Building on health security capacities in Indonesia: Lessons learned from the COVID‐19 pandemic responses and challenges

Abstract As an active member country of the WHO's International Health Regulation and Global Health Security Agenda, Indonesia, the world's fourth‐most populous and largest archipelagic country has recorded the second‐highest COVID‐19 cases in Asia with over 1.8 million cases in early June 2021. This geographically and socially diverse country has a dynamic national and sub‐national government coordination with decentralized authorities that can complicate a pandemic response which often requires nationally harmonized policies, adaptability to sub‐national contexts and global interconnectedness. This paper analyses and reviews COVID‐19 public data, regulations, guidance documents, statements and other related official documents to present a narrative that summarizes the government's COVID‐19 response strategies. It further analyses the challenges and achievements of the country's zoonotic diseases preparedness and responses and lastly provides relevant recommendations. Findings are presented in four sections according to the Global Health Security Agenda capacities, namely epidemiological surveillance (detect capacity); laboratory diagnostic testing (respond capacity); data management and analysis (enable capacity); and the role of sub‐national governments. The COVID‐19 pandemic has been a catalyst for the rapid transformation of existing surveillance systems, inter‐related stakeholder coordination and agile development from the pre‐pandemic health security capacities. This paper offers several recommendations on surveillance, laboratory capacity and data management, which might be useful for Indonesia and other countries with similar characteristics beyond the COVID‐19 response, such as achieving long‐term health security, zoonoses and pandemic prevention, as well as a digital transformation of their governmental capacities.


| INTRODUC TI ON
Health security is defined by the World Health Organization (WHO) as a set of proactive and reactive activities to minimize the impacts of acute public health events that endanger people's health across geographical regions and international boundaries (WHO, 2020a).
The International Health Regulations (IHR) were established in 2005, providing a legal instrument governing the effective and timely response towards outbreaks and other health emergencies that may occur among countries (WHO, 2008(WHO, , 2017. To date, there are 196 member countries that are legally bound by the IHR, which requires them to report to the WHO about public health events (WHO, 2007), as well as establishing capacity for surveillance and response towards health emergencies, including potential outbreaks (WHO, 2020b). Indonesia joined the IHR since it came into force in 2007 and has taken part in global health security responses ever since (Ministry of Health Republic of Indonesia, 2011). Subsequently, the Global Health Security Agenda (GHSA) was established with 29 member countries in 2014, increasing to 65 in 2018 (Ministry of Health Indonesia, 2018). There are eleven GHSA action packages including zoonotic disease control; strengthening national laboratory systems; and workforce development, linking public health with law and multi-sectoral rapid response, which are highly relevant to this paper (Centers for Disease Control and Prevention, 2014). Indonesia has been actively participating in the GHSA and was appointed as chair of the Steering Group in 2016 (WHO, 2016).
The coronavirus disease (COVID-19) is a newly emerged infectious disease that has become a global pandemic impacting many aspects of everyday life (Abebe, 2020;Singhal, 2020). Since the first confirmed case in December 2019 in China, the total number of confirmed cases reached over 172.6 million, causing 3.72 million deaths worldwide by the beginning of June 2021 (WHO, 2021). In Asia, Indonesia has recorded the second-highest number of COVID-19 cases, after India, standing at a total of 1.85 million confirmed cases, and over 51 thousands deaths (idem).
Indonesia faces a unique context as an upper-middle-income country (World Bank, 2019); it is the world's largest archipelagic country and fourth-largest population, divided administratively into 34 provinces and 514 districts/cities, whose each sub-national government has decentralized authority (Central Bureau of Statistics Indonesia, 2013). It also has 1331 ethnic groups, 2500 local languages and six recognized religions (Naim & Syaputra, 2011), all of which present a harmonization challenge for the deployment of any national campaign.
According to a recent report, approximately half of the countries reviewed globally had strong operational readiness capacities in place, in order to respond to potential health emergencies, such as the COVID-19 pandemic (Kandel et al., 2020). In Indonesia specifically, the government responded systematically since January 2020 by creating standardized public health and clinical response protocols (MoH Indonesia, 2020d), which have been revised five times up to April 2021. These protocols aim to provide guidance on five sectors; however, this paper will only review the first three, where data are currently readily available. These sections are as follows: a) epidemiological surveillance; b) laboratory-based response; and c) clinical and clinical data management (corresponding to detect, respond and enabling functions of the health security toolkit). Subsequently, the pre-existing governmental preparedness towards zoonotic diseases is presented as a key element in relation to the health security perspectives and how the system evolved during the COVID-19 pandemic, based on publicly available data, documents, regulations and statements. Capacity building and collaboration between different stakeholders are necessary as the world 'builds back better' in the post-pandemic era. Thus, this manuscript also contains a short section on the role of local governments within Indonesia, their risk assessments and relative contributions, in particular concerning the implementation aspect of centrally disseminated guidelines.

