Scaling up public health interventions: case study of the polio immunization program in Indonesia

Abstract

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.

How Vertical Global Health Programs Can Contribute to Universal Health Coverage: Service Delivery Implementation Lessons from Polio Eradication

“…( 30)At the community level, integrated health services posts ("Posyandu") delivered polio immunization along with maternal and child health and nutrition, which may have contributed to stronger health service delivery. (30)We found lower odds of identifying polio implementation process as a main internal contributor for strengthening service delivery in Eastern Mediterranean region. For example, in Pakistan, polio supplementary immunization activites were criticized as being disjointed from routine childhood immunization services and other primary health care services.…”

How service delivery implementation strategies can contribute to attaining universal health coverage: lessons from polio eradication using an implementation science approach

“…Some studies showed that SMNet program continued to support routine childhood immunization, and improved primary health care service delivery in Uttar Pradesh, Bihar and West Bengal [ 14 , 17 , 29 ]. In Indonesia, the polio program was integrated in the existing sub-national government institutions for immunization [ 30 ]. At the community level, integrated health services posts (“Posyandu ” ) delivered polio immunization along with maternal and child health and nutrition, which may have contributed to stronger health service delivery [ 30 ].…”

“…In Indonesia, the polio program was integrated in the existing sub-national government institutions for immunization [ 30 ]. At the community level, integrated health services posts (“Posyandu ” ) delivered polio immunization along with maternal and child health and nutrition, which may have contributed to stronger health service delivery [ 30 ]. We found significantly lower odds of identifying polio implementation process as a main internal contributor for strengthening service delivery in Eastern Mediterranean region.…”

What are the barriers and facilitators to polio vaccination and eradication programs? A systematic review

“…Specifically, evidence synthesis of the barriers to and facilitators of polio eradication programs improves complex health interventions [2], especially in resource-constrained settings. Numerous researchers have documented implementation factors with regard to polio vaccination and eradication in the literature [2][3][4][5][6][7]. Systematically reviewing these lessons across nations may be relevant for the formulation and implementation of other vaccination programs.…”