated that extreme poverty has increased by 7% just several months into the COVID-19 pandemic. It also undid the 20-year growth achieved from poverty reduction programs. In 2020 alone, the pandemic dragged almost 37 million people under the extreme poverty line of US$1.9 per day. If this poverty line is applied to low-income and middle-income countries with US$3.2 per day, 68 million people have fallen under this standard since 2019.

But, to “fall under the poverty line” is a euphemism. The real definition is how people can survive from day to day. The newly poor people are most likely women who are working in informal sectors who do not have access to social assistance. During pandemic, women have an added unpaid care work; taking care of children, husband, and sick people when they were supposed to be at school, at work, or at healthcare facilities.

Indonesia’s bad handling of COVID-19 further throws the economy in time where recessions are sustained. As seen in Figure 1, economic growth in the beginning of COVID-19 pandemic was at the lowest since 1999, that is -5.32% y-on-y31 and -4.19% q-to-q32 in Q2 2020. The new normal and PSBB relaxation measures at the end Q2 2020—which was hoped to ease Indonesians out of the economic recession—was instead increasing the COVID-19 rate and made Indonesia to stay at the minus level of y-on-y in Q3 2020 (Sparrow et al., 2020). The economic crisis due to the COVID-19 pandemic is not contributing to the increasing 1.6 million new poor people in March 202033 and the rise in unemployment rate of 37.6% in August 202034.





COVID-19 pandemic affects the short-term and long-term economy. In the short term, the COVID-19 pandemic results in an economic crisis through the implementation of PSBB and activity restrictions that hit the demand and supply sides in the economy (Allen & Mirsaeidi, 2020). For the supply side, the prolonged PSBB caused “economic freeze”, which is capable to decrease the productivity of labour force and decrease the investment and capital flow; while on the demand side, the rise in layoffs, increasing uncertainty in economic condition, and the declining income in households and government cash caused a lower consumption level of the people and the government (Mohadded et al., 2020). In Indonesia’s case, the biggest cause in economic crisis due to the health policies related to COVID-19 is the decrease in investment that falls under the supply side, which is then followed by the public consumption and government consumption on the demand side (Sparrow et al., 2020). In the long run, COVID-19 pandemic will decrease the human resources quality due to: (1) rise in death rate and sick rate because of the permanent effect of COVID-19 to human bodies and disruption in essential health services and (2) access to education that is hampered by the PSBB.

Chapter 2.

Don’t Waste a Crisis.

Your Patient’s or Your Own.

M.F. Weiner, Medical Economics 53,no. 5, March 8, 1976.



Health and economy have a reciprocal relationship, both are indispensable from one another35. The economic crisis

occurred because of COVID-19 pandemic

can create a bad impact to the health level

now and in the future. Specifically, the crisis can weaken the health system through at least two ways: (1) a decrease in the quality of human resource in the future, and (2) a decrease in health coverage and financial loss in health service sector.

The word “pandemic” comes from the Greek “pan-“ (all) + “demos” (people or population) = “pandemos” = “all the people”. Pandemic means that the

disease is spreading all over the world and

infecting almost all the people.

The prefix “pan” can also mean that the disease affects all aspects of society. An

article in India about the influenza pandemic in 1918 stated as “a set of

mutually exacerbating catastrophes”, which means in a blink of an eye, health crisis becomes an economic crisis, a food crisis, a housing crisis, a political crisis. Everything collides.

The cost benefit evaluation in handling the pandemic that places health and economy as the false dichotomy has taken away thousands of lives. The

broken health system is the one causing the vicious cycle in economic, political, and social systems.

35 Sachs, J. D., Ahluwalia, I. J., Amoako, K. Y., Aninat, E., Cohen, D., Diabre, Z., Doryan, E., Feachem, R. G. A., Fogel, R., Jamison, D., Kato, T., Lustig, N.,

Mills, A., Moe, T., Singh, M., Panitchpakdi, S., Tyson, L., & Varmus, H. (2001). Macroeconomics and Health: Investing in Health for Economic

Development. In Report of the Commission on Macroeconomics and Health. https://doi.org/10.1038/nm0602-551b



The scientific evidence showed that the economic crisis in Indonesia contributed to the low birth rate, the rise of stunting, wasting, and undernutrition cases, increasing stress and mental problems, and the decrease in life expectancy and death ratio36,37,38,39. The increase in poverty in COVID-19 pandemic can also bridge the

impact of crisis to the decrease in health

status through a) the rise in unhealthy habits, such as smoking and drinking alcohol, b) the rise in stress which triggers mental illness and body inflexibility (allostatic load), and c) the inability to access healthcare40.

In Indonesia’s case, the economic crisis due to COVID-19 has the potential to increase the double-burden maltrunition cases in form of stunting for children and the deficit in nutrition for mother due to the decrease in food security, and cases of overweight and obesity because of the limited choice in physical activities41. On

the other hand, layoffs, the decrease in income, and reduction in PBI subsidy in pandemic has decrease the level of health

coverage ownership by 2.7% of the total active members. This happened four

months after the first case of COVID-19 was announced, so it reduced the public access to healthcare42.

On top of that, the economic crisis also has a negative impact on the supply side of healthcare. The rising number of

COVID-19 patients who are filling up bed capacities, the restricted number of elective treatments, and the fewer visits to health facilities will lead to an increase

in loss or bankruptcy in the health providers, which will result to an increasing inequality of healthcare access43. In Indonesia’s case, the growth rate of health service industry has decreased y-on-y as much as 6.7% point since March until June 202044.

36

37

38

39

40

41

42

43

44

Bhutta, Z. A., Bawany, F. A., Feroze, A., Rizvi, A., Thapa, S. J., & Patel, M. (2009). Effects ofthe Crises on Child Nutrition and Health in East Asia and

the Pacific. Global Social Policy, 9, 119–143. https://doi.org/10.1177/1468018109106888Friedman, J., & Thomas, D. (2009). Psychological health before, during, and after an economic crisis: Results from Indonesia, 1993-2000. World

Bank Economic Review, 23(1), 57–76. https://doi.org/10.1093/wber/lhn013Hopkins, S. (2006). Economic stability and health status: Evidence from East Asia before and after the 1990s economic crisis. Health Policy, 75(3),

347–357. https://doi.org/10.1016/j.healthpol.2005.04.002Waters, H., Saadah, F., & Pradhan, M. (2003). The impact of the 1997-98 East Asian economic crisis on health and health care in Indonesia. Health

Policy and Planning, 18(2), 172–181. https://doi.org/10.1093/heapol/czg022Bloom, D. E., & Canning, D. (2003). The Health and Poverty of Nations: From theory to practice. Journal of Human Development, 4(1), 47–71. https://doi.org/10.1080/1464988032000051487

UNICEF. (2020). COVID-19 and Children in Indonesia: Action List to Overcome Socio-economic Challenges (May issue).

