Ivan Ariavan (360info)
Melbourne, Australia ●
Mon, April 11, 2022
More than a quarter of a million people live in Indonesia, spread across an archipelago of thousands of islands. This geographic reality is a double-edged sword. On the one hand, it becomes very difficult to ensure that every citizen has equal access to health services. On the other hand, during an epidemic, the government can prevent the disease from spreading across the archipelago – if it has the right early warning system in place
Three things are essential for a well-functioning pandemic alert system: timely detection and reporting of symptoms; accurate diagnoses supported by rapid investigation and confirmation of cases; and an efficient disease tracking system.
Indonesia has several early warning systems. The Early Warning and Response System (EWARS) tracks 23 types of infectious diseases such as pneumonia and influenza-like illnesses that can become epidemics or outbreaks. It gets its data weekly puskemas (Municipal Health Center) reported. To detect increasing cases, EWARS relies on a disease diagnosis and response algorithm and an outbreak response algorithm.
However, a weekly report can’t quickly flag outbreaks, so in 2020 the Department of Health added an event-based surveillance capability designed to identify significant cases and report them to the government for immediate response. However, EWARS did not recognize COVID-19 as quickly as it should have. Another disadvantage is that EWARS is not fully connected to the hospital and laboratory information system.
Indonesia has numerous health information systems at central and sub-national levels. In 2021, research firm Reconstra conducted internet search mapping that identified at least 155 central-level systems. The Department of Health identified hundreds of systems, including at least 77 puskemas level and 55 at hospital level.
To complicate the picture, Indonesia’s decentralized system of government allows regions to customize healthcare systems to best meet local needs.
This large, fragmented health information system places an enormous workload on clinical health workers and program managers in subnational agencies. Data entry personnel is scarce in Indonesia, so healthcare workers often need to enter data as part of their job.
Most health professionals and program managers have multiple roles, from delivering services like immunizations to administrative tasks like budget filings to program implementation. Previous reviews have identified an urgent need for administrative staff specifically trained in the health information system.
Although there is no process to provide feedback on the speed and accuracy of recording and reporting, the overwhelming responsibilities of health care workers and managerial staff seem to affect the timeliness and accuracy of the data entry process. Data validation and verification are also suboptimal because program managers have a lot of other work to do. Differing approaches to data collection also create difficulties. For example, regular disease prevalence is tracked through a three-year basic health survey, but the measles-rubella vaccination campaign used separate daily SMS-based reporting.
Against this background, the development of a new pandemic warning system faces many challenges. The new system requires political support, adequate infrastructure and human resource development. During the transition, there must be no period during which monitoring is suspended. On the other hand, it takes years of effort as well as enormous resources and full support from all programs to integrate the existing systems or make them interoperable.
The new system must connect the most important pieces of the puzzle: examining patients, treating patients, and tracking the spread of disease. The government can assign responsibility for each piece. For example, health workers can focus on disease management and epidemiologists can support the traceability system. In order to relieve the state system, some processes can be carried out in cooperation with other parties – for example, mass vaccinations can be carried out by doctors or health workers who do not work in state institutions.
Indonesia’s growing economy over the past decade has encouraged urbanization, subnational connectivity, and population mobility, all of which increase the potential for future outbreaks. Before the pandemic, Indonesia established the world’s largest single-payer health insurance system, eventually achieving near-universal health coverage. In recent decades, the country has also increased average life expectancy, reduced infant mortality, and launched better family planning initiatives that have halved fertility rates.
COVID-19 could jeopardize some of these achievements. As the country recovers, Indonesia needs to allocate resources to building a better alert system for future pandemics.
The author is a lecturer and researcher at the Public Health Research Center of the University of Indonesia. His work focuses on statistical modelling, survey design and analysis. He was financially supported by DFAT Australia.
Originally released under Creative Commons by 360info™.