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Exploring the sustainability of polio immunization in Indonesia’s decentralized health system.
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These lessons learned from a polio eradication initiative in Indonesia should be considered by countries who are weighing a transition to a decentralized health system.
Sustaining an effective evidence-based health intervention will maximize its impact in public health. Political and governmental reforms impact immunization program sustainability both positively and negatively. This study aims to explore sustainability of polio immunization in a decentralized health system taking lessons learned from a polio eradication initiative in Indonesia.
- Competing priority has been identified as the major challenge to sustain polio-related activities during a health system transition.
- During government transition, most of the national budget was allocated for political and governmental purposes, therefore, the health budget was cut. This impacted polio immunization coverage in the following years.
- The reforms caused disparities between local governments. To ensure that local government undertake 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. However, five years after the enactment of this policy, it was reported that not all district governments applied all of the indicators mentioned in this policy.
- Many local governments were more interested in curative health care such as constructing new facilities or refurbishing existing hospitals, rather than strengthening the public health infrastructure. In addition, local governments are more concerned over the shortages of medical officers, rather than closing the gaps for deployment of public health professionals.
- The health budget was reduced and the priority was curative. Therefore, the budget for promotion and prevention was decreased and ultimately the coverage of polio immunization decreased during the transition.
- The transition 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 and APBD was not enough to fund healthcare services. The inadequate budget for healthcare at local government resulted in disruptions within the health system and lost coordination.
- Front line workers at PHC and integrated health posts at village level, where immunization was delivered, played an important role for community mobilization. However, lack of sufficient health funding at district level has encouraged more Puskesmas to become self-funded, for example by instituting additional charges for service delivery. As immunization was mostly delivered at PHC, the lower income families could not afford the additional health service fees and withdrew from the facilities.
- During the transition, it was reported that the capability and capacity of local government was not adequate in planning, budgeting, and utilizing their budget effectively and efficiently.
- Supervision of the districts, especially for surveillance, decreased within the decentralized health system.
- After decentralization, where freedom of speech was assured and information was more freely spread, there was more rejection to immunization.