Introduction
By the end of 2024, COVID-19 had resulted in over 777 million cases and over 7 million deaths worldwide.1 The COVID-19 pandemic profoundly disrupted health, social and economic development worldwide.2 It is regarded as the second most critical pandemic in modern history after the 1918 influenza pandemic.3 Less than a year after WHO declared COVID-19 a pandemic, the first COVID-19 vaccines were rapidly developed and distributed.4 Widespread COVID-19 vaccination has yielded major health and economic benefits, preventing new waves and variants.5 A modelling study estimated that between December 2020 to December 2021, COVID-19 vaccines averted at least 14.4 million deaths globally.6 Conversely, inequitable vaccine allocation risks exacerbating viral evolution, sustaining transmission7 and causing preventable deaths and morbidities.8
Corporate control of manufacturing and advance purchase agreements by wealthier countries created major inequities in global vaccine access.9 Months before vaccine approval, high-income countries (HICs)–14% of the global population–had preordered over half of early supplies.10 By mid-August 2020, the USA, the UK, the EU and Japan had each secured hundreds of millions of doses, far exceeding their population needs.11 Limited global manufacturing capacity further delayed access in low-income countries (LICs).12 By end-2023, primary dose coverage in HICs (75.08%) and upper-middle income countries (76.88%) was 1.3 to 2.8 times higher than in lower-middle income countries (58.84%) and LICs (27.63%).13 Inequities also occur within countries, often disadvantaging vulnerable populations. In LMICs, such disparities are evident between rural and urban populations and across socioeconomic levels.14 In Indonesia, despite the Ministry of Health (MoH) reported that 74.53% of the targeted population had received primary doses nationwide by October 2023, several provinces remained below 50%.15
Early vaccine allocation was constrained by limited supply, with governments struggling to contextualise prioritisation further delaying responses, causing preventable disabilities and deaths among vulnerable groups.16 While the WHO issued allocation guidance, implementation varied across countries due to political, economic and contextual factors.16 Defining and prioritising ‘vulnerable populations’ remained an enduring point of policy discussion.17 This paper outlines Indonesia’s experience and lessons for strengthening vaccine equity, emphasising the role of national governance and delivery capacity alongside global efforts.
This study employed document analysis using secondary sources, given the limited data and peer-reviewed publications on COVID-19 vaccine equity in Indonesia. We conducted purposive searches of publicly available government and institutional documents, complemented by snowballing and reference tracking, using combinations of keywords, including ‘COVID-19 vaccination’, ‘vaccine equity’, ‘vulnerable group’, ‘distribution’ and ‘immunisation policy’, in both English and Indonesian. Sources included government policies, official reports, civil society publications, mainstream media, academic articles and reports from international development agencies from 2020 to 2023. Documents were included if they provided substantive information and excluded if not relevant or insufficiently detailed. Data were analysed using thematic analysis through iterative reading and inductive categorisation of key themes related to vaccine equity. As this study relied on secondary sources, we did not directly interview vulnerable populations. However, we drew on published reports from the Coalition for Vaccine Access—a network of 12 organisations representing vulnerable groups (ie, women with disabilities, indigenous communities, women-headed households and environmental advocates)—which provided insights based on their implementation and advocacy experiences.
Assessing the national COVID-19 vaccination programme landscape
Indonesia, an archipelagic LMIC of over 270 million people, had 24.16% of its population living in poverty by World Bank standards in 2021.18 Stark socioeconomic inequities exist: the western region, being wealthier and more urbanised, ranks higher overall in health development indices.19 The western region’s greater wealth, urban growth, larger population and infrastructure reflect long-standing national priorities that have deepened the west-east divide,20 a disparity also evident in COVID-19 vaccination coverage.
