Reforming the Health Architecture

The Kompas.id news report titled "Achievements of Immunization are Still Low, Disparities Occur in the Regions" (Jul. 23) is interesting to assess. This highlights that the first phase of the National Child Immunization Month (BIAN) program will fail to reach the 95 percent target.

The reason why immunization coverage is at 46 percent is because of the school holidays. At first glance, this reason makes sense considering that the first phase of the BIAN program was held almost simultaneously with the school holidays.

However, it seems that school holidays are not an appropriate reason for this case. The government should have been aware of changes in the situation or potential constraints such as school holidays, and a solution should have been offered.

What really happened to the immunization coverage in Indonesia?

Faux disparities

The phenomenon of disparity or inequality between regions on child immunization coverage is not a new topic. Since 1977, Indonesia has adopted the Expanded Program on Immunization by the World Health Organization.

Unfortunately, while it has been a routine program for almost 45 years, there are still many children who have not received complete immunizations. In 2013, only about 59 percent of children were fully immunized. In 2018 only 58 percent of children aged 12-23 months received complete immunizations. In fact, in 2017 Indonesia was listed as the fourth-largest country in the world with unvaccinated children, according to a UNICEF report.

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The situation worsened during the pandemic. Around 800,000 Indonesian children did not receive routine immunizations, and it is estimated that immunization coverage has dropped by 20 percent. This means that the immunization coverage only reached 43 percent (Fonjungo et al, 2020). If this is not addressed, it is likely that outbreaks will continue to threaten the safety of the nation's future generations.

According to the author, the disparity in immunization coverage is a faux disparity.

Currently around 36 percent of children’s deaths in Indonesia are caused by infectious diseases that could have been prevented by immunization. According to the author, the disparity in immunization coverage is a faux disparity.

Long before the news on the coverage of BIAN emerged, the health disparities, especially between disadvantaged areas, border areas and islands (DTPK) and the Java region, had long been identified. Poor access, inadequate quality of health care and its facilities and the unequal distribution of healthcare workers are common in the DTPK. In addition to the disruption in the target of the health program, these factors also contribute to the occurrence of preventable deaths.

Recent data reveal that the child mortality rate in Java and Sumatra is less than 10 per 1,000 births. However, in Maluku this figure is 2.5 times higher (Wiseman et al, 2018). This is a slap in the face for optimistic viewers about the National Health Insurance (JKN) as a solution to eliminate health disparities. Then what is the root cause of the health disparity?

Root of the problem

The health disparity is the result of an imbalance in the health status of the community. This situation is the aftermath of inequity in access and inequality in the services and health care received by the community.

The differences lie in the life expectancy, mortality and morbidity rates, as well as health programs, such as the coverage of child immunization. The WHO has declared immunization coverage and anti-vaccine sentiment as two of the 10 global health threats, the author believes this is an omen. Reflecting on the implementation of the first phase of the BIAN, it seems that the central government has not prepared the healthcare system in the regions, especially in the DTPK and the community. Why is this?

However, in practice the immunization program is quite risky because the role of parents, especially mothers, is very large in deciding to postpone or refuse immunization of their children.

First, there is information asymmetry. In accordance with the principles of the health program management, immunization coverage will be on target if there is a match between the offer of immunization benefits and the needs of the target. However, in practice the immunization program is quite risky because the role of parents, especially mothers, is very large in deciding to postpone or refuse immunization of their children.

Rumors about vaccine safety, parental education and the influence of the social environment are actually triggers to information asymmetry. Even the polarization about vaccines has proven to have far-reaching implications. For example, Indonesia fell victim to anti-vaccine sentiment from Nigeria around 2003-2004, which as a result caused repeated cases of polio. The asymmetry that continues creates distrust and even leads to the boycott of several types of vaccines in Indonesia.

Second, there are barriers to social structure. This situation is often found in the DTPK area. For example, several regencies in the Indonesia-Timor Leste border admit that several national priority health programs have not been realized due to the high rate of pregnancies outside of religious marriages. As a result, it is difficult for the government to target all children born outside of religious marriages. In fact, almost all of those cases have not been registered as recipients of government programs.

Third, there is disparity in the quality of the regional health systems. Since the decentralization of the health system in Indonesia has taken effect, regional readiness and capacity has been lagging. The BIAN's poor performance in the first phase indirectly reflects the performance of the regional health systems. This can be seen from the unpreparedness of the health facilities and human resources.

This situation is exacerbated by the scarcity of trained health personnel and equipment for health facilities.

As revealed by Oktarina et al in 2020, people are reluctant to immunize because health workers cannot answer all the questions about immunization, and the waiting time is uncertain. This situation is exacerbated by the scarcity of trained health personnel and equipment for health facilities.

Fourth, there are operational problems. As an archipelagic country, ensuring equal access to immunization across remote areas is still a challenge. This is due to the high cost of transporting vaccines and other medical supplies to the DTPK. On the other hand, the infrastructure for the vaccine supply chain has not yet fully reached remote areas.

Improving performance

As a pioneer of global health architecture in the Group of 20, we should be ashamed of the coverage of the first phase of the BIAN. This is an indication that the domestic health architecture must be addressed first. The foundation of our health system must be strengthened by managing the performance of routine immunization programs.

In order not to repeat the same failure in the second phase of the BIAN, we should not solely rely on the coverage target. Coverage is important, but the readiness and quality of the program delivery system is much more important.

The two main targets for improvement are community acceptance and immunization coverage. Acceptance is increased through strengthening literacy on immunization and creating trust in health workers. Here, a mix of relevant skills is needed. For example, the community health center (Puskesmas) doctors, health promoters, village health workers, traditional leaders, community leaders and religious leaders, need to invite the community to participate in immunization.

The vaccine coverage can be increased by improving the delivery system. For example, by implementing a special strategy to reach targets that are difficult to reach. In addition, it is necessary to monitor and evaluate immunization coverage in the regions. Furthermore, it is important to identify high-risk areas and make improvements in the program.

This all requires commitment and collective work. Each region in Indonesia has particular characteristics and uniqueness so the improvement of immunization performance must be region sensitive. The local administration is of course the division which knows the ins and outs of the health of the region best. By continuing to coordinate with the central government to fix the immunization program, it is hoped that the health disparities among regions can be overcome soon.

PEREGRINUS H SEBONG

Perigrinus H Sebong

Perigrinus H Sebong,Health Activist at DTPK, Lecturer of Faculty of Medicine at Unika Soegijapranata

(This article was translated by Kurniawan Siswo)