IN FOCUS: Hospital beds, oxygen in short supply as Indonesia wages fierce battle against COVID-19
With the pandemic worsening, CNA looks back at how the situation unfolded from one that seemed to be under control, to record cases after the Idul Fitri holiday.
JAKARTA: Donning full personal protection equipment (PPE), Hary Akbar raced his ambulance through the traffic.
It was early July, and the volunteer ambulance driver had just picked up a 56-year-old COVID-19 patient in Tangerang, on the outskirts of Jakarta.
However, the hospital he first drove to rejected the patient as it was out of beds. After scouring Tangerang, he decided to try his luck in Jakarta.
“I was anxious, especially because I had been in the ambulance with the patient for a while, afraid that I could contract the disease. But I wasn’t worried he would die because he was still conscious,” the driver recounted.
After 6 hours on the road and being rejected by 12 hospitals, Mr Akbar and the patient agreed to call it a day and returned to the latter’s home.
The following day, Mr Akbar returned to the patient’s residence, intending to continue with the search.
But the patient had died, breathing his last around 3 hours after Mr Akbar dropped him off.
“I didn’t know because he was still aware when I dropped him home. He could still talk,” he told CNA.
Mr Akbar’s account reflects how Indonesia’s healthcare system has been overwhelmed as COVID-19 cases spike.
After a first wave of cases last year, things appeared to have tapered off by the first quarter of this year as people began to come to terms with what they thought was a new normal scenario.
However, things took a dark turn after the Idul Fitri holiday in May, with new daily caseload records being set repeatedly.
Despite emergency curbs being implemented, hospital beds are lacking and many COVID-19 patients have reportedly been denied treatment, forcing them to self-isolate at home.
Meanwhile, informal sector workers are reeling from the prolonged restrictions.
Indonesia is at the moment recording the world’s highest COVID-19 daily caseload and deaths, and experts are concerned that there may be long lasting damage as the pandemic drags on.
As of Friday (Jul 30), there have been more than 3.3 million cases in the country and more than 92,000 deaths.
MARCH 2020: FIRST CASES EMERGE
When neighbouring countries Singapore and Malaysia announced their first COVID-19 cases last year in January, Indonesia still reported zero infections.
At the end of February, the government budgeted 72 billion rupiah (US$4.97 million) to promote tourism, targeted at those from Europe and America as travellers from China were unable to visit due to a lockdown imposed in their country to curb the coronavirus.
A few days later though, President Joko Widodo announced that two Indonesians had contracted COVID-19.
The caseload grew quickly. In less than two weeks, the country reported its first death linked to COVID-19.
With the number of cases growing, Jakarta converted its 2018 Asian Games Athlete’s Village into a COVID-19 makeshift hospital. By the time it opened doors to patients on Mar 23, Indonesia had over 500 cases.
At the end of March, Mr Widodo announced that he had signed regulations needed for cities and provinces to enforce restrictions to curb COVID-19. He did not declare a nationwide lockdown.
The large-scale social restrictions (PSBB) would allow cities and provinces to shut down non-essential services and limit religious and social activities, subject to the approval of the health minister.
On Apr 10, Jakarta was the first to implement PSBB for two weeks.
Jakarta, which is also the centre of Indonesia’s economic activity, extended the PSBB several times before relaxing certain measures in July, only to reimpose it again in September as the cumulative national caseload breached 200,000.
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In November, the statistics agency said that Indonesia had fallen into its first recession in 22 years. The economy contracted by 2.07 per cent in 2020.
In late December, Jokowi, after earlier expressing disapproval over how some of the ministers were handling the pandemic, reshuffled his Cabinet. He replaced six ministers, among them the health minister, social affairs minister and tourism and creative economy minister.
As cases continued to spike into the new year, the government decided to replace PSBB with curbs called community-level public activity enforcement (PPKM), which allowed local community leaders to impose restrictions in their area without the approval of the health minister.
The national vaccination programme was launched on Jan 13, with Jokowi receiving his first dose of the Sinovac vaccine. Then, he set the target of 181.5 million people, which translates to roughly 70 per cent of the country's 270 million population, to be inoculated by early 2022.
After hitting a record-breaking 14,518 new cases on Jan 30, the number of infections started to decline.
This was followed by what Indonesians then called a period of “new normal”, with many workers returning to their offices. People started to gather and Jakarta’s notorious traffic, which was gone for a few months in 2020, was also back.
MAY 2021: IDUL FITRI SPARKS CONCERN OVER 2ND WAVE
In the lead-up to Idul Fitri, the government announced that there would be a travel ban from May 6 to May 17 to prevent people from going to other provinces to celebrate the end of Ramadan.
Nevertheless, it did not stop people from travelling. Some decided to travel before May 6 or after May 17, while others managed to find loopholes during the travel ban period.
