Keywords

1 Introduction

Health security is a term that has been used on multiple occasions during the COVID-19 pandemic. It is defined by the World Health Organization (WHO) as “a set of proactive and reactive activities to minimize the impacts of acute public health events that endanger people’s health across geographical regions and international boundaries” (World Health Organization (WHO) 2020). In 2005 the International Health Regulations (IHR) were established, providing a legal instrument for the effective and timely response towards outbreaks and other health emergencies (World Health Organization (WHO) 2008, 2017). Member countries are legally bound to report event with an impact on public health, as well as to establish surveillance and response capacities towards health emergencies, in particular potential infectious diseases outbreaks (World Health Organization (WHO) 2020). Subsequently, in 2014, the Global Health Security Agenda (GHSA), providing a toolkit of policy recommendations, divided into 11 work-packages. Indonesia participates actively in the GHSA and in 2016 became the chair of the Steering Group (World Health Organization (WHO) 2016).

Indonesia formulates a particularly interesting example in terms of internet connectivity, accessibility to healthcare services and diseases surveillance, which this Chapter is going to investigate in some depth in relation to digitization of healthcare. Previous Chapters focused on highly developed economies (e.g., chapter “The Emergence and Growth of Digital Health in Saudi Arabia: A Success Story” focusing on Saudi Arabia), and on transition economies (e.g., chapters “The Digital Divide Based on Development and Availability: The Polish Perspective”, “Potential of Digital Health Solutions in Facing Shifting Disease Burden and Double Burden in Low- and Middle-Income Countries”, “Health Inequalities and Availability: Needs and Applications”, and “Digitalization of Healthcare in LMICs: Digital Health and the Digital Divide Based on Technological Availability and Development”, focusing on Poland, Vietnam, Cyprus and China respectively). Indonesia provides the central example of the current Chapter due to the most recent introduction of universal healthcare across the country in 2018 (Agustina et al. 2019), as well as the highly developed rate of digitization observed in relation to healthcare (Lazuardi et al. 2021; Aisyah et al. 2020).

Indonesia within low- and middle-income countries (LMICs), is classified as an upper–middle-income country (World Bank 2019). It is the world’s largest archipelagos and has the fourth-largest global population, administered into 34 provinces and 514 districts/cities, with each sub-national government having decentralized authority (Central Bureau of Statistics Republic of Indonesia 2013). From an ethnographic perspective, Indonesia includes 1331 ethnic groups, 2500 local languages and six recognized religions (Naim and Syaputra 2011). All of these aspects are important to understand, as they formulate a highly fragmented background against which any national healthcare campaign would have to overcome a harmonization challenge—especially the deployment of new technologies in relation to healthcare digitization.

Prior to COVID-19, the Indonesian government pursued the strengthening of routine human, animal and wildlife surveillance, for detecting and responding to zoonotic diseases that can potentially cause a public health emergency (President of the Republic of Indonesia 2019). These disease surveillance collaborations were of limited regional scope and timescale, and/or with a narrow focus on a particular disease (Adisasmito et al. 2017; Aisyah et al. 2022a; Budayanti et al. 2020). However, they were considered successful at the local level, as they laid the foundation for inter-governmental collaborations during healthcare emergencies and proved a useful experience during the COVID-19 response (Aisyah et al. 2021a; Azhar et al. 2010; Hartaningsih et al. 2015). The COVID-19 pandemic has acted as a catalyst for further developing Indonesia’s laboratory and healthcare capacity, by providing a platform to interconnect these services, but also the opportunity to scale them up. Specifically, the Indonesian government concentrated its efforts in fostering collaborations, thus scaling up testing and increasing laboratory capacity from 1 designated reference laboratory to 685 designated laboratories within the first 12 months of the pandemic (Aisyah et al. 2021a), and over 1000 as of January 2023. Here we look into some of the aspects that allowed for this positive outcome to materialize, as well as the challenges that still remain.

2 Data Infrastructure

Indonesia has experienced a rapid advancement of telecommunications in the last two decades, predominantly in the most populated areas, e.g., Java Island. The number of Indonesians using the internet has also experienced an exponential growth, increasing from an estimated 8.1m in 2005 to over 57m in 2015, with 80% of the country’s internet users located on the islands of Java, Sumatera and Bali (Jurriëns and Tapsell 2017). Thus, behind the increasing connectivity with telecommunications and data infrastructure lies an uneven distribution of these services across the country. The Indonesian government is aware that uneven access to telecommunications has the potential to widen a potential digital divide, hence investment incentives have been provided to companies to ameliorate the costs of developing infrastructure in geographically challenging areas, and so that infrastructure costs do not form the most significant barrier to accessibility. Narrowing the digital divide remains a huge challenge for the Indonesian government and society (Purbo 2017), aiming to harness the potential of digitization of healthcare, and the further development of healthcare services provision as part of the newly introduced universal healthcare coverage.

3 Data Laws and Regulations

The introduction of digital technologies in Indonesia did not occur in a vacuum, but was the result of collaborations between local and international organizations. At the same time, Indonesia developed the legal frameworks for data protection, specifically the regulation No. 20 of 2016 by the Ministry of communication and Information, where personal data protection in national law is stipulated explicitly. Further regulations regarding healthcare data, secondary use of healthcare data, and the regulation of algorithms used in Artificial Intelligence (AI)-driven decision-support systems are also anticipated in the near future.

