Ensuring Climate is Well Considered When Planning, Developing, and Reforming PHC

Introduction

Climate change has resulted in steadily rising global temperatures, with the world’s 10 warmest years occurring between 2014 – 2022. One adverse implication of increasing temperature is the shift in vector- and water-borne disease patterns—this is especially threatening for Indonesia which carries a triple burden of diseases. The incidence of vector-borne diseases such as dengue fever in Indonesia has increased within the past 20 years, despite the effort to alleviate the issue. Areas that previously had cooler temperatures are at higher risk, such as Bandung, which had the highest number of cases of dengue fever in 2022. Moreover, extreme weather events, such as floods, can increase the risk of water-borne diseases, such as cholera and typhoid fever, especially in warmer and less-developed countries where poor sanitation and hygiene conditions prevail. 

Other harmful consequences of climate change may include both immediate and long-term health issues. It can be heat-related deaths, nutrition-related, well-being issues and socio-demographic inequalities. El Niño is predicted to impact food security, burdening Indonesia’s agricultural sector which makes up 12.4% of the GDP. This imposes greater risks for one out of five children in Indonesia who are stunted. On top of these trends lies the exacerbation of existing health disparities that exist among vulnerable socio-demographic groups. The digression of mental well-being due to the climate crisis is another issue that is less responded to, especially in Indonesia where many people don’t get the services needed. While not yet a threat due to Indonesia’s geographic state, increasing heat-related deaths may pose concerns for the future. This proposal, however, will mainly focus on the communicable diseases related to climate change.

Indonesia is vulnerable to the impacts of climate change, be it due to its high cost to economy and its uncertainty. The estimated cost of climate-related diseases will bear its brunt on Indonesia by up to 1.86% of the National GDP, or equivalent to 137.65 trillion rupiah. This number may grow due to warmer temperatures and the unpredictable fluctuation of weather patterns, while approximately 40% of Indonesia’s people are already vulnerable to multiple climate hazards. Moreover, inpointing how much worse weather catastrophes may get remains complex and more likely to be underestimated. This uncertainty signals Indonesia’s dire need to transform all life-sustaining sectors, including health, with consideration to climate change. Primary healthcare (PHC), as the first contact point between the public and health services, plays an immensely great role in ensuring comprehensive care for all. This research aims to understand the importance of climate change to be considered when planning, developing, and reforming Indonesia’s primary healthcare landscape. 

Methodology 

This research employed a qualitative policy stock take to identify the incorporation of climate change in existing policies governing primary healthcare in Indonesia. The data is sourced from grey literature, including reports and policy documents related to PHC and climate. The policies are compared against the WHO Operational Framework for Building Climate Resilient Health Systems. The objective of this research is to understand Indonesia’s PHC policy landscape and identify how far climate change is incorporated. The research question is to what extent does Indonesia incorporate climate change into its PHC policy? 

The significance of this research is that it serves as a support that is data-driven to reduce the costs of climate-related diseases in Indonesia. The scope of this paper is limited to Laws (Undang-Undang), Ministry of Health regulations (Peraturan Menteri Kesehatan) and related guidelines, and regulations from other relevant ministries. This paper does not consider international regulations and guidelines, as well as technical guidelines from other ministries. The focus is mainly on policy products that have direct jurisdiction over the planning and execution of PHC in Indonesia. 

Discussion 

The State of PHC and the relation to Climate Change 

At the global level, climate change has the potential to exacerbate 58% of prevalent infectious diseases, especially through the notable alteration in the geographic pattern of vector-borne and water-borne zoonotic diseases. AWHO study shows that around 12.6 million (22.7%) deaths in 2012 could be attributed to environmental risks, such as water, sanitation, hygiene, and agricultural practices that allows for vector proliferation and contact between vectors and humans. Moreover, there is an increasing number of studies that found evidence on deforestation and agricultural development linked to the changing in the malaria ecology, suggesting higher incidence of malaria infections that can lead to death. According to the WHO, more than 2 billion people live in countries that experience water scarcity, a situation that is projected to worsen due to climate change and population growth. It is estimated that approximately 1 million people per year die from diarrhoea globally, a preventable disease with appropriate measures. By addressing the underlying risk factors of climate change, the annual mortality rate of 395,000 children under the age of 5 could be substantially reduced. 

