The challenges experienced can be categorized into three main buckets:

1.

Challenges in high-level decision making and corresponding financing for vaccine procurement and delivery

2.

Limitations of existing procurement and distribution systems

3.

Limited confidence in the programmatic feasibility and sustainability of PCV introduction

Each of these required a multi-stakeholder led differentiated approach to resolve the challenges. The section below outlines the learnings from the key approaches that were proven effective between 2017 and 2022 (see Fig. 1).

Fig. 1

Key challenges experienced, and approaches undertaken to accelerate PCV decision making in Indonesia. PCV Pneumococcal conjugate vaccines

Challenge 1: Challenges in high-level decision making and corresponding financing for vaccine procurement and deliveryAction: Practice targeted advocacy for change and effective coordination among key stakeholders

Indonesia was slated to transition out of Gavi support at the end of 2017 and had been ramping up co-financing obligations towards fully self- financing. The cost of vaccine procurement for antigens offered in the routine immunization program was already taking up the highest allocation (22%) of all MOH strategic preventive purchases [2]. While pneumonia was the leading cause of child death, procuring PCV for delivery nationwide will significantly increase the government’s vaccine procurement budget by three-fold [3]. There was significant hesitation among key decision makers on government capacities to allocate and disburse necessary funding to make this introduction possible. Given domestic funding allocations are done on an annual basis (note that this has since been revised, and multi-year planning and budget allocation for health is possible in country, and in nascent stages of implementation at the time of this publishing), there was also high a risk of funding not materializing on a timely basis year-on-year to sustain post-introduction. Indonesia also has a decentralized governance for health suggesting that operational costs for PCV implementation will need to be secured at the subnational level. Coordination between national and subnational stakeholders was fragmented, further adding to the challenges.

To mitigate this, CHAI and partners helped to map expanded set of stakeholders required for introduction decision making and supported with effective coordination. Upon identification of key decision makers, CHAI facilitated regular meetings with the same representatives each for accountability and follow up. CHAI also used the Gavi Transition timeline as a burning platform for the government to consider introducing PCV at a more affordable price while it is still accessible as a Gavi-eligible country.

CHAI then developed multi-year cost projections and annual plans to reflect the national PCV introduction strategy, and helped the MOH visualize gains by conducting a cost-effectiveness study [4]and developing advocacy decks tailored to different audiences. This showcased that PCV is highly cost-effective and also affordable if procured at a certain price. The advocacy materials also highlighted how PCV introduction can reduce overall child mortality, offset the costs of pneumococcal disease treatment endured by the National Health Insurance, and helped Indonesia achieve the Sustainable Development Goals (SDG). By fostering high level government ownership and engagement (within MOH including the Procurement Unit and Planning Bureau; but also across sectors including with the Ministry of Planning, Ministry of Finance, and Office of the President) MOH were able to secure the necessary buy-in and corresponding financial commitment. Targeted advocacy efforts were also conducted at the subnational level to ensure plans and budget for PCV introduction/ delivery activities could be secured ahead of introduction.

Challenge 2: Limitations of existing procurement and distribution systemsAction: Map out and acknowledge the limitations, coordinate relevant stakeholders to jointly navigate the complexities and develop consensus on the way forward

Historically, vaccines procurement for the routine immunization program in Indonesia was conducted locally using the country’s e-catalogue system [5]. Indonesia has domestic vaccine manufacturing capacities i.e., through Biofarma, a state-owned pharmaceutical company that manufacturers and/or imports all vaccines in the EPI program. This strong local preference is mandated through a Ministerial decree, with small exceptions when Biofarma is not able to fulfill MOH request via local production and importation is needed. While this is primarily to ensure supply security as well as to promote scientific and economic development, the government had to decide whether to continue waiting for a domestic product to be ready or to start importing for public health reasons.

As a consequence, there was also limited experience up until then for the MOH in accessing UNICEF Supply Division (UNICEF SD) pooled procurement mechanisms for health commodity purchasing and poor use of global market intelligence on available products, pricing, supply availability and reliability [6]. PCV products were imported and locally available in the private fee-based health service facilities, however the price of which remained around 5 times higher than the global eligible price commitments (USD 20/dose compared to USD 3.5/dose). Hence, securing PCV supplies locally would be very inefficient and severely limit government capacities to introduce and scale up nationally.

Recognizing this challenge, stakeholder consultations were conducted to increase knowledge/awareness, assess the opportunities of procuring through different mechanism, and identify potential risks as well as implications. Through close coordination with global and country partners, CHAI supported the government to navigate complex legal and regulatory policies to execute the new procurement process and successfully access the Gavi Advanced Market Commitment (AMC) mechanism, ensuring advance payment and securing PCV vaccine supplies at affordable prices. Activities implemented include conducting cost-effectiveness analysis of PCV in Indonesia context, comparing UNICEF AMC price with government’s self-procurement price (USD 162 vs USD 747 per QALY gained1); developing cost-projection analysis for accurate estimate of budgetary needs and affordability; facilitating capacity building for MOH staffs on procurement and market intelligence; engaging intensely stakeholders beyond MOH, e.g., Office of the President to increase awareness on the high-impact of PCV program to reduce child mortality and position Indonesia well in reaching SDGs, Ministry of Finance to showcase cost-saving potential of pneumonia prevention through PCV program vs. pneumonia treatment incurred by the National Health Insurance; as well as initiating regular coordination with local manufacturer to understand timeline for potential domestic product so MOH can make informed decision for introduction. In collaboration with UNICEF, CHAI also supported in planning logistics and handling to distribute vaccines to subnational cold chain points.

Challenge 3: Limited confidence in the programmatic feasibility and sustainability of PCV introductionAction: Conduct small scale demonstration projects or feasibility studies to build evidence

Despite strong global evidence, some important stakeholders still needed to be convinced of the benefits of the introduction and its operational feasibility within the context of Indonesia. And concerns were also expressed around country capacities to achieve high coverage for new vaccines, given that the last (and only) new vaccine introduced in recent years was the first dose of Inactivated Polio Vaccine (IPV) in 2016 (note that second dose of Measles and Rubella MR2 vaccine was rolled out between 2017–2018, but unlike IPV this was a switch from MCV2 and in that sense less complex) which reached 66% coverage, thirteen percentage points lower than Penta3 coverage, despite being offered at the same time-point.

To alleviate these, CHAI supported the MOH in executing a demonstration project for PCV in select areas to assess programmatic feasibility. During which, best practices based on experience in other countries were implemented to ensure strong introduction process, e.g., carrying out readiness and post-launch assessments, identifying cold chain capacity gaps. In West and East Lombok where PCV was introduced in 2017, the coverages of PCV 1 and 2 are comparable to well-established Penta 1 and 2, and all coverages are above 80% (see Fig. 2).

Fig. 2

Key recommendations from Indonesia’s PCV decision making experience. PCV Pneumococcal conjugate vaccines