| DE TEC T C APACIT Y: EPIDEMIOLOG IC AL SURVEILL AN CE
Implementation of surveillance-including during the COVID-19 pandemic-is critical to limit disease spread and enable economic and social activities to resume as quickly as possible. Thus, efficient and effective laboratory capacity (Lippi & Plebani, 2020;Tang et al., 2020) coupled with high-quality data-collated and interpretable-is necessary to support analyses, integrated across disciplines and across sectors.
The Indonesian Government's surveillance system is managed by the Ministry of Health (MoH), which has five surveillance subsystems: a) infectious diseases, b) non-infectious diseases, c) health environment and behaviour, d) population health problem and e) health dimensions (MoH Indonesia, 2003). Since 2017, the MoH also has established a permanent Public Health Emergency Operating Centre (PHEOC) unit which is linked to the existing surveillance Impacts • Analysis of the health security capacities and responses provided in this paper might be useful for Indonesia and other resource-restricted countries with diverse and large populations, complex geography or decentralized sub-national authority.
• Multi-sectoral coordination between government bodies, private sector and the community is very important in providing an emergency healthcare response that can be used in the future healthcare provision, such as to achieve long-term health security and systemic digital transformation.
• Sufficient number of skilled human resources remain a pressing challenge to implement the planned and intended future responses on the ground. systems above to prepare for emergency health situations (MoH Indonesia, 2017aIndonesia, , 2019. Prior to the COVID-19 pandemic, the Indonesian government issued an instruction to national and sub-national bodies to collaborate in detecting and responding to zoonotic diseases that can threaten national and global health security, including the routine human, animal and wildlife surveillance (President of Indonesia, 2019).
Such zoonotic disease surveillance initiatives were of limited regional scope; however, their relative success at the local level set the tone for the subsequent pandemic response (Azhar et al., 2010;Hartaningsih et al., 2015). Table 1 describes the chronological order of the MoH responses to the pandemic from early 2020, a month after the outbreak occurred in Wuhan, China. By mid-January 2020, the national government already appointed 22 provinces to prepare the Early Awareness and Response System against COVID-19. The first official guideline on clinical and public health COVID-19 response was released on 28 January 2020 and then was revised five times in alignment with the WHO's guidelines.
Contact tracing and self-quarantine are prominent aspects of outbreak detection and prevention (Keeling et al., 2020;Kucharski et al., 2020;Ruebush et al., 2021). In Indonesia, COVID-19 contact tracing is sub-nationally led and resource intensive. Specifically, by early November 2020, the total number of contact tracers across Indonesia reached over five thousand people (MoH Indonesia, 2020c). Figure 1 depicts the contact tracing process where the tracers submit a daily report with close contacts details through an online system, called 'Silacak', which was established in November 2020 (Bantu Daerah Deteksi COVID-19, 2020).
However, three main challenges were observed. Firstly, data discrepancies occurred between national and sub-national governments, even though the COVID-19 information system for data recording was centralized into the New All Records (NAR TC-19), developed by the MoH. This information misalignment was caused by (i) sub-national laboratories that only sent reports to sub-national health facilities but not to the MoH as well, leading to higher positive cases reported at a sub-national as compared to the overall national level (Nugraheny, 2020); (ii) domicile location discrepancies (i.e. it contained the health facility's address, instead of the patient's) (Nurulliah, 2020); and (iii) staff unavailability in areas of high COVID-19 transmission, resulting to reporting delays and some laboratories reporting only PCR-confirmed positive cases instead of the total number of people tested (MoH Indonesia, 2020a).
The second challenge was the officers' capacity to collect and report real-time data through surveillance systems. At the beginning of the pandemic, there was an insufficient number of trained, human resources to undertake the reporting tasks, with laboratory staff already overburdened with sample analyses, and many embedded within institutions monitoring zoonotic diseases, following slightly different laboratory protocols. Consequently, there was a variable completion rate for the initial sub-nationally derived data, until staff numbers were consolidated. In addition, the initial version of the system recorded data in free text, making data input lengthy and data analysis difficult, before being streamlined and consistency of data input addressed in updated versions (Manafe, 2020;MoH Indonesia, 2020d).
Thirdly, the contact tracing reporting system development, where information was integrated centrally and became interoperable was unable to keep up with the sudden surge in cases during the first wave, although this was addressed in subsequent waves. As a result, some cases incurred delayed recording and reporting (MoH Indonesia, 2020a;Nugraheny, 2020). The exact impact of such a delay is difficult to quantify as it was time-limited and only for some locations; however, it demonstrated that the scalability and flexibility of existing detection capacities could be further improved.

