By Hasbullah Thabrany (Chief of Party, the USAID-Health Financing Activity in Indonesia – personal view) and Virginia Wiseman (London School of Hygiene & Tropical Medicine, The Kirby Institute at University of New South Wales)
In this blog series we are giving a voice to practitioners, implementers and policy-makers involved in national COVID-19 responses in low- and middle-income countries. These posts seek to facilitate timely cross- learning by sharing opinions, insights and lessons on the challenges and actions taken by those on the COVID-19 front line.
As of the end of May 2020, the Indonesian government reported 1,613 deaths out of a total of 26,473 confirmed cases, a fatality rate of 6.1%. While Indonesia’s mortality rate is slightly higher than the current world average (5.9%), it is still relatively low given the country’s population size (approximately 267 million). There are many reasons for this, including the low rate of testing. To date, Indonesia has one of the lowest rates of COVID-19 testing in the world with only 1,183 per million people tested. The presence of underlying conditions in COVID-19 patients also make it difficult to determine the cause of death. The prevalence of smoking amongst adult males in Indonesia is 82.7%, placing these individuals at higher risk of acute respiratory tract infections and more likely to have complications from COVID-19. Despite issues of under-reporting, the number of confirmed cases is on the rise in Indonesia with a significant spike occurring between the 1st April and the 31st May 2020 when the number of cases rose from 1,677 to 26.473. This is in contrast to other countries such as China, South Korea, Australia and some European countries where the number of reported cases has plateaued or is on a downward trend.
After widespread criticism of government inaction, on the 31st of March 2020 the President of Indonesia issued a government regulation (No. 21/2020) on large-scale social distancing (LSSD). The LSSD policy delegates responsibility for the implementation and enforcement of this regulation to local governments and authorizes provincial governments to close schools, offices, recreation/tourist areas, limit public transportation, supplement the national social assistance programs, and undertake appropriate actions to enforce the law. By the third week of April, a ban on traditional mass home comings (known as mudik) during the fasting month of Ramadhan was also introduced. LSSD has triggered a major debate across the country about the rationale for banning mudik. In this blog we discuss some of the implications and challenges of implementing these policies across a country of around a quarter of a billion people, the vast majority of whom live on Java, which is the most densely population island in the world.
Even outside a pandemic situation, public policy implementation in Indonesia presents a major challenge politically, socially, and economically. This is not least because it is held together through a decentralized government system consisting of 74,000 villages, 514 cities/districts and 34 provinces each with an elected head. Policies are not always consistent across these various levels of government. Strong directive from the national government can also be is interpreted as a potential threat to democracy which has been embraced by so many since its establishment in 1998. On April 15, the President expressed his disappointment on television pointing out that only one third of cities/municipalities had followed his LLSD policy response and reallocated existing budgets to focus on controlling the COVID-19 outbreak. Three weeks after the introduction of the LSSD policy in Jakarta, the COVID-19 curve remains on an upward trend. Debates about delayed decision making, the need for urgent lock downs, and protecting the economy, continue.
Social distancing measures
As is the case for many other countries, the Indonesian government is confronted with the difficult task of weighing up the likely deaths from COVID-19 against deaths from economic deprivation and preventable diseases. The LSSD policy is resulting in substantial economic losses, especially for those who work in Indonesia’s informal sector. These workers are typically involved in construction, food markets, and many other small businesses where they earn a daily cash wage, have little or no savings, and no access to social safety nets. There are currently 74 million workers in the informal sector compared to 55 million people in the formal sector. The LSSD policy requires employers to pay part or full salaries to their employees while they are based at home. But for labourers in the informal sector, working from home means no income. In addition to increasing cash transfers to the existing 10 million households of the Conditional Cash Transfer (CCT) programme by 25%, the government is now also offering cash transfers to those that have fallen below the poverty line due to the pandemic (i.e. the ‘newly poor’) and subsidising food, electricity and other essentials.
Loss of income
The loss of income due to the pandemic also threatens contributions made by the 224 million current members of the National Health Insurance Scheme (NHIS). Since starting in 2014, the NHIS is suffering from six years of consecutive deficits. In January 2020, the President issued a decree raising premiums for the NHIS. Although the cost of health care for COVID-19 cases will be financed by the national budget, the indebted NHIS is now facing the impossible situation of rapidly increasing claims and falling contributions due to loss of income especially amongst Indonesia’s vulnerable informal sector workers. There is also huge variation in access to health care facilities across Indonesia. The country has an estimated 321,544 hospital beds which equates to about 12 beds per 10,000 people, a quarter of which are critical care beds. The ratio of doctors to population is also low at around 4 per 10,000 people. Even though the comparative ratios for large cities like Jakarta are higher (i.e. 13 doctors and 30 hospital beds per 10,000 people), health services in these cities are under considerable pressure and struggling to cope with the ever-increasing number of COVID-19 patients.
There are additional ‘cultural’ challenges to implementing the LLSD policy in Indonesia, one of the biggest and most immediate has been mudik. Each year around 20-30 million Muslims return to their home villages to celebrate Ramadhan Festival with their extended family. Most travellers typically make the exodus on crowded buses, trains and ferries, increasing the risk of spreading the virus. These travellers are also expected to place further pressure on resource-constrained health facilities outside the major cities, many of which were already understaffed before the pandemic. Under growing pressure, the President introduced a ban on all inter-provincial public transport, except for logistics and essential services. However, regardless of the ban, many people insisted on taking part in mudik or had already left before the ban was implemented.
The logistics are inevitably complex and the economic fallout huge but like so many countries Indonesia has now taken considerable strides towards implementing social distancing policies. These actions will continue to take their toll on the poor. Continuing to extend Indonesia’s social protection system to those who are currently not beneficiaries but likely to face impoverishment due to the pandemic is of paramount importance. This needs to be backed up by strong, united and consistent messaging around social distancing that is executed . Finally, much can be learnt from the thousands of trusted community networks across the country that are ramping up efforts to protect households that are falling through the cracks of social distancing and relief packages.
Image credit: Wikipedia Commons [A beach in Padang appear to be quiet as the Indonesian government calls on the public to implement social distancing]