The role of Primary Health Care (PHC) as the first point of entry for seeking healthcare services is important in avoiding such deaths from preventable diseases. A case in point is that Indonesia has been actively promoting a primary health care development since 1960s when the 5-year development plan (Pembangunan Lima Tahun or Pelita) mandated to build at least one or two Puskesmas in every subdistrict. Puskesmas were initially developed to provide an equal access to affordable and quality healthcare, especially for those who live in rural areas. By 1979, Indonesia had more than 4,300 Puskesmas facility across Indonesia that focused on providing promotive, preventive and curative care. During the period of 1997 to 2020, Indonesia recorded a remarkable decrease in mother’s mortality rate from 390 to 110 deaths per 100,000 cases.

Over the past 5 years (2016-2021), Indonesia has steadily increased the number of public health centers (Puskesmas) by 5.4% in order to enhance public accessibility. The annual utilization rate of Puskesmas has increased 14% as well, indicating that more people are using Puskesmas for their healthcare. Implementing the new approach of primary care integration (ILP), MoH organizes the primary health services based on the life cycle, along with the integration of the National Health Information System. Furthermore, Indonesia’s dedication to implementing National Health Insurance (JKN) serves as an additional endorsement for the utilization of PHC, where approximately 87% of Indonesian population had obtained insurance coverage in 2021. 

Increasingly, Indonesia’s capacity to effectively deliver PHC is threatened by both supply and demand aspects. On the supply side, resources such as physical infrastructure, health workers, and population coverage are already lacking as is. The current ratio of PHC facilities per sub-district in Indonesia indicates the availability of a minimum of 1 facility per sub-district. However, the distribution is still lacking, with a ratio of 0.29 in the eastern part of Indonesia (Papua) in 2021 which indicates that there are sub-districts in Papua where no PHC facility is available. In regard to human resources, the number of MoH’s nine categories of priority health workers have only been satisfied by 49% PHC facilities across Indonesia. Some areas are also disproportionately low in physicians, as shown by the percentage of PHC facilities lacking physicians in Papua, reaching 49.5%. 

On the demand side, PHC surveillance must be equipped to serve the vulnerable population faced with the implications of climate change. Indonesia may face an increasing trend of diseases such as dengue and other emerging infectious diseases in areas that were previously unaffected, and it will hurt Indonesia’s health system if dealt without appropriate preparation and coordinated responses. In the MoH Regulation No.45/2014 on Health Surveillance, many points were made to include vector-borne and water borne diseases as main surveillance categories. None, however, were made with the basis to respond to the increasing climate change implications. In Cimahi, while the number of dengue fever cases are increasing, the input indicator of vector-borne disease surveillance is still lacking. The human resources capacity is insufficient and the absence of health services participation in the surveillance is becoming the concern of the health office (Dinas Kesehatan). The process of surveillance involves data collection, management, and analysis, which requires sufficient technology and human resource capacity. In Japan, for example, the government has been taking action to strengthen the resilience of its national health system by issuing heatstroke alerts and monitoring outbreak situations of infectious diseases transmitted through insects in endemic regions. Failure to accommodate the needed factors may result in the inefficiency of predicting future disease trends.

Along with strengthened disease surveillance in response to higher and unpredictable extreme climate events, it is also imperative to incorporate enhanced infrastructure measures, particularly the distribution and adoption of climate-resilient PHC physical buildings. Increased hydro meteorological disasters, such as floods, may hamper PHC centers’ capacity to respond during times of disaster. For instance, floods that happened in Jakarta (February 2020), Tangerang (May 2022), and Tangerang Selatan (September 2022) disrupted health services and the use of supporting devices. According to the Indeks Risiko Bencana Indonesia created by BNPB, vulnerability of health infrastructure correlates with the amount of health facilities available. It is also important to ensure health facilities are built in climate-safe areas and the retrofitting of existing health facilities in vulnerable areas.

There are severe implications on fiscal capacity if climate change is not integrated into PHC. Globally, the cost of climate change on health systems is estimated to be USD 2 – 4 billion annually by 2030. The negative impact of climate change in Indonesia’s health sector is estimated to be 3.45% of Indonesia’s GDP). In 2022, Indonesia has spent Rp153.5 trillion on health and Rp112.74 trillion on climate change. This is relatively less than what Indonesia has spent for other adaptation measures such as energy subsidies in 2022, amounting to Rp148.15 trillion in direct subsidies and Rp268.13 trillion on compensation for fuel and electricity. WHO recommends that every country allocates an additional 1% of GDP to PHC; Indonesia is only at Rp5.9 trillion or approximately USD 370,000 dollars, less than 0.1%. 