Sparrow, R., Dartanto, T., & Hartwig, R. (2020). Indonesia Under the New Normal: Challenges and the Way Ahead. Bulletin of Indonesian Economic

Studies, 56(3), 269–299. https://doi.org/10.1080/00074918.2020.1854079Blumenthal, D., Fowler, E. J., Abrams, M., & Collins, S. R. (2020). Covid-19 — Implications for the Health Care System. New England Journal of

Medicine, 383(15), 1483–1488.Sparrow, R., Dartanto, T., & Hartwig, R. (2020). Indonesia Under the New Normal: Challenges and the Way Ahead. Bulletin of Indonesian Economic

Studies, 56(3), 269–299. https://doi.org/10.1080/00074918.2020.1854079

Health Crisis:COVID-19

EconomicCrisis

Decrease in healthand quality of

human resources

EconomicGrowth

Social DistancingPolicy

Social protection policy and countermeasuresin health impact due to crisis

Source: writer’s compilation

Short term Long term

Figure 4 Impact simulation of pandemic handling towards economic growth



The “pan” prefix could also mean that this problem cannot be solved alone. We

cannot be safe on ourselves, just like there is not one policy that can be panacea. In the beginning of pandemic, the limited amount of scientific knowledge available about the

SARS-CoV-2 virus made the COVID-19 policymaking an uncertain territory. There was only a limited amount of science-based evidence to be

orchestrated with policy elements that are connected with a good accuracy in execution. Because of that, with a spirit of solidarity, the government should have a higher bargaining power to persuade the

wider public and ask for science-based

recommendations from multiple sources

especially the scientists and civil society in Indonesia. While outside of Indonesia, with many other countries facing the same challenges, to take a more active role in health diplomacy through multilateralism is the right path to take.

Pentahelix as a conduit for multi-actor partnership—a multi-sector development is often mentioned as part of the government’s public communication, but it has never really been implemented consistently since the beginning of the pandemic. It is impossible to handle the

pandemic using usual approaches, given its huge magnitude. That is why the WHO strategic document underlined the

importance of whole-of-government and

whole-of-society approach. The success in pandemic control requires involvement

from various stakeholders from global, regional, national, sub-national, and the community level to build together a collective action in handling COVID-19.

Unfortunate, maybe, because the culture of bureaucracy has been going on for years, and the government tends to work in silo. The government is used to using

their own bureaucracy machine and

The figure above shows that in the short term, the pandemic can cause economic crisis which will decrease health quality, leading to impact in human and economic growth in the long term. The reciprocity between economy and health affirms that to combat crisis during COVID-19

pandemic, there needs to be a sustainable policymaking to cut the “vicious cycle” existing in economy and health problems. Unfortunately, Indonesia’s government’s policies right now are only focusing on short-term economic recovery through “new normal” measures, inaccurately targeting policy beneficiaries, and arranging the 2021 annual budget that is not aligned with the crisis handling in

202045.

The absence of trustworthy and integrated national data makes it difficult for the government to calculate the ‘real’ economic cost of COVID-19 pandemic. An

analysis by Yusuf (2020)46 concludes that a

strong intervention (such as an effective lockdown) can decrease economic growth in 2020 to 1.0% without fiscal stimulus and 1.8% with fiscal stimulus. However, in the long term (2019-2030) it will result to a higher economic growth (5.1-5.2%) compared to minimum intervention

scenario (4.8%). Also concluded in the analysis that the economic loss from the strong intervention strategy is much lower compared to the minimal

intervention scenario. The difference in

loss could reach 5,600 trillion Rupiah without calculating mortality value and can reach 14,000 trillion Rupiah—almost on par with Indonesia’s GDP in 2019—if we calculate the economic value of avoidable

deaths. The hard-hitting impacts of

COVID-19 to the global and national

economy is a reminder that health is one component of the long-term investment

in human resources, just as important as other factors of economic growth47.

Ibid.

Arief Anshory Yusuf (2020, 14 April), Measuring the “Real“ Economic Cost of Covid-19 Pandemic. Accessed from: http://sdgcenter.unpad.ac.id/men-

gukur-ongkos-ekonomi-sesungguhnya-dari-wabah-covid-19/

Remes J, Dewhurst M, Woetzel J. Research: Poor Health Reduces Global GDP by 15% Each Year. Harvard Business Rev. 2020 Jul 8; Available from:

https://hbr.org/2020/07/research-poor-health-reduces-global-gdp-by-15-each-year

45

46

47



Pandemic handling requires a speedy action, although with a risk in failing if the wrong step is taken. So it is important for

the government to always evaluate and learn their lesson to be able to adapt well

with the changing needs during

pandemic. The speed and agility in responding is key for a country as diverse and as large as Indonesia.

Policy that is based on data and sense of urgency cannot be ignored. In crisis

condition, the direction of government policy will affect the decisions made by the public officials in national or sub-national levels. In Indonesia’s context, policy crisis is a byproduct of the low sense of urgency since the beginning of the pandemic. Policies are decided

half-heartedly and not prioritizing health as the main determinant in decision

making. The lenient social distancing at

the start of the pandemic is also a

reflection of the government’s dubiousness.

The government is driven by the fear of economic collapse, and that is their main framework in determining the steps taken to handle the pandemic. Policy crisis is also reflected clearly in the way the pandemic is communicated to the

public. The government made use of

public’s anxiety as a reason to filter the information that can reach the wide

public48. The mistake in setting priorities

was also seen at the beginning, where the government was too focused on

increasing hospitals’ capacity. The government ignored the prevention

aspect and did not put effort in breaking

the chain of transmission, and they were also late in strengthening puskesmas

whose strategic roles are important in

responding to COVID-19.

This policy crisis brough about serious implications. This is apparent from

people’s behavior, who are not obeying health protocols, resulting to the spike in cases and it is not coming down anytime

governance without involving the civil

society groups, the corporate/business world, or the experts and scientific institutions. The involvement tends to be

superficial, only functions as a formality, and often not based on the value of

“partnership among equals”. In practice, the involvement of other development

stakeholders outside of the government is

still restricted by regulations and complicated bureaucracy, even in the emergency pandemic situation.

This lack of clarity should be seen as an opportunity to impose new ways and objectives. It is important for the

policymakers to take advantage of this situation actively, especially to increase their knowledge about the process of

change through formative evaluation.

Although the window of opportunity has passed, the government should hold tightly to the compass of case handling: to increase the technical know-how of the

health system such as detecting cases, tracking cases, and isolation; reporting data transparently; assigning clear roles between the central and regional

government; and implementing policies that protect the people and

communicating it using risk

communication and behavior change

principles.

