Background

The number of deaths from COVID-19 continues to rise globally, but data quantifying the impact of the pandemic on other major infectious disease burdens in low- and middle-income countries (LMIC) are scarce. Interruption of supply chains, diversion of resources and overwhelmed health systems could have severe collateral effects on existing public health programmes.

COVID-19 control measures, such as lockdowns and patient hesitancy might limit access to and uptake of health care services, affecting diagnostic testing, disease management, vaccine uptake, among others. Models have estimated that in high-burden settings, deaths due to HIV (mostly due to antiretroviral therapy  interruptions) and tuberculosis (mostly due to reductions in timely diagnosis and treatment) could increase by up to 10% and 20%, respectively, over 5 years, compared with if there was no COVID-19 pandemic.

Further, reduced uptake of routine childhood vaccinations, due to temporary programme suspensions or hesitancy, could lead to excess vaccine-preventable deaths. Moreover, it is crucial to define health system factors at the district level associated with lesser or greater resilience to the COVID-19 burden, and to identify those target groups who were more or less affected.

Indonesia is a diverse, middle-income nation, with the world’s fourth largest population (270 million) spread out across the vast archipelago, has unique challenges to reaching universal health coverage through a decentralized health system. Concurrent with growing non-communicable disease burdens, high infectious disease burdens persist, particularly of respiratory infections, diarrheal diseases and tuberculosis.

Globally, it is ranked the 3rd high-burden TB country (~1 million new cases per year; incidence 391/100,000 pop), and it has one of the fastest growing HIV epidemics (~46,000 new cases per year; ~640,000 people living with HIV). Pre-COVID, only 58% of children aged 12-23 months were fully immunized -below the 93% government target.

In Asia, Indonesia has the second-highest number of COVID-19 cases (6.5 million) and deaths (159K), with an estimated 61% excess mortality rate in Jakarta. Concerns have also been raised about the effects of the COVID-19 epidemic and social lockdowns on the government’s health services, but to date no rigorous analyses have quantified the national and district-level impacts on the care cascades for HIV, TB, and childhood vaccination uptake.

To present, there are limited published data from LMIC that quantify the effects of COVID-19 on health services and patient-related outcomes of HIV, TB, and vaccine-preventable diseases, which may compromise long-term individual health and public health objectives. Even fewer studies seek to learn lessons from pre-pandemic district-level health policy and health system readiness that build resilience to significant shocks like COVID-19; lessons that would strengthen resilient health systems in a post-pandemic world.

As Indonesia manages the COVID-19 pandemic, the health system should be bolstered to prioritize efforts to close any gaps in HIV and tuberculosis testing and treatment, as well as immunization coverage.

Aims

This study intends to assess the influence of the COVID-19 pandemic and lockdowns on TB and HIV care cascades and childhood vaccine coverage at the national and district levels in Indonesia, by important risk groups.

In addition, we will describe the policy environment and health system preparation indicators associated with more resilient districts, as well as the most susceptible groups based on affluence, health care access, and other characteristics.

The outcomes of the study can aid in identifying public health priorities and informing creative strategies. Future public health responses can be informed by research on service disruptions and the variables that inhibited those services during the COVID-19 lockdown.

Importance

To date, there are few published data from LMIC that quantify the effects of COVID-19 on health services and patient-related outcomes of the major infectious diseases HIV, tuberculosis and vaccine-preventable diseases, which may set back individual health and broader public health goals in the long-term.

There are even fewer studies seeking to learn lessons from pre-pandemic district level health policy and health system preparedness that foster resilience to major shocks such as Covid-19; lessons that would enhance robust health systems in a post-pandemic world. As Indonesia is managing the COVID-19 epidemic, the health system should be strenghtened to make efforts to catch-up with any gaps in HIV and TB testing and treatment as well as vaccination uptake with the highest priority.

The study findings can help identify public health priorities and inform innovative strategies. Research into service disruptions, and the factors that impeded those services during the COVID-19 lockdown, can inform public health responses to future outbreaks.