Medan, Indonesia – Indonesia officially kicks off its vaccine booster programme on Wednesday, with free jabs for the elderly and those without the means to pay, according to the Ministry of Health.
But the decision to make the majority of Indonesia’s 270 million inhabitants pay for the boosters out of their own pockets has fuelled controversy.
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“Why has the government suddenly come up with the idea of boosters? If it is because the government is worried about waning antibodies, then it is OK as that is relative to the pandemic,” Pandu Riono, an epidemiologist and professor at the University of Indonesia, told Al Jazeera.
“But if it is related to the pandemic, then the vaccines should be free.”
The government has yet to confirm how much the vaccine booster shots will cost, although estimates have circulated online using data from the UNICEF Vaccine Market Dashboard, which lists the price of vaccines across different countries.
Potential prices range from as low as $2.75 for a shot of AstraZeneca to $23 for a Pfizer booster.
“There is talk that the vaccines will be around 300,000 Indonesian rupiah ($21) but in practice, they could potentially charge more in a private clinic so the price could go up to to 1 or 2 million ($70-140) per shot,” Alexander Arifianto, a research fellow at the Indonesia Programme at the S Rajaratnam School of International Studies in Singapore told Al Jazeera.
“Putting a price tag on the booster will add to vaccine hesitancy. The more it costs, the more people will be hesitant to have it.”
Indonesia’s vaccine programme has already had its share of struggles, including a sluggish rollout and vaccine procurement issues.
Only about 117 million Indonesians have been fully vaccinated out of a population of more than 270 million since the campaign began on January 13 last year.
Most people have been given the Chinese-made Sinovac vaccine after Indonesia participated in the manufacturer’s late-stage trials.
There are also large discrepancies in vaccine coverage between different areas of the archipelago.
Populations in Jakarta and Bali are almost fully vaccinated, while areas such as Aceh and West Papua have managed to vaccinate only about 20 percent of residents, according to data from the Ministry of Health.
“I’m not sure that the paid vaccine programme is going to help Indonesia reach a large number of people. With less than 50 percent of [all] Indonesians fully vaccinated, the government needs to encourage the rest of the population to get vaccinated first,” said Arifianto.
With so many people still awaiting the all-important first shots, “Indonesia will continue to be vulnerable”, he said.
He adds that while expecting people to pay out of pocket for the booster is a serious concern, a more pressing problem for the government is sourcing the necessary vaccines.
“Middle-income nations like Indonesia have struggled to get vaccines like Moderna and Pfizer because [the makers of those vaccines] have prioritised countries that can pay upfront quickly,” he said.
When the booster scheme was announced early this month, Health Minister Budi Gunadi Sadikin told the media that Indonesia would need 230 million doses of booster shots and that it currently had roughly half that number in stock. It is unclear where Indonesia is planning to source the additional shots.
On Sunday, Indonesia’s Food and Drug Monitoring Agency authorised the use of Sinovac, Pfizer, AstraZeneca, Moderna and Zifivax, another Chinese-made vaccine, for the booster programme.
The next day, the ministry released a convoluted set of instructions explaining which booster shots people could get based on their initial shots.
Unlike other countries around the world, Indonesia is advising people to stick with a single product – individuals who received two doses of Sinovac have been told they can only have a Sinovac booster, those who got Moderna can only have Moderna and those who got the Pfizer jab only a Pfizer or Moderna booster.
Neighbouring countries such as Singapore and Malaysia, meanwhile, have encouraged vaccine mixing and recommended that those vaccinated with Sinovac have an mRNA booster of Pfizer or Moderna.
Many countries globally have also recommended a mix of shots because it is thought to prompt a better immune response.
In December last year, a study conducted in Oxford in the United Kingdom found that people had a better immune response when they received a first dose of AstraZeneca or Pfizer-BioNTech shots followed by Moderna nine weeks later.
But Indonesia’s policy on boosters may be a reflection of what the government has available and the difficulties it has had with procurement, analysts said.
“If the government can’t source enough vaccines, only giving booster vaccines to priority groups like the elderly looks like a kind of vaccine rationing,” said Arifianto.
“That will create a problem with the rest of the population. This is a huge country with a huge population and an uneven health structure.”
Indonesia has reported more than four million cases of COVID-19 since the start of the pandemic and almost 150,000 deaths, the highest toll in the Asia Pacific.
And while current cases fluctuate between 400 and 500 a day – a fraction of the peak recorded last July – there are concerns about Omicron.
New survey released by @indikatorcoid indicates 55% of Indonesians opposed the govt vaccine booster programme. Likely caused by its cost (since a significant percentage will be delivered by private MDs and clinics on fee-for-service basis) & lack of info about targeted population https://t.co/4LPVMNeY8N
— Alexander Arifianto (@DrAlexArifianto) January 9, 2022
More than 150 people have been confirmed to have the more transmissible variant since it was first reported in Indonesia last month. The majority of cases have been linked to international travellers entering Indonesia, but cases of local transmission have also been detected in cities including Jakarta, Surabaya and Medan.
The arrival of Omicron contributed to the government’s decision to bring forward the start of the booster programme, which was initially supposed to get under way once vaccine coverage had reached 70 percent.
But analysts worry it risks further undermining the existing vaccination programme.
“Maybe some people don’t need a booster but they are worried, so they will pay for it and use up a vaccine,” said Riono.
“In some areas, people have not had their first or second dose. The government should make a rule that only people in areas where 60 or 70 percent of the population has been vaccinated can have a third dose.
“Even then it should only be people in priority groups such as the elderly and people with comorbidities or those who deal directly with the public.”
In the city of Medan, a trainee Catholic priest, Friar Fernando, told Al Jazeera that he was still waiting to hear about a potential booster shot. He preferred not to share his full name.
In the initial vaccination campaign, members of the clergy were given priority because of their interactions with the public.
He said it was unclear who would qualify for a free vaccine this time around.
“As far as I am aware it is only healthcare workers who were considered essential workers this time,” Fernando said. A booster effort for front-line workers begun last July as the Delta wave hit means about 1.3 million people have already had a third shot, most of them healthcare workers.
Before Wednesday’s campaign, survey group Indikator.co.id found that 55 percent of Indonesians disagreed with the concept of booster vaccines, which Arifianto said could be due to cost coupled with a lack of clear public health messaging.
In Medan, student Glory Nainggolan, who is fully vaccinated, told Al Jazeera that she was worried about the effect of a third vaccine on her health.
“I think two vaccines is enough. I’m worried that the side effects will be really strong if I have a third vaccine,” she said. “The side effects I experienced last time were already much stronger after my second vaccine.”
“I think it is unnecessary for ordinary people and boosters should be reserved for healthcare workers who battle the virus on a daily basis.”