Observing the rising number of cases, we have to be ready to face the peak of pandemic where tens of thousands or even hundreds of thousands of people will be treated every day. Indonesia

should be able to get out from the

implementation trap that is the

business-as-usual approach, landed on the principles of normal life. The process

in policy implementation does not have to be forced to a rigid form. The COVID-19

handling programs that demands

conformity will only result to a superficial compliance. Demanding conformity means robbing off important information

and restricting to use the knowledge of

street-level bureaucrats as resource.48 Putri, R. D., & Putri, R. D. (2020, February 4). Gelombang Diskriminasi dan Rasisme yang Muncul Akibat Hoaks Corona. Tirto.Id. https://tirto.id/gelom-

bang-diskriminasi-dan-rasisme-yang-muncul-akibat-hoaks-corona-ewFs



communication that is easy to understand, (5) collecting feedback from the public and encouraging dialogues, (6) making sure the message that is conveyed by the government and the mass media is well-coordinated, (7) avoiding to change information too frequently and prevent different narratives coming out from

different government institutions, and (8) disseminating information through

various channels to reach the public.

Unfortunately, the Indonesian government does not fulfil WHO’s checklist of risk communication. Instead

of translating the scientific evidence, communicating it transparently, and building a mental model so that the public

can understand how infection happens, the government started their risk

communication with a massive appeal for

the public to stay calm. This rhetoric is only an umbrella message and not supported by comprehensive information and openness to dialogue.

From their communication style, the government showed denial in scientific models and recommendations, and often inconsistent in conveying messages. Although the government have done

several routine efforts such as daily press conference and daily COVID-19 report, and also establishing information center to

combat hoax and misinformation in society, people’s behavior change does not go as well as expected and the government only conveyed messages without implementing evidence-based

policies.

Risk communication needs a modified environment to encourage behavior change. Asking the public to abide to 3M

rules without implementing policies and

factors that will support the behavior

change is ineffective. Intervention in

emotional attachment, cognitive

soon. The policy crisis also has impact in public’s loss in trust to the government.

The protests relation to regional election

that was still carried out and the rejection of vaccine from the people were some

examples on how public’s trust to the government is very low right now.

Risk communication is the standard and compulsory in handling pandemic, functioning as the main pillar in responding and anticipating the panic wave in the society. The central role of

risk communication is elaborated in

International Health Regulation (2005) and is also one of the indicators in Inter Action

Review (2020). However, it has been countless times since March 2020 where the government made comments and

unsuitable communication to the public, some of which were downgrading, lacking empathy in people’s lives, and undermining the impact of this pandemic.

This negates experts’ careful measures, and seemed to be an insult and also

lowering the public’s sense of urgency.

WHO put spotlight on the role of risk communication as a channel of exchange for information, recommendations, and opinions between elements in real time as an integral part in handling pandemic. In such a dark and uncertain situation, policymakers should be able to build people’s trust so that every element in the society is willing and to follow their policy and be involved in the implementation on

the ground.

Experts in risk communication and health emergency situation have formulated factors that are effective to establish trust from the public towards policymakers: (1) admitting uncertainty in the message, including predictions and reminders, (2) transparency in data, (3) spreading information correctly, (4) building a narrative in science



knowledge, and environmental modifications are important to prompt sustainable behavior change49. A group of

English researchers50 have also

formulated the principles in behavior

change communication to accelerate the

adoption of physical distancing protocols in COVID-19 pandemic. As Indonesia is an

archipelagic geography with a big population and a vast diversity, the behavior change policies are also going to

be diverse.

49

50

Switch, C. and Switch, D. (2011). Switch. London: Random House Business Book.

Bonell C, Michie S, Reicher S, et al. Harnessing behavioural science in public health campaigns to maintain ‘social distancing’ in response to the COVID-19

pandemic: key principles, J Epidemiol Community Health 2020;74:617-619.

Chapter 3.

8

“When the facts

change, I change my mind - What do you do, sir?”

John Maynard Keynes

development policy in 2021. Every scenario has their own distinct characteristics and are equally plausible.

From our mapping of tendencies as analyzed in Chapter 2, there is an indication of two main moving factors, which are (1) the availability of vaccines and (2) economic recovery. We use both of them as the standard elements in developing these scenarios.

In terms of vaccine availability, according to data from WHO, currently there are more than 200 candidates of vaccines that are on developing stage. As per December 1st 2020, 13 vaccines have entered the third phase of clinical trials. Soon, the tendency to give domestic vaccine with Emergency Use Authorization (EUA) will increase51 especially in countries with adequate health service capacity and safety

The future is something that can be engineered and planned based on factors and events from the past and the present. Looking at 2020 being dominated by failures and huge loss of millions of people’s lives around the world; we cannot separate and look at things as one independent event. Our success in rebuilding our future after the pandemic heavily depends on our own awareness in looking at the past world before the pandemic; the world right now that is ravaged because of the pandemic; and the future world that will be rebuilt.

Chapter 1 and 2 have elaborated many events and reflected the moving factors, tendencies, and main challenges that have significantly shaped Indonesia’s health system throughout 2020. Based on those three aspects, we have developed a simple scenario to anticipate the approach the direction of health

51 In the time of writing of this report, the US, Canada, the UK, and Singapore have issued the Emergency Use Authorization (EUA) for vaccines produced

by Pfizer-BioNTech.



monitoring52. Countries with lower capacity in immunization services will keep relying on medicamentosa alternative therapy.

In the future, the same thing can still happen, but there could also be a shift in situation if COVAX authorize one single-dose vaccine candidate and start distributing it to 3% of Indonesian population or 8,100,000 people by the end of Q1 or the beginning of Q2 2021—which is generally more favored. In the most optimistic scenario where the Government is successful in vaccinating 60% of population or 160 million people (438,356 people every day), the health protocol can only be released gradually in 2022 at the earliest.

In terms of economic recovery, the turnaround has started to happen53. The tendency of contraction in Q3 2020 is smaller compared to the contraction is Q2 2020, which was 5.32%. Almost all GDP components from expenditure side is improved. From the demand side, in Q3 2020, although limited, it started to increase, consistent with the household consumption data. In the future, this tendency should be maintained—that the recovery will be a swoosh shape54. But there is an equal probability that if there is another outbreak, the economic recovery pattern will be K-shaped55.

We combined the possibilities that can happen in terms of the vaccine availability and the economic, illustrated in four scenarios as follow:

Scenario 1: Imagined Nation.

In this scenario, single-dose vaccines are readily available, with high efficacy. As a country registered in WHO’s ACT Accelerator, Indonesia has access to vaccines that have been approved, covering 20% of the total population. The distribution process will be done gradually until end of 2021. The first 3% is estimated to be distributed by the end of Q1 or beginning of Q2 2021.

