We listed ten potential participants for in-depth interviews. During the data collection process, the participants recommended other potential participants and snowball sampling was applied. In total, we interviewed 27 key informants consisting of 16 from the national level, seven from the sub-national level, and four frontline workers from various institutional backgrounds (Table 1). Face-to-face interviews were conducted with 22 participants, and phone interviews were conducted with 5 participants.
This study found that sustainability components affected each other and led to declining immunization coverage during health system transition, summarized in Fig. 2. Using a predetermined sustainability framework, this study developed nine themes and 18 categories (Table 2).
Competing priority at the national and sub-national level
Competing priority has been identified as the major challenge to sustain polio-related activities during a health system transition. Priority in districts changed; therefore, not all districts allocated adequate amounts of money for polio eradication, resulting in decreased quality and quantity of polio-related activities. Moreover, during government transition, most of the national budget was allocated for political and governmental purposes. Therefore, the health budget was cut (Fig. 2). This impacted on polio immunization coverage in the following years. It was reported that the coverage dropped, and then the outbreak occurred in 2005 (Fig. 3). The Non-Polio Acute Flaccid Paralysis (NPAFP) rate was also affected with a slight decrease during the transition (Fig. 4). However, it increased dramatically in 2005 due to the WHO supported Surveillance Officers (SOs) in every province, initiated in 2002. The NPAFP is an indicator for the sensitivity of surveillance acute flaccid paralysis (AFP), a polio symptom. The cut off is one case of AFP per 100,000 (1/100,000) children under 15 years old. If the NPAFP rate is less than 1/100,000, it indicates a missing AFP case in the population .
During the transition from a centralized to a decentralized system, maternal and child immunization coverage and availability remained pressing issues at the district level in Indonesia. Complete child immunization in most districts in Indonesia was below the WHO recommendation threshold of 80% . In 2002, complete child immunization coverage in central java (Cilacap, Rembang, Jepara, Pemalang, Brebes) and East Java (Trenggalek, Jombang, Ngawi, Sampang, Pamekasan) was below 51%, with the lowest level at 9% in Sampang district, East Java .
“…with democracy process in the district, they choose their leader (mayor), of course, the priority of each district is different… The most important thing is to convince the policymakers both at central and district level that this (polio) is a priority, this is an investment and will give huge impact” (Informant 9, Manager at National level).
Disparities at the sub-national level
The reforms also caused disparities between local governments. Disparities become a threat to health due to the new leader's lack of understanding and awareness around funding for health services; this is especially true in poor districts or municipalities. To ensure that local government undertook certain public measures, the MoH issued a decree in 2005 pertaining to 26 types of minimum/essential public health services that the local government must perform. Of these 26 services, 16 were related to public health, such as maternal and child health, promotion and prevention of prevalent diseases, school health and disease surveillance . However, five years after enacting this policy, it was reported that not all district governments applied all of the indicators mentioned in this policy .
The preventive measure was not a priority in health budget allocation
Many local governments were more interested in strengthening curative health care, such as constructing new facilities or refurbishing existing hospitals, rather than strengthening the primary care infrastructure. In addition, local governments are more concerned about the shortages of medical officers rather than closing the gaps for the deployment of public health professionals at the grassroot level .
“…we conduct advocacy to the government to develop minimum service standard (SPM) where the districts have to have indicators for polio. Though it is applied for immunization, I think it is not powerful enough” (Informant 17, Technical Assistant at National Level)
Decreased health budget during the transition
At the central level during the transition, the national budget was concentrated for government reform. The health budget was reduced, and the priority was curative. Therefore, the budget for promotion and prevention was decreased (Fig. 2). This severely impacted on immunization supervision and surveillance. The supervision for immunization received less attention and less funding. Therefore, the coverage of polio immunization decreased during the transition (Fig. 3). Moreover, the polio-free status obtained since 1995 made the government complacent about the AFP surveillance; thus, the NPAFP rate decreased during the transition (Fig. 4).
