Background The scaling up of public health interventions has received greater attention in recent years; however, there remains paucity of systematic investigations of the scaling up processes. We aim to investigate the overall process, actors and contexts of polio immunization scaling up in Indonesia from 1988 until 2018. Methods A mixed method study with sequential explanatory design was conducted. We carried out a quantitative survey of 323 actors involved in the polio program at national and sub-national levels, followed by Key Informant Interviews (KII)s. Document review was also carried out to construct a timeline of the polio eradication program with milestones. We carried out descriptive statistical analysis of quantitative data and thematic analysis of qualitative data. Results The scaling up of polio immunization in Indonesia started as a vertical expansion approach led by the Ministry of Health within a centralized health system. The coverage of immunization increased dramatically from 5% in the earlier 80s to 67.5% in 1987; incremental increases followed until achieving Universal Child Immunization (UCI) in 1990 and subsequently 95% coverage in 1995. Engagement of stakeholders and funding made the scaling up of polio immunization a priority. There was also substantial multisector involvement, including institutions and communities. Local area monitoring (LAM) and integrated health posts (Posyandu) were key to the polio immunization implementation strategy. Challenges for scaling up during this centralized period included cold chain infrastructure and limited experience in carrying out mass campaigns. Scaling up during the decentralized era was slower due to expansion in the number of provinces and districts. Moreover, there were challenges such as the negative perception of immunization side-effects, staff turnover, and the unsmooth transition of centralization towards decentralization. Conclusion Vertical scaling up of polio immunization program intervention was successful during the centralized era, with involvement of the president as a role model and the engine of multi sector actors. Posyandu (integrated health posts) played an important role, yet its revitalization after the reform-decentralization era has not been optimum.

Background Sustaining an effective evidence-based health intervention will maximize its impact on public health. Political and governmental reforms impacted on immunization program sustainability both positively and negatively. This study aims to explore the sustainability of polio immunization in a decentralized health system taking lessons learned from a polio eradication initiative in Indonesia. Methods We collected qualitative data through in-depth interviews with 27 key informants from various backgrounds at district, provincial, and national levels, consisting of frontline workers, managers, and Non-government Organizations (NGOs). We conducted thematic analysis and triangulated using document reviews. We also conducted member checking and peer debriefing to ensure trustworthiness. Results Competing priority was identified as the significant challenge to sustain government commitment for polio immunization and AFP surveillance during the transition toward a decentralized health system. Variation of local government capacities has also affected immunization delivery and commitment at the sub-national level government. The government reform has led to a more democratic society, facilitating vaccine rejection and hesitancy. The multi-sector partnership played a significant role in maintaining polio immunization coverage. Strong and continuous advocacy and campaign were essential to raising awareness of the community and policymakers to keep polio in the agenda and to maintain the high polio immunization coverage. Conclusion Competing priority was the major factor affecting high polio immunization coverage during the decentralization transition. Strong advocacy is needed at every level, from district to national level, to keep polio immunization prioritized.

No abstract

Background Indonesia is the second country with the highest number of malaria cases in Southeast Asia. Private health providers including community pharmacies often become the first point of care for the population seeking malaria treatment; however, public–private partnerships for malaria control are not widely implemented. This paper explores the acceptability of  a public-private partnership program on the  provision of subsidized artemisinin-based combination therapies (ACTs) in community pharmacies from the perspectives of private health providers, patients, and program implementers. Methods The study was conducted in Manokwari District in West Papua Province, one of the highest endemic districts in Indonesia. Qualitative methods using interviews and focus group discussions (FGDs) were employed to explore the following dimensions of acceptability: affective attitude, burden, ethicality, intervention coherence, opportunity cost, perceived effectiveness, and self-efficacy. Study participants were program implementers, private health providers, and pharmacy clients. Audio-recorded interviews were transcribed and analyzed using thematic analysis. Secondary data on malaria cases and the use of ACTs reported by community pharmacies were also recorded. Results Only one-fourth of the total community pharmacies in Manokwari participated in the partnership, suggesting low coverage of the program. The proportion of malaria cases reported by community pharmacies increased from 6.9% in 2018 to 30.7% of cases. Most participants had a positive attitude towards the program, which might be associated with the perceived effectiveness of the partnership in improving access to ACTs. Despite the good understanding of the intervention by the participating pharmacies, limited involvement of private physicians often resulted in non-standardized treatment practices. The partnership also imposed a burden on private health providers in terms of human resources and time which entailed significant opportunity costs. A number of ethical issues might undermine the equity of access to ACTs. Conclusion Despite the positive attitude to the partnership, the perceived burden might outweigh the tangible benefits, posing threats to scaling up the intervention and sustainability. Innovations to simplify the administrative procedures in combination with performance-based incentives are needed to improve implementation. Engagement of patients and physicians is needed to increase the effectiveness of the partnership.

Background: 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.Methods: We collected qualitative data through in-depth interviews with 27 key informants in from various backgrounds at district, provincial, and national levels, consisting of frontline workers, managers and NGOs at national and sub-national level. We conducted thematic analysis and triangulated using document reviews. We also conducted member checking and peer debriefing to ensure trustworthiness. Results: Competing priority was identified as the major challenge to sustain government commitment for polio immunization and AFP surveillance during the transition toward a decentralized health system. Variation of local government capacities has also affected immunization delivery and commitment at sub-national level government. The government reform has led to a more democratic society, which is also conducive for rejection and vaccine hesitancy. Multi sector partnership has been identified to play a big role in maintaining polio immunization coverage. Strong and continuous advocacy and campaign are essential to raise awareness for the community and policy makers to maintain the high polio immunization coverage. Conclusion: Competing priority was the major factor that affected high coverage of polio immunization during the decentralization transition. Strong advocacy is needed at every level, from district to national level, to keep polio immunization prioritized.