Reflection on Two Years of COVID-19 Pandemic in Indonesia: Lessons Learned Must Be Lessons Shared
Introduction
The first case of COVID-19 in Indonesia was recorded on 2 March 2020, after a dance instructor named Sita Tyasutami and her mother were confirmed positive for the virus. Sita is predicted to have contracted it from a Japanese citizen living in Malaysia. It is been almost two years since Indonesia has been hit by Coronavirus Pandemic to the point where as 7 January 2022, the total number of cases reached 4,265,187 with 5,494 active cases based on data released by the COVID-19 Task Force.[1] As of 25 August 2021, there have been 1,967 health workers who have died in the war against the pandemic.[2] The impact of the number of victims of the corona virus not only hit the health field, but also the Indonesian economy in a broader picture. There are at least 59 countries that prohibit Indonesian citizens from entering their territory. This prohibition is predicted to cost Indonesia Rp262 trillion in the export sector.[3]
Beside COVID-19 and Indonesia, the World Health Organization (WHO) noted that the world has experienced outbreaks and epidemics caused by more than 20 infectious pathogens over the past 10 years (see figure 1).[4] COVID-19 is the latest in a series of health threats, but it won't be the last. In fact, the number of outbreaks of infectious diseases is increasing over time. This fact is due to the massive and rapid movement of people across countries[5]; the emerging of new and adapted pathogens; and housing residents which are getting closer to untouched nature due to deforestation, domestication of wild animals, and increased consumption of meat resulting the transmission of pathogens from animals to humans (zoonosis).
Generally speaking, the government has promoted three main responsive policies as an effort to fight the COVID-19 pandemic, namely tightening health protocols to control community mobility, classifying the alert status of each area at the PPKM (Enforcement of Restrictions on Community Activities) level of 1 to 3, and massive vaccination of all elements of age and occupation. First, the government implements a mandatory policy of antigen testing or PCR testing for domestic air travel. On the other hand, COVID-19 Task Force has issued Decree No. 2/2022 on Entry Point, Quarantine Zones and mandatory RT-PCR for Indonesians travelling into the country from abroad. Second, the government periodically evaluates the implementation of PPKM in each region.
In the latest developments, the Minister of Home Affairs issued instruction No. 1/2022 regarding the implementation of restrictions on community activities at level 3, level 2, and level 1 COVID-19 in the Java and Bali regions; and instruction No. 2/2022 to regulate PKKM in Sumatera, Nusa Tenggara, Kalimantan, Sulawesi, Maluku, and Papua regions. Third, the government targets vaccination of more than 208 million people, consisting of health workers, elderly Indonesian citizens, public officials, vulnerable communities and the general public, as well as people around aged 12-17. Based on the total target, the Ministry of Health noted that more than 170 million people had been vaccinated with the first dose (81.97% of the target) and more than 117 million people had been vaccinated with the second dose (56.24% of the target).[6]
Not to mention, no country is thoroughly ready to face a global disease outbreak, including Indonesia. The government's efforts to fight the COVID-19 pandemic are always overshadowed by the difficult choice between tightening health protocols and considering the negative impact on the country's economy. In an effort to quantify Indonesia's readiness to counter health threat, the authors use the Global Health Security (GHS) Index. This index consists of six categories, namely prevention, detection and reporting, rapid response, health system, compliance with international norms, and risk environmental. Then the question that arises is “how to improve Indonesia’s health security index to prevent and mitigate the future pandemic or endemic?”
Global Health Security (GHS) Index
GHS Index is a measure used as a standard in assessing the safety and capabilities of 195 countries in the health sector. The first GHS Index was developed in October 2019 by a collaboration between Nuclear Threat Initiative (NTI) dan Johns Hopkins Center for Health Security. This index is crucial for author in order to be a set of measurement to examine Indonesia’s preparedness for the next epidemic or pandemic in the future. There are six categories of measurement used to assess a country's health security, which are prevention, detection and reporting, rapid response, health system, compliance with international norms, and risk environmental:[7]
Prevention: prevention of the emergence or leakage of pathogens, including those that have the potential to pose a public health threat. This category includes testing antimicrobial resistance (AMR), zoonotic disease, biosecurity, biosafety, dual-use research and culture of responsible science, and immunization.
Detection and reporting: early detection and reporting of potential epidemics that will become international threats. Indicators from this category include assessing laboratory systems strength and quality, laboratory supply chains, real-time surveillance and reporting, surveillance data accessibility and transparency, case-based investigation, and epidemiology workforce.
