Health Care of Refugees in Indonesia: A Case Study in Kupang City, Indonesia

Backgrounds: This study analyzes Indonesia's readiness to balance its role in responding to its internal and external health system situations, including the capacity of health advocacy and diplomacy in providing health services to the refugees. The analysis aims to provide recommendations to the government from the perspective of human rights and health security. Methods: Triangulation through observations, interviews with experts, and related literature and news searches were carried out using a qualitative approach to obtain thematic phenomena to validate data. Interviews were conducted using content analysis to get thematic phenomena based on structured interview guidelines to obtain the expert judgment. The selected informants are the main stakeholders in the health sector who meet appropriateness and adequacy principles. They also meet Tremblay's ideal informants' criteria, namely, role in community, knowledge, willingness, communicability, and impartiality. Results: Stakeholders have inadequate lines of communication, resulting in a lack of proper coordination between agencies. The Port Health Oce (PHO) in Kupang was not involved in handling refugees despite its crucial role in preventing the entry and exit of potential disease outbreaks. The government of Indonesia established Presidential Regulation No. 125 of 2016 to deal with refugees abroad. However, the law has not been appropriately implemented. The city government of Kupang has not maintained an optimal balance between human rights and health security. Conclusions: Health advocacy and diplomacy capacity are needed to strengthen health resilience in preventive measures while recognizing the refugees' right to health as part of human rights.


Background
The world is experiencing the biggest refugee crisis since World War II. During the United Nations High Commissioner for Refugees' UNHCR dealing with refugees, the organization acknowledged that the highest number of refugees eeing their countries due to war, persecution, and various other con icts had reached 70 million. Moreover, according to UNHCR's annual Global Trends Report, more than 2.3 million refugees ee in search of haven, reaching an average of 37,000 new cases each day, half of whom are under 18. Although refugees have left their home countries, they have not been granted citizenship status or have been denied the application in new states and transit countries. As a result, they are often not given certain human rights, such as the right to a decent life, education, and access to good health services.
The Universal Declaration of Human Rights (UDHR) con rms that recognizing humans' natural dignity and equal and absolute rights is based on world independence, justice, and peace. Article 25 of the UDHR explains that everyone, including his/her family, has the right to a standard of living that guarantees his/her health and well-being, including food, clothing, housing, health care, and social services. Each United Nations (UN) member state has stated in the UN Charter their belief in essential human beings and humans' dignity and value in enhancing social progress to improve living standards.
As a UN member state, Indonesia is responsible for guaranteeing human rights to its citizens, including refugees who layover in Indonesia before heading to their destination country. As stated in the UN's declaration, respect for the values of human rights has been rmly embedded in the Constitution of Indonesia. By following the mandate of Indonesia's 1945 Constitution, the state is responsible for guaranteeing everyone in the country a prosperous life, one of which is access to health care. The right to health is an essential aspect of human rights. Therefore, Indonesia is responsible for providing good health services for these refugees, regardless of their circumstances.
The great responsibilities and objectives of protecting refugees require vigilance due to the Indonesian people's potential health risks. Following globalization and the initiation of Global Health Security (GHS), the World Health Organization (WHO) established the International Health Regulations (IHR) to protect the world from various disease threats. IHR requires its member countries to develop and maintain the ability to detect, assess, mark, and respond to multiple public health threats globally. Thus, Indonesia is responsible for protecting the public from various health threats that can disrupt national security. This commitment has been implemented with Presidential Regulation No. 125 of 2016 on Handling of Refugees from Abroad. Until the end of December 2017, Indonesia hosted more than 13,840 refugees from 49 countries and was dominated by con ict-affected countries, such as Afghanistan (55%), Somalia (11%), and Iraq (6%). The refugees are scattered in various Indonesia regions and placed in the Immigration Detention House in coordination with the local District / City Government. Kupang City is the capital of East Nusa Tenggara Province that has implemented the regulation and is willing to accommodate refugees from abroad. The administrative law's success is also a humanitarian call, aside from the obligation to enforce the rule. However, respect for human rights and values such as equality and solidarity must still consider the Indonesian people's health aspects for national security.
Balancing the two responsibilities is not easy: responding to the internal situation of Indonesian public health and the external condition of refugee reception. Thus, to achieve equilibrium in the government's role, health advocacy and diplomacy capacity at the central and regional government levels is needed to coordinate, communicate, and strengthen support networks. This study analyzes the readiness of the government in balancing its role in responding to internal and external situations, including the capacity of health advocacy and diplomacy in health services for refugees in Kupang City. This analysis will be used in making recommendations to the Indonesian government from the perspective of human rights and health security.