52

53

54

55

Food and Drugs Administration (FDA) emphasized that the vaccine to SARS-CoV-2 virus will be deemed effective when it can protect at least 50% from the vaccinated people. It is important to ensure the vaccine is safe because it can cause Adverse Events Following Immunization, such as immunolog-ic and allergic responses (e.g.: ADE (Antibody Dependent Enhancement), VAERD (Vaccine Associated Enhanced Respiratory Disease), dan ERD (Enhanced Respiratory Disease).Basri, C. M. (2020, November 11). Recession and Economic Recovery. Kompas.id. https://www.kompas.id/baca/opini/2020/11/11/resesi-dan-pemba-likan-ekonomi/The recovery pattern of a swoosh shape (Nike logo) where the economic growth reached the lowest point in the Q2 2020, then picked up and will achieve a positive growth in Q1 2021.In the cross-sector and earning group context, economic recovery might be K-shaped. The recovery will happen unevenly, some are peaking up, some are falling down like the letter K.



Vaccines are readily available with high efficacy

Vaccines are not readily available and/or with low efficacy

Economic recession

gets worse

Economic recovery happens

Scenario 2“Building Castles in

the Air”

Scenario 1 “Imagined Nation”

Scenario 3“Bad Dream”

Scenario 4“Would It Return?”

Apart from that, six types of COVID-19 vaccines are also being prepared for vaccination program in Indonesia through bilateral partnership mechanism: Bio Farma, Astra Zeneca, Sinopharm, Moderna, Pfizer Inc and BioNtech, and Sinovac Biotech56. The first vaccine that will be delivered is from Sinovac BioTech in December 6th 2020 as many as 1.8 million doses, and 30 million doses in the form of bulk raw material will arrive in January 2021.

In this scenario, it is also assumed that the economic recovery goes on in full speed and/or the Government has a high commitment in managing the externalities due to COVID-19. The government has and is allocating budget to give out vaccines to all population according to Article Number 4 Year 1984 about Disease Outbreak. Meanwhile, part of the population are also able to access vaccines from the vaccine service providers to shorten queueing time. Herd immunity can be reached in 2021 and soon the economy can operate 100%.

56 The Ministry of Health Decree (Kepmenkes) Number HK.01.07/ Menkes/ 9860/ 2020 about the Determination of vaccine types to carry out coronavirus disease 2019 (COVID-19) vaccination.



Problem

The availability of vaccines

Current condition Challenges in 2021

In December 16th 2020, the President Joko Widodo issued a public statement that the COVID-19 vaccine will be free for all. The President also ordered his officials to prioritize vaccine program in the financial year 2021 and to recalculate our financial budget.

This decision annulled The Ministry of Health’s regulation HK.01.07/Menkes/9860/2020 which programmed two vaccination schemes: the free ones to be managed by the Ministry of Health, and the independent/paid ones to be managed by the Ministry of State Owned Enterprise.

Implicitly, this instruction targeted a 100% immunization coverage in 2021. This target is higher than the previous 60%, or 160 million people to be covered by end of 2021.

In rough estimation, if everyone needs two doses of vaccine to be immuned, Indonesia needs at least 320 million doses. If added with vaccine wastage rate of 15%, the total need is 368 million doses of vaccines.

Through the ACT-Accelerator mechanism, COVAX facility under WHO guaranteed vaccine availability of 20% from total population with gradual distribution starting from Q1 or beginning of Q2 until the end of 2021. Some ongoing bilateral commitments on vaccines are: (1) Sinovac: 3 million doses and 15 million bulk; (2) Sinopharm: 65 million doses; (3) Astra Zeneca/Oxford: 100 million doses. The local seed vaccines (Vaksin Merah Putih) is currently being produced by Eijkman, LIPI, UI, UNAIR, UGM, and ITB. These vaccines are targeted for large-scale production starting from January 2021, partnering with pharmaceutical industry: Kalbe, Sanbe, Dewoong Infion, Biotis, and Tempo Scan Pacific.

Indonesia needs to do two things: adding the number of doses and the diversity in COVID-19 vaccine portfolio. This can be done by buying the vaccines on our own or bilaterally between countries, business-to-business or together with other countries that we collaborate with regionally (ASEAN and/or OKI, Organisasi Konferensi Islam).

If we are going ahead to buy on our own, there are two mechanisms: buying from producers in Indonesia and/or from outside of Indonesia.

If we buy on our own, BPOM has to be extra careful before we issue the permit of emergency use. The chosen vaccine should be safe and has the efficacy at least 60-70% according to WHO standard. The most ideal option is to wait until phase 3 of clinical trial is completed. The other option is to choose vaccines that have been tested safe and with good efficacy and have gone through interim phase 3 test that has been published in scientific journals.

When choosing the vaccine, the data should be opened to public via BPOM. This openness in data is one of the efforts to increase public trust to the chosen vaccine by the Government.

Regional multilateralism is more beneficial because we can pool our buying power so that we can give a guarantee in volume for various vaccine manufacturers to produce new COVID-19 vaccine in a large scale and making an early investment that is risky from the manufacture side. On the other hand, the existence of BPOR (Badan Regulator Obat Regional) will accelerate the licensing process. Partnership with OKI countries has the potential to mitigate vaccine hesitancy in countries with major Muslim populations.



8

Problem

Targeting


There are 6 groups targeted for vaccines with total population of 160 million people, which are:

1.

2.

3.

4.

5.

6.

The first target is given to the front workers who are handling COVID-19, including the health workers, law enforcement, Indonesian National Armed Forces/Indonesian National Police, and public services, in total of 3.4 million people.

The second target is public figures/Key Opinion Leaders, mainly leading religious figures and local government agencies (sub-district, RT/RW, and village), in total of around 5.6 million people.

The third target is all education workers starting from pre-kindergarten, kindergarten, elementary school, junior high school, high school, and university, of 4.3 million people.

The fourth target, is to government apparatus in central and regional levels, of 2.3 million people.

The fifth target is recipients of BPJS, of 86 million people.

The public and other economic agencies, of 57 million people.

The criteria in receiving vaccines are:

1.

2.

3.

4.

Aged 18-59 years old

Individuals who are healthy without comorbidities

Not pregnant

Never been infected by COVID-19

WHO recommends priority of vaccines to health workers, elderly people, people with certain conditions, and other vulnerable groups to suppress death and sick rates.

Unfortunately, based on the result of interim analysis, only Moderna and Pfizer that are safe and reaches the desired level of efficacy for elderly people. Indonesia does not yet have a procurement agreement with the two vaccine manufacturers. Indonesia also does not have a cold chain that is required for the distribution of these vaccines.

With the very limited amount, health workers and public servants should be prioritized. Especially those who are working in highly infectious zones, for example: health facilities, nursing houses, prisons, and others. Then the other vulnerable groups will follow.

The acceleration of vaccination process and the shortening of queueing time should be supported with a massive civil data collection by Puskesmas and RT/RW staff, combined with population data and comorbidities and epidemiological investigation in province level.

The government is preparing One Data Vaccination Information System (Sistem Informasi Satu Data Vaksinasi) COVID-19, covering a variety of data, including BPJS data, to determine the target groups. These target groups will be sent a text message via SMS to schedule and locate the vaccination point.