Economic activity was also high in the lead up to Idul Fitri, with many visiting markets to prepare for the festivities.
On May 12, a day before Idul Fitri, the country’s health ministry revealed that Sinovac, which was the main plank in the country’s vaccination programme, was 98 per cent effective at preventing death and 96 per cent effective at preventing hospitalisation among a group of inoculated Indonesian medical workers.
The findings were based on data from about 120,000 medical staff in Jakarta who had received the vaccine between January and March.
A few days after Idul Fitri, Jakarta’s COVID-19 makeshift hospital recorded its lowest occupancy since its inception at 16.22 per cent.
Nevertheless, the government said that it anticipated a hike in COVID-19 cases as last year's Idul Fitri’s holiday led to an increase of about 60 to 70 per cent of infections.
Thus, they added up to 72,000 isolation beds, about 20,000 of which were already occupied before the holiday.
At least 7,500 intensive care unit (ICU) beds were also added, of which around 2,000 were occupied before Idul Fitri.
When interviewed by CNA on Jun 2, health minister Budi Gunadi Sadikin said that the government expected the spike in cases after Idul Fitri to peak by the end of June because based on previous holidays, the number of COVID-19 cases will continue to climb up to seven weeks after the vacation period.
At that time, the daily infections stood at around 5,000 cases, up from around 3,000 around Idul Fitri.
By mid-June, the daily caseload had doubled. And by the last week of June, Indonesia recorded more than 20,000 daily cases, as reports about hospitals being overloaded started to emerge.
Mr Sadikin said on Jun 25 that more hospitals and beds have been prepared in Jakarta to handle the surge in cases.
He also took the opportunity to assure the public that there was sufficient oxygen supply on Java island amid reports that it was about to run out of oxygen.
Mr Sadikin said that of Indonesia’s total oxygen production capacity, 25 per cent is used for medical purposes and the rest is for industries.
DELTA VARIANT FUELS SURGE
This year’s post-Idul Fitri spike in caseload is significantly higher than last year’s and several regions have seen an increase of more than 200 per cent.
Coordinating Minister for Maritime Affairs and Investment Luhut Pandjaitan admitted on Jul 1 that the government did not expect the spike would be so high.
The government has indicated that most COVID-19 cases currently are the Delta variant.
Experts interviewed by CNA believe the highly contagious variant played a significant role in the surge of COVID-19 cases.
Dr Masdalina Pane, head of the Professional Development Division of the Indonesian Association of Epidemiology Experts (PAEI) and member of the national COVID-19 task force said that about 92 per cent of cases now are the Delta variant.
Professor Zubairi Djoerban, head of the COVID-19 task force at the Indonesian Medical Association (IDI) said that the Delta variant is very easily transmittable and more dangerous compared to the initial variant resulting in patients needing treatment at a hospital.
He also noted that antibodies developed by previous strains as usually found in people who had been infected with COVID-19 do not seem to offer much protection against Delta.
“So there are some people who already got COVID-19 but then got reinfected,” he said.
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Dr Pane and epidemiologist from Surabaya’s Airlangga University Atik Choirul Hidajah opined that weak testing and contact tracing exacerbated the condition.
“Because the suspected cases have not been traced, so there is no testing. And if people are not tested, they cannot be treated,” Dr Hidajah pointed out.
HOSPITAL BEDS, OXYGEN IN SHORT SUPPLY
With daily cases regularly breaching the 25,000 mark, the government decided to implement broad emergency community restrictions starting Jul 3 until Jul 25 on the populous island of Java as well as Bali.
Initially called PPKM Emergency but later renamed to PPKM Level 4, people’s movements were restricted according to the sectors that they work in, namely non-essential, essential and critical sectors. All malls were shut while dining-in was banned.
Mr Pandjaitan, who was appointed by the president as the PPKM Emergency coordinator for Java and Bali, said that the restrictions must be enforced as the country had seen a spike in COVID-19 cases of about 230 per cent since the end of May.
The restrictions were later enforced in 15 other regions outside of Java and Bali.
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By early July, hospitals in the archipelago were almost full, said Dr Lia Partakusuma, secretary-general of the Association of Hospitals in Indonesia on Jul 5 in a hearing at the parliament.
On Java island, the bed occupancy rate (BOR) of many hospitals has reached 90 per cent. Thus, people were urged to isolate themselves at home unless they are severely ill.
While the government prepared new COVID-19 makeshift hospitals and added more beds, it also launched free telemedicine services in Jakarta for patients with mild symptoms to ensure they still receive medical care while isolating at home. Those who participated in teleconsultations would also receive free medicines.
Despite the government’s assurance on Jun 25 that there was sufficient oxygen supply on Java island, dozens of patients reportedly died at a hospital in Yogyakarta in early July after it ran out of oxygen supply.
