|Year : 2022 | Volume
| Issue : 1 | Page : 5-11
Lessons learned from COVID-19 pandemic: Indonesia's perspective
Andi J Tanra M.D., Ph.D , Musfiqoh Tusholehah M.D
Department of Psychiatry, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
|Date of Submission||11-Jan-2022|
|Date of Decision||25-Jan-2022|
|Date of Acceptance||27-Jan-2022|
|Date of Web Publication||26-Mar-2022|
Andi J Tanra
RSP UNHAS Building, 5th Floor Perintis Kemerdekaan Road, Tamalanrea, Km 11, Makassar 90245
Source of Support: None, Conflict of Interest: None
Background: Coronavirus disease in 2019 (COVID-19) pandemic caused by severe acute respiratory coronavirus-2 started in Wuhan and caused a global outbreak, including Indonesia. Indonesia is ranked fourth as the most populous country globally, with disparities in health, socioeconomic, and education. In this review, the authors intend to report the COVID-19 pandemic situation in Indonesia. Methods: We collect the relevant information from various resources such as government official data and press releases news outlets, as well as COVID-related studies based in Indonesia. Results: Indonesia does not have a uniform and one-way disaster preparedness system; this problem can be seen at the beginning of the pandemic where policy changes often occur and confuse the public. This situation has an impact on the high rate of transmission and death due to COVID-19. In addition, the pandemic is forcing people to implement social restrictions that affect people's income. Various efforts have been made by the government to deal with COVID-19, but the results are still not satisfactory. Conclusion: The pandemic of COVID-19 affects all Indonesians, physically, mentally, and economically. Fighting the pandemic is not one man's job; the Indonesian government is required to collaborate with the citizens to conquer the disaster of COVID-19 pandemic.
Keywords: First wave, mental health, public health, second wave
|How to cite this article:|
Tanra AJ, Tusholehah M. Lessons learned from COVID-19 pandemic: Indonesia's perspective. Taiwan J Psychiatry 2022;36:5-11
|How to cite this URL:|
Tanra AJ, Tusholehah M. Lessons learned from COVID-19 pandemic: Indonesia's perspective. Taiwan J Psychiatry [serial online] 2022 [cited 2023 Jan 31];36:5-11. Available from: http://www.e-tjp.org/text.asp?2022/36/1/5/341032
| Introduction|| |
Bhinneka Tunggal Ika from the passage of Sutasoma, which means “unity in diversity,” is the national motto of Indonesia and reflects how vast and diverse Indonesia's archipelago is. As a maritime country, Indonesia has 16,065 islands [Figure 1] and is ranked the fourth for the most populated country, with the majority of the population occupying the island of Java (56.58%) and the island of Papua being the island with the least people (1.60%) .
According to Statistics Indonesia, young people aged 0–14 years old dominate the population with an overall life expectancy of 71 years . As measured by the Gini ratio, Indonesia's level of economic inequality is 0.38 and has not changed much compared to the previous year . According to the Legatum Institute, Indonesia has low living conditions despite good social capital and enterprise conditions and ranks the 57th out of 167 countries .
Inequality of educational opportunities in Indonesia is one of the factors for the low Programme for International Student Assessment score of Indonesian children who rank 74 out of 79 countries ,. The inequality is influenced by various factors, namely gender, government subsidies, education of the head of the household, number of household members, and per capita expenditure. Children living on the island of Java have better educational opportunities than children living in eastern Indonesia due to the distribution of the population, which is followed by the allocation of resources .
A large population requires a large number of health services. The Indonesian health service system adheres to a tiered referral system with pusat kesehatan masyarakat (puskesmas) as the primary health facility. Puskesmas are not limited to curative services but also run promotive and preventive services, as well as involve the community's active rôle in maintaining the local community's health. A referral is made if the case is beyond the competence of the puskesmas doctor or requires more advanced examination, to a secondary service, a general hospital which will be tiered according to the level of competence. This referral system has not worked optimally due to geographical constraints, funding, health resources, and service quality being not equal to the standard, and access to services being unaffordable for some .
According to a report from the Ministry of Health of Indonesia, only 19.97% of puskesmas have a shortage of doctors, and nearly 50% of puskesmas have an excess of doctors. Those under-staffed health centers are located in the provinces of West Papua, Papua, and Maluku. The location of excess doctors is mainly on the island of Java. As for other health workers, nationally, only 15.7% of puskesmas are in shortage of nurses, and 12.91% of puskesmas are short of midwives. Like the distributions of doctors and resources, many health workers are concentrated in western Indonesia . In addition, individuals living in urban areas have a 1% chance of being healthy compared to people living in rural areas. The opportunity is associated with the levels of education and income .