Not any less important, the Government should make sure that the recoded data is not only done for those who receive vaccines from the Government, but also those who pay on their own.



Problem

Funding


Unless the vaccination target changes after the new President’s instruction, Indonesia will start the COVID-19 immunization at least in February 2021 with initial target of 107 million people vaccinated. For that, the budget needed is 61.4 trillion Rupiah. If the vaccination target is 160 million people, the Government will need at least 160T. This is higher than the current budget allocated, that is 34T.

Indonesia has to revise the annual budget in the beginning of 2021. There is still some fiscal space to make vaccine free for all, from the infrastructure budget and security defense.

The budget for vaccines can also be achieved with using remaining funding from National Economic Recover (PEN, Pemulihan Ekonomi Nasional) 2020, which until the beginning of December 2020 was only used around 63%. Remaining Funds from SILPA on other lines plus other funding channels such as philanthropy or foreign aid can also be an alternative.

If the budget reallocation is not done meticulously, the country’s financial burden due to deficit will be bigger. The posture of 2021 annual budget with budget deficit on GDP that is now at 5.7% should be maintained as financial prudence.

Delivery arrangement

The Ministry of Health handles the distribution flow of vaccines for adults, which platform is not yet defined well.

Assuming that the Government will use distribution path owned by the Ministry of Health, once the vaccine has passed the permit issue (EUA) from BPOM, the government will distribute it through the Health Department in provincial and city/regency levels, going to 10,134 puskesmas in sub-district level, 2,877 hospitals/state-owned and private clinics, and 49 KKPs (Kantor Kesehatan Pelabuhan, Port Health Office) plus the working area.

The role of primary healthcare such as puskesmas and its network becomes vital to ensure the vaccination process is carried out well and distributed to all corners of the area.

Infrastructure readiness should be improved, seeing only 77.6% puskesmas have freezers and 90% puskesmas have cold boxes and vaccine containers in good condition.

If the government get vaccines from different manufacturers, the delivery system has to follow the agreed requirements with respective suppliers. Vaccines that need ultra-cooling system -20 and -70 is only possible in big cities and in health facilities who have special cooling devices. Meanwhile, the areas with restricted infrastructure can receive the vaccine with general cooling system.

Using different vaccines with different efficacy levels can result in a different effectiveness in different locations and populations. A modelling in the US estimated in order to reach herd immunity, the vaccines should cover 100% of population with 60% efficacy level. Vaccine with higher efficacy level, for example 70%, will require 75% coverage. So, with differing efficacy levels, there could be more population that needs to be vaccinated. This has to be calculated carefully, involving the experts.

With the target of 158.6 million, and utilizing all the 13,011 puskesmas, hospitals, and clinics in Indonesia, every health facility should carry out the vaccines to at least 12,190 people. To shorten queueing time, houses and other vaccine facilities can be involved.

The government themselves have prepared 440,000 health workers and 23,000 immunization workers. That amount is less than ideal. The ideal ratio of immunization workers to immunization



14

57

58

59

Sipahutar, R. Y. (2020, January). Database Development Immunization Program in the Effort of Identifying Adverse Events Following Immunization (KIPI), Individual-based in Health Office in Surabaya Year 2020. http://repository.unair.ac.id/96730/1/1.%20HALAMAN%20DEPAN.pdfCovid-19, S. P. (2020, November 17). COVID-19 Vaccine Survey in Indonesia – Analysis of COVID-19 Handling. Covid19.Go.id. https://covid19.go.id/p/ha-sil-kajian/covid-19-vaccine-acceptance-survey-indonesiaWHO Technical Advisory Group on Behavioural Insights and Sciences for Health. Meeting report: Behavioural Considerations for Acceptance and Uptake of COVID-19 Vaccines. 15 October 2020.

Problem Current condition Challenges in 2021

target is 1:20. So the ideal number for vaccine workers is 107 million, where every province will need on average 95 people every day, depending on their population count. That estimation has not accounted the distribution time, public delivery, and other technical stuff.

The government should also make sure that other essential immunizations are not disrupted. In this condition, the renewal in calculation of Workload Indicators of Staffing Needs (WISN) in healthcare should be revisited.

Adverse Events Following Immunization (KIPI, Kejadian Ikutan Pasca Imunisasi), such as immune response and allergy (for example: ADE (Antibody Dependent Enhancement), VAERD (Vaccine Associated Enhanced Respiratory Disease), and ERD (Enhanced Respiratory Disease).

KIPI surveillance is a way of early detection, responding to KIPI case in quick and accurate manner, lowering the negative impact of immunization to individual health and immunization program. KIPI is directly reported by health workers/direct patients to service-provider facilities.

Every event is reported to the Health Department in regency/city and provincial levels, complete with investigation for analysis, plus recommendations from the Regional Commission of KIPI Assessment and Treatment (Komda PP KIPI) and the National Commission of KIPI Assessment and Treatment (Komnas PP KIPI)57.

A regular post-marketing surveillance through a vaccine adverse events reporting system (VAERS) that is responsive and built from the community to national level can help quickly respond to reports quickly. The use of this technology can simplify and accelerate reporting and follow-ups.

The development of P-Care towards electronic personal health records (PHR) will be an effective alternative technology. This approach will record vaccination history, alongside with the side effect, and can report directly to the system once the KIPI is there. However, the issue of personal data protection can be a challenge here.

Vaccine hesitancy

The online survey58 carried out by the Ministry of Health, ITAGI, UNICEF, and WHO in September 2020 showed that 27.6% of respondents have not decided to be immunized and 7.5% of respondents rejected to be vaccinated. The rejection was followed by many various reasons, where 59% of them not sure of the safety, 43% not sure of the effectiveness, 24% are afraid of the side effects, 25.8% do not believe in vaccines, and 15.7% because of religious values.

To increase vaccine delivery everywhere, it is important to create a supporting environment and remove barriers. Several important factors that should be considered are: location, cost, time, a quality health service with adequate manpower, information, and regulations59. Instead of forcing vaccines through regulations and sanctions, it is better for the government to try increase their vaccine coverage through ways of supporting environment mentioned above.



Problem

The government heavily relies on COVAX allocation and independent vaccination to reach at least 67% coverage, due to budget constraint.

Current condition Recommendations

It will take some time for COVAX to distribute globally to achieve 20% coverage of population. Relying only on COVAX allocation will significantly slow down the COVID-19 handling.

A survey from ITAGI, WHO, and UNICEF shows that from 65% respondents who are willing to be vaccinated, 35% are willing to pay, 27% are not sure, and 38% are not willing to pay for vaccine.

31% of the respondents who are willing to be vaccinated and pay, are willing to pay up to 50,000 Rupiah< 28% up to 100,000 Rupiah, and 4% up to 500,000 Rupiah.