Rapid response: rapid response to mitigate the spread of an epidemic. Indicators in this category are emergency readiness and response planning, executing plans, relations between public health and security authorities, threat communication, access to communication facilities, and trade and travel restrictions.
Health system: Adequate health system to treat the sick and to keep health workers safe. This category tries to examine health capacity in clinics, hospitals, and community care centres; supply chain for health system and healthcare workers; and infection control practices.
Compliance with international norms: create a system to strengthening national capability, financing policy to address gaps, and adhering to global norms. This category includes compatibility with international health regulations (IHR), WHO Joint External Evaluation, and commitment to sharing biological information of a pathogen.
Risk environment: Assessing overall risk of an environment and country’s vulnerability to biological threats. This category includes political and security risks; socio-economic resilience; infrastructure adequacy; environmental risks; and public health vulnerabilities.
Lessons Learned Must Be Lessons Shared
The 2021 GHS Index report shows that Indonesia is ranked 45th out of 195 countries, with a score of 50.4 points out of 100. Apart from Indonesia's score which is above the overall average of the country, which is 38.9 points, our country is still in the moderate category (a score between 40.1 to 60).[8] On the other hand, we are still far behind from neighbouring countries such as Thailand which is in 5th place with a score of 68.2 and Singapore that is in 24th place with a score of 57.4.[9] Furthermore, the value obtained by Indonesia is an accumulation of six categories of indicators that are important to be studied more deeply, namely prevention, detection and reporting, rapid response, health system, compliance with international norms, and risk environmental.
Prevention
Prevention indicators in the GHS Index include prevention of resistant antimicrobials, prevention of zoonotic diseases, biosecurity systems, biosafety systems, dual-use research and a responsible scientific culture, and immunization. Departing from this assessment component, Indonesia will get 31.8 points in 2021. The value has decreased because nationally, we got a score of 35.2 in 2019.[10] One of the reasons for this decline was the threat of an epidemic or pandemic from zoonotic diseases. Zoonoses means disease caused by the transfer of viruses, bacteria, parasites, and/or fungi from animals to humans. This is significant because various findings indicate a link between COVID-19 and bats as the source of the pathogen.
On the other side, the author has not found publicly accessible evidence regarding Indonesian laws and regulations that include clear rules regarding identification and measures to minimize the threat of spreading pathogens from animals to humans. The sources in this regard are the official website of the Ministry of Health(https://www.kemkes.go.id/index.php), Ministry of Agriculture (https://www.pertanian.go.id), and the National Research and Innovation Agency (https://www.brin.go.id).[11] Although identification and risk reduction for the occurrence of zoonotic diseases from animals to humans is not specifically described, Indonesia has several national regulations and strategic plans on zoonotic diseases. These rules and plans include: Presidential Decree Number 30/2011 on Zoonotic Control and the Ministry of Health has an Action Plan for the Prevention and Control of Vector and Zoonotic Diseases for 2015-2019.[12]
Detection and Reporting
Sub-indicators of detection and reporting according to the GHS Index include quality and strength of laboratory systems, laboratory supply chain, real-time monitoring and reporting, transparency and accessibility of surveillance data, case-based investigations, and epidemiological resources. Despite Indonesia's score which is higher than the world average, which is a score of 55.4 out of an average of 32.3, there are still a lot of homework that this country must complete in order to be more resilient in dealing with epidemics and pandemics in the future. One thing that the author focuses on is the laboratory supply chain.
There is little evidence to suggest that there are plans to drastically increase laboratory authorisation and licenses to enhance the capacity of the public health system, particularly in the event of an outbreak. On the other side, Indonesia has specific plans for several infectious diseases, such as Legionellosis, Monkeypox, Meningococcus, Leptospirosis, MERS, and Ebola, although these plans do not include special considerations for permitting or licensing laboratories to complement national public health capacities.[13] Regarding COVID-19 pandemic, Ministry of Health Decree NumberHK.01.07/MENKES/405/2020 on Coronavirus Disease 2019 (COVID-19) Examination Laboratory Network has regulated list of official laboratories. It includes 12 regional laboratories and 3 private laboratory networks, with a total of 163 laboratories.[14]
Rapid Response
Indonesia has a plan related to the response when a health emergency occurs, which aims to deal with infectious diseases that have the potential to cause a pandemic. Minister of Health Regulation Number 75/2019 on Health Crisis Management includes ways to deal with sudden death events due to pandemics. The regulation also covers information systems, logistics and reporting organizational structures, and general policies that must be taken during and after a health disaster.[15]
Apart from the regulation, in practice Indonesia still has a lot to improve. It can be seen from the rapid response score of 50.2. Although this number is still above the world average, 37.6, there are several sectors that Indonesia must improve in order to become a more resilient country in facing health crises in the future, namely: strengthening the emergency preparedness system; regular training on response implementation planning; linkages between public health institutions and security authorities; communication of threats in a directed, clear, and transparent manner; and strict one-door traveling and trade restrictions.