| RE S P OND C APACIT Y: L ABOR ATORY D IAG NOS TI C TE S TING
Rapid and accurate laboratory diagnostic testing has been an essential response component to the current pandemic (Hendarwan et al., 2020;Kubina & Dziedzic, 2020;Shyu et al., 2020). Therefore, the Indonesian MoH regulated the COVID-19 laboratory testing quality standards from the outset (MoH Indonesia, 2020b). In order to include new laboratories in the COVID-19 testing network, subnational governments should propose a laboratory. An examiner then assesses it against MoH requirements and reports the outcome to the National Institute of Health Research and Development (NIHRD). Lastly, the NIHRD creates a network permit, allowing the said laboratory to input data into the centralized NAR TC-19 data system. A similar approach was used successfully in Indonesia for the establishment of a surveillance laboratory network for Avian influenza from 2014 onwards (Hartaningsih et al., 2015).  This caused an additional strain on resources and concerns over data quality (Nashr, 2020;West Java Provincial Government, 2020). Taher, 2020).

| THE ROLE OF SUB -NATIONAL G OVERNMENTS
During the 2012 avian influenza (H5N1) outbreak, the Indonesian MoH involved sub-national governments through a series of consultations to formulate prevention strategies and integrated surveillance of poultry and humans; raising awareness of zoonotic diseases; increasing referral hospital and laboratory capacity; simulated avian influenza response; as well as strengthening research and the Disaster Countermeasures], n.d.; Koagouw, 2020). Sub-national governments were tasked to quality check, monitor and evaluate the submitted reports to prevent any potential data errors so that specific epidemiological zones can be determined, and appropriate actions taken. This was an efficient mode of operation, as it ensured that a general roll-out of guidelines could be achieved to a national standard, while taking into account local specificities and capacities.
Moreover, sub-national governments were able to undertake laboratory, human resources, infrastructure and facility mapping to help the national government measure pandemic response capability. For instance, DKI Jakarta showed a rapid COVID-19 response, based on an unprecedented public-private collaboration by maintaining a 97-strong public and private laboratories network by February 2021. Private sector participation was critical in increasing testing and tracing capacity, as facilitated by local knowledge (Aisyah et al., 2021). In parallel, DKI Jakarta developed an integrated information system that included not only the number of confirmed cases, but also the capacity of hospital beds, distribution maps and area control maps (Government of DKI Jakarta Province, n.d.).
Several other provinces showed similar initiatives, customized to their needs. The Central Java province developed the Jogo Tonggo (Saving Neighbours) application to eradicate COVID-19, utilizing a community-based approach. Jogo Tonggo empowers residents for active participation to protect each other from COVID-19 transmission through citizens associations (Government of Central Java Province, 2020). Jogo Tonggo also allows citizens to report any social problems related to the pandemic (Government of Surakarta City, n.d.).
However, the following challenges emerged within Indonesia's complex decentralized government authorities (Hill & Vidyattama, 2016;Von Luebke, 2007). Firstly, the variation in sub-national capacity due to the decentralized authority and fiscal ability resulted in differences in capacity and human resources between provinces, cities and districts (Lebang et al., 2021). Secondly, the reporting systems developed independently by different subnational governments, persisted and had to be reorganized rapidly and with a substantial resource strain in order to streamline into a national reporting system, facilitating a national-level analysis (MoH Indonesia, 2020a; Nashr, 2020; West Java Provincial Government, 2020). Thirdly, highly varied geographic conditions and different levels of population mobility between rural and urban areas had a significant influence in the implementation rate of the pandemic control measures, in some cases resulting to different interventions and comprehension (BNPB, 2021). For instance, DKI Jakarta introduced a set of measures called PSBB (Tim DetikCom, 2020), while its neighbouring province, West Java, introduced a different policy called PSBM. These different names, abbreviations and measures caused confusion, especially for those who commute between provinces (Shalihah, 2020). This has proven effective in multiple settings for COVID-19 (Crooks et al., 2020;Nunziata et al., 2020) as well as for other disease outbreaks (Barbadoro et al., 2020;McGinnis et al., 2020). More centralized systems might detract from an established sub-national capacity in an effort to respond to pandemics via tertiary level healthcare (Banatvala, 2020). Thus, a balanced approach is needed, as the role of the sub-national government within the Indonesian context remains critical, in verifying and monitoring real-time cases, and implementing public health policies.