Coronavirus disease in 2019 (COVID-19) is an infectious disease that attacks the respiratory system caused by the severe acute respiratory coronavirus-2 virus. It was initially discovered in Wuhan, China, and spread rapidly throughout the world, causing a pandemic that is still ongoing at this writing as of February 2022. Clinical manifestations may vary from asymptomatic to severe symptoms. In general, the common symptoms are fever, cough, loss of smell (anosmia), and shortness of breath. Detecting viral RNA in throat swab specimens through a polymerase chain reaction (PCR) test is the golden standard for diagnosis. Management of the disease is evolving up to the present time and depends on the stage of the disease .
| The First Wave of COVID-19 Pandemic in Indonesia|| |
The beginning of COVID-19
President Joko Widodo announced the first case of COVID-19 in Indonesia on March 2, 2020. A Japanese citizen originated the transmission who was living in Malaysia to Indonesia (www.straitstimes.com/asia/se-asia/indonesia-confirms-two-coronavirus-cases-president). The government reminded the public to stay calm and alert and decided not to announce the confirmed cases' location to avoid public panic. Still, on March 14, 2020, the government decided to reveal the location. As the daily test capacity was increased, cases began to rise and pushed the government to repurpose the Kemayoran athlete's village as a makeshift hospital for asymptomatic COVID-19 patients. The government formed The COVID-19 national task force (Satgas COVID-19) to speed up handling COVID-19 and serves as the primary reference for management and source of information related to COVID-19.
In early April 2020, the Daerah Khusus Ibukota Jakarta Government imposed large-scale social restrictions (Pembatasan Sosial Berskala Besar, PSBB) for 14 days and only allowed essential workers to leave the house. The central government followed the decision and imposed national scale restrictions in school and workplaces, holidays, religious activities, as well as activities in public places or facilities. The central government also encouraged people not to go on homecoming (mudik) on Eid in 2021 to reduce the risk of transmission. The efforts of the central and regional governments in reducing the number of COVID-19 are increasing rapid tests on citizens, giving incentives for medical personnel, stopping the export of medical equipment, being involved by religious public figures, halting holidays, providing business funding assistance for small and medium-sized entrepreneurs, and increasing national food reserve.
COVID-19 health protocol
The government also involves the community in tackling COVID-19 by implementing health protocols (protokol kesehatan [prokes]) in the form of Five Ms, namely washing hands (mencuci tangan dengan sabun), wearing masks (memakai masker), maintaining distance (menjaga jarak), staying away from crowds (menghindari keramaian), and reducing mobility (mengurangi mobilitas) . Inside the hospital, several policies related to Five Ms are also enforced, such as providing waiting rooms with chairs that are spaced apart, lots of places to wash hands and hand sanitizers, especially at entrances and exits of the rooms or buildings, and barrier in the outpatient clinic consultation rooms [Figure 2], [Figure 3], [Figure 4], [Figure 5].
|Figure 3: Increasing amount of sinks available for hand-washing before entering the hospital|
Click here to view
The government used television, social media, and even billboards to spread the health protocol. In addition to the government, people from various backgrounds also support and spread the protocol, especially on their social media. A study using the partial least squares structural equation modeling showed that the level of knowledge and government announcement positively affected community compliance with health protocols . In gender, women tend to be more obedient to health protocols than men .
Dealing with hoax and misinformation
Hoax and misinformation flourish due to a low level of digital literacy, which hinders people from following health protocols and ultimately contributes to the increased rate of infection. The Ministry of Communications and Informatics of Indonesia urges the public to use their fact-checker webpage at www.turbackhoax.id, which was established in 2017, to validate circulating news . In addition, the people, from doctors, health workers, researchers to community leaders, work hand-in-hand to help educate the people against the circulating hoax and misinformation. A quantitative study that analyzed the content of the webpage at www.turnbackhoax.id from January to June 2020 showed a declining trend due to the government's continuous education and the community itself .
Transparency of cases and death rates due to COVID-19 has made the public panic and flocked to the pharmacy and stocked various personal protective equipment, such as masks, face shields, hand sanitizers, and rubbing alcohol, triggering shortages of supply and rising those prices. The moment was taken advantage of by the hoarders to reap enormous profits. People also bought groceries in large amount at the nearest supermarket when the issue of lockdown was being negotiated by the government. A study that observed the public reaction in the first 48 h after the announcement of the first case of COVID-19 showed that panic buying and perceived risk of covid are related to the level of knowledge .