Health System
There is not enough evidence that Indonesia has plans or agreements to utilize domestic manufacturing capacity in order to produce medical needs, such as medical countermeasures (MCMs), medicines, vaccines, equipment and health protective equipment. Regulation of the Government Goods/Services Procurement Policy Agency (LKPP) No. 13/2018 on the Procurement of Goods/Services in Handling Emergencies has outlined the acceleration of procurement procedures during disasters, including non-natural disasters such as epidemics and infectious diseases. Various equipment has been registered in the regulation, but there is no specific elaboration regarding medical equipment.
Up to now, there has been no detailed publication of legal agreements between the government and producers and distributors in order to accelerate and maximise the supply of medical equipment needs during a health emergency, either on the websites of the Minister of Health, Minister of Defense, and the National Disaster Management Agency (BNPB). Judging from the gap between LKPP regulation No. 13/2018 and collaboration with manufacturers and distributors of medical devices, it is important for Indonesia to start building partnerships. The partnership in question can be with state-owned enterprises (BUMN) or with private parties. In consideration of reflecting on the supply chain score for health systems and healthcare workers, Indonesia has only reached a score of 38.9 (health system sub-indicator). Although this value is already above the global average, it certainly cannot be said to be resilient to face potential epidemics and outbreaks of infectious diseases in the future.
Compliance with International Norms
Indonesia's Compliance with International Norms score is far above the world average, but this score cannot be said to be sufficient. With the current score of 68.9 points, this country still needs to improve in order to strengthen multilateral cooperation because the pandemic is a global issue – it cannot be solved alone. Indonesia has cross-border cooperation as part of ASEAN regarding infectious disease emergencies, such as SARS, H5N1, H1N1, and Ebola. In addition, together with China, ASEAN issued a joint declaration to exchange epidemiological information, technical guidance and solutions for epidemic prevention and control.[16]
Regardless of the cooperation with ASEAN, this country still has to improve. There are at least two points that become WHO’s focuses for Indonesia.[17] Firstly, the approach with all parties to International Health Regulations (IHR) in all departments and agencies must be strengthened. Second, continuous training and planning methods must be developed in all institutions for maximisation of IHR implementation.
Risk Environment
The risk environment consists of several assessment indicators, namely political and security risk, socio-economic resilience, infrastructure adequacy, environmental risks, and public health vulnerabilities. One thing that is still Indonesia's big homework and is directly related to the threat of infectious diseases is public health vulnerabilities with a score of less than 50.
In order to increase community resilience against health threats, there are several fundamental things that must be met. Access to quality health facilities, access to sanitation and clean water, increased per capita state spending on public health, and public trust in health workers are absolute requirements for a more resilient Indonesia to face the dangers of epidemics or pandemics in the future.
Conclusion
The author offers a way to answer the question "how to improve Indonesia's health security index to prevent and mitigate the future pandemic or endemic?" based on the GHS Index indicators. The combination of the GHS Index and reflection on national needs and conditions in the last 2 years can be a solution to prevent and mitigate the impact of the outbreak of infectious disease in the future. Any efforts to minimize the latent danger of health security risks are an obligation. In addition, globalization (movement of goods, people, and information) after the COVID-19 pandemic does not only relevant in the realm of acceleration, but also on the resilience of countries.
