Measuring Indonesia H1N1 Pandemic Preparedness through Stakeholder Analysis

Preparedness activities for the outbreak and pandemic of emerging infectious diseases in Indonesia were carried out after the 2003 SARS threat. The first confirmed human laboratory case of H5N1 was found on July 2005 in a 38-year-old man living in the outskirts of Jakarta. Cases quickly began to mount with numerous poultry dying of the virus. Indonesia quickly became the center of the H5N1 pandemic-only Vietnam reported more human cases [1].

disseminate this pandemic situation, leaflets and posters were printed and distributed, radio drama series and talk shows were aired, hygiene kits were handed out to families traveling, and so forth [4,6].

Methods
Stakeholder analysis is a systematic method to collect and analyze important information from stakeholders to help develop strategic plans for promoting their cooperation in influenza pandemic preparedness/ response. Stakeholders are key informants who consist of five broad groups: major international health organizations, key national/regional policy makers, health systems, major opinion leaders, and private sectors.
Eighteen qualitative interviews have been conducted to collect stakeholders' viewpoints and opinions through open-ended and discovery-oriented questions designed to make them fit with our analysis purposes. Adjusting to different characteristics of stakeholders, two sets of slightly modified questions were composed. Prior to the interviews, stakeholder analysis toolkit which specially designed for ensuring effective interviews was developed. During interviews, stakeholders had to reflect on their perspectives, personal experiences, or undocumented local knowledge. The result is first-hand information focusing on stakeholders' own capacity strengths, gaps, and constraints regarding influenza pandemic control.
In addition to interviews, we also gathered and examined secondary information, including newspapers, published/unpublished reports, and conference papers. These were utilized to provide broader insights and background knowledge on H1N1 pandemic preparedness/ response, particularly in Indonesia. (Table 1) Governance and organization Komnas FBPI (NCAICPP)    to the public through its media and communication center. Komda FBPI as local commissions will channel national commands to and coordinate with provincial, district, or city administrators in their respective regions to discuss policy application and make necessary adjustment to local situations. The commission structure is shown in Figure 2 [7][8][9]. By the middle of 2008, Komnas FBPI has carried out strategies showed in Figure 3 [3,8].

Border control
National measures were taken after WHO raised pandemic alert level to phase 4 in April 2009. The Minister of Health (MoH) ordered thermal scan to be conducted in international airports (including Banten's Soekarno-Hatta and Denpasar's Ngurah Rai) and alerted 100 referral hospitals for pandemic attack [4].
The MoH also announced initiatives to improve standard pandemic response procedure and health alert system. All strategic international airports and seaports must conduct a more rigorous health inspection and be equipped by thermal scanner and body cleaners. Health alert cards must be provided in border posts and given to all air passengers arriving at Indonesian international airports [10]. Passengers were detected, inspected, and observed by airport doctor. If suspected, then they were given Tamiflu and sent to referral hospital for isolation. Their blood samples were then dispatched to National Institute of Health Research and Development (NIHRD) Jakarta for further laboratory testing [11].  Hospital, 6 were positive H1N1 cases while the remaining was only Influenza-Like Illness (ILI) [12].

Case management
Komnas FBPI adopted WHO's H1N1 standard case management, which is nevertheless rather difficult to carry out due to its similar symptoms to influenza or ILI [12]. The scheme starts with thermal scanning of all passengers before departure or upon arrival at an airport. If detected, they would be brought to airport health office and examined by a physician. If rendered as H1N1 suspects, then they would be given Tamiflu, sent to a designated referral hospital, and put in an isolated room. Their blood specimen would be taken for laboratory examination. If the result was negative, they would be released, but if H1N1-positive, isolation would continue. The hospital would then report the case to the Directorate General Centers of Disease Control and Environmental Health (DG CDC EH) for further action [13][14][15].
Due to the large number of suspected people and relatively minor prevalence of H1N1, many passengers complained about these procedures. Therefore, several weeks after the number of suspects reached 1000, the procedure was eased and airport physician was given a full authority to give Tamiflu and refer suspected patients based on individual consideration. The procedures constantly changed and by the end of 2009 no confirmed H1N1 case had been found. It was also decided that persons in contact with the patient were not necessarily be given Tamiflu; maintaining distance with patients was more important [10,16].

Information, Education, and Communication (IEC)
The IEC strategy has been carried out since 2006. In terms of information, the Komnas FBPI has disseminated several different messages using flyers, pamphlets, T-shirt, key chain, travel bag, watch, and other merchandises. In terms of communication, all messages related to influenza pandemic preparedness/response were delivered through television, radio, puppet shadow performance, drama, and others. In terms of education, the channels were mostly public and private schools, women organizations, farmer groups, Islamic schools, local leaders, journalists, community groups, wet market vendors, private companies, and so forth [7]. Workshop was the most effective forum to educate them, while simulation of pandemic preparedness/ response in upcountry would give practical benefits for the community involved [5,17].

