Identifying the Weak Foundation of Public Health Resilience for National Disaster Policy in Indonesia’s Mid-term Development Agenda 2015–2019: A Policy Content Analysis

Received : August 27, 2019 Accepted : January 17, 2020 Published: May 25, 2020 Abstract Indonesia is one of the most susceptible nations toward natural disasters in the world. Since 1992, approximately 37 tsunami incidents have occurred in Indonesia, with at least 1,244 cases of natural disasters during 2018. Despite the overwhelming impact of disasters on Indonesia, Public Health Resilience, as an approach to disaster countermeasures, has been poorly elaborated in Indonesia’s development agenda (National Mid-term Development Plan (NMDP), or Rencana Pembangunan Jangka Menengah Nasional (RPJMN), 2015 2019). By utilizing the method of policy content analysis, this study aimed to analyze the policy background of Public Health Resilience against disasters in the NMDP 2015 2019 and National Disaster Management Authority (NDMA)’s, or Badan Nasional Penanggulangan Bencana (BNPB), Strategic Plan 2015 2019. The results showed that the NMDP 2015 2019 and NDMA‘s Strategic Plan 2015 2019 lack the scientific background for Public Health Resilience building in Indonesia. Enhancing the scientific background in these plans will enhance focus on evidence-based Public Health Resilience establishment.


Introduction
Indonesia's geographic location in the Pacific's Ring of Fire, which is the most active seismic zone on earth, contributes to the high number of natural disasters that occur in Indonesia. Approximately, 90% of earthquakes globally occur in this Ring of Fire, where the risk of tsunami is exceptionally high. In addition, the world's highest number of deaths caused by the tsunami is recorded in Indonesia. 1,2 The incidence of natural disaster in Indonesia has an increasing trend. 3 Despite the dreadful history of natural disasters, the early warning system of Indonesia is considered ineffective. 4,5 Based on the results of the risk assessment, the total number of people exposed to the tsunami disaster risk is 4,102,406 people in all provinces in Indonesia, with potential losses reaching IDR 879 trillion. 6 The National Mid-term Development Plan (NMDP), or Rencana Pembangunan Jangka Menengah (RPJMN), 2015 -2019 is the third implementation stage of the 2005 -2025 National Long-term Development Plan, or Rencana Pembangunan Jangka Panjang Nasional (RPJPN), which is the guideline for ministries or institu-tions in preparing the Ministry or Agency Strategic Plan and is considered by regional governments for adjusting their res pective regional development plans to achieve national development targets. In accordance with NMDP 2015 -2019, the National Disaster Management Authority (NDMA), or Badan Nasional Penanggulangan Bencana (BNPB), arranged the NDMA Strategic Plan 2015 -2019. The NDMA assists the President of the Republic of Indonesia in coordinating the integrated disaster mana gement planning and emergency activities and in implementing disaster management and emergencies before, during, and after disasters (prevention, preparedness, emergency handling, and recovery).
Strategies implemented before disasters occur aim to decrease people's vulnerability by increasing their resilience. 7 Despite the overwhelming impact of disasters on Indonesia, Public Health Resilience, as an approach to disaster countermeasures, is only mentioned once in NMDP 2015 -2019. The NMDP is also the policy agenda for Indonesia's nationwide development.
This study aimed to analyze the transformation from the concept to the implementation of Public Health Resilience against disasters in Indonesia's development agenda 2015 -2019 and its derived policy for disaster management, NDMA's Strategic Plan 2015 -2019.
The concept of resilience focuses on preparedness, mitigating vulnerability toward catastrophic events, such as pandemics, climate change, terrorism, or even natural disasters. 8 Keim,9 notes that public health is uniquely located at the community level by promoting safety and health to reduce pre-existing health threats, build social capital, and strengthen community resilience. In building resilient communities, eight levers (capacities), such as wellness, access, education, engagement, self-sufficiency, partnership, quality, and efficiency, should be supported; these levers can be applied in disaster preparedness planning. 10 The measurement of community resilience is essential for its operationalization and implementation. Measurement allows communities, states, and the nation as a whole to analyze the implementation of hypothesized links among inputs into the community resilience process and outcomes. These eight levers are in line with the disaster risk reduction values of Sendai Frameworks and Essential Public Health Services for Preparedness and Recovery. 9,11,12 Method Policy content analysis on NMDP and NDMA's Strategic Plan 2015 -2019 was conducted. This study intended to analyze the policy content, specifically about Public Health Resilience, to find alternative solutions for the Public Health Resilience concept of Indonesia's development agenda (NMDP 2020 -2025), especially on its policy background. 13 This study was developed on the basis of validated criteria for policy background analysis, as shown in Table 1. 14 Based on the criterion in Table 1, policy documents were mapped and critically appraised with the supporting literature study. To ensure the consistency of the appraisal and to minimize the subjectivity of this study, the mapping and analysis of the documents were cross-checked among the authors and consulted with policy experts from NDMA and the Indonesian Ministry of Health.