Other than fiscal implications, many groups of Indonesians are also at stake. Health is a fundamental right that the government is obligated to provide—therefore, the provision of PHC that is integrated to climate change should be done to accommodate the vulnerable groups and people in Indonesia.  Children, pregnant women, and older adults are three of the more climate-vulnerable groups. In Indonesia, children (0 – 14) make up 24% of the population, while the elderly (60+) make up 11%. Even under current conditions, Indonesia’s maternal mortality rate is at 189 deaths per 100,000 live births, while the target in SDGs is less than 70 deaths per 100,000 live births. Sea level rise will also impact coastal communities, which is where around 70% of Indonesia’s population live. Changes at the governmental level are needed to catalyze the policy landscape to support climate integrated PHC. 

Strengthening PHC is therefore paramount as it plays the important preventive and promotive roles, not only in relation to diseases but also decarbonisation. A study on the health sector’s carbon footprint indicates that 4.4% of the world’s greenhouse gas emissions originate from the health sector, originating from patient transport or space and water heating. This number is estimated to be equivalent to 770 coal-fired power plants. Considering the hefty impact the health sector has on the world’s emissions, Indonesia should also plan for the decarbonization of PHC through retrofitting its infrastructure and improving resource management.

Status quo: Current policy is not enough to support the magnitude of this problem 

Several policies and guidelines on PHC implementation and execution exist at the global level. Dating as far back as 2005, the WHO has International Health Regulations (IHR) that serve as the first legally binding international law on health, providing a multi-hazard perspective on health emergencies. The nexus between climate and health was then further recognized in 2008 during the 61st World Health Assembly, through Resolution 61.19 pertaining to Climate and Health. In the implementation of mainstreaming climate into health systems, an example is the Operational Framework for Building Climate Resilient Health Systems by the WHO, released in 2015. In efforts to translate these documents locally, Indonesia has acknowledged the IHR through conducting Joint External Evaluations (JEE) as a preparedness measure to face the next emerging pandemics, but not yet on climate change-related health issues. As the global trend of climate and health continues, Indonesia should strengthen its health systems in order to provide a well-adaptive healthcare as a public good for the people.

Despite the urgency, Indonesia has a long way to go in terms of financial capacity to deliver PHC, especially considering the climate crisis. The 2023 State Budget (Anggaran Pendapatan dan Belanja Negara or APBN) showed that over half (54.5%) of health spendings were allocated to health financing transformation, while a mere 7% was allocated to PHC transformation. Financing for climate mitigation and adaptation in the health sector reached Rp52.4 billion in 2020, approximately 2% (199.9T) of the total health spendings in 2020. While it is a start, the numbers are still lacking compared to other climate-vulnerable sectors. Kementerian PUPR, Kementerian Perhubungan, and Kementerian Perindustrian are the top 3 ministries who have allocated the most for climate adaptation and mitigation within 2018 – 2020. Considering that the health sector is projected to face around Rp6 trillion annually until 2024, there is a dire need to invest in preventive measures. 

The Ministry of Health’s recent Six Pillars of Transformation haven’t considered climate issues as a fundamental issue. Without diminishing the importance of the Six Pillars, specific programs and funding for climate-related health issues are still lacking. The MoH Regulation No. 1018/2011 on Health Sector Adaptation on the Impact of Climate Change, one of the earlier regulations governing climate and health, has recently been replaced with MoH Regulation No. 2/2023 on Environmental Health. However, the integration of climate issues into health remains minimum. In the newly passed regulation - Chapter 44 of MoH Regulation No. 2/2023, there is a mention of strategies such as (but not limited to) strengthening commitment and leadership for climate resilience, strengthening organizational capacity and human resources, and implementation of climate resilient technology and infrastructure have been mandated. Measuring future progress on this would require a comprehensive work plan for climate-health, which hasn’t been seen yet.  

Lack of direction at the national level may translate into disconnection at the local level. The sporadic response to the climate-related health issues of Puskesmas across Indonesia may be related to the limited progress in climate issues and health integration. A study in Padang in 2019 found that the climate adaptation systems, such as drought early warning systems and institutional collaboration related to climate change, in Puskesmas are improving, but doubts that it will be sufficient for the future. While Puskesmas are authorized to set priority programs in their respective work areas, direction from central government is needed to reinforce the importance of instilling climate change concerns. 