[1] Sari, Haryanti Puspa. (2022). UPDATE 7 Januari: Bertambah 518, Kasus Covid-19 di Indonesia Capai 4.265.187. Kompas.com: https://nasional.kompas.com/read/2022/01/07/16242841/update-7-januari-bertambah-518-kasus-covid-19-di-indonesia-capai-4265187, was accessed on 7 January 2022. [2] Supriatin. (2021). Hingga 24 Agustus 2021, Sebanyak 1.967 Nakes Gugur Terpapar Covid-19. Merdeka.com:https://www.merdeka.com/peristiwa/hingga-24-agustus-2021-sebanyak-1967-nakes-gugur-terpapar-covid-19.html, was accessed on 7 January 2022. [3] Rakhmat, Muhammad Zulkifar. (2020). Indonesia’s poor COVID-19 responses take a toll on its global image. https://theconversation.com/indonesias-poor-covid-19-responses-take-a-toll-on-its-global-image-150939, was accessed on 7 January 2022. [4] World Health Organization. Disease Outbreak News (DONs). WHO: https://www.who.int/emergencies/disease-outbreak-news, was accessed on 8 January 2022. [5] The International Civil Aviation Organization (ICAO) report in 2018 noted that there were a total of 4.3 billion airplane passengers or approximately 60% of the total population. [The International Civil Aviation Organization (ICAO). (2018). The World of Air Transport in 2018. ICAO: https://www.icao.int/annual-report-2018/Pages/the-world-of-air-transport-in-2018.aspx, was accessed on 7 January 2022.] [6] Kementerian Kesehatan Republik Indonesia. (2022). Vaksinasi COVID-19 Nasional: Data per Tanggal 10 Januari 2022 Pukul 18.00 WIB. Kemkes: https://vaksin.kemkes.go.id/#/vaccines, was accessed on 11 January 2022. [7] Nuclear Threat Initiative & Johns Hopkins Center for Health Security. (2021). GHS Index Methodology. Global Health Security Index. P 6. [8] The GHS Index categorization scale is divided into 5 groups, namely groups with a score of 0-20; the group with a score of 20.1-40, the group with a score of 40.1-60, the group with a score of 60.1-80, and the group with a score of 80.1-100. [Jessica A. Bell and Jennifer B. Nuzzo. (2021) Global Health Security Index: Advancing Collective Action and Accountability Amid Global Crisis. Global Health Security Index. P 22.] [9] Ibid. [10] Nuclear Threat Initiative & Johns Hopkins Center for Health Security. (2021). 2021 GHS Index Country Profile for Indonesia. GHS Index: https://www.ghsindex.org/country/indonesia/, was accessed on 20 January 2022. [11] Those ministerial websites were accessed on 20 January 2022. [12] Presiden Indonesia. (2011). Peraturan Presiden Nomor 30 Tahun 2011 tentang Pengendalian Zoonosis. JDIH BPK RI: https://peraturan.bpk.go.id/Home/Details/41196/perpres-no-30-tahun-2011, was accessed on 20 January 2022; Kementerian Kesehatan Republik Indonesia. (2017). Rencana Aksi Pencegahan dan Pengendalian Penyakit Vektor dan Zoonosis Tahun 2015-2019. Kemkes: https://e-renggar.kemkes.go.id/file2018/e-performance/1-465842-4tahunan-265.pdf, was accessed on 20 January 2022. [13] Nuclear Threat Initiative & Johns Hopkins Center for Health Security. (2021). Country Score Justifications and References: Indonesia. GHS Index. P 34. [14] Kementerian Kesehatan Republik Indonesia. (2020). Keputusan Menteri Kesehatan Nomor HK.01.07/MENKES/405/2020 tentang Jejaring Laboratorium Pemeriksaan Coronavirus Disease 2019 (COVID-19). Kemkes: https://infeksiemerging.kemkes.go.id/download/KMK_No._HK.01.07-MENKES-405-2020_ttg_Jejaring_Laboratorium_Pemeriksaan_COVID-19.pdf, was accessed on 24 January 2022. [15] Kementerian Kesehatan Republik Indonesia. (2019). Peraturan Menteri Kesehatan Nomor 75/2019 tentang Penanggulangan Krisis Kesehatan. [16] Association of Southeast Asian Nations. (2020). Joint Statement Special Video Conference of ASEAN Plus Three Health Ministers in Enhancing Cooperation on Coronavirus Disease 2019 (COVID-19) Response. ASEAN: https://aseanplusthree.asean.org/joint-statement-special-video-conference-of-asean-plus-three-health-ministers-in-enhancing-cooperation-on-coronavirus-disease-2019-covid-19-response/, was accessed on 8 January 2022. [17] World Health Organisation. (2017). Joint External Evaluation of IHR Core Capacities of the Republic of Indonesia. WHO: https://apps.who.int/iris/bitstream/handle/10665/272363/WHO-WHE-CPI-REP-2018.9-eng.pdf?sequence=1&isAllowed=y, was accessed on 8 January 2022
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