Results
The NMDP 2015 -2019 and NDMA's Strategic Plan 2015 -2019 documents were electronically obtained from the Indonesian Government's official webpage. [15][16][17][18] The obtained documents were further analyzed on the basis of a validated predefined set of background criteria for document policy analysis.
Based on the adopted health policy background analysis criteria14, the summary of the findings is presented as a checklist in Table 2.
Full-term Public Health Resilience is only mentioned

Discussion
Disaster events are a public health concern that affect the social determinants of health within communities with regard to the impacts of such events on communicable diseases, non-communicable diseases (NCDs), and mental health. 19,20 Four categories of communicable diseases in disasters exist, namely, communicable diseases due to contaminated food supply and water, respiratory infections, vector-borne diseases, and communicable diseases due to wounds and injuries. 7,21,22 In the long term, disasters also affect the increasing incidence of NCDs. The declining food production due to the agricultural impact of disasters and inadequate food supply may also contribute to malnutrition and decreased productivity. 21 Psychosocial disorders, such as post-traumatic stress disorder (PTSD), have also been linked to disaster events, where 68% out of 160 disasters during 1981 and 2001 reported PTSD cases. 21 Another study highlights that disasters can potentially cause violence, either selfdirected or interpersonal, due to the personal distress caused by the scarcity of basic needs, powerlessness, and aggravation. 23 Seaman, et al., 8 and Dyakova, et al., 24 define resilience for public health as the population ability to endure, adapt, and innovate thinking and functioning in challenging circumstances within uncertainty or adversity. Public Health Resilience has eight specific goals, namely, wellness, access, education, engagement, selfsufficiency, partnership, quality, and efficiency. 10 Unfortunately, within the analyzed policy documents, these goals are neither mentioned nor clearly elaborated on the basis of definite scientific backgrounds.
Policy background is categorized as explicit when it uses multiple sources on the basis of quantitative or quali tative analysis and is interpreted from multiple sci-entific sources. 14  Within the analyzed documents, in-text citations only mention NDMA's internal institution data, such as Indonesia's Disaster Data and Information, www.bnpb.go.id, and the Indonesian Disaster Risk Index. Hence, the policy with regard to the multiplicity of data resources is unclear. From these internal institutional data, quantitative and qualitative analyses must be conducted, as the policy also stated the conclusion of the data obtained. Neither scientific sources nor observational results were found in documents.
A scientific study is essential to improve the quality of human lives. 25 The lack of scientific evidence within the analyzed policy documents highlights the common problems that policymakers face in arranging the policy; that is, to decode the study results or to discern policy issues into written statements. 26 This problem can be solved by seeking help from external scientific or policy advisers. A knowledge-driven approach in policymaking can utilize knowledge to solve specific problems where scientific approaches with dependable rigor, robustness, and objectivity can be trusted by all. 26,27 A clear scientific background within the policy can also make a clear distinction for other health policy criteria that follow the policy background arrangement, such as goals, resources, monitoring and evaluation, and obligation. 14 Dobrow,et al.,28 also emphasize that the explicit attention to the research relevance of the policy can clarify the role of stakeholders in engagement and feedback mechanisms. In the policy-making process, scientific background is the foundation of any decisions being made. A lack of scientific background providing rationale for the policy means that its foundation is not dependable enough to be trusted by policy actors, including the public, whom the policy is being made for.
Due to time constraints, the confirmation procedure from policy actors and the public is excluded, and the analysis is solely conducted through policy documents. To minimize the potential subjectivity in the research conduct, this study adopted the validated document policy criteria by Cheung,et al. 14

Conclusion
The

Recommendation
For the sake of embedding Public Health Resilience establishment in Indonesia's development agenda, policy makers must strengthen the scientific background of the next period of the Mid-term Development and Strategic Plans for 2020 -2024 to ensure a great focus on evidence-based Public Health Resilience establishment. This problem is potentially solved using external scientific or policy advisers.

Competing Interest
Authors declare that have no competing interests to disclose.

Availability of Data and Materials
The authors have full access to all the data in the study and take responsibility for the integrity of the data.

Authors' Contribution
Gita Miranda Warsito, Meiwita Paulina Budiharsana, and Sharyn Burns participated in the planning, analysing data and reviewing the article drafts. Gita Miranda Warsito contributed in developing the study framework, collecting and analysing data, drafting and reviewing the article drafts. Meiwita Paulina Budiharsana contributed in developing the study framework and reviewing the article drafts. Sharyn Burns contributed in study planning, reviewing and editing the article.