Methods
This study uses a qualitative approach to explore relevant stakeholders' views through in-depth interviews with selected informants. The interviews were conducted using content analysis to obtain thematic phenomena based on structured interview guidelines in obtaining the expert judgment. The selected informants are the main stakeholders in the health sector who meet the principles of appropriateness and adequacy. They also meet Tremblay's criteria of ideal informants, namely, role in community, knowledge, willingness, communicability, and impartiality.
Triangulation through observations, interviews with experts, and related literature and news searches are also carried out for data validation. The implementation analysis model used in this study is a combination of the framework of Edward III, Van

Results
Kupang City is the administrative center of the Province of East Nusa Tenggara and is located in the province's southeastern part. The city has an area of 180.27 km 2 . As of September 2019, Kupang City had 234 refugees, of whom 69, 92, and 73 were accommodated in Ina Boy Hotel, Lavender Hotel, and Kupang Inn Hotel, respectively. Unmarried refugees who were supplied together with married ones were distinguished.
The Head of the Immigration Division of the East Nusa Tenggara Regional O ce Erwin F.R accompanied by the Head of the Kupang Detention House said that the local government inhabited by refugees must handle the refugees from abroad. Handling refugees in Kupang City, mainly their health services, is carried out by the International Organization for Migration (IOM) in collaboration with UNHCR and the city's local, regional government. Previously, IOM was responsible for meeting all the refugees' needs. Since 2018, IOM has provided an allowance fee for refugees, which is calculated per head based on their daily needs, in the form of food and medications. The allowance fee is IDR 1,250,000 for adult refugees and IDR 750,000 for child refugees. Some refugees objected to these amounts due to inadequacy in ful lling their daily living expenses. This amount is compounded by the high cost of living in Kupang City compared with other cities in the vicinity, such as Surabaya City, which also accommodate refugees.
Based on the information gathered from the Puskesmas (Public health center) in Kupang, the most common illnesses suffered by refugees were cough, colds, and diarrhea, which were related to the refugees' lifestyles and habits in their homes. Every refugee who consults a health worker adheres to the same process, followed by the Kupang community in general. They need to queue at the Puskesmas to be served provided with medicines. In cases of illness that require a referral, the referral is not directly provided by the Puskesmas. A doctor at the Puskesmas will contact the IOM to submit a resume for the According to the Regulation of the Minister of Health of the Republic of Indonesia No. 2 of 2014 on the classi cation of PHA, the PHA plays a vital role in preventing the entry and exit of potential disease outbreaks through epidemiological surveillance activities, quarantine, reemergence, bioterrorism, biological elements, chemical and radiation safeguards in the working area of airports, ports, and national land borders. The PHA prevents the entry of diseases that could be brought by refugees abroad.
Based on various policies in several European countries receiving refugees, France has a Couverture Universelle Maladie Protection Complementaire (CMU-C) program. This program provides health insurance for immigrants and refugees to access services from medical examinations to medical treatment for illnesses. The entire costs needed are borne by Aide Médicale d'État (State Health Assistance). The program also provides temporary guarantees for health services to immigrants and refugees who are not registered in the program due to certain conditions such as contracting infectious diseases, pregnancy, and emergency conditions that require immediate medical treatment.
Italy uses the Toolkit World Health Organization to assess health service capacities in dealing with the in ux of immigrants and refugees. After being registered and accommodated in shelter centers, every immigrant and refugee will get a unique code as an identi cation code used in accessing essential health and emergency services. The code helps identify the medical history of immigrants and refugees while still protecting their privacy rights. All of the access to health services is free of charge. The code can be used at any time and can be updated if the validity period expires.
Turkey collects data using a framework from the STEPwise approach to surveillance (STEPS) developed by WHO. The program focuses on immigrants' and refugees' data that can affect the risk of disease transmission from the refugees and immigrants (WHO Regional O ce for Europe, 2018).

Conclusions
Access to health services is a human right guaranteed by Indonesia's constitution. Everyone has the right to acquire good health services. The government of Indonesia established Presidential Regulation No.
125 of 2016 to deal with refugees abroad. However, the law has not been implemented effectively. The city government of Kupang has not maintained an optimal balance between human rights and health security. Health advocacy and diplomacy capacity are needed to strengthen health resilience in the preventive dimension while ful lling refugees' right to health as part of human rights. This study recommends the expansion and integration of stakeholder collaboration networks and prioritizing refugees' health issues to ensure all Indonesian people's health. The authors declare that no ethical issues may arise after the publication of this manuscript. Ethical approval was given by the IRB of Faculty of Public Health Universitas Indonesia Number 322/UN2.F10.D11/PPM.00.02/2020. Every informant was provided with this study's information sheet and signed to be involved in this study.

Consent for Publication
All of the authors agreed to be personally accountable for their own contributions and ensured that questions related to the accuracy or integrity of any part of the work are appropriately investigated, resolved, and the resolution documented in the literature. Every informant verbally stated that they were willing to publish their statement in this study.

Availability of Data and Material
All data and materials described in the manuscript will be freely available to any scientists wishing to use them for non-commercial purposes.

Competing Interests
The authors have no con icts of interest with the material presented in this manuscript.

Funding
There is no speci c funding for this work.