Background
Since the year 2001, Indonesian government had proposed a decentralization health system, but it wasn’t carried out until 2003. This is due to the completion of the strategic steps, for the new decentralization health system, made by the Ministry of Health. The main objective for the decentralization health system is to accomplish the national health development based on the initiative and aspiration from the people in order to achieve “Healthy Indonesia 2010”. Following the new system, Decentralization Units have been formed since July 2001 in every province in Indonesia. This new health system led to the overall changes in the health system.
The structural organization of the national health system is no longer focused in the central government, whereas it is now focused in each province. Nowadays, the central government is a health system supervisor rather than a provider. The Immunization program is held by Puskesmas and Posyandu.
Immunization Program in Indonesia is a program that government proposed to reduce the high number of infant mortality rate. This program was started in 1977, and in 1980s the government started the Indonesia’s Expanded Program on Immunization with its main objective was to protect the minimum of 80% of all children with basic EPI vaccines. The immunization program is managed in the very low level structure of health system, the Posyandu, in all the villages in Indonesia to facilitate the immunization for all the children in isolated areas. Government even set up the “Pekan Imunisasi Nasional (PIN)” every year in order to improve this program. Besides promoting the program, the government also appointed a state owned enterprise, PT. Biofarma, to provide the vaccines.
Functions of the program
Immunization program in Indonesia has a major function which is to assure that all Indonesian children are fully immunized against diphtheria, tetanus, hepatitis B, whooping cough, poliomyelitis, measles, and tuberculosis and tetanus toxoid.
Regulations
1. Government Act on Health No. 23/1992, stated that “Health System should be implemented by the community with government as facilitator”
2. Government Act on Local Government No. 22/1999, regulate the regional governance in Indonesia
3. Government Act on Financial Balance Between Central Government and Local Governments No. 25/1999, constitute about financial equity between central and regional governments
4. Government Act No. 20/2001, comprise the function of guidance and supervision of government implementation applied to local government
5. Ministry of Health Decree No. 468/MENKES-KESOS/SK/V/2001, which has been amended by decree No. 511/MENKES/SK/V/2002, about National Health Information System (NHIS)
Policy initiatives and reforms
“Healthy Indonesia 2010”, is a vision of National Health Department that was first introduced in September 1998 that focuses health development specifically in health promotion and prevention rather than curative and rehabilitative services. Ministry of Health and Social Welfare put their efforts together to achieve this goal.
Decentralization Policy in 2000 regulates about the authority of Central government and Provincial governments. This policy gives more authority to the local government in ruling their own territory.
Decentralization Health System policy is standardizes the performance of health delivery service in every region in Indonesia to accomplish the “Healthy Indonesia 2010”.
National Health Information System Policy is a policy to support the achievement of Indonesia Healthy 2010 by promoting accurate, updated and networking information about health.
Outputs
A. Immunization Coverage
Immunization coverage in Indonesia shows how many districts in Indonesia are covered by this immunization program. World Health Organization has made an estimation of the coverage in Indonesia since 1980 until 2006. There are seven types of vaccination that are delivered by this program, including BCG, DTP1, DTP2, HepB3, MCV, PAB, and Pol3.
In general, there are 440 districts in Indonesia and at least 70% of the total districts in Indonesia are promoting this immunization program. For more details about each immunization, the data are listed below.
1. BCG (Bacille Calmette Guerin) Vaccine
Based on the data given by the World Health Organization, we can see that overall there is an increase in number of national coverage for BCG vaccine from 1980 until 206. But, the number of national coverage in 2006 (82% coverage) is less than the one in 1996 (87%).
2. DTP1 (Diphtheria Toxoid Tetanus and Pertusis) Vaccine, first dose
For DTP1 vaccine, there is also a boost in coverage from 1980 until 2006. Nevertheless, from year 2001 the number of immunization coverage is decreasing.
In 2001, 91% of the total districts run this program, but the number of coverage is turn out to be 88% in 2006.
3. DTP3 (Diphtheria Toxoid Tetanus and Pertusis) Vaccine, third dose
For DTP3 vaccine, there is also a boost in coverage from 1980 until 2006. Nevertheless, from year 2001 the number of immunization coverage is decreasing. In 2006, this program only covers 70% of the whole area in Indonesia, whereas in 2001 there are 76 % of areas are covered.
