Childhood pneumonia is one of the leading causes of death in low- and middle-income countries, claiming nearly 800,000 lives every year.[1] In Indonesia alone, an estimated 10,000 lives are lost to this preventable illness each year.[2][3] Children suffering from severe pneumonia urgently need medical oxygen to survive which is often unattainable for the poorest and most vulnerable— a crisis catastrophically exposed by the COVID-19 pandemic.
Access to lifesaving pneumococcal conjugate vaccines (PCV) is critical to protect children against severe pneumonia. Introducing and increasing access to these vaccines is especially important in countries that face the ‘double-burden’ of respiratory infection deaths from COVID-19 and pneumonia. Almost 150 countries around the world have reduced pneumonia mortality by providing PCV as part of their routine immunization programs.[4]
Based on the success of PCV in other countries, in 2017, CHAI recommended the prioritization of different new vaccine introductions, including PCV, to the Indonesian government. Between 2017 and 2019, we supported a demonstration program in selected districts in Nusa Tenggara Barat (NTB) and Babel provinces to show effective use and the positive impact of PCV in the communities. Based on the national schedule, three doses of the vaccine are given to children at the ages of two and three months alongside pentavalent vaccines, and another at 12 months. With over 85 percent of children receiving their third dose of PCV vaccines, the success of this work culminated in the decision to introduce PCV nationwide.
A long wait to introduce vaccines nationwide
Despite the tremendous challenges and delays caused by the COVID-19 pandemic, the government of Indonesia undertook a massive effort to introduce PCV vaccines into its routine public immunization program, while also introducing COVID-19 vaccines in 2021. Following a great deal of advocacy and effort to navigate complex regulations and coordinate across multiple ministerial stakeholders, CHAI and partners supported the government to access the vaccine doses at a significantly reduced cost (approximately one-fifth the cost as the best available price in the private market). This was done through Gavi’s innovative Advanced Market Commitment (AMC) financing mechanism which provides equitable access to vaccines to countries regardless of income status[5]. The first 1.6 million doses of the PCV vaccine arrived in Jakarta in April 2021 and were successfully introduced in the four provinces of NTB, Babel, East Java, and West Java, covering 14 percent of total births in Indonesia.
CHAI helped the Indonesian government to implement best practices based on our experience in other countries and the demonstration districts, such as introducing readiness and post-launch assessments and identifying cold chain capacity gaps to plan and strongly implement the vaccine introduction. We provided substantial hands-on technical assistance to the central and subnational governments to implement the rollout in the four focal provinces. We helped the governments develop accurate forecasts and cost projections, held advocacy meetings in communities, led healthcare worker trainings, and conducted readiness assessments.
PCV training in Bogor, West Java, June 2021
Adapting to COVID-19 challenges
Like in most countries, the COVID-19 pandemic significantly burdened the capacity of the health system in Indonesia, disrupting demand and delivery of all essential health services, including routine vaccinations. Due to fear of contracting COVID-19, the number of caregivers and children accessing primary healthcare in Indonesia decreased; many health facilities experienced partial closure or reduced service provision, and health workers were diverted to the COVID-19 response. This adversely impacted demand and access to vaccinations. Unfazed, CHAI helped national stakeholders adapt to the changing situation, from sequencing introduction of PCV based on supply availability to shifting to online training and monitoring methods.
The situation was no better in 2021 when Indonesia experiences the Delta variant-driven second wave of the pandemic during which, a staggering one in three people tested positive for the virus at its peak.[6] CHAI provided additional support at the national and sub-national levels to analyze coverage trends at the health facility level to assess underlying challenges and design tailored interventions to resolve bottlenecks and enable improved uptake of PCV vaccines. Since the introduction of the vaccine in June 2021, over 100,000 newborns have received their first dose of the PCV vaccine in Indonesia.
Looking forward
Following the vaccine’s successful introduction in the selected provinces, nationwide expansion is now planned in 2022 with up to 4.5 million children across the country set to be protected every year. Once target coverage is attained, the lives of an estimated 7,356 children under five will be saved each year.[7]
With the new ministerial efforts to intensify and accelerate scale-up, PCV is set to reach all provinces by 2022. CHAI will continue to support the national introduction in 2022 by working to build government capacity and sharing lessons learned from earlier phases to inform the scale-up approach. This milestone will save the lives of thousands of children across the country for years to come.
This work was supported by funding from the Bill & Melinda Gates Foundation. For more information, please contact Anithasree Athiyaman at aathiyaman@clintonhealthaccess.org or Niken Widyastuti at nwidyastuti@clintonhealthaccess.org.
[1] Save the Children, Progress of Childhood Pneumonia, 2017-2021. https://resourcecentre.savethechildren.net/pdf/progress_on_childhood_pneumonia_2017_-_2021.pdf/
[2] UNICEF, Rights to Breath: Addressing Pneumonia on Children. https://www.unicef.org/indonesia/stories/pneumonia-lombok
[3] Stop Pneumonia, Fighting for Breath in Indonesia, A call to action to stop children dying from Pneumonia. https://stoppneumonia.org/wp-content/uploads/2019/11/Indonesia-12.11.2019-Web.pdf
[4] International Vaccine Access Center (IVAC), Johns Hopkins Bloomberg School of Public Health, VIEW-hub. www.view-hub.org
[5] Gavi, Pneumococcal AMC. https://www.gavi.org/investing-gavi/innovative-financing/pneumococcal-amc/about-pneumococcal-amc
[6] Al Jazeera, Indonesia quells COVID, but is a new wave on the way? 16 September 2021. https://www.aljazeera.com/news/2021/9/16/indonesia-covid-wave
[7] Suwantika et al. Cost-effectiveness and Budget Impact Analyses of Pneumococcal Vaccination in Indonesia, 2019. https://www.hindawi.com/journals/jeph/2021/7494965/