The lack of government commitment is in line with society’s lack of awareness. A recent nationwide CSIS survey found that Indonesian youth prioritize social welfare issues, such as the price of groceries and job availability, compared to the worsening environment and pollution. When asked about future concerns, environmental conditions and health remain unpopular compared to social welfare issues. This is a fair illustration of how low climate issues rank amongst other priorities in Indonesia. 

To further understand the consideration of climate change and PHC, this paper includes a qualitative policy stock-take of PHC at the national level. Five classifications of policy products adopted from WHO Guidelines on Climate and Health Systems were employed, which are (1) governance, (2) infrastructure, (3) human resources, (4) finance, and (5) enabling factors (data). The documents were traced to find indicative keywords, including climate (iklim), climate change (perubahan iklim), environment (lingkungan), global warming (pemanasan global), increasing temperatures (kenaikan suhu/temperature), disasters (bencana alam). The substance of the policy products was then analyzed to understand the context of the inclusion of these terms.

After understanding policy products under each classification, there is a general understanding that climate change isn’t used as a basis for planning, developing, or reforming PHC in Indonesia. It is merely used as a supplement toward other main priorities, especially in elaboration on environmental health.  

1. Governance - Climate change’s urgency resulted in the mandate of the Direktorat Jenderal Pengendalian Perubahan Iklim (Ditjen PPI) under KLHK through Permen P.18/MENLHK-II/2015 in 2015. Ditjen PPI is responsible of coordinating the formulation and implementation of policies in climate change control, including mitigation, adaptation, reduction of GHG, amongst others. However, the sectors regulated include the main five emitting sectors as mentioned in Indonesia’s ENDC, which are energy, waste, IPPU, agriculture, and forestry. The health sector is barely touched by KLHK’s mandate, even though climate change adaptation and mitigation are included in its mandate. The main planning agency in Indonesia, Bappenas, is the coordinator for SDGs and reports directly to the president. As stated through Perpres No. 18/2020 on RPJMN, climate resilient development is part of Indonesia’s national priority programs. Bappenas has since released a document on Climate Resilient Development, stating that the health sector would be facing challenges in the rise of vector-based diseases and heat-related conditions. The key ministry for health is indeed the MoH, supported by Kementerian PUPR, Kementerian Sosial, BNPB, BMKG, and BRIN. Therefore, it is inclining to look at regulations by the MoH that govern climate and health. At the national level, it is apparent that the main law governing health, Law Number 17 of 2023, has not yet mainstreamed the concept of climate change as a threat. Terms related to climate change are only used to complement descriptions of environmental health. The definition of environment is used in the scope of livelihoods, and otherwise, sectors outside of the MoH’s jurisdiction. This indicates a disconnect between the technical definition of environment and how climate change is a threat toward the environment. However, this law upgrades its scope on disaster-related health. While not all disasters are related to climate change (i.e. earthquakes, landslides), this is a step forward toward linking multisectoral risks toward health.
2. Infrastructure - Climate resilient health infrastructure has the potential to improve the reliability of primary health service provision. However, our current health infrastructure policy (MoH Regulation No. 40 of 2018) has not yet added climate resilient infrastructure into consideration. The current policy focuses on conducting environmental studies as a requirement to provide health infrastructure, yet overlapping responsibilities between ministries stand. Since the MoH focuses on health, environmental aspects are entrusted to the Ministry of Environment and Forestry. This silo perspective between government bodies on responsibility of environmental considerations may hamper the implementation of climate consideration in health.   
3. Human Resources - Climate-related capacity building for health workers is not yet mainstreamed. Demands for environmental health workers exist, where a few of their job descriptions include waste management and zoonotic disease control. However, the job descriptions are not fully related to their capacity in facing climate change. At the community level, environmental health is included as a PHC program, yet no guidelines on the scope of activities were derived. Most PHC programs are still oriented to other ongoing health challenges such as increasing vaccination rates or tuberculosis.
4. Finance - The allocated fund for health is still curative-oriented. The allocated funds for health programs are only 3.62% of the total allocated funds for healthcare and national health insurance (JKN). The technical funding law of MoH does not explicitly state points related to climate. If any, it only mentions strengthening health and disease control and does not mention communicable disease prevention. Regarding the need to accommodate climate integrated PHC, climate has yet become the main consideration of health financing policy. The MoH has only received budget allocation for climate adaptation which is more of a response than prevention. However, there is one step forward taken in MoH Regulation No. 8 of 2021 on the procurement of solar cells in health infrastructure.
5. Enabling factors - Moh Regulation No. 45 of 2014 sets a foundation for environmental health and communicable disease surveillance but doesn’t relate the two. This is apparent since the policy doesn’t consider the threat of exacerbated trends due to climate change in its background. 

