Covid-19 has put enormous pressure on health systems around the world, including in Indonesia. More than six months into the pandemic, cases continue to climb, suggesting the peak is yet to come.
According to official figures, there were more than 350,000 positive cases and more than 10,000 deaths from Covid-19 from March to the end of October. With numbers still rising, there is an urgent need to assess preparedness for the coming months.
Preparedness for a health disaster on this scale depends on several factors, including timely management by government, accurate and accessible data and information, and the ‘surge capacity’ of health facilities and workers. Indonesia’s health system has performed better in some of these areas than others.
Turning first to management, Indonesia has, unfortunately, experienced a governance crisis in handling Covid-19. The government’s initially unscientific response – including at least 37 blunders by government officials in the first four months of the year – along with poor coordination and a fragmented policy approach, has led to deteriorating public trust in authorities. Despite 241 new policies being pushed through by July, case numbers and death rates continue to rise.
Overlapping authority has been the main obstacle to effectively handling Covid-19 in Indonesia. Multiple and overlapping laws have been used to handle the crisis, including laws on communicable disease outbreaks (Law No. 4 of 1984), disaster management (Law No. 24 of 2007), and health quarantine (No. 6 of 2018). The resulting confusion has posed difficulties for delegation of authority and coordination among actors.
For example, the initial Covid-19 Rapid Response Taskforce formed at the start of the year was given structure, functions and tasks that overlapped with the National Disaster Management Agency (BNPB). This has not been completely resolved by the Taskforce’s replacement, the Committee for Handling Covid-19 and National Economic Recovery. Further, despite the existence of several laws on the matter, there are no guiding protocols or standard operating procedures for disaster management, which is only ever carried out on a temporary basis that is unsustainable.
This shows that Indonesia urgently needs to strengthen its command system for disaster response. The best way to do this would be to strengthen the role and function of BNPB. This is a non-departmental government institution at the ministerial level, and should act as the director and executor of disaster management in Indonesia. A clearer command system would enable it to better coordinate the various ministries, agencies and levels of government involved.
As mentioned, another element that is essential to ensure resilience before, during and after a disaster is an effective health information system that can support rapid decision-making. In May, two months into the pandemic, only 20 of Indonesia’s 34 provinces had created publicly accessible websites with clear information on Covid-19. Of Indonesia’s 514 districts and municipalities, only 290 had updated websites. The lack of reliable and accurate data has severely limited Indonesia’s ability to respond to the pandemic, including its ability to distribute social assistance.
Further, there has been no integration of surveillance data and hospital data, causing delays in reporting recovery and death rates. This has also affected the government’s response in preventing, managing and tracing the spread of the disease, since available data does not accurately reflect the situation on the ground.
Indonesia needs to strengthen its data infrastructure as well as its standards, information exchange, and human resources. This will enable better integration of data in policy-making, and improve coordination and collaboration among key stakeholders.
Medical facilities and staff have proved unprepared for the Covid-19 pandemic. Only four of 34 provinces had sufficient ventilators available at the start of the outbreak – North Kalimantan, Bangka Belitung, DKI Jakarta and West Sulawesi – all other provinces were underequipped. Covid-19 referral hospitals, isolation rooms and intensive care units in hotspots are now exceeding maximum capacity.
Facilities and staff are also unevenly distributed across the archipelago. For example, East Java is home to 367 lung specialists, with each doctor serving 107,000 people, while Bengkulu has just four specialists, each serving up to 500,000 people.
Inequalities are seen not only across provinces, but also within them. In North Sumatra, for example, Medan has 98 lung specialists, while South Tapanuli district has just one. The absence of adequate health personnel risks increasing the fatality rate of the outbreak, which is already bad enough.
Task shifting, which involves a redistribution of health workers, is being recommended as a way to quickly and evenly strengthen the national health workforce. This can involve shifting specific tasks from highly qualified health workers to those who are less qualified (with a shorter training time) to make more efficient use of the available human resources.
The last factor we use to assess preparedness is surge capacity, and here Indonesia has, again, done badly. Research has indicated that it is already too late to sufficiently increase capacity to handle the upcoming peak of the outbreak.
The transmission scenario in parts of the country has shifted from contained “clusters of cases” to widespread “community transmission”, as defined by the World Health Organisation, further burdening the health system. Research conducted in Yogyakarta and Jakarta by Gadjah Mada University (UGM) earlier this year suggested the main reason for this was a lack of prevention protocols in public spaces such as places of worship, shopping centres, and offices.
As Jakarta emerges from another month of large-scale social restrictions (PSBB) into a more relaxed “transitional” period, health facilities must prepare their medical supply stockpiles, distribution channels and workforces – including by recruiting more volunteers – to anticipate another surge in cases. “New normal” protocols to prevent the spread of the disease must be intensively promoted down to the grassroots level.
The government is making efforts to improve coordination among actors and agencies, as indicated by budget reallocations, and is importing medical devices and establishing emergency referral hospitals, among other anticipatory measures.
Taking stock of Indonesia’s experience with the pandemic so far, further efforts must also be made to clarify the disaster response command system, address staff and equipment shortages in the health sector, and strengthen available data infrastructure for use in policy-making.
The Covid-19 pandemic is not over yet, and the health system must fixed quickly – the virus won’t wait.