Scaling Up Public Health Interventions: Case Study of the Polio Immunization Program in Indonesia

"The polio immunization program must be owned by local stakeholders and decision makers."

The frameworks for scaling up public health interventions - for transforming health research interventions into pathways towards achieving development goals - are diverse. Examples of elements of such frameworks include: leadership responsibility, packaging of new ideas, communication, social system strengthening, measurement and feedback, and knowledge management. This paper investigates the process, actors, and contexts of polio immunisation scaling up in Indonesia from 1988 to 2018.

The researchers carried out a quantitative survey of 323 actors involved in the polio programme at national and sub-national levels, followed by key informant interviews (KIIs) and a document review (to construct a timeline of the polio eradication programme, with milestones). All data were collected between June 2018 and March 2019.

The research revealed that the scaling up of polio immunisation in Indonesia started as a vertical expansion approach led by the Ministry of Health (MoH) within a centralised health system. Global Polio Eradication Initiative (GPEI) management was under direct control of the MoH until 1999. The second scaling up model emerged in the decentralisation era between 2006 and 2014. In the decentralisation era, there was no longer direct command from the central level to the provincial level, as well as from provincial to the district level. Local governments became responsible for the delivery of immunisation programmes in their areas. Still, however, the central government remained responsible for additional immunisation activities.

Findings from both the centralised and decentralised era showed that polio immunisation scaling up required collaboration of stakeholders and the community. Successful advocacy requests to national leaders made polio a priority programme, with support from the non-health sector. Polio immunisation was also well received by the community because of a massive movement towards community-based campaigns. Local area monitoring (LAM) and integrated health posts (Posyandu) comprised of basic health activities from and for the community were key to the polio immunisation implementation strategy.

Among the challenges faced: limited availability of outreach activities, competing priorities in the decentralisation era, negative perception of immunisation side effects, and suspicion of vaccine ingredients that are considered forbidden by Muslims (haram), despite awareness campaigns. High staff turnover and the less-than-smooth process of transitioning from centralisation towards decentralisation contributed to a lack of continuity and accountability.

Reflecting on the findings, the researchers share these communication-related lessons learned: "The previous success of the program occurred because of the commitment of MoH as the leading actors and the involvement of multisector organizations so it could reach the community. This commitment is based on good coordination and communication, as well as great leadership. Actors at sub-national (provincial and district) level conveyed good leadership from polio eradication stakeholders at the beginning of the implementation of this program, especially at early NIDs [National Immunisation Days]. Trust in employees, intense communication and flexibility to carry out programs make stakeholders and program managers at the sub-national level feel comfortable. Good communication within polio immunization program actors enables the activity to run well. Communication can increase the awareness of the involvement of stakeholders and communities. High awareness in the community will produce high participation as well....Social engagement cannot only rely on planned activities from the central government, but must combine social mobilization from local and pragmatic activists in order to produce a successful movement..."

In conclusion: "Vertical scaling up polio immunization program in Indonesia works fine during the earlier stage, yet requires linkages among system levels so that a program with a specific focus can be delivered. MoH's decision to involve the president was critical since it promoted participation of non-health sector actors in the program. Posyandu played an important role, yet its revitalization after the reform-decentralization era has not been optimum."