Mr Pandjaitan said at a press conference on Jul 5 that oxygen distribution was hampered due to a threefold to fourfold increase in demand. He asked oxygen producers to fully dedicate their supply to medical needs.
Across Java and Bali, snaking queues were seen at oxygen centres as people tried to buy oxygen for their loved ones who have tested positive.
Some had to buy oxygen because they had family members who were self-isolating at home. There were also others who needed to procure oxygen for their loved ones who were hospitalised as the facilities had no stock.
These oxygen centres, which are mostly run privately, sell oxygen tanks as well as oxygen supply for a refill.
“I have been to two other places, they were all out of stock,” said Mr Faisal, a recently recovered COVID-19 patient, when met at an oxygen centre in Jakarta on Jul 8.
He wanted to purchase oxygen supply for his parents, who were down with COVID-19 and whose oxygen saturation was below 90 per cent.
Speaking at a virtual press conference on Jul 9, deputy health minister Dante Saksono said that Java’s oxygen production capacity was 1,400 tonnes daily, but Java and Bali needed 2,600 tonnes every day.
Indonesia has since received oxygen concentrators from Singapore, South Korea, India and Switzerland.
Under an arrangement known as the “Oxygen Shuttle” programme, Singapore will also send regular shipments of oxygen supplies to Indonesia at its request. More than 500 tonnes of oxygen will be shipped to Indonesia from Jul 19 until August.
Despite these measures, oxygen remains highly sought after, especially when people are self-isolating at home.
Without immediate access to proper healthcare and supervision, there have been cases of people dying at home while undergoing self-isolation, according to non-governmental organisations.
READ: As spike in COVID-19 cases taxes healthcare system, some Indonesians have little choice but to isolate at home
Jakarta-based health think tank Center for Indonesia’s Strategic Development Initiative (CISDI) reported that in West Java province, more than 400 COVID-19 patients died in the first week of July while isolating at home.
Furthermore, citizen coalition LaporCOVID-19 noted that 1,100 people died between June and Jul 30 in 17 provinces, among them were elderly people who died alone at home while isolating.
The health ministry has no data on the number of COVID-19 patients who died at home, but an official with Jakarta’s health agency who is the head of disease prevention and control Dr Dwi Oktavia told CNA that since the end of June, the city has buried about 300 deaths with COVID-19 health protocols every day.
This figure included 30 to 40 daily deaths at home. The capital city’s health agency has so far recorded 1,284 deaths at home.
Meanwhile, the government is trying to address a shortage of healthcare workers.
Authorities are trying to recruit about 3,000 doctors and 16,000 to 20,000 nurses by identifying those who have just graduated or are currently in their final semesters.
In order to prevent more health workers from contracting COVID-19, the government has started to inoculate them with Moderna booster shots.
INFORMAL SECTOR WORKERS BEAR THE BRUNT
It is not just on the medical front that the situation is dire. The pandemic has caused an economic crisis not seen in over two decades in Indonesia.
As of August last year, 29.12 million workers or 14.28 per cent of Indonesia’s total working-age population were affected by the pandemic.
Many employees had their working hours reduced, experienced job loss or reduced wages.
When the economy recovered slightly, the number of people affected by the pandemic fell to 19.1 million or about 9.3 per cent of the country’s working-age population in February this year.
About 8.75 million were unemployed in February, a rise of 26.26 per cent compared to the same period the previous year, according to data from the statistics agency.
In Jakarta where PPKM is currently being enforced until Aug 2, fishmonger Nawawi and prayer clothes seller Mia Daud were among those reeling from the restrictions.
As a seller of basic essential necessities, Mr Nawawi has been allowed to continue to trade at a wet market in South Jakarta. But his income has shrunk dramatically.
“Before this PPKM I could earn five million rupiah per day. But now, sometimes I don’t even get one million,” said the man who goes by one name.
Mdm Daud had to close her shop from Jul 3 to Jul 25, as it was not considered a daily essential service.
“When restrictions were first introduced (last year), I could sell alternatively online or via social media. But during this PPKM, everything had to stop because our market shut down early and I didn’t have the chance to pick up my goods,” she told CNA.
Indonesia lost its status as an upper-middle-income nation this month, just a year after it was classified as one. The World Bank downgraded Indonesia to lower-middle-income status as of the beginning of July, with a gross national income per capita of US$3,870, down from previously US$4,050.
Notwithstanding the downturn, economist Sri Adiningsih from Yogyakarta’s Gajah Mada University believes that economically, the worst is over for Indonesia.
But she noted that the social impact on people’s lives is significant and thus the government needs to provide meaningful incentives when imposing restrictions, especially to micro-businesses.