Seeing the survey result and people’s reluctance to pay for vaccine, it will stall the COVID-19 vaccination program and efforts to eradicate the pandemic and to recover the national economy.

The central government should show their commitment by making vaccination as the prioritized program apart from 3T. Hoping all the regional governments to have the same capability and commitment to support their own community, including co-financing, will be difficult.

If the independent scheme option is carried out, the Government should impose pricing limit. The price per dose would vary around 450,000-500,000 Rupiah, depending on the type of vaccine.

In this situation the government has some limitations to carry out 3T massively. Added with the resistance and limited access of vaccine, the periodical social distancing measure (intermittent suppression) is still an important option, to prevent further outbreak and buy time for the health services.

Some regional governments are still implementing PSBB, especially in Jakarta, Bodebek, and Tangerang Raya. Jakarta Provincial Government have never retracted PSBB completely, only relaxing in certain periods with a transitional PSBB. Transitional PSBB proved to be unable to lower the cases in Jakarta, as it keeps on increasing. The PSBB enforcement and health protocol are highly criticized by the public and deemed to be ineffective.

A comprehensive policy improvement and implementation that supports the enforcement of PSBB and the public’s compliance for health protocol, accompanied with a strong 3T effort, and distribution of social assistance and stimulus for the people affected. Read the complete recommendation here: http://bit.ly/CISDIPembatasanSosialCovid19 and http://bit.ly/CISDIKapasitasTesCovid19.

Scenario 2: Building Castles in the Air.

In the second scenario, we assumed that the vaccine is available but the country has limited resources to purchase and make sure for an equitable distribution, as in the current eco-nomic crisis, situation is not getting any better, plus may other technical problems. On the other hand, the pressure to quickly open the economy is also a reason that social distancing is not favored by the President.



Problem

In the current economic recession, the government can only facilitate a very limited social assistance, so they are avoiding implementing stricter social distancing measures.


In Article Number 6 Year 2018 about Health Quarantine, it is compulsory for the government to provide all resources needed. In that context, including social assistance.

In the current condition, the government seems to avoid the social distancing option, because on top of making the economy suffer, the government is also mandated to give out social assistance, while the government budget is starting to run out because of the prolonged pandemic.

The disorganization in social assistance has happened since the beginning of pandemic. The issues revolve around the targeting database, mistargeting, and corruption by the Minister of Social Affairs.

Until the beginning of December 2020, from the total budget 203 T for all social recoveries including various social assistance schemes, the uptake on the budget was 57%. The distribution of social assistance will end in 2020.

During an economic recession, with or without social distancing, distributing social assistance to those in low and vulnerable socioeconomic status is important.

The improvement and update of Integrated Social Welfare Data (Data Terpadu Kesejahteraan Sosial) should also be the priority in 2020 and Q1 2021.

To help those affected by COVID-19, being the most vulnerable, it will be better targeted if the aid is converted to cash transfers, so the recipient has more freedom in deciding how to spend the money based on their own needs.

According to microeconomic theory, being given more amount of choices will give someone a higher sense of satisfaction compared to in-kind assistances such as sembako. Secondly, cash money can be spent in next-door shops or in traditional markets, so the flow of money for those in small, micro, and ultra-micro businesses can still be significant. Thirdly, the centralized distribution of sembako will require a lot of added costs such as costs for transportation, packaging, staff involved, and various administrative and reporting fees. This would leave the beneficiaries getting less than what they are set out to, not as much as the allocated budget.



Scenario 3: Bad Dream.

Vaccines are not available. The government tries to eradicate SARS-CoV-2 as soon as possible. This action needs an aggressive test and track, which requires extensive resources in the middle of economic recession. This situation is exactly what is happening in Indonesia at the time of writing of this report. Read our full report about non-pharmaceutical public health interventions against COVID-19 in: http://bit.ly/CISDIPembatasanSosialCovid19 and http://bit.ly/CISDIKapasitasTesCovid19.

Scenario 4: Would It Return?

Vaccines are not available, but the Government has a fiscal space to guarantee the availability of antiviral therapy to treat COVID-19 and turn it into a milder disease, so the whole population is safe and gradually can develop natural herd immunity. While on waiting period, the Government has the authority to expand social assistance.

This scenario is not an empty dream. If it takes 2-360 years to eradicate the pandemic only with vaccines, the waiting period to reach herd immunity will be super prolonged.

Problem

The availability of medicines


Indonesia has been part of the Solidarity Trial—trial program by WHO to conduct clinical trials towards four alternative therapies: (1) remdesivir; (2) chloroquine or hydroxychloroquine; (3) lopinavir + ritonavir; and (4) lopinavir + ritonavir + interferon (ß1b).

All of the mentioned medications are in the National Formulary valid per April 1st 2020 (the Ministry of Health Decision No. HK.01.07/MENKES/813/2019), except remdesivir that has to imported directly from 5 medical suppliers appointed by Gilead Sciences.

Chloroquine is locally produced in Indonesia by PT Kimia Farma (Persero) Tbk, while the raw material hydroxychloroquine is produced by PT Dexa Medica is still imported

Chloroquine or hydroxychloroquine was then excluded from the Solidarity Trial. The same with the combination of lopinavir and ritonavir, because the trial result showed that hydroxychloroquine and the combination of lopinavir ritonavir resulted to very small or nearly no decrease in COVID-19 death rate, compared to treatment standard.

Remdesivir is the only medication approved by Food and Drug Administration (FDA) for COVID-19 treatment.

PT Kalbe Farma Tbk and PT Amarox Pharma Global has reduced the price of remdesivir with trademark Covifor from 3 million Rupiah per vial to 1.5 million Rupiah per vial. The state-owned issuer, PT Indofarma Tbk, distributed antiviral drug for Covid-19 patients, Remdesivir, with brand name Desrem which costs 1.3 million Rupiah per vial (small bottle) to hospitals. Stock available per October 2020 is only 400,000 vial.

With its limited access and high price, it will put challenge to the accessibility of safe, efficacious, quality, and affordable medicines. Unless this medication is included in the national formulary and borne by BPJS.

Integrating COVID-19 service to the JKN system takes public commitment, PNPK settlement, Clinical Practice Guide, and a new calculation on the new tariff.



60 Anderson, R. M., Vegvari, C., Truscott, J., & Collyer, B. S. (2020). Challenges in creating herd immunity to SARS-CoV-2 infection by mass vaccination. The Lancet, 396(10263), 1614–1616. https://doi.org/10.1016/s0140-6736(20)32318-7

Problem Current condition Recommendations

In this situation the government has a lot of freedom to do the 3T measure properly.

Some regional governments are still implementing PSBB, especially in Jakarta, Bodebek, and Tangerang Raya. Jakarta Provincial Government have never retracted PSBB completely, only relaxing in certain periods with a transitional PSBB. Transitional PSBB proved to be unable to lower the cases in Jakarta, as it keeps on increasing. The PSBB enforcement and health protocol are highly criticized by the public and deemed to be ineffective.