On 2 March 2020, Indonesia confirmed its first COVID-19 case. The government enforced non-pharmaceutical interventions—masking, social distancing, work-from-home policy and lockdowns—while awaiting effective vaccines and treatments. However, limited preventive and diagnostic measures, coupled with delayed responses, caused exponential case growth, many remaining undetected.21
Indonesia was among the first of the Association of Southeast Asian Nations countries to secure vaccine supplies, signing bilateral agreements with Chinese manufacturers and distributing Sinovac in January 2021.22 Initial priority went to healthcare workers, frontline workers and older people. However, vaccine rollout presented significant challenges–poor governance, limited facilities, logistics constraints and health workers shortages–causing inequities in allocation.23 While infrastructure and human resources for vaccination were still developing, the nation struggled with COVID-19 response and essential healthcare provision.24 The 2021 rollout lagged behind the rapid spread of the Delta variant, driving a surge in cases and deaths and overwhelming health facilities.25
By June 2021, fewer than 10% of Indonesians had received a primary dose, while daily cases surpassed 55 000.15 By end-2021, coverage disparities were stark, Jakarta neared 100%, while eastern provinces, such as Papua, remained below 30% and uptake among older people stagnated under 30%.15 Although 73.04% of the targeted population had received primary dose, inequities across regions and populations remained evident by 2022.15 Public interest in booster shots and even primary doses declined, driven by distrust in government, reduced urgency, efficacy concerns, halal issues and fear of side effects.26 27
As of October 2023, primary dose coverage reached 74.53% of the targeted population defined by the MoH.15 Despite overall high coverage,28 disparities persisted: 49.2% of municipalities, 67.3% of older people aged 60 and above and 61.9% of children aged 6–17 nationwide had primary dose coverage below 70%, the threshold set by the MoH to achieve herd immunity.15 As shown in figure 1, vaccination coverage decreases towards eastern Indonesia, reflecting socioeconomic policies favouring the western region that have contributed to health worker shortages, inadequate infrastructure and limited fiscal capacity.29 Besides, achieving herd immunity depends not only on the quantity of people vaccinated, but also on vaccine effectiveness, virus transmissibility, waning immunity, and both distribution and uptake.30 Faster waning during the Omicron wave led to reinfections even in highly vaccinated populations,31 underscoring the need to prioritise vulnerable groups.
In May 2023, WHO declared the end of the COVID-19 emergency, followed by Indonesia in June 2023, reclassifying it as endemic under the claim that daily cases neared zero and most of the population had developed antibodies.32 Consequently, starting 2024, free vaccines are limited to priority groups with incomplete or no primary doses, as defined in Minister of Health Decree No. 2193/2023, including older adults, older people and adults with comorbidities, frontline workers, pregnant women, adolescents over 12 years old, and immunocompromised groups. Furthermore, vaccine supply is now limited to a few local brands, further reducing uptake. Similar phenomena in African countries, where lower demand and reduced production, combined with waning urgency, decreased public interest.33
COVID-19 vaccine delivery in Indonesia encountered substantial challenges, including administrative, financial, infrastructure and informational barriers.29 Slow bureaucracy, unclear leadership, weak preparedness policies and inadequate reporting and supervision hindered implementation. While private companies, philanthropic and political parties helped expand coverage, conflicts of interest undermined equity and accountability.22 Police and military involvement also reduced acceptance in sensitive areas like Papua, where tensions exist between them and the civilians.29 The government’s repeated plan during the peak of the COVID-19 pandemic to charge for vaccines reflected difficulty in recognising vaccines as public goods.34 Weak transparency and accountability systems further exacerbated inequities across groups and provinces.35
Putting the last first: who should we prioritise?
Under Minister of Health Decree No. 4638/2021, Indonesia implemented a phased COVID-19 vaccination programme (see table 1) based on projected vaccine availability in 2021 and guidance from WHO Strategic Advisory Group of Experts on Immunisation and Indonesia Technical Advisory Group on Immunisation. Priority was given to high-incidence areas and other special considerations. For example, Java received 70% of doses, reflecting 68% of national cases. The policy allowed adjustments as the situation evolved.