In early April 2020, all provinces in Indonesia had confirmed cases of COVID-19, and the central government declared COVID-19 a national disaster. The uneven quality standards of the health-care system throughout Indonesia are a liability to face COVID-19. Indonesian health system could not catch up with the explosion in the number of confirmed patients requiring treatment. Hospitals are mandated to prepare isolation rooms, negative pressure rooms, barriers, additional ventilators, and intensive care unit beds in a short time.
Medical personnel and health workers are at the risk of contracting COVID-19, with several puskesmas and hospital services having to suspend the service temporarily for self-isolation which increases the workload of health workers, making them vulnerable to illnesses and burnout. Indonesian Medical Association (Ikatan Dokter Indonesia [IDI]) reported that 159 doctors, 9 dentists, and 114 nurses died from COVID-19. The number of death is remarkable as compared to the ratio of doctors and residents in Indonesia being 1:4000. The death of doctors and health workers means that citizens are at risk of losing the opportunity to get the health services they need.
Since it was first detected, new cases of COVID-19 continued to rise even after one year, and experts stated that tracing and testing were still inadequate. Indonesia could not entirely depend on vaccination program alone to eradicate the virus. This pandemic shows Indonesia's health services gap, with Java Island having the highest number of tracing and testing done compared to other islands. Therefore, the government strives to close this gap by accelerating development, especially for areas of 3Ts (frontier, outermost, and underdeveloped).
Economic impact and social aid
The implementation of social restrictions (maintaining distance and avoiding crowds) decreases community mobility, and this also causes national losses. These losses are difficult to cover if the government does not immediately resolve the pandemic . One of the government's schemes to cope with the economic impact is to provide social aids (bansos), such as delivering necessities, electricity bill relief, and credit restructuring to the affected communities. However, this has not been effective due to problematic distribution, lack of socialization, and unclear complaint lines. The target of social aid receivers affected by COVID-19 is 60% of people in the poverty line, different from the usual year of only 30%. The public also helps each others through fund-raising from various crowd-funding initiatives, such as the website shown at www.kitabisa.com through the hashtag #BersamaLawanCorona. The initiative resulting in around 171 billion Rupiah has been collected from 800 thousand donors, channeled to PPE for health workers, supporting facilities for hospitals or health-care facilities, food and medical assistance for the vulnerable population.
| The Second Wave of COVID-19 Pandemic in Indonesia|| |
In mid-June 2021, the Ministry of Health of Indonesia reported that 82% of specimens in Kudus City tested positive for whole-genome sequencing were delta variant, following the researcher's hypothesis, which stated that the increasing infected patients in Kudus City were related to the presence of this variant. The delta variant was first identified in India in December 2020 and has been causing a drastic increase in cases and spread rapidly to other countries. This variant has been classified by the World Health Organization (WHO) as a “variant of concern (VOC)” because it has a high transmission rate, stronger binding to receptors on lung cells, and potential reduced response to monoclonal antibodies .
The satgas COVID-19 stated that the pandemic in Indonesia entered the second wave marked by confirmed cases of COVID-19 that reached 54,000 people daily and a record-breaking of 1205 deaths by mid-July, surpassing the peak of cases that occurred in January and overtaking India as a new epicenter. The cause of this spike in cases is multifactorial, including:
- The policies related to COVID-19 are unclear at best. Differences in policies between the central government and regional governments have confused the people.
- The 3T (testing, tracing, and treatment) efforts are more intensive in big cities with adequate resources compared to the district and rural levels. Therefore, the number of COVID-19 infections may be higher than that of official data show.
- Government is in a dilemma with the economic downturn when prioritizing the pandemic because there is always the threat of a recession await.
- Widely circulated hoaxes and misinformation motivate people to disobey health protocols, also due to economic difficulties, and the low level of literacy makes people not fully aware of the dangers of violating health protocols.
Hospitals are functionally collapsing because overloaded with the drastically increasing infection rate, according to the chairman of IDI, Adib Khumaidi. The collapse is indicated by the bed occupancy ratio (BOR) exceeding the standards set by the WHO, medical devices and medicines (especially oxygen) are depleted, and health workers are tired to the point that some hospitals set up temporary emergency ERs using tents to accommodate patients with substandard medical equipment. The government continues to remind the public of implementing health protocols to reduce the infection rate in this second wave and prioritize oxygen production to meet medical needs of 800 tons per day.
