The Jakarta Post
Last month Indonesia observed pekan imunisasi nasional (national immunization week). Despite the hype around immunization, Indonesia's vaccination coverage has flickered around 85 percent for the past five years, behind neighboring low-income countries like the Philippines, Vietnam and Cambodia.
In decentralized Indonesia, the capacity of local governments to deliver health services is very critical. Immunization coverage still very much varies across regencies ' about a third of regencies have immunization coverage of less than 40 percent. This brings into question the effectiveness of our current practices and what innovative solutions can be used to improve Indonesia's immunization coverage.
With a decentralized system, decision-making power shifts from the central administration to the smaller units of regional administrations. An order from the central government is no longer adequate to get things done.
With this shift, local government agents, each with their own private agenda, need the proper incentive structure to adequately carry out the functions expected of them.
One possible example is by linking salary bonuses or career progression opportunities in a government agency to the growth of immunization coverage. This would foster innovative solutions from the regional administration level that could be carried into practice.
Incentive structures can also be set for smaller decision-making units such as health-care facilities, health workers and families.
Austria had long instituted a negative price to important health-care services. Every pregnant mother receives a 'mother-child' passport that records health-care examination visits. Upon completion of the passport, the mother receives financial compensation equivalent to the average monthly income of an Austrian worker.
In another setting, the UK has tied physician bonuses to performance. Upon achieving a target of 90 percent immunization coverage rate, the physician will receive a bonus of approximately a quarter month's salary. This bonus increased the number of practices with more than 90 percent immunization coverage from 73 percent.
There are many opportunities to implement similar systems in Indonesia. We already have a variation of the mother-child passport that also records children's immunization history: Buku Kesehatan Ibu Anak (The Mother and Child Health Book). Currently, the book is not tied to any financial incentives, thus reducing the effectiveness. The book is often lost or forgotten.
Similarly, under the Social Security Management Agency's (BPJS) universal health coverage system, general practitioners and primary health-care facilities in Indonesia now have a catchment population, allowing the UK to pay for a performance system to be implemented.
Some might ask if this intervention costs money. Yes, it will. However, studies have shown that immunization is a cost-saving intervention, meaning that savings received in the future, such as averted health-care expenses in the future and increased future income and productivity, overpass the monetary spending incurred today.
In conclusion, the efforts we have been making for the past few years are inadequate to expand vaccination coverage. Indonesia needs to implement innovative solutions, such as realignment of financial incentives, to further boost immunization coverage.
The writer is a former employee of the Health Ministry and a researcher at the Harvard School of Public Health, evaluating the cost of vaccination programs in developing countries.
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