A comprehensive policy improvement and implementation that supports the enforcement of PSBB and the public’s compliance for health protocol, accompanied with a strong 3T effort, and distribution of social assistance and stimulus for the people affected. Read the full recommendation here: http://bit.ly/CISDIPembatasanSosialCovid19 and http://bit.ly/CISDIKapasitasTesCovid19.

Social assistance

The government can facilitate more social assistance to make people stay at home.

The government should design the social assistance policy that favors a more even societal distribution, for example by giving priorities to the digital infrastructure and literacy to fight digital inequality; investment in education and vocation to increase skills and retrain skills; improving health access especially ones that are related to vaccines (as an anticipatory step) and expanding the social protection system.

diseases are also reported to be disturbed in 69% of countries, where NCDs in the past 10 years have turned into the highest death cause globally and also in Indonesia62. UNICEF reported 84% health facilities in Indonesia experience disruption in giving immunization service63. A survey by CISDI also found 62% of puskesmas reported disruption in activities outside of their buildings related to NCDs64.

The decline in essential service is caused by the falling demand side and supply side. A decline in demand side is caused by the collective fear or the fear of getting infected. While the decrease in supply side is caused by the drop in the capacity of health facilities in giving services because so many health workers are infected. Apart from that, there is a disturbance in medicine distribution and availability and medical supply65. In Indonesia, 92% of puskesmas reported a decline in patient visit during the



Although the fundamental of health perspective on these four scenarios are different, all the options require political commitment, maturity in institutions technicalities, a solid governance with integrity, and a qualified human resources capacity.

All the scenarios expect a reformation in primary healthcare as an anchor in handling COVID-19. A strong primary healthcare will be able to give people their right to be healthy, through preventive, promotion, treatment measures and also rehabilitation. In times of pandemic, those functions are disrupted. Our primary healthcare, be it state-owned or private-owned fail to distribute resources. WHO recorded globally 90% of countries are failing in delivering essential healthcare61. Disease prevention program through immunization becomes the most affected service, where 70% of the country report a decline in service. Healthcare for non-communicable

61

62

63

64

65

In WHO global pulse survey, 90% of countries report disruptions to essential health services since COVID-19 pandemicNoncommunicable diseases (who.int)Rapid Assessment: Immunization Services in Indonesia | UNICEF IndonesiaPolicy Brief (3 November 2020) copy (cisdi.org)In WHO global pulse survey, 90% of countries report disruptions to essential health services since COVID-19 pandemic

pandemic66. CISDI did a survey on the adequateness of PEE in the early period of pandemic on 714 health facilities. Throughout the survey period, March 28th to April 2nd 2020, it was founded that only 9.5% health facilities that have enough face masks, and at that time even only 2.1% of health facilities that had Hazmat suit as PPE67. The essential service that is not served has a long-term impact on the global public health profile. The World Bank stated that the disruption in health service in the current pandemic will bring a future health crisis with an equally severe impact compared to COVID-1968.

A Lancet study estimated for every 15% of the drop in essential case in the last 6 months will result to the 253,500 child deaths and 12,190 of maternal deaths. In other scenario, the 45% drop in 6 months will cause 1.1 million child deaths and 45,000 of maternal deaths69.

The handling of COVID-19 requires a solution that starts from the health system approach, not case-based approach. Case-based approach will only result to a waste in resources, an uncoordinated action, and unfinished problems. A health system approach will activate all the functions from all elements in that system to respond to COVID-19 effectively. Primary healthcare is an enabler and a basic foundation of an effective response that every country has to do. The government provides primary healthcare for the public through puskesmas. As one system, puskesmas has a network of service to 10,134 other puskesmas that are spread across Indonesian and connected with the referral hospitals and an adequate health ecosystem. The number of health workers in puskesmas are recorded 784,35870. The

66

67

68

69

70

Apeksi: Stok APD Langka Buat Pemda Terpaksa Beli dari Perantara - Nasional Katadata.co.idCISDI: Survey of FKTP readiness in handling COVID-19 March 29th-April 2nd 2020 in 714 health facilities in Indonesia. Unpublished.Killer # 2: Disrupted health services during COVID-19 (worldbank.org)Early Estimates of the Indirect Effects of the Coronavirus Pandemic on Maternal and Child Mortality in Low- and Middle-Income Countries by Timothy Roberton, Emily D. Carter, Victoria B. Chou, Angela Stegmuller, Bianca D. Jackson, Yvonne Tam, Talata Sawadogo-Lewis, Neff Walker:: SSRNAnalysis on the distribution of health workers in Indonesia based on the regulation of Ministry of Health No. 75/2014 about puskesmas.

involvement and the strengthening of puskesmas during COVID-19 response will be able to increase the country’s ability to do early detection through an effective surveillance. The same thing with the testing, contact tracing, isolation and early treatment in community level and will be more effective to do in puskesmas. In the behavior change campaign such as the adoption of 3M, puskesmas has a community-based health effort platform (UKBM), which can mobilize people such as political figures, key opinion leaders, and key groups to fight the pandemic together.

COVID-10 pandemic strengthens the need for a reliable primary healthcare. As a matter of act, Indonesian puskesmas was once an example to the world for implementing the concept of primary care housing integration and avenues for integration. Primary healthcare in Indonesia since the 1970s have adopted an integrated service model called puskesmas, where the individual effort for health (UKP) and the community effort for health (UKM) are integrated into one entity (Bappenas, 2016). Through UKM, puskesmas can do risk communication and educate people to take up 3M behavior, including to do early detection via surveillance using puskesmas’ network. With UKP, puskesmas can do the diagnostic process in the beginning for COVID-19 suspects to do isolation and self-quarantine. For those with medium and heavy symptoms, puskesmas can do referrals so that the patient can get the proper treatment as soon as possible. Both of these efforts can decrease the burden in the hospitals by preventing as many people as possible to be infected in the community level and to cut death rates by handling cases early for those who are confirmed positive.



8

environmental health posts. Therefore, more attention should be paid for the staff composition in puskesmas who have the main competency in promotion and preventive health. On top of that, the priority in program and funding should reflect on the direction of strengthening public health, such as surveillance, health promotion, and others.