New social restriction measure
The government replaced the PSBB with public activity restrictions (pemberlakuan pembatasan kegiatan masyarakat, PPKM) which has stricter rules than PSBB. This rule was initially enforced in Java and Bali and was followed by several other big cities. The details of the rules are:
- Offices in nonessential sectors must implement 100% work from home (WFH); for essential sectors, they are allowed to work from the office (WFO) with a maximum of 50% of employees by implementing strict health protocols. Critical sectors include finance and banking, capital markets, payment systems, information and communication technology, non-COVID-19 quarantine handling hotels, and export-oriented industries.
- The critical sector is allowed to WFO by implementing strict health protocols. These vital sectors include the fields of energy, health, security, logistics and transportation, the food, beverage, and supporting industries, petrochemicals, cement, essential national objects, disaster management, national strategic projects, basic utility construction, and the industry to fulfill basic needs of the community.
- Educational activities are strictly online.
- The operating hours of supermarkets, traditional markets, and grocery stores are limited to 20.00, with a maximum visitor capacity of 50%.
- The operating hours of pharmacies and drug stores are allowed to 24 hours.
- Activities in shopping centers/malls/trade centers are temporarily closed.
- Restaurants, cafes, street vendors, hawker stalls located in separate locations or shopping centers/malls may only provide delivery and take-out services and are prohibited from accepting dine-ins.
- Construction and project sites may fully operate by implementing strict health protocols.
- Places of worship such as mosques, prayer rooms, churches, temples, monasteries, temples, and other public places that function as places of worship are temporarily closed.
- Public facilities, public parks, tourist attractions, or other public areas are temporarily closed.
- Art and cultural, sports, and social activities such as museums and sports facilities are temporarily closed.
- Passengers of public transportation, mass transportation, conventional and online taxis, and rental vehicles are limited to a maximum of 70% of passengers by implementing strict health protocols.
- A maximum of 30 people attends a wedding reception by implementing strict health protocols and not providing meals.
- Domestic travelers using long-distance transportation (airplanes, buses, and trains) must present a vaccine certificate for at least the first dose, as well as an H-2 negative PCR test for aircraft travel and an H-1 negative antigen test for other long-distance transportation.
- Masks are mandatory when doing activities outside, and wearing a face shield without a mask is prohibited.
The government officially started the COVID-19 vaccination program on January 13, 2021, with President Joko Widodo was the first recipient. This program targeting 70% of the population of around 181 million people and requiring approximately 363 million vaccine doses. The vaccination program is divided into four stages of recipients, namely :
- Stage 1: health-care professionals, health assistants, supporting staff, and medical students.
- Stage 2: public officers (military, police, law enforcement officers airport/port/station/terminal officers), banking sector workers, state electricity companies regional drinking water companies, community service officers, and the elderly (> 60 years).
- Stage 3: vulnerable population (geospatial, social, and economic).
- Stage 4: general public.
Vaccine developers used in Indonesia and received emergency use authorization from Badan Pengawas Obat dan Makanan - Republik Indonesia (BPOM, Indonesian Food and Drug Administration) include CoronaVac, Novavax, Pfizer BNT, Sinopharm, AstraZeneca, Sputnik V, and Moderna. All vaccines are given in two doses except Novavax, spaced according to the recommendations of their respective developers (www.kesmas.kemkes.go.id).
Many health workers have been infected and died from COVID-19; therefore, the government has added a third dose of booster vaccination from the developer Moderna starting mid-July 2021 to strengthen the immune system of health-care professionals [Figure 5]. One hundred million injections have been given to various Indonesians, with 30% of the first dose of vaccine, 17.3% of the second dose, and 43.6% of the third dose of vaccine for health workers.