| DISCUSS ION
Regarding the capacity to respond, there were severe challenges in the scaling up of the response as the extent of the pandemic became apparent. The challenges included the availability, recruitment and training of staff; guaranteeing the availability of reagents and the adequacy of personal protective equipment (PPE); and capacity sharing within the laboratory network. These challenges were universal and not specific to Indonesia (Bhattacharya et al., 2020;Rasmussen et al., 2020). The effective response within the Indonesian context came from coordinating the agglomeration of different diagnostic laboratories under a single network umbrella.
This approach was successful, however presented integration and harmonization challenges in turn. In effect, this was a similar approach as to the sub-national governments described previously, except the collaboration took place horizontally, that is across governmental departments and agencies. This policy has similarities to the recommendations successfully followed in other settings, where a rapid surge in capacity was needed (Carenzo et al., 2020;Sparks et al., 2021). Particular mention needs to be made to the contribution of sub-national governments who were able to mobilize, train and mentor additional laboratory staff and community volunteers for data input, tracking and tracing (MoH Indonesia, 2020e).
In order to enact an enabling capacity, the agile flow of data and reporting is required. Beyond infrastructural needs, any system would need to be query-able by end-users and connected to networks nationally. This requires interoperability across institutions and sectors in national and sub-national levels. This is urgently needed for pandemic surveillance (Buckee, 2020) and is viewed as a long-term commitment towards the digital transformation in Indonesia. As the national government continues to strengthen the management and real-time flow of centralized data, sub-national governments find themselves as both data generators and end-users. Thus, it is critical to define the role of sub-national governments in the utilization and dissemination of comprehensive, accurate information. if substantial progress is to be achieved.

| LI M ITATI O N S
According to the WHO, high-level operational readiness will allow a timely, effective and efficient response. Achieving readiness is a continuous process of establishing, strengthening and maintaining a multisectoral response infrastructure that can be applied at all levels, which follows an all-hazard approach, and which focuses on the highest priority risks. Operational readiness builds on existing capacities to design and set up specialized arrangements and services for an emergency response.

CO N FLI C T O F I NTE R E S T
None to be disclosed. While two authors are affiliated with Aceso Global Health Consultants Ltd, which is a private company, we declare that this research project does not receive funding from Aceso Global Health Consultants. The company does not have a role in the study design, data collection and analysis, decision to publish TA B L E 2 Summary of challenges and recommendations to build health security capacities in Indonesia

Health security capacity Challenges Recommendations
Detect capacity • Data discrepancies between national and sub-national governments • Officers' capacity to collect and report real-time data through surveillance systems • Capacity of national tracing reporting system to keep up with sudden surge of cases • A balance coordination between centralized national approach and accommodating subnational dynamics Respond capacity • Uneven distribution of laboratories across provinces • A limited number of qualified, laboratory-trained human resources • Oversight alignment and standardization across national and sub-national government structures • Horizontal collaboration across laboratories, owned by different governmental agencies • Enhance sub-national government's contribution to mobilize human resources as volunteers Enabling capacity • Systems integration of many different data sources and data warehouses • The lack of trained human resources for data input • Systems interoperability due to both the institutional and geographical fragmentation • Shifting the view from time-bound project into a long-term commitment towards digital transformation • Enhancing the role of sub-national governments in utilizing and disseminating information or preparation of the manuscript. Dr. Logan Manikam is the director of the company, and Gayatri Igusti is an employee of the company.
However, both of them contributed to this paper on a pro-bono basis.

D I SCL A I M ER
Where authors are identified as personnel of the International Agency for Research on Cancer/WHO, the authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the International Agency for Research on Cancer/WHO.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are openly available in Satgas COVID-19 Republik Indonesia at https://covid 19.go.id/.

E TH I C A L A PPROVA L
There was no ethics approval required for this study, as the data have been released publicly by the government of Indonesia.