Missed Opportunities in the Early Response to COVID-19 in Aceh Province: January to May 2020

Coronavirus Disease (COVID-19) pandemic has had catastrophic health and economic impacts worldwide. As of 20 September 2020, Indonesia ranked the third-highest fatalities due to COVID-19 infection in Asia and the second-highest confirmed cases in Southeast Asia. Aceh, a province in the westernmost of the country, has also been impacted by the virus infections. This study aims to investigate the current Central and Aceh provincial government-led responses to the COVID-19 pandemic from January to May 2020. It utilizes existing regulations, official reports, and relevant websites to assess and analyze the responses. The results identify delayed early responses taken by Central and Aceh governments to stop and prevent the virus transmission; the absence of lockdown implementation (border restrictions at entry points such as borderland areas, seaports, and airports); premature introduction of the new normal era; the absence of checkpoints and village alert teams throughout 23 districts; and inadequate enforcement of the established regulations to halt the spread of the virus in the province. Various recommendations are provided to enhance the current responses to COVID-19 in the province in order to reduce the pandemic risk to the community going forward and strengthen the pandemic preparedness and response system. the Aceh government and its key relevant agencies based on the current regulations formulated during the COVID-19 pandemic in Aceh province.


Introduction
The coronavirus disease  was first identified as the cause of respiratory tract infectious disease outbreak in December 2019 in Hubei province, China (Cheng et al., 2020). The Chinese province recorded 24,953 confirmed COVID-19 cases and 699 deaths from December to February 2020 (WHO, 2020c). After the World Health Organisation (WHO) declared this situation as a Public Health Emergency of International Concern (PHEIC) on 30 January 2020 (Shaw et al., 2020), the virus rapidly spread to more than 200 countries. It impacted a great number of populations across different countries worldwide (WHO, 2020a). As of 17 August 2020, the WHO had recorded 21,516,760 confirmed cases, with 766,663 deaths due to the COVID-19 global pandemic (WHO, 2020c).
As a member of the global community with significant business and tourism cross-country exchanges, and with a developing and a somewhat under-resourced health system (3% of GDP on healthcare in 2019), Indonesia has not been spared the COVID-19 infection or its devastating health impacts (