In collaboration with the Ministry of Health of Indonesia and the COVID-19 handling committee and national economic recovery, the Ministry of Communications and Informatics of Indonesia launched the PeduliLindungi smartphone application to facilitate surveillance, trace cases, and isolation. In addition, the government is also testing the adjustment of community activities by screening quick response codes before entering crowd centers or transportation facilities [Figure 6]. PeduliLindungi also includes vaccination status, vaccine certificates, COVID-19 test results, and contact history with COVID-19 patients.
|Figure 6: A quick response scan to limit the crowd before entering a shopping mall through PeduliLindungi phone application.|
Click here to view
A survey on vaccine receipts conducted by the Ministry of Health of Indonesia in September 2020 with 115,000 respondents from 34 provinces indicated that two-thirds of respondents wanted to be vaccinated. The reasons respondents doubted were related to its safety and effectiveness, lack of trust in vaccines, and problems regarding the halal status of vaccines . One of the efforts to increase the vaccination rate and suppress the spread of COVID-19 is to impose mandatory vaccines for travelers and show proof of vaccination in the form of a vaccine certificate and negative result of the COVID-19 PCR test at least 48 hours before departure.
| Mental Health Tolls|| |
The pandemic has an impact not only on physical health but also on mental health. Data from self-reported questionnaires of 4010 participants in the Indonesian Psychiatric Association (Perhimpunan Dokter Spesialis Kedokteran Jiwa Indonesia, PDSKJI) webpage at www.pdskji.org showed that in the first five months of the pandemic, 65% admitted to experiencing anxiety symptoms, 62% depressive symptoms, and 75% experiencing trauma. One in five participants admitted that they had be better off dead. Seeing this phenomenon, it is natural that symptoms of anxiety, depression, or trauma are significantly higher because of the dramatic news and blowing things out of proportion, new disease with fast transmission and no known cure yet. In addition, with the implementation of social restrictions, people are forced to WFH, there are even several types of businesses such as entertainment and tourism that have to close their businesses because of this regulation. Learning from home brings its own problems for children and parents, parents are forced to become teachers to accompany children, even though they have no teaching experience, and children feel pressured, resulting in decreased learning performance.
The result is in line with a study conducted by Anindyajati et al., which showed one in five Indonesians might experience anxiety during the early onset of the pandemic, especially in women, low education level, unmarried, unsatisfactory support system from family and coworkers, what is interesting from this study is that health workers have a low risk of experiencing anxiety due to COVID-19 due to high knowledge about symptoms and prevention .
In contrast with Anindyajati et al.'s findings, Pabilang and Tanra reported psychological impact that affecting the health-care workers. A study on 68 nurses in the COVID-19 isolation ward showed that 45% of participants had poor stress resilience due to work in the COVID-19 ward and causing significant psychological distress . The differences between these two studies can be influenced by various things, in a previous study done by Anindyajati et al., the research subjects were the general population, in contrast to Pabilang et al. who only included HCW as research subjects. Although HCWs have a lower risk of anxiety than the general population, this does not reduce the fact that COVID-19 affects the anxiety level of society including health workers.
A study on residents in the Medical Faculty of Hasanuddin University, Makassar, showed that a history of psychiatric disorder dan COVID-19 survivor is significantly vulnerable to experiencing stress and anxiety related to COVID-19. Junior residents have higher stress levels than senior residents. One of the things that might contribute is that the junior residents are going through an “adjustment phase” to their new residency situation. Weekly workload of > 40 hours is also associated with high stress levels, especially at the peak of waves I and II. Residents' perceptions of the availability of PPE also affect the level of anxiety because the residency system in Indonesia is not hospital-based but university-based, therefore residents are not considered hospital staff, and hospitals are not required to provide PPE for residents on duty, especially at the beginning of a pandemic where the availability of PPE is still minimal .
The government has published guidelines for psychosocial support in the COVID-19 pandemic to build community resilience but unfortunately, only a small percentage of health workers know this. In addition, the central and regional PDSKJI also provides free psychosocial assistance for the public in offline or online setting through various social media platforms (covid19.go.id). There are many accessible and affordable telemedicine services from multiple mental health professionals such as psychiatrists, psychologists, counselors, and social workers . Unfortunately, all of these privileges are limited to only small percentages of Indonesian, the rest could only wish due to geographical settings, limited smartphone ownership, limited internet coverage, and low socioeconomic level.
| Conclusion|| |
The disparities in Indonesia's health, economic, and education systems are increasingly visible in the face of the COVID-19 pandemic and serve as a difficult barrier to overcome the pandemic. The government needs to strengthen the formation of data-based policies, and in addition to that, well-establish policy dissemination is also required to ensure good implementation. Bhinneka Tunggal Ika's motto is relevant now more than ever, where the government needs to work together with the Indonesian people to conquer the COVID-19 pandemic.
| Financial Support and Sponsorship|| |
[TAG:2]Conflicts of Interest[/TAG:2]
The authors declare no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]