“…during the transition, government focus was on funding the government reform. Health budget was cut. Moreover, the priority was for curative…” (Informant 25, Manager at National level)
Even though a decentralized health system has been applied, vaccine procurement has remained centralized. Funds for procuring and supplying regular vaccines for immunization programs were mainly sourced from the APBN (National Budget and Expenditure) and managed by the Director-General of Pharmaceuticals and Medical Devices, MoH. For the delivery, MoH shared the costs with the district governments.
“…the difference is that now, programs become more integrated and cost-sharing is applied” (Informant 5, Technical Assistant at National level)
Low health budget at the sub-national level
Decentralization allowed the local government to develop and finance local initiative health programs. However, implementing health programs at local level depends on local fiscal capacity, regulation, and political process. Meanwhile, one of the impacts of decentralization led to widening the fiscal capacity gap between local governments. However, in both poor and rich local governments, the health budget from the general allocation fund (Dana Alokasi Umum/DAU) and APBD was not enough to fund the healthcare services. Moreover, budget constraints were more common in several districts after decentralization due to public health budget reduction .
The inadequate budget for health at local government resulted in disruptions of program implementation at the local level and thus resulted in lost coordination within the health system. As a result, the central government initiated to provide de-concentration budget through the Specific Allocation Fund (DAK - Dana Alokasi Khusus) for the health sector. Therefore, the central government still funded the highest health budget during the transition (Fig. 5).
The central government established minimum service standards to standardize which public services must exist, including immunization. Immunization is also included in Children Protection Laws, Health Laws, and Regional Government Laws stating that immunization is a must for all children in Indonesia. These regulations required every district government to allocate a budget for immunization. Unfortunately, around half of the districts in Indonesia did not comply with the mandated 10% of the local budget for health. This affects the allocation for immunization service delivery, increasing immunization outreach, and maintaining cold chain equipment .
Collapsed Puskesmas (primary health center - PHC) and Posyandu (integrated health post)
Community mobilization is pivotal in immunization programs. Front line workers at PHC and integrated health posts at the village level, where immunization was delivered, played an essential role in community mobilization. However, the lack of sufficient health funding at the district level has encouraged more Puskesmas to become self-funded by instituting additional charges for service delivery. As immunization was primarily delivered at PHC, the lower-income families could not afford the additional health service fees and withdrew from this facility, further jeopardizing their health status. Moreover, during the decentralization transition, many people financially suffered from the monetary crisis [21, 22]. Figure 6 demonstrates that the contact rates to the public hospital, PHC and Posyandu decreased during the transition. The contact rate is a proportion of new visits in a population per year. It is a performance indicator of healthcare facilities .
Furthermore, in 1997, Posyandu attendance by children under 5 was 57%. It decreased further in 1998 to just 42%. Similar trend was also reported in Susenas (National Socio-Economic Household Survey) 1995, 1997 and 1998. The province-specific surveys during the crisis revealed low contact rates for public facilities and a large number of Posyandu inactive . This affected immunization coverage. In the following years, the coverage dropped, and the outbreak occurred in 2005 (Fig. 3). This shows how vital community engagement was for immunization.
“…In 98, we experienced a multi-dimensional crisis, monetary crisis. Therefore, Mr President had to step down. Back then, our strength for immunization was Posyandu (integrated health post), after the crisis, Posyandu collapsed” (Informant 4, Former Manager at National Level)
Insufficient leadership capacity among policymakers at the sub-national level
The local capacity and political process influenced the development of local health programs. During the transition, it was reported that the capacity of local government in planning, budgeting, and utilizing their budget effectively and efficiently were not adequate. The local government’s actions in allocating insufficient funding to health budgets for health might be due to poor judgment in decision-making. This disparity hindered local progress in developing capacity . In addition, inadequate leadership and vision among bureaucrats at the local level were identified as major factors that facilitated the local government to continue implementing the old system even after decentralization, rather than answering the current health-related needs and problems, such as immunization and polio.
“Decentralization is necessary, but it was supposed to be well prepared. Capacity building for the policymakers at the district level need to be conducted before the enactment. From my point of view, districts capacities were not ready for decentralization. They were still dependent to the central level” (Informant 6, Manager at National level)
Differences in human resource capacity at the national level before and after decentralization
Several informants reported differences in terms of human resource capacity at the national level before and after the government reform. In addition, prominent leadership and governance issues were identified during the decentralization transition; including issues around transparency, accountability, health strategy, guideline implementation, and system design , which affected the health-related decisions and policies they made.
