Perspectives of National Civil Society Organizations on the Development of National Climate-Resilient Health System in Indonesia

Abstract

Indonesia confronts escalating climate-health threats, with climate-sensitive diseases projected to impose USD 21.6 billion in economic losses between 2021 and 2050. Despite legislative progress, including ratification of the Paris Agreement and the 2025–2030 National Action Plan on Health, implementation of climate-resilient health system development remains uneven, constrained by weak cross-sectoral coordination and limited local adaptive capacity. Civil society organizations (CSOs) play an increasingly recognized governance role in this landscape, yet their perspectives and experiences navigating the conditions that shape climate-resilient health system development remain underexplored. This exploratory qualitative study used criterion and snowball sampling to recruit national-level CSOs in Indonesia. Semi-structured, open-ended in-depth interviews were conducted with organizational leaders between April and May 2026 via Zoom. Analysis followed a combined deductive-inductive thematic approach, guided by an integrated conceptual framework drawing on political economy analysis and the WHO Operational Framework for Building Climate-Resilient and Low-Carbon Health Systems. Coding and thematic analysis were conducted in ATLAS.ti (version 23). The study was granted an exemption determination by the University of Washington Human Subjects Division (STUDY00025479). Six national CSOs participated in the final analysis, representing diverse organizational mandates spanning public health, faith-based, reproductive and sexual health, humanitarian, and policy advocacy functions. Thematic analysis yielded six themes: (1) a reactive rather than anticipatory health system orientation, with critical gaps in the integration of climatological and health surveillance data; (2) uneven climate-health exposure across populations and geographies, compounded by the individualization of structural risk that suppresses collective demand for adaptation; (3) a fragmented and deprioritized policy landscape, marked by siloed ministerial mandates, absent gap assessments, and limited political will; (4) formal decentralization undermined in practice by fiscal centralism and performance incentives that reward budget absorption over adaptive outcomes; (5) CSOs functioning as strategic intermediaries in a governance vacuum, embedding climate change within programmatic theories of change while navigating structural constraints on their influence; and (6) significant multilateral influence on the national agenda alongside private sector absence and the structural hollowness of formal civil society participation in decision-making. Findings reveal a governance landscape defined by systemic fragmentation, political and fiscal centralism constraining subnational adaptive capacity, structural inequality amplifying climate-health vulnerability among marginalized communities, and the under-resourced deployment of CSOs to fill institutional gaps. Strengthening climate-resilient health systems in Indonesia requires a legally grounded inter-ministerial coordination mandate, formal integration of climate-sensitive disease surveillance with health information systems, subnational performance frameworks oriented toward shared climate-health outcomes, and systematic mechanisms for meaningful civil society participation in policy design. The ground-level knowledge held by CSOs represents an irreplaceable governance resource whose mobilization is essential for equitable and effective climate-health adaptation.