Despite the climate crisis' looming threats, Indonesia’s primary healthcare system is not yet integrated with climate concerns. There are three layers of explanations to consider, which exist at the top, middle, and grassroot level. At the top level is the lack of political direction in mainstreaming climate change into PHC, which can be seen through the results of the policy stocktake that don’t yet acknowledge climate change as an issue. The policies we have are limited to acknowledging climate change, yet no action has been taken to integrate climate response. At the middle level is an issue of coordination between relevant institutions. MoH should be working hand-in-hand with related ministries under the likes of the One Health concept, involving stakeholders of human health, animal health, and environmental health. Supporting institutions such as the Ministry of Finance should also be involved to overcome financial challenges. At the bottom level lies the lack of awareness of climate and health issues at the community level. Advocating for climate-health issues to be present in the policy landscape means having enough people understanding the importance.

Best practices and policy recommendations 

One best practice to implement is the WHO Guidelines on Climate and Health Systems. The operational framework for building climate resilient health systems was published with the urgency of integrating climate into health systems. The framework consists of 10 indicators, which the authors have simplified into 5, namely: leadership and governance; health workforce; integrated risk monitoring and early warning; climate resilient and sustainable technologies and infrastructure; and climate and health financing. Through this framework, countries can assess the current PHC system and measure the gaps.

Leadership and Governance

Good leadership and multisectoral collaboration serve as an anchor for integrating climate change in PHC. Examples of this are found in Norway and Bulgaria, with the existence of a working group between relevant ministries and government agencies. Germany has made space for dialogue on human health and climate change at the governmental level, opening the door for collaboration and innovation. 

Governing policies on mainstreaming climate into health can be done through legislative developments, either through amendment of existing policies or the introduction of new ones. In Austria, the NAS point up the continued examination and amendment of the legal framework, as in regulation on epidemics and infectious disease.

At one point, Indonesia was on track with MoH Regulation No. 1018/2011 on Climate Change Adaptation Strategy in the Health Sector. This regulation was made under the consideration of the MoH as a member of the National Council on Climate Change (Dewan Nasional Perubahan Iklim or DNPI). After President Regulation No. 16/2015 declaring the merge of DNPI to the MoEF, members’ functions became grey areas. The continuation of collaboration efforts for mainstreaming climate health into the health sector was no longer focused. 

Health Workforce

As communicable diseases are becoming more widespread under the changing climate, it is necessary to improve the capacity of the health workforce to respond to environmental risks and treat climate-related diseases. Some countries started to initiate the development of new training materials and modules on specific aspects of climate change, and further education for already qualified health professionals. Belgium details plans to train new students and health professionals about short and long term impacts of climate change on health systems as well as the provision of health care. 

Integrated Risk Monitoring and Early Warning 

Other countries have also started to understand the co-benefits of mainstreaming climate change into health adaptation plans. In efforts for better disease forecasting, Japan is monitoring vector-based outbreaks and issuing heatstroke alerts. At the practical level, Japan is using these forecasts to predict the emergency transport demand. Countries in Europe also use a similar approach to forecasts and early warning systems, such as the MODIRISK Initiative in Belgium with a specific target to eradicate exotic mosquitoes that appear due to shifting weather patterns.  

Climate Resilient and Sustainable Technologies and Infrastructure

Improvements in sustainable technologies and resilient infrastructure is crucial for achieving a better resilience to climate change impacts. The most mentioned infrastructural interventions in NAS and NHS were focusing on the infrastructure capacity to withstand and protect people from the risk posed by climate change. Bulgaria and Germany plan strategies to safeguard health care facilities from the extreme weather, for example, improving building insulation and developing passive cooling systems in hospitals. 

Indonesia details the use of solar cells on PHC’s facilities with MoH Regulation No.8/2021 on Operational Instructions for Health Sector Physical Special Allocation Funds (DAK) of Fiscal Year 2021. Although climate change has been considered, the solar cells on PHC are only aimed at sustainability and do not meet the definition of “resilient”. The attempt to develop a climate change-resilient PHC infrastructure was not effectively defined yet. 

