Ensuring Sustainability of Polio Immunization in Health System Transition: Lessons from the Polio Eradication Initiative in Indonesia

"Strong advocacy is needed at every level, from district to national level, to keep polio immunization prioritized."

Indonesia introduced polio immunisation into the routine immunisation programme in 1981, followed by initiation of a polio eradication initiative called Erapo (Eradikasi Polio) in 1991. The Government of the Republic of Indonesia had a strong commitment to implement this policy, which resulted in polio elimination in 1995. However, the immunisation programme faced challenges in maintaining its performance during political and governmental reform in 1998. This study explores the sustainability of polio immunisation during health system transition by gleaning lessons learned from polio eradication initiatives in Indonesia.

In 1999, political and social landscapes in Indonesia shifted from authoritarian to democracy and decentralisation. Following the political reform, Indonesia's health system also transitioned to a decentralised system. In this system, the relationship between The Ministry of Health (MoH), Provincial Health Office (PHO) and District Health Office (DHO) is not hierarchical. The polio eradication programme is under the Directorate General of Disease Control and Prevention (DGDC) and implemented by the Directorate of Surveillance and Health Quarantine (DSHQ) within DGDC. The responsibility for developing information, education, and communication (IEC) material is under Directorate of Health Promotion.

For the study, the researchers collected qualitative data through in-depth interviews with 27 key informants from various backgrounds at district, provincial, and national levels, including frontline workers, managers, and representatives of non-governmental organisations (NGOs).

The study found that sustainability components affected each other and led to declining immunisation coverage during health system transition. Competing priorities at the national and sub-national levels were identified as the major challenge to sustain polio-related activities during the transition. The reforms also caused disparities between local governments. These disparities become a threat to health due to the new leaders' lack of understanding and awareness around funding for health services, especially in economically poor districts or municipalities. There was also insufficient leadership capacity among policymakers at the sub-national level. Furthermore, supervision of the districts, especially for surveillance, decreased within the decentralised health system.

As there were competing priorities at the district level after decentralisation, continuous and robust advocacy for polio immunisation became essential. The researchers suggest that advocacy should be conducted at the national level and the provincial and district/municipalities level. Unfortunately, the capacity for advocacy within the sub-national governments varied. This considerable gap requires capacity building for advocacy.

Another issue during the movement to decentralisation was collapse of Puskesmas (primary health centres - PHCs) and Posyandus (integrated health posts). Frontline workers at PHCs and Posyandus at the village level, where immunisation was delivered, played an essential role in community mobilisation. However, the lack of sufficient health funding at the district level encouraged more Puskesmas to become self-funded by instituting additional charges for service delivery. Lower-income families could not afford the additional health service fees and withdrew from this facility, disengaging them from the community mobilisation that is "pivotal in immunization programs".

On the theme of community mobilisation, the first National Immunisation Days (NIDs) in 1995 are described here as having been festive and engaging, increasing community awareness on immunisation, beyond just polio. Most people voluntarily participated in this event, although some hesitancy existed in a small percentage of people. However, after decentralisation, where freedom of speech was assured and information was more freely spread, there was increased rejection of immunisation. For example, during a mop-up campaign in 2005, the media incorrectly blamed the polio vaccine for several coincidental adverse events during the first round of immunisation, causing misunderstanding and suspicion among the public.

Many strategies and measures were implemented to tackle the negativity against vaccinations, such as leverging the role of professional organisations to take action against doctors who opposed vaccines and using multi-modal interventions to raise the awareness of the community. Sensitisation of community and stakeholders was intensively conducted during polio campaigns. Ulama, public figures, community leaders, and other champions were involved in socialisation to convince the community that immunisation is important. Various media sources were used for community sensitisation, such as roadshows, printed media, mass media, electronic media, and social media, to counter the negative campaign against immunisation that intensified after decentralisation. However, most of the study's informants stated that the quantity and integration of sensitisation efforts have decreased.

Regardless of many challenges faced during decentralisation, most informants mentioned that the success of the polio eradication initiative was due to the characteristics of the programme, such as clear and detailed plans, targets, strategies, and impact indicators. This clear detail also attracted multiple sectors and partners to become involved in polio-related activities.

According to the researchers, there is a range of potential approaches to improve prioritisation in a decentralised health system: (i) Engage with sub-national governments as advocacy partners regarding immunisation financing; (ii) support research to analyse how current centre-local relationships exist; and (iii) engage directly by promoting ongoing policy and practice dialogues.

Also, delegating responsibility to various community workers is vital for the sustainability of an intervention. Besides regular coordination meetings at the national, provincial, district, and health facility levels, involving the private sector, NGOs, community leaders, and volunteers can provide timely feedback to improve immunisation delivery services.

With regard to community mobilisation for immunisation, having champions is critical to ensure sustainability. IEC strategies have been widely used and showed positive results. Various approaches during polio campaigns have been identified as having a significant impact, such as use of radio and television for messaging, involvement of religious organisations, and interpersonal communication between caretakers and community leaders and health workers. The lesson learned in Indonesia and elsewhere is the need for integrated media, especially when communities are confronted with negative rumours or reject vaccination.

In conclusion: "Ensuring immunization sustainability is essential to maintain its effectiveness in the community....However, in a decentralized health system, the sustainability of immunization is a challenge mainly due to...competing priorit[ies], inadequate local government capacity in managing ...program implementation, and vaccine hesitancy. Therefore, strong advocacy and community sensitization, and capacity building are instrumental in addressing those challenges."