Pneumonia has been identified as one of the leading causes of death among children in Indonesia. President Joko “Jokowi” Widodo has declared reducing infant mortality as one of his government’s top priorities. Efforts through behavioral change and medical treatment targeted at preventing this childhood disease should, therefore, be at the heart of the government’s health programs. The Jakarta Post’s Elly Burhaini Faizal takes a closer look at the issue in this Special Report.

It is good to see that the progress of the country’s efforts to solve various health issues has been quite remarkable. A health campaign dubbed the People’s Healthy Lifestyle Movement (Germas) was introduced nationally in November 2015 to improve the quality of life and well-being of all Indonesian people. The movement aims to change people’s behavior and encourage them to adopt a healthier lifestyle.

In particular reference to combating pneumonia prevalence, the need to convert to a healthy lifestyle was introduced on a massive scale. Campaigns have been launched for mothers to be committed to exclusive breastfeeding and to follow a balanced dietary intake as such measures could help prevent a weak immune system.

Campaigns have also been held for healthy living habits, such as hand washing with soap prior to eating, getting involved in massive tobacco control, as well as creating a healthy environment with zero pollution.

However, various health challenges that continue to hamper society, such as stubbornly high infant and maternal mortality rates, a staggering rate of children with stunted growth and the growing burden of diseases, obviously show that the government’s work is far from over.

Apart from behavioral changes, efforts to prevent infant deaths will certainly need medical measures. Specifically for pneumonia, Indonesia is obviously in dire need of new vaccines, such as the pneumococcal conjugate vaccine 13 (PCV13), which has been introduced to reduce pneumonia cases through a PCV immunization pilot project held in the West Nusa Tenggara regencies of East Lombok and West Lombok in October 2017, followed by Bangka Belitung in 2018.

“We need to expand pneumonia vaccination if we want to reduce drastically reduce infant mortality rate,” said the National Development Planning Agency’s (Bappenas) nutrition and child health director, Pungkas Bahjuri Ali, in a discussion on drug and vaccine management in Jakarta on Oct. 8.

The 2018 Basic Health Survey (Riskesdas) shows that the prevalence of pneumonia increased last year to 2 percent from 1.85 percent in 2013. Nationwide, confirmed cases of pneumonia in children under 5 stand at about 500,000 per year from 2015 to 2018. Confirmed cases of pediatric pneumonia last year reached 505,331, of which 425 patients died.

Pungkas said the government had also drawn a road map for the inclusion of pneumonia vaccination into its basic, complete immunization program by 2024 at the latest. However, the government’s plan to introduce PCV13 is now facing a financial barrier because it might further burden the state budget because of its high cost.

“Pushing forward, health promotion and disease prevention programs are much better because they are more effective and efficient. However, with our limited budget, it becomes a serious challenge for the government to be able to increase health promotion and disease prevention programs amid our tight budget,” Pungkas told The Jakarta Post.

“The challenge now is how we can make budget spending more efficient. We want to optimize the use of our budget through efficiency in the procurement of drugs and vaccines,” he added.

PCV13 was first introduced in the United States in 2000 and has since reached most countries around the world.

Indonesian Technical Advisory Group on Immunization (ITAGI) health systems specialist Prof. Soewarta Kosen said it was unfortunate to see that as of today, the government had not yet provided PCV in its immunization programs while in fact, 145 countries had used the vaccine. With its high potential to prevent diseases and lower the cost of health care, PCV13 has been highly recommended by the World Health Organization and other world health bodies to be included in national immunization programs (EPI).

As a so-called “sophisticated” vaccine, PCV, which provides protection against 10 to 13 strains of the (pneumococcus) bacteria, can be manufactured only in the US and Europe, making it difficult for the government to expect a transfer of technology for its state vaccine maker, Bio Farma.

However, Soewarta said, this is not a reason for the government to refuse the inclusion of pneumonia vaccines into its EPI because Gavi, the Vaccine Alliance, has offered PCV13 procurement support under the Advance Market Commitment (AMC) scheme via UNICEF.

AMC-UNICEF is an agreement to fund the purchase of an as yet unavailable but urgently needed vaccine in a developing country.

Under the AMC-UNICEF scheme, Indonesia can buy PCV13 at only US$2.93 per dose, far lower than the market price of $20. As a result, Soewarta said, the government’s vaccine cost for three doses of vaccine injections per infant would amount to only Rp 615.3 billion ($43.95 million). With around 5 million infants needing to get vaccinated per year, the government may save Rp 3.58 trillion annually from vaccine procurement only, the analyst added.

“The new vaccine procurement system, AMC, which has helped countries procure expensive vaccines, including for pneumonia, allows Indonesia to accelerate the adoption of PCV13 — which has been proven effective and provides herd immunity — into its national routine immunization program.”

As the Dec. 31 deadline for the government’s agreement to participate in the AMC scheme draws nearer, Bappenas, the Finance Ministry, the Health Ministry and the National Procurement Agency (LKPP) have continued their discussion on whether Indonesia will adopt the pneumonia vaccine into its national immunization program.

“We know that from the [AMC price scheme] offered by UNICEF, we can save on costs,” Purwanto, director of budgeting for the human development and culture department at the Finance Ministry’s Budget Directorate General, told the Post recently.

In the 2019 state budget, the Finance Ministry allocated Rp 355.34 billion to procure PCV13 for 1.42 million babies with a vaccine market price of Rp 249,491 per dose. In 2020, the government plans to spend Rp 343.02 billion to procure PCV13 for 1.74 million babies, with a vaccine price of Rp 197,226 per dose.

“If we buy PCV13 by using the AMC scheme, we may need to spend only Rp 75.64 billion, in which the vaccine price will be only Rp 43,500 per dose. We can save Rp 267.38 billion from this scheme,” said Purwanto, adding that what the government must first ensure is that the AMC scheme did not contradict with prevailing regulations on the procurement of government goods and services.

According to the LKPP, Presidential Regulation (Perpres) No. 16/2018 on the procurement of goods and services has actually allowed the government to access imported vaccines through international procurement schemes such as the AMC.

“The AMC is a pure business scheme. We refer to them as ‘procurement consolidation’, in which a business entity sells similar goods in huge quantities, resulting in far lower prices,” said Fadli Arief of the LKPP. “This is what we know as ‘value of money’.”

While praising the AMC scheme, University of Indonesia (UI) public health expert Hasbullah Thabrany said although PCV was very costly, Indonesia should have been able to buy the pneumonia vaccine without having to rely on financial support from international donor groups.

He cited the government’s readiness to provide energy subsidies worth Rp 125.3 trillion, almost equal to the government’s budgetary allocation for the health sector.

“Why is the government reluctant to invest in people’s health through vaccination?” Hasbullah said.

He sees vaccines as a long-term investment, so their benefits should be seen not only from the amount of money the government can save when purchasing them, but also from their effect on people’s health, including their high productivity in the future.

“It all depends on how far the government is committed to improving the health of its people,” Hasbullah said.

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