However, implementation sometimes diverged from the plan. Reports indicated early access for elites and their families,36 while older people and people with comorbidities were denied vaccination.37 Cases of vaccine smuggling and illicit sales involving officials and health workers were documented,36 with 71 public complaints in 2021, including 27 linked to local leaders.38 Limited supply turned vaccines into a scarce commodity, with people willing to pay significantly higher prices for early access, yet no specific measures were taken to address these issues.29 The MoH also allocated doses beyond local governments such as to the military, police, national intelligence agency, and political parties, granting privileged access for elites and their networks.39
Phase 1 began in January 2021, targeting 1.46 million healthcare workers. Phase 2 followed in February 2021, targeting 21.5 million older adults aged 60 years and above and 17.3 million public workers. In response to the rapid spread of the Delta variant, the government accelerated the vaccination by advancing phase 3 and phase 4. Phase 3, initially planned for July 2021, was advanced to May 2021 for 63.9 million vulnerable groups, while phase 4 was moved to July 2021, covering 77 million from the general population and 26.7 million adolescents. Implementation accelerated during phase 4, reaching up to 2 million doses per day—approximately forty times higher than phase 1—through expanded delivery sites and private sector involvement. Phase 5 later included children aged 6–11 years. The target population expanded from 181.6 million to 234.7 million people (≃83% of the population) as eligibility widened for children and adolescents. As part of the acceleration strategy, vaccination was made mandatory under Presidential Regulation No. 14 of 2021 (later revoked after Indonesia declared the pandemic was over), with sanctions for non-compliance. Although national supply eventually improved, vulnerable groups continued to face structural barriers, widening inequities in access.29
Limited equity perspectives in the regulation
Despite acceleration, vaccine equities persisted due to limited national policy frameworks specifically ensuring vaccine access for vulnerable groups, who were disproportionately affected during the COVID-19 pandemic.40–42 Existing operational policies, including Minister of Health Decrees No. 10/2021 and No. 4638/2021, lacked an operational definition of ‘vulnerable groups’, relying instead on broad WHO recommendations. The policies have not yet fully centred on rights, where individuals are entitled to a set of rights that must be guaranteed to facilitate vaccine access. These guidelines were not adequately translated or adapted to Indonesia’s specific needs and context.
Inadequate data on vulnerable groups
To accelerate vaccination, the MoH issued Circular Letter No 15242/2021 prioritising vulnerable communities, including people with disabilities, indigenous people, prison inmates, social welfare beneficiaries, Indonesian migrant workers in distress, and individuals without a National ID. However, implementation was hindered by fragmented and non-integrated, granular data on vulnerable groups spread across different ministries. For example, the Ministry of Social Affairs maintains the Integrated Social Welfare Database to determine eligibility for social assistance, while the MoH collects disability data through Basic Health Research based on health-related functional criteria. This illustrates differences in disability data across ministries. It remains unclear whether any consolidation mechanism exists to determine vaccination priority based on these datasets, creating confusion in the field about prioritisation. Combined with weak governance, these fragmented data systems translated into access inequities: many remained unable to access vaccines due to the lack of identification cards, reporting systems from subnational to national levels often failed to accommodate necessary modification, confusion over target population prioritisation in the field and the misguided allocation of vaccines to political parties that prioritised constituents.29
Defining vulnerable groups
No consensus exists on defining vulnerable populations during the pandemic. However, they are commonly characterised as groups facing significant socioeconomic or health barriers to accessing services, making them more susceptible to COVID-19 morbidity and mortality.41 Table 2 compares WHO and Indonesian government frameworks. While WHO provides global guidance on prioritisation, Indonesia adopted these recommendations and added geospatially, socially, economically vulnerable communities in phase 3. This broad definition was later operationalised and tailored to Indonesian context which remained aligned with the WHO framework, though only through a circular letter.
The Omnibus Health Law No. 17/2023 further defines vulnerable groups, but lacks implementing regulations to operationalise these definitions or guide different stakeholder action. Its scope remains limited to COVID-19, and a national vaccination roadmap for vulnerable groups is still absent. Existing policies continue to rely on broad, ambiguous categories (ie, geospatial, social and economic aspects), while the absence of clear operational definitions, fragmented data systems, weak governance, and an underprepared health system constrain high-risk groups identification, coverage monitoring, and proactive outreach. These gaps also undermined transparency in vaccine allocation, despite disproportionate risks of morbidities and mortalities from COVID-19 and access barriers faced by vulnerable populations.