Puskesmas should be the supervisor of the area and collaborate with independent clinics and practices to serve healthcare in a mutually supportive ecosystem. The complexity of health problems that is faced now, such as the rise in disease burden, the more personal need of healthcare, also the limitation of the government to provide facilities and human resources, show that a there is an urgently need in partnership with non-governmental bodies (WHO, 2016)72. A report from National Bureau Statistics (BPS) stated that 55.5% of population access outpatient service from a private health facilities and practices; only 33.7% visited puskesmas; and the rest go to the hospitals and traditional remedy (BPS, 2019)73. Within the function of puskesmas as the regional coordinator to healthcare, especially UKP with the independent clinic and practice, it is not yet optimally utilized. This is evident by the unsynchronized data between health facilities in one working area of puskesmas. This results to many unmeasured outcomes and undetected problems. In the context of outcome, from the 2018 Basic Health Research (Riskesdas) it is stated that only around 12% of mothers gave birth in puskesmas and 35% give birth in clinics of individual practices. The coordination between health facilities becomes very important because during COVID-19 pandemic, as shown in BPS data, more than 50% of people are using the outpatient service at private health facilities. Coordination with puskesmas the surveillance of

To support those roles, the transformation of national health system is a inevitable to strengthen the strategic role of puskesmas in facing COVID-19 pandemic and any pandemic threat in the future. Currently the primary healthcare in Indonesia has many strategic and structural challenges, among them: (1) the prioritization of UKP instead of UKM; (2) the power of puskesmas as area supervisor is not optimal; (3) the minimal involvement of private and independent clinics. To reach a quality healthcare for all, the reformation of primary healthcare should cover principles of accessibility, coordination, comprehensiveness, and continuity (Espinosa-González, 2019)71. Service transformation should touch upon: (1) support in regulation and policy direction from the central players about the strategic role of puskesmas in national health system; (2) policymaking and siding with regional government who invest health development through puskesmas, including providing a quality human resources and complete facilitation in effort to achieve SPM in health field; (3) an environment that supports multisectoral collaboration or pentahelix In supporting puskesmas’ role; (4) health policy that is connected with culture and social policies, economic and trade, and others. Those factors will strengthen a healthy paradigm and also be a vital component in a solid health system.

To realize a strong health system to face pandemic, there needs to be a strong health effort from the community. Unfortunately, the current design of puskesmas tends to accommodate individual health service or curative measures instead of public health. The staffing architect in puskesmas is filled with health workers whose main competency is to give curative service, so there are many health workers such as nurses and midwives who fill in the health promotion, health surveillance, and



71

72

73

Challenges in the implementation of primary health care reforms: a qualitative analysis of stakeholders’ views in Turkey (nih.gov)WHO. 2018. Technical Series on Primary Health Care: The Private Sector, Universal Health Coverage and Primary Health Care. WHO. Geneva.download.html (bps.go.id) Susenas 2019.

influenza-like illness (ILI) and Severe Acute Respiratory Infection (SARI) becomes important to detect people with COVID-19 suspect. If the puskesmas fails in coordinating, many data will not be recorded while puskesmas is the only facility whose outputs are related directly with key program indicators such as SPM, PIS-PK and SDGs (Bappenas, 2016).



Closing

"Pandemic is not a word to use lightly or carelessly.

It is a word that, if misused, can cause

unreasonable fear, or unjustified acceptance

that the fight is over, leading to unnecessary

suffering and death." Tedros Adhanom Gebreyesus



Drastic times call for drastic measures.

Throughout the 100 years of human

history, there has never been an event

with the magnitude as big as COVID-19. In

the span of one year, COVID-19 has

infected 60 million people and more than

1.5 million of them dead. The world seems

to try to hold on, trying to escape from a

dark and long tunnel as a winner. Some

countries succeed, and many others are

still trapped in the vicious cycle of

pandemic. It is like a plane about to crash

down, and currently it feels like a stall

period—the period where the plane is hard

to control and the pilot is trying their

hardest to fight against gravity that pulls it down. At the 10th month of the

pandemic, many lockdowns and social

distancing are in tow, which we have to

admit brings a lot of real consequences in

many sectors outside of health. We also

have to remember that the real root cause

is the emergency in health system that is

caused by an infectious disease.

The efforts in eradicating pandemic have

not been paid off. The number of cases

keep increasing and social distancing

does not seem to yield a significant impact. The economic and political

demands make the social distancing

relaxation happen too early and now it is

hard to revert this dynamic. As the

consequence, the economy will not

recover as expected. And from the

political point of view, although Pilkada

was carried out, there were many

casualties created in exchange of it.

Meanwhile, the pandemic is still spreading

uncontrollably.

There is no other way to save people’s live

and fundamentals of health development;

the government has to return to the

fundamental of pandemic handling: test,

trace, isolate—although when the time

comes, a safe and high-efficacy vaccine are available. The government’s

consistency in doing this, including data

transparency, should increase public

compliance in undergoing health

protocols.

“Damage” and the excess problems that

have happened to more than two-thirds of

2020 have to be solved. Several problems

that will become more complex with the

pandemic:

1.

2.

3.

4.

5.

Social-cultural and economic

implications: violence to women and

children, domestic violence, the rising

poverty rate to 3 years ago, increase in

unemployment, and stigma about

COVID-19 on patients or health

workers.

Political and citizenship implications:

increasing distrust in government

information and policy in general,

especially on pandemic handling.

Economic implication—especially in

livelihood and well-being: the

dichotomy in health and economic

proves to be untrue. Economic welfare

cannot be reached without a good

health profile. A never-ending pandemic causes the economy to be

weak and in questionable position.

Policy implication: the shock resulted

from the pandemic is huge that it

needs a shift in policy priorities of at

least 1-3 years ahead. The pandemic,

becoming a strategic and main

variable in policymaking in all

development sectors, not only in

health.

Implication on values: pandemic and

its impact made us question

fundamental things such as which

side are we siding with in developing

the country, to existentialism and

humanitarian values.

A few factors that can be a catalyst in

recovering the reality, to name a few:

1. Being active as a country that believes

in multilateralism advocate and act as

one: the changing geopolitical

condition that has changed

significantly because of pandemic. It very clear that the countries that are

To escape from this situation safely

signals the bravery to maneuver with

unusual steps—even drastic. Only with a

leadership that stands above all interests,

solidarity towards all parties be it

development actors or the community; we

will survive and regain the essence of our

lives.



2.

3.

4.

5.

On top of the technical issues and the

unending homework, many efforts in pan-

demic control shows that the best quali-

ties as humans: innovation, a heroic act

for the health workers in the frontline, and

the ordinary people showing care and

effort in keeping their families, neighbors,

and community together.

fast to response, soon take a strategic

position in global or regional

multilateralism, at the same time

activating the surveillance and

national readiness; proven successful

to control the pandemic. Even, it can

shift to be strong countries after the

pandemic is over because of its

success in protecting the human

capital integrity.

Building new young generation in

global health as a long-term

investment in human capital in order

for Indonesia to become an active

player in global health field.

A certain direction about objectives,

priority of national development

policies that are built with

partnerships with all development

actors and through using

methods/approach that is based on

evidence.

Strengthening of primary healthcare

as the foundation of public health

development with important key in

service integration and community

involvement as the driver of health in

the area, which will further strengthen

how communities face threats and

health challenges.

Collecting public and community

strength. Especially in health

reformation, the participation and

ownership from the people will

increase the strength of primary

healthcare.

cisdi health outlook 2021

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