4. HepB3 (Hepatitis B) Vaccine, third dose
The immunization coverage for Hepatitis B vaccine is dramatically increasing since 1992. In 2006, 70% of total districts in Indonesia are covered by this immunization program.
5. MCV (Measles Containing Vaccine)
Based on the data, generally there is an increase in number of national coverage for MCV delivery from 1980 until 206. But, the number of national coverage in 2006 (72% coverage) is less than the one in 1996 (79%).
6. PAB (second and subsequent doses of tetanus toxoid)
Based on the data, generally there is an increase in number of national coverage for MCV delivery from 1980 until 2006. But, the number of national coverage in 2006 (72% coverage) is less than the one in 1996 (79%).
7. Pol3 (Polio Vaccine), third dose
Based on the data, generally there is an increase in number of national coverage for Polio vaccine (third dose) delivery from 1980 until 2006. But, the number of national coverage in 2006 (70% coverage) is less than the one in 1996 (83%).
B. Number of Toxoid Tetanus (TT) Coverage for Pregnant Women
Instead of increasing, the number of TT coverage for pregnant women in Indonesia was decreasing since the year 2000. The top three provinces with the largest coverage number are Bangka Belitung (90%), West Nusa Tenggara (84.2%), and DKI Jakarta (79.1%). Whereas the three lowest are East Java (6.6%), Banten (11.3%), and Papua (17.9%).
Target and Standard Sets
Indonesian government has made the target according to the UCI (Universal Child Immunization), which is the number of immunization coverage must at least 80%. Indonesian government had targeted to immunize at least 80% of children under the age of one for diphtheria, tetanus, and pertussis; and 90% for measles.
There are 6 out of 33 provinces in Indonesia which had met the target, including Bali (100%), DI Yogyakarta (99.09%), Lampung (90%), Central Java (89%), Jambi (88.95%), West Nusa Tenggara (87.53%), and Southeast Sulawesi (86.87%).
According to the World Health Organization, total number of districts in Indonesia with more than 80% of DTP3 coverage in 2006 is 69%, number of districts with 80% of MCV coverage in 2006 is 87%, and number of districts with at least 80% of TT2 coverage for pregnant women is 25.
Outcomes
A. Number of Disease Eradication
1. Number of Polio Eradication
Since 1995, there is no report on polio cases in Indonesia, but in 2005 polio has re-emerged as 345 cases were reported. This number is decline significantly into two cases in 2006. This result is due to the success of the PIN program in late 2005. The percentage of non polio AFP rate is increasing since 2001, this shows that the possibility of wild virus could potentially occur in Indonesia has decrease along the time. But, this result is the national data; there is still a possibility of poorly immunized districts that are covered by other districts.
2. Measles Mortality Reduction
Government through Puskesmas and Posyandu had carried out measles second opportunity immunization to increase the effectiveness of the vaccine. This second opportunity immunization was given in order to decrease the measles mortality rate. From the table, measles second opportunity immunization carried out since 2002.
B. Infant mortality rate
Since 1995, infant mortality rate (per 1,000 birth) has been decreasing form 55in 1995 to 35 in 2002. This decreasing rate shows that immunization program in Indonesia has succeeded in decreasing the infant mortality rate.
C. Under-five mortality rate
Under-five mortality rate per 1,000 populations can be another indicator of the outcomes from this immunization program. The lowest the number, the most succeeded this program. Based on the data given from the Intercensal Population Survey /SUPAS 1995 Estimation, the under-five mortality rate is decreasing from 1998 to 2002.
Key Performance Indicators
A. Effectiveness
To see the effectiveness of Immunization Program in Indonesia, we can look from the number of disease eradication, infant mortality rate and under-five mortality rate in Indonesia. How well this program is in improving children health in Indonesia? Based on the data above, we can see that there is a decrease in number of polio eradication and measles reduction in 2006. The infant mortality rate is also decreasing in 2002. The under-five mortality rate only slightly decreases from 1998 to 2002. We can say that the immunization program in Indonesia is quite effective in fighting the diseases that can be prevent with vaccines.