Building on these recommendations, the authors recommended additional groups listed in box 1 should be considered vulnerable in Indonesia during a pandemic. People with disabilities face multiple healthcare barriers and higher costs, worsening health and financial precarity.43 Socially marginalised groups, such as trans women without a national ID, are often excluded from free healthcare services and vaccination due to lack of legal recognition.44 Indigenous communities, residents of outermost or conflict-affected regions, refugees and asylum seekers also struggle with access due to poverty, isolation, or lack of identification. Evidence from Indonesia shows lower socioeconomic and educational status correlates with lower immunisation coverage.45 Phase 3 vaccinations ultimately raised concerns over which vulnerable groups were actually prioritised, with coverage unmonitored and transparency lacking.
Recommendations for defining vulnerable populations in the context of a pandemic
Authors’ recommendations
People with disabilities;
Individuals without a national identification number;
People without access to adequate healthcare services (eg, those living in geographically challenged areas or without healthcare facilities within 5 km);
People with low socioeconomic status;
People who are socially marginalised (eg, religious minorities, gender minorities);
People living in regions affected by social, agrarian and/or armed conflicts; and
Refugees and asylum seekers.
Lessons learnt and strategies for protecting the most vulnerable
From a national policy standpoint, national pandemic prevention, preparedness and response (PPR) should adopt whole-of-government and whole-of-society approaches, alongside the five core components of health emergency preparedness: collaborative surveillance, community protection, safe and scalable care, access to countermeasures, and emergency coordination, as detailed in the 2024 International Health Regulations amendments and the WHO’s strategic preparedness and response plans.46 47 This holistic approach is essential to embed equity in the national policy framework.
In Indonesia, integrating an equity lens into the national pandemic PPR framework requires aligning the National Action Plan for Health Security (NAPHS) and vaccination strategies with global standards while tailoring them to local contexts. NAPHS establishes the strategic foundation, while deployment strategies should operationalise it through clear guidelines on vaccine allocation, prioritisation, and definitions of vulnerable groups, supported by dedicated budgets. Although vulnerability may shift across pandemics, structural risks such as low socioeconomic status persist. Indonesia’s challenges in identifying and prioritising vulnerable populations, particularly limited disaggregated data and unclear operational definitions, are consistent with broader patterns across LMICs. Many LMICs faced structural constraints in health information systems, including insufficient disaggregated data across key equity dimensions, limiting the identification of underserved groups.48
While WHO’s disease-specific guidance offers a baseline, national adaptation is essential. For example, Australia’s COVID-19 Vaccination Policy (2020) and National Rollout Strategy (2021) were supported by detailed roadmaps, including tailored plans for Aboriginal and Torres Strait Islander Peoples, with clear roles, equity measures and implementation guidance.49 While Australia is an HIC, Indonesia can draw lessons to strengthen provincial and district-level implementation, especially where technical guidance and resource allocation are limited.
Effective prioritisation requires reliable disaggregated data on vulnerable groups. Such data enables better targeting and informed decision-making during pandemics. Equitable vaccine allocation also requires robust governance, with transparent systems tracking procurement through monitoring and evaluation. For future pandemics, Indonesia needs a clear operational framework to identify vulnerable groups, backed by stronger regulations and targeted outreach. Instead of punitive measures, enabling approaches, including mobile vaccination, disability-friendly facilities and accessible information, are critical to reducing barriers. These solutions require long-term investment and political commitments beyond crises, and should be institutionalised in national policies and guidelines. Further research is needed on defining vulnerability and guiding equitable vaccine allocation at the country level.
Actionable steps are summarised below:
Institutionalise equity clauses in the NAPHS and the following regulations, requiring adoption and action by all stakeholders.
Develop an interoperable health data system with disaggregated sociodemographic data.
Implement a whole-of-government and whole-of-society approach, breaking siloes and ensuring meaningful civil society engagement.
In pandemics, ensure vaccination strategies include:
Clear operational definitions of vulnerable groups.
Specific outreach strategies.
Transparency provisions for vaccine allocation.