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In honor of World Immunization Week celebrated in the last week of April, it is important for us not only to reflect on the powerful impact that vaccinations have in keeping our communities healthy but also to reevaluate the steps we make in eliminating vaccine-preventable diseases. Vaccination is widely recognized as one of the most lifesaving and cost-effective public health interventions to date, preventing a global estimate of 2 million to 3 million deaths per year. 

The Vaccines for Children program, for instance, created in response to the United States’ measles epidemic between 1989 and 1991, reportedly saved US$295 billion in direct costs from hospitalizations and $1.38 trillion in total societal costs within 20 years.

In Indonesia, however, the benefits and the glowing reputation of vaccines’ efficacy have instead been tainted by mistrust and rejection from some of the most conservative and peripherally located segments of the population.

At the heart of the matter is a poorly planned government vaccination program that failed to consider the socio-cultural and ethical aspects of immunization, further engendering ineffective communication strategies, which ultimately inflicted real costs and impeded efforts in reaching targeted communities with diverse social and cultural backgrounds.

Even though the effectiveness of vaccinations in reducing the burden of infectious diseases has been widely recorded, some ASEAN countries, including Indonesia, have seen a dip in measles vaccination rates in recent years, falling below the World Health Organization’s (WHO) recommended 95 percent mark — the herd immunity level at which all children within a community are fully protected from the disease.

In 2017, Indonesia saw a spike in measles cases in an outbreak that affected more than 11,349 people, an increase of 58.09 percent from the previous year. Despite the government’s subsequent efforts to roll out a two-phase measles-rubella (MR) vaccination campaign during 2017 and 2018, the country is still falling behind in its goal of eliminating the disease by 2020.

In fact, Indonesia is still vulnerable to these resurgences in the future as average national measles vaccination coverage rates are less than satisfactory at 87.33 percent for the first dose and only 60 percent for the second dose, which are clearly still not up to the aforementioned herd immunity threshold prescribed by WHO.

Progress in achieving expansive coverage was significantly impeded by growing ethical concerns surrounding the MR vaccine used in the government’s nationwide campaign. Public trust began to deteriorate after the Indonesian Ulema Council (MUI) — the country’s highest Islamic cleric body — declared the vaccine haram in 2016 because of the use of porcine-derived components in its manufacturing process.

Although the MUI has, since then, altered its position and issued Fatwa No. 33/2018 permitting the use of the MR vaccine because of an emergency situation, given severe risks posed by the disease, the damage has been done as vaccination rates continued to plummet. The rates are even more dire in certain provinces.

The government continues to face resistance, especially from more conservative provinces, namely Bangka Belitung, Riau and Aceh, which retain extremely low coverage rates of 18.17 percent, 15.22 percent and 6.73 percent respectively. Subsequent efforts by the government to remedy this damage had little impact on reshaping public perceptions, especially within these areas.

Convincing vulnerable and marginalized communities to accept vaccinations involves more than disseminating knowledge about vaccines. Devising a well-planned communications strategy based on thorough situational analysis and engaging relevant local and national-level stakeholders is crucial for eliciting support.

For example, the government’s negligence in establishing a communications procedure that acknowledges the socio-cultural diversity prevented it from responding more decisively to unanticipated sentiments of vaccine hesitancy that are distinct to each locality.

Furthermore, the government’s slow response in approaching the MUI to conduct preliminary discussions about the vaccine’s ethical implications and its potential role in improving the worrying public health situation resulted in a costly outcome that could have been quietly averted by aligning their goals. Hence, the justification behind the use of the MR vaccine could have been transparently advocated sooner by the MUI without instigating and aggravating public mistrust.

Moreover, the central government’s lack of preparedness in garnering the support of local officials also inflicted serious consequences. Despite receiving the Health Ministry’s circular on the MR vaccination program following MUI’s declaration, a number of regional heads such as Aceh’s acting governor did not utilize the new edict to persuade the public about the importance of the MR vaccination program and, instead, ordered its delay because of lingering doubts.

Poor communications between central and provincial officials resulted in weak coordination, which obstructed their holistic understanding of the matter.

Building public trust in vaccines, especially in Indonesia, requires a well-planned and highly tailored communications strategy that helps navigate through deeply rooted characteristics that pervade extremely heterogeneous localities. The government’s misstep in not actively finding other channels of communication, such as through local religious leaders, produced an MR vaccination program that lacked support and, thus, became defenseless to attacks.

Such an approach was used in Bihar — a predominantly Muslim state in northern India that suffered from the highest concentration of remaining polio cases in Asia — where India’s government succeeded in increasing polio vaccination coverage by working closely with local imam in drafting appeals that were sensitive to the community’s distinct culture and identity. Given the large influence and authority that local religious leaders wield at the grassroots, particularly in Indonesia, partnering with religious leaders could have allowed the government to slowly gain back public confidence and mobilize support for its MR immunization program.

Given Indonesia’s growing budgetary deficit and the pressing financial constraints placed on its healthcare system, effective and well-planned healthcare programs with cost-efficient outcomes are indispensable. Just last year, Indonesia experienced a considerable economic loss estimated at Rp 5.7 trillion caused by the measles-rubella disease outbreak.

Surely, the country cannot afford any future missteps in its policies and programs in such a way that not only creates blunders and wastes taxpayers’ money but, more importantly, threatens the lives of its young generation. The government must be proactive in developing healthcare programs that are grounded in extensive research and equipped with responsible communications practices.


Katyana Wardhana is an intern at Kiroyan Partners. She recently graduated with a Bachelor’s degree from Tufts University where she pursued a double major in economics and international relations, as well as a double minor in political science and art history. The views expressed are her own.

Source: The Jakarta Post, April 27, 2019, page 6.

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