“…The quality of human resources decreased, and that nepotism emerged. Smart people, and should be promoted, were pushed away. Those who could not stand anymore resigned and moved to WHO, UNICEF. I was really sad. Those who got promoted are those who did not have any achievement” (Informant 6, Manager at National level)
Adaptation of funding sources
During the transition, the most significant change was the funding source, as previously it had been the central government that funded the program. After decentralization, the program fund was the responsibility of the national and sub-national governments together. However, there was still a division of responsibility. National Government was responsible for procurement and providing guidelines; the provincial government was responsible for the supervision and technical assistance; and, district government was responsible for operations and delivery. Each responsibility was funded by each level budget. However, this funding stream may not be smooth and adequately allocated. Budget allocation has been explained in the funding stability section.
Supervision of district was decreased
In the decentralized health system, supervision from the central level was shifted to the provincial level. Therefore, supervision of the districts was conducted by province government. However, as all provinces do not have adequate resources, supervision of the districts or municipalities became a challenge. Therefore, supervision of the districts, especially for surveillance, decreased within the decentralized health system (Fig. 2).
“What’s the impact of decentralization? Economic became number one, efficiency. Budget was cut. Health budget was cut. Therefore, the quantity of supervision to the health post decreased” (Informant 25, Technical Assistant at National level)
“With the decentralization enacted, the central level cannot directly supervise district; the supervision is only up to province level. The province is the one that has the responsibility to supervise the district. This responsibility is also a challenge because provinces do not have sufficient resources to do so. Therefore, the supervision on AFP surveillance performance decreased” (Informant 3, Technical Assistant at National level)
Coordination and review meetings were held regularly at the provincial and national levels to maintain communication of polio networks and evaluate AFP surveillance performance. This activity was supported by external funding (WHO) by hiring a surveillance officer (SO) at the provincial level, which started in 2002. The term of reference of SO was terminated in 2014.
There was a gap in advocacy capacity among the sub-national levels
As there was competing priority at the district level after decentralization, continuous and robust advocacy for polio immunization became essential. Advocacy should be conducted at the national level (within the MOH and other Ministries such as Home Affairs and Planning) 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. An advocacy consultant was also hired to plan effective advocacy strategies.
“What we can do is convince the policymakers… thus, advocacy has to be our mandatory activity. However, the capacity to conduct advocacy seems to be insufficient. We need a motivator, communication specialist, advocate to convince the local government, local representative board, to allocate resources for polio” (Informant 3, Technical Assistant at National level)
Public health impacts
The first NIDs conducted in 1995 were very festive and engaging as most people voluntarily participated in this event, although some hesitancies existed in a small percentage of people. However, after decentralization, where freedom of speech was assured and information was more freely spread, there was more rejection to immunization. For example, during a mop-up campaign in 2005, media incorrectly blamed the polio vaccine for several coincidental adverse events during the first round of immunization, causing misunderstanding and suspicion among the public.
Legal issue due to AEFI
All vaccines which are used in national immunization program are safe and effective if it is used appropriately. However, they still possess the risk to have an adverse event after vaccination. This adverse event is called Adverse Event Following Immunization (AEFI). It may range from mild to severe. This adverse event may cause public questioning on vaccine safety. Therefore, the investigation to determine AEFI is essential, and it is built in an AEFI surveillance system. The aim of AEFI Surveillance is to detect, correct and prevent immunization program fault, identify a potential problem in certain vaccines, prevent false accusations in coincident events, maintain public trust in the immunization program, identify likely unintended events and develop hypotheses that will be tested with study, estimate the prevalence of AEFI in certain population, and contribute in developing and adjusting contraindication, risk/benefit analysis and information for health workers who deliver immunization and patients .