Climate and Health Financing

Sustainable and long-term financing for the climate and health nexus begins within. This highlights the importance of Indonesia’s national budget and its commitment to funding primary health care. The recent decision to erase the 5% mandatory allocation for the MoH could be a weak link if the output-based funding mechanism to replace the mandatory allocation is not set in motion. Even before the erasure of the 5% mandatory allocation, the allocation of the national budget for primary healthcare in Indonesia only reached 0.05%, far below the recommended 1% by the OECD. Due to the lack of commitment at the national level, commitment at the subnational level also prevails. To commit funds for climate-related health initiatives, allocation for national health should be secured first. 

Several arguments are made in regards to the proportion of the budget allocated for health care, one of which suggests health expenditure targets should be at least 5% of a country’s GDP. Countries well over the 5% mark include the United States (16.6%), Germany (12.7%), France (11.9%), Japan (11.5 %), and Austria (11.4%). Korea experienced a growth in health expenditure over the years (4.6% of GDP in 2003 to 8.1% of GDP in 2018) due to increased government policy to expand health coverage. Compared to the average health expenditure of OECD countries in 2018 at the 8.8% mark, Indonesia only reached 3.1%. Higher commitments of budget allocation is essential for wider health coverage.

International support and assistance should be viewed as supplements, but not the main mechanism to gain funds. Financing may be done through multinational development banks, such as what the Asian Development Bank has committed to through different kinds of funds. Other grants are also available. Most available assistance is not through the form of money, but through technical assistance, which can also alleviate the cost. 

Based on the analysis conducted, we propose several steps so that primary healthcare can effectively contribute to reducing the cost of health due to climate change:

1. Consolidating primary healthcare enabling factors such as better multi sector governance and calling for national commitment for coordination through (generating domestic political will):
2. Forming a climate-health specific working group to increase the involvement of cross-ministries and relevant organizations (health and climate research institutions, specialized professional organizations) in health-related climate policy making; 
3. Reviving MoH Regulation No. 1018/2011 through technical guidelines and further acknowledge climate change as a challenge to be addressed in health settings; 
4. Strengthening the coordination with local government and optimizing their role for administering the primary healthcare services in the area. The local government should identify population segments with low PHC distribution and provide climate-resilient PHC infrastructure. 
5. Building and retrofitting primary healthcare infrastructure to be disaster resilient through:
6. Policies supporting the provision of low-carbon infrastructure such as solar cells, energy efficient appliances and lighting, optimized ventilation, among others;
7. Facilitating the retrofitting of PHC buildings and providing the according incentives, specifically through communication with Kementerian PUPR;
8. Strengthening health workers’ capacity to respond to climate-related diseases through:
9. Providing health workers with modules and training to understand the urgency of climate change and its impact on health; 
10. Equipping health workers’ capacity through technical assistance to improve in:
11. Prevention capacities, such as mapping vulnerable communities, disease surveillance, laboratory and diagnostic capabilities, and planning appropriate climate-related health intervention programs, and
12. Response capacities, such as outbreak management and response;
13. Collaborating with international organizations to provide technical assistance or capacity buildings for climate-related health programs and interventions;
14. Further increasing the number of health workers throughout all PHC facilities; 
15. Promoting diverse streams for climate-health financing through:
16. Sustainable and long-term oriented allocations in the annual national and subnational budgets with specific climate-tagged budget for the health sector;
17. International development partners, UN bodies, multinational development banks (MDBs); and
18. Other grants, such as the Green Climate Fund, Adaptation Fund, UN CTCN
19. Supporting the capacity to prevent the spread of climate-aggravated infectious disease through health promotion and surveillance systems through: 
20. Preparing for the increase of climate-related disease by enhancing the use of available weather, disaster, and other related data to predict outbreaks. This should be done through increased communication with national and subnational level offices of the BNPB and BMKG;
21. Constructing early warning systems using data to predict disease trends and uprises of supplies and infrastructure needed to tackle related health challenge;
22. Strengthening of digital health information systems for timely reporting
23. Enhancing subnational surveillance level through building integrated databases including climate-related data.

Conclusion

From the findings, the consideration of climate change in Indonesia’s PHC is still minimal despite its importance and urgency. The acknowledgement of climate change and other related terms in the policy documents are only at the surface level. While environmental health is a crucial part of PHC, its implementation is still limited to the MoH. Overlapping responsibilities concerning the environment are currently still passed over to the Ministry of Environment and Forestry, while Bappenas’ function as a planning ministry also plays a role in the trajectory of climate-health policy. Increased coordination between government bodies are needed to reduce the silo view of the climate-health nexus. It is imperative that future policy products consider climate change as a foundation to solve future health challenges that could be exacerbated by climate change.