Surveillance
There are two surveillance systems: (1) routine ILI (Influenza-Like Illnesses) and SARI (Severe Acute Respiratory Infection) surveillances, and (2) continuous surveillance of human H5N1 case. ILI surveillance is carried out in health centers, started in 2005 with only 20 ILI sentinels, while SARI surveillance is conducted in 15 hospitals; both are now covering some Indonesian provinces [11,18]. However, H1N1's relatively minor symptoms make it treated differently with H5N1. The surveillance results during H1N1 pandemic in Indonesia until September 2010 showed that: [10,16].
b. Cases were found in 25 provinces out of 33 provinces in Indonesia.
e. 54% of confirmed patients were male.
g. 78.7% of cases had no history of visiting other countries.

Antiviral strategy
Antiviral drugs have already been part of national policy since 2006 when Indonesia was threatened by a high number of lethal H5N1 human cases. In 2006/2007 and 2008 the MoH distributed, respectively, 16.5 million and 2,950,000 capsules of Tamiflu/oseltamivir to more than 8,800 health centers, 44 referral hospitals and other public hospitals, airport health offices, and sub-section of Disease Control and Environment Improvement in all 33 provinces and 404 districts/ cities throughout Indonesia. In 2008, Japan International Cooperation System (JICS) and ASEAN also bequeathed 1,962,400 stockpile of Tamiflu to Indonesia.
Actually, due to the apparent decrease of H5N1 cases in Indonesia, the MoH was reluctant to purchase more Tamiflu/oseltamivir to avoid overstock and early expiry date. However, alarmed WHO's declaration of H1N1 pandemic and its prevalence in Indonesia, the MoH finally decided to purchase 850,000 capsules of Tamiflu by using emergency budget in the very same year. WHO also assisted Tamiflu provision in Indonesia in two stages: in May and December 2009 with 2,500,000 and 1 million capsules respectively? This huge number of medicines plus the 2008 additional stockpile were then distributed in July and December 2009 to the same targets with the number of referral hospitals expanded from 44 to 100.

Vaccine strategy
No vaccine policy was instituted by the MoH except the hajj pilgrims who were required to get seasonal influenza vaccination before fulfilling their final religious duty. Some private companies in Indonesia also required their employees to get seasonal influenza vaccination.
Indonesia, Eijkman Research Institute, and Biopharma Company to develop H1N1 and H5N1 vaccines by using virus strain already found in Indonesia [3,18].

Discussion
In order to deal with H1N1 pandemic, all of ASEAN countries have already developed their national pandemic plans after H5N1 outbreaks began in 2003. Massive support on technical and financial has been provided to ASEAN countries, especially those that have been severely affected by H5N1, such as Indonesia, Vietnam, Thailand, Cambodia and Lao PDR. One of the most important responses to mitigate the impact of pandemic (H1N1) 2009 is the surge capacity in the healthcare system. The lack of healthcare facilities and personnel in several Southeast Asian countries could be a limiting factor for early treatment.
In Indonesia, NCAICPP in collaboration with the MoH, has made careful preparation for overcoming H5N1 pandemic. Despite of this, ILI and SARI surveillances conducted in January-July 2010 revealed that H1N1 and H5N1 threats remains prevalent with no certainty over the potential re-assortment of both viruses. This stakeholder analysis has obtained existing strengths, gaps, and constraints on important components of pandemic preparedness/response in Indonesia, including the aspects of organization and governance, resources mobilization, communication challenges, and hypothetical scenarios.
In terms of organization and governance, Indonesia already has NCAICPP with its 10 strategic plans. Nevertheless, this commission lacks of direct access and authority to carry out those programs, so its capacity cannot be optimized. Moreover, some stakeholders recognized weak leadership qualities, which may prove a hindrance to combating H1N1 pandemic in Indonesia.
Despite being handsomely charted on paper, Indonesian health system suffers from weak implementation, most likely because of unqualified human resources and inflexible budget during pandemic response. Budget allocation for health emergency is reasonably high, but inflexible bureaucracy and regulation have made disbursement slow. Health manpower is not equally distributed and few are welltrained in pandemic preparedness/response. Facilities for pandemic response are not equitable and inefficiently utilized. For example, top referral hospitals own sufficient facilities, whereas some district hospitals lack of them. Equipment for detecting ILI in the international airport health offices is still inadequate, whilst relatively minor material like body cleaners are provided excessively. Antiviral drugs stockpile is available despite not meeting WHO's recommended level of 25% of the population, a costly standard which Indonesia is unable to reach.
Despite having no vaccination policy, Indonesia has tried to develop the vaccine by facilitating collaboration between reputable scientific institutions. Although some referral laboratories have relatively adequate resources, the smaller ones must content with limited facilities mainly supplied WHO and CDC Atlanta, especially RT-PCR test primers.
Previous experiences with H5N1 have provided Indonesia a better organization and governance system, specifically trained workforce, and comprehensive stock of equipment, drugs, and facilities to overcome H1N1 pandemic. Nevertheless, some notable constraints and gaps between plans and implementation of H1N1 pandemic preparedness/ response were also reported to have decreased its strengths. For better influenza pandemic anticipation in the future, the MoH and its commission must generate a wider coverage of intensive, regular, and integrated ILI and SARI surveillances to ensure accurate and early warning data.