After decentralization, democracy was more widely implemented, and the awareness of freedom of speech increased. This gave rise to legal issues known as an AEFI. After decentralization, the number of health staff who were sued due to AEFI increased. This made health staff afraid to deliver immunization services, and they requested protection to carry out their duties. The strategy taken by the MoH was to develop national immunization guidelines as Ministry Decree. Previously, the guidelines were signed by the authority at the directorate-general level, which was not strong enough to become a legal basis for health staff carrying out their responsibilities. This change enabled health staff to have legal assurance when they work in adherence to the guidelines.
“…in a centralized era, we did not care about the legal standing of regulation, so we only made national guidelines signed only by the director-general. When AEFI occurred, there was no fuss and suing or legal action. After the reformation, due to arisen legal issues, health staff became afraid to give the vaccination. They pushed us to develop national guidelines as MoH decree” (Informant 6, Manager at National level)
Involving key persons as a strategy tackling anti-vaccine movement
Many strategies and measures were implemented to tackle the negativity against vaccinations, such as using the role of professional organizations to take action against doctors who opposed vaccines and using multi-modal interventions to raise the awareness of the community.
“I even attended the seminar on anti-vaccine to counter their arguments. I challenge that person to argue with scientific evidence. I don’t know how I could be fearless back then, hahaha” (Informant 5, Manager at National level)
Sensitization of community and stakeholders was intensively conducted during the polio campaign. Ulama, public figures, community leaders and other champions were involved in socialization to convince the community that immunization is very important. Various media sources were used for community sensitization, such as roadshows, printed media, mass media, electronic media, and social media, to counter the negative campaign against immunization that intensified after decentralization. However, most of the informants stated that the quantity and integration of sensitization efforts have decreased.
“…in socialization, we engaged MUI (Indonesian Ulama Council) to give endorsement (fatwa)… we also made polio campaign in TV starred by celebrity...We engage many brands to support the campaign by providing merchandise. We engage the Ministry of Information and Communication to make regulations for those who want to advertise on TV must convey a little polio message. I think that worked” (Informant 5, Manager at National level)
NID was perceived as the most prominent community movement in health
Though routine immunization has been provided since 1977, the peak of the immunization campaign came with the first NIDs in 1995. This is because it was so exciting and has been claimed as the largest community mobilization for health in Indonesia. In addition, the eventful NIDs provided a strong impression upon the community, and the polio eradication campaign increased community awareness on overall immunization, extending further than just polio. Therefore, the community perceived that immunization is a health need, not simply an enforced obligation.
“Massive polio campaign has increased the awareness of the community on immunization. Immunization has become their needs” (Informant 1, frontline worker)
No significant impact of decentralization on polio strategic planning
There was no significant impact of decentralization on polio strategic planning. Most of the informants mentioned no difference in the polio program before and after decentralization because the Indonesian government followed a global polio policy. The implementation of polio immunization followed the updated recommendation from WHO. In 2012, the World Health Assembly declared polio as a public health emergency and expressed the need for a comprehensive endgame strategy. As a result, WHO developed a polio eradication and endgame strategic plan for 2013–2018. Indonesia started to implement the polio endgame strategy to maintain polio-free status and achieve the global eradication target in 2020. Following the updated strategic plan, Indonesia switched the polio vaccine from tOPV to bOPV and introduced one dose IPV to enhance and strengthen the immunization program. Poliovirus containment and environmental survey were also added into the activities.
“We have prepared for the transition process. The process has been run well enough. The document has also been developed. Our roadmap has also been adjusted to the global roadmap on polio eradication. We have implemented switching, improving surveillance, and improving laboratories’ capacity to ensure the eradication process succeed” (Informant 9, Manager at National level)
The characteristics of the polio eradication initiative as a contributing factor for the success of the program
Regardless of many challenges faced during the implementation, most informants mention that the success of the polio eradication initiative was because of the characteristics of the program. Clear and detailed plans, targets, strategies and impacts were identified as the factors that facilitated the implementation of the polio eradication initiative. This clear detail also attracted multi sectors and partners to become involved in polio-related activities.
“Polio eradication has a clear, detailed program, clear goal and target. With the same goal, the role of each actor was also clear, so that it attracted partners to involve…” (Informant 21, Polio Partners at National level)