4 Impact and Example of National Scale Implementation

As described by Aisyah et al., in Indonesia, a digital response and management system specific to public health was built and implemented through the pandemic. It incorporated the following aspects: detection, prevention, treatment, and monitoring (Aisyah et al. 2023). Beyond the main, national-scale deployment of the COVID-19 tracing app (Aisyah et al. 2022b), a total of 36 digital technologies supported more localized healthcare management aspects, such as telemedicine apps providing consultation and local treatment options for individuals exhibiting mild COVID-19 symptoms, as well as information for asymptomatic, infected ones. Of those digital technologies, 11 pre-existed the pandemic, and were expanded during its course. Each of these digital technologies facilitated a mix of remote consultations and prescribed medication delivery services (Aisyah et al. 2023).

Even though there was no precedent for a national-scale rollout of a digital healthcare application prior to the pandemic, there was an aligned thinking in this direction as evidenced by the launch of the Digital Health Transformation blueprint in December 2021. During the pandemic (and almost immediately after the blueprint launch) the health protocol compliance app [Bersatu Lawan COVID-19 (BLC)] became a mainstay of the entire government system, with dashboards showing aggregated, population-level information, the latter customized for the level of access and selection of information relevant to the role and functions of the accessing institution (Aisyah et al. 2021b). For example, the dashboards of the local police department and of the Ministry of Health would contain differently customized dashboards reflecting their different priorities as defined by their functions.

In particular, during COVID-19 pandemic, the Indonesian government developed several innovations using information systems and technology to support the pandemic control programs. For example, the Ministry of Health successfully integrated laboratory test results across more than 1000 laboratories for automatically identified people who were infected to be followed up for contact tracing and treatment (Aisyah et al. 2022c). Another innovation was the development and utilization of Peduli Lindungi as a mobile application used by the community to get information on the COVID-19 cases distribution across regions, automatically linked with laboratory test results, screening of COVID-19 status eligibility to enter public facility, and linked with COVID-19 vaccination records and certificate (Aisyah et al. 2023). The application has been downloaded by more than 100 million people so far. The Indonesian government also has successfully vaccinated more than 200 million people for COVID-19, where the information of COVID-19 vaccination coverage across 34 provinces can be accessed by the public in a designated dashboard (Indonesian Ministry of Health 2023). A public dashboard was also developed showing the COVID-19 situation across 514 districts/cities (number of cases, number of deaths, number of hospital admissions, COVID-19 vaccination coverage, etc). This momentum of digitization was followed-up by the development of the Digital Health Transformation Strategy 2024 Blueprint that laid the foundation for the enterprise architecture of health technology in Indonesia (Indonesian Ministry of Health 2021). It is hoped that the Blueprint will accelerate the government’s goal of providing universal, affordable, equitable and quality care nationally, while taking advantage of digital technologies.

There were a number of key elements that drove the success of the national-scale digital healthcare application implementation:

Firstly, there was commitment by the entire political and administrative system, from the office of the Presidency, to the different Ministries, to regional and local administrative units. This was particularly important in the initial adoption of the developed digital tools. Secondly, the diffusion of digital technology was facilitated by the standardized protocols regarding data input, and the standardized information display regarding aggregated data. This helped provide a common understanding of the information to the lowest administrative level, and importantly for public servants- who all had access to the app- it allowed for a uniform message and common understanding to be disseminated to the population. Thirdly, the technology development was coupled with the efforts for expansion of laboratory capacity. As such, the system was not creating yet another siloed unit, but it was evidently cross-supporting additional initiatives and vice versa. Fourthly, the immediacy of information, in near real-time (i.e., with a maximum space of information incorporation of 24h), ensured that the information is relevant even in the face of a fast-paced pandemic.

5 Way Forward

The multisectoral coordination behind the development and implementation of the digital healthcare applications in Indonesia is probably the most pronounced difference to the implementation of digital healthcare applications in other parts of the world, where multidisciplinarity was not achieved to a desired level (Benítez et al. 2020). Furthermore, it highlighted how the micro-level data provided primarily by police officers, military personnel, and community ambassadors (e.g., community/village leaders), can be effectively aggregated at a national scale, applying then big data analytics to analyze these reports on a weekly basis, to provide updates to policy makers and inform government response policies. The massive download of healthcare applications (over 100m downloads), also highlights the necessity for universal internet connectivity, coupled with the rollout of the universal healthcare system.

The way forward would need to include five key elements:

  • Continued infrastructure development to improve the reach and performance of this and future digital healthcare applications, in particular in terms of data security.

  • Continued stakeholder support for the implementation of digital healthcare applications, even if those need to be more localized and not necessarily at the national scale. Stakeholder support in this instance includes the implementation of and adherence to appropriate ethical and legal frameworks.

  • Continued multidisciplinarity, as Indonesia’s healthcare needs are complex, and unlikely to be addressed by single vertical initiatives.

  • Continued education of the professional workforce to utilize digital healthcare applications as appropriate, laying the foundation for a future generation of technology adopters and users, and

  • The transformation of the existing digital healthcare application capacities to expand and incorporate seasonal and/or endemic diseases, so that it can transform into a more systemic healthcare surveillance tool.

6 Conclusion

This Chapter presented a high-level view on the use of digital health technologies in Indonesia, in particular those introduced for COVID-19 detection and response management. This is particularly significant as universal healthcare coverage was introduced within Indonesia in 2018, and such technologies have acted at scale and in addition to greater behavioral and systemic pressures in the healthcare sector. Additionally, it is significant to note the multisectoral coordination among government bodies, higher education institutions, research institutions, and the private sector, that has created a fertile ground for the creation and introduction of such new technologies. Thus, the example of Indonesia is a useful case study for the utilization of digital healthcare technologies within the context of LMIC settings, and in aid of public health decision-making.

This Chapter also acknowledges the many remaining challenges, common amongst LMIC settings, such as absence of a dedicated data privacy framework, technological access disparities, and the ability to support the introduction of such innovations by trained, skilled staff. Thus, any potential benefits of implemented digital healthcare technologies, need to be considered alongside the need of maintaining an active governmental support for the long-term.