She said that 98 per cent of Indonesia’s micro, small and medium enterprises are micro enterprises. Almost 90 per cent of those who work in micro, small and medium enterprises are employed by micro enterprises.
“So they are very dependent on day to day economic movements, unlike formal workers who receive a monthly salary.”
“If the economy is stopped abruptly, the impact will be quite huge and the government seems to realise this. So sometimes, it focuses on health, but other times when things have gotten better, they focus on the economy,” said Prof Adiningsih who was head of the presidential advisory board from 2015 to 2019.
Last Sunday, Mr Widodo said that the current restrictions will continue until Aug 2, but several adjustments related to community activities and mobility will be made.
Traditional markets selling daily basic necessities may open as usual while traditional markets that sell other than daily basic necessities, may open with a maximum capacity of 50 per cent until 3pm.
Street vendors, grocery stores, mobile phone voucher agents or outlets, barbershops, laundromats, hawkers, small automotive repair shops, car wash, and similar small businesses are allowed to open until 9pm.
Assistance will be given to micro and small businesses where 3 million new recipients will receive 1.2 million rupiah each.
Moreover, the government will provide fiscal incentives by bearing the Value Added Tax (VAT) of rentals in shopping centres from June to August 2021.
Prof Ardiningsih said that in the best scenario, the economy could grow by 3 per cent this year.
“I don’t think it will be as bad as last year because last year we were still shocked, and initially there was no safety net.”
She said that people have now adjusted themselves to the new normal and have found new ways of getting income if they were economically affected by the pandemic, even though things may not necessarily be better.
“We will begin to develop because we have adapted. The worst is over for the economy. We won't grow at 5 per cent, or 6 per cent, it will take time. But I think we will grow positively gradually.”
"WE WILL SEE MORE PEOPLE DIE": ANALYST
Amid the challenging situation, the government has urged people to remain optimistic.
To curb COVID-19, the government aims to optimise testing, tracing and treatment of COVID-19 patients in Java and Bali starting Jul 26.
The target is to find at least eight close contacts per patient by optimising digital tracing.
The health minister said in early July that it would increase testing and tracing by four times the current rate so that it can test 400,000 cases daily, although as of the end of July, testing remains at around 100,000 to 200,000 cases daily.
Furthermore, the government also plans to set up centralised quarantine centres to monitor patients.
The government is also trying to increase the capacity of ICUs by supplying central oxygen in regions with high fatality rates to reduce deaths.
Meanwhile, the president is continuing to push ahead with more vaccinations.
The national inoculation target has grown to 208 million people since adolescents can now also be vaccinated with Sinovac in Indonesia. Jokowi wants 2 million doses to be administered daily in August.
So far, about 7.5 per cent of the population have received both doses of the vaccines.
Mr Widodo also hopes that 7.5 million people of Jakarta’s 10.5 million residents can be vaccinated by the end of August to reach herd immunity there.
Yogyakarta currently has the highest BOR nationally at 85 per cent. Jakarta's BOR is now 60 per cent.
Despite the measures, public policy expert Agus Pambagio from think-tank PH & H Public Policy Interest Group underlined that the policies need to be clear.
“PSBB, PPKM and then various forms of PPKM, I myself am confused: ‘What is the difference between one from the other? How will it be implemented on the ground?’
“I pity those who need to implement them such as the police, military, public order enforcers, every apparatus, they are confused and people become apathetic,” he said.
Meanwhile, a sociology Associate Professor at Nanyang Technological University Sulfikar Amir said the problem is that Indonesia does not have a permanent mitigation framework for the pandemic.
“So they just come up with new terms, whenever they have a new situation,” Assoc Prof Amir told CNA.
“I am not blaming the government, but in this kind of situation, only the government has the resources, the authority to do everything that we need.”
In the current situation, Assoc Prof Amir believes that the socio-economic challenges are not as worrying as the healthcare situation.
“Maybe there won’t be unrest, but we will see more people die,” he said.
“We will see long damage in terms of public health. Of course the socio-economic impact will be substantial as well because Indonesia is now increasing in debts and it’s going to take years to recover from the economic restrictions which we have now.”
The national debt has crept up from US$403 billion in 2019 to US$414 billion in July this year, according to the central bank.
Finance minister Sri Mulyani Indrawati said earlier this month that borrowing is “an instrument to save our citizens and our economy”.
"We (finance ministry) respond with whatever it takes. Whatever we do to save the people and the Indonesian economy. This step has implications for the state budget deficit," she noted.
Chairman of the Indonesian Health Economics Association (InaHEA) Professor Hasbullah Thabrany noted that rising debt in the current situation is inevitable.
While the debts would eventually be repaid over time given the taxes collected, it may require a long repayment period, he said.
“We can do it in 25 years, but we cannot do it in 10 years. One generation (is needed and) that’s okay, we still have time,” said Prof Thabrany.