B. Efficiency
Efficiency of this program can be seen by the program itself. Are there any Standard Operating Procedures for this program? Does the National Immunization Week (Pekan Imunisasi Nasional) perform well?
Standard Operational Procedure of this Immunization program is based on the availability of the Multi-Year Plan (MYP) for immunization. Based on the survey, since 2001, Indonesia had covered the MYP from 2002 until 2006, and this MYP included the budget and annual work plan for immunization services.
The report from the Ministry of Health Indonesia shows that PIN had succeeded in every district in Indonesia. This means that this Immunization Program is efficient enough.
C. Equity
Based on the WHO Statistical Information System, from 440 districts in Indonesia, there are 69 percent of the district which had met the immunization standard for DTP vaccine, 53 percent met the standard for measles, and only 25 percents met the immunization standard for Tetanus toxoid for pregnant women.
This result explains that the Immunization Program has not reached all of the districts. Immunization Program in Indonesia has not fulfilled the equity criteria since only several districts that had achieve the standard immunization.
D. Quality
The existence of surveillance in this program can be a parameter for Quality of this Immunization Program. Based on the WHO Statistical Information System, there is no surveillance conducted for measles and laboratories confirmation measuring impact of vaccination against invasive bacterial diseases during the immunization program, although in the project plan, surveillance is included the whole program.
Safety can also be one of the parameter for quality of this program. Government has set the work plan for immunization injection safety including the activity work plan for waste management, and monitoring adverse effects after immunization. Nevertheless, there is no real action in dealing with these adverse effects. Government only takes the reports.
We can assume that the quality of this Immunization Program needs to be improved.
E. Sustainability
Since 2004, all the districts in Indonesia have been supplied by vaccines for immunization. This means that the government can maintain the sustainability for the vaccines since 2004. But, there is one thing that is very important.
Feedback
A. Effectiveness
To ensure the effectiveness of this program, central government must always cooperate with the local government in order to provide the best health services in Indonesia. The planning and management for Immunization program in Indonesia need to be improved in order to achieve the effectiveness of this program. The MYP should also include the surveillance from the production of vaccines until the vaccines delivery.
B. Efficiency
In order to improve the efficiency of this Immunization Program, Ministry of Health must provide clear guidelines for the local health districts.
C. Equity
The immunization program needs to be enhanced especially in remote areas if the government wants to achieve their target (which is 80% of Indonesian children under one year old get their DTP vaccines and 90% for measles). This is crucial if the government want to achieve their goals based on equity in immunization access.
D. Quality
Immunization surveillance has to be enhanced by providing the surveillance for measles national case and also for the laboratory confirmation of impacts against invasive bacterial disease. This is important in order to find out how much the immunization has succeeded in reducing the diseases caused by bacteria. Surveillance is important to maintain the quality of the immunization given.
Instead just providing the work plan for safety management in immunization program, government should provide the actions need to be taken if there are an adverse effect cases after the immunization, because it will increase the people’s trust for the safety of these immunizations.
E. Sustainability
Although all the districts have received the vaccine’s supplies, but government should pay great attention whether these vaccines are still in good conditions. Government should also ensure the sustainability of this vaccine’s supplies in the future.
How to Improve Immunization in Indonesia
A. Provide more Puskesmas and Posyandu
Based on the data, not every districts covered by this program, this is mean that the immunization program did not reach the equity criteria. In the future government has to provide more Puskesmas and Posyandu especially in remote areas. To make sure the effectiveness of the new Puskesmas and Posyandu, government are supposed to ensure that all the infrastructures are functioning according to the objective, because there are many Puskesmas and Posyandu are not perform well in health care services. This can be done by providing training to the nurses in these health centers.
B. Surveillance enhancement
Surveillance program must be improved to assure the quality and the successful of this immunization program. There surveillance should start from the earliest step which is the production of vaccines in PT. Biofarma (the implementation of Good Manufacturing Practices). Afterward government should conduct the surveillance for vaccines delivery process to the target areas, this is to make sure that all the vaccines are still in good quality and also effective. The last surveillance need to be conduct during the immunization process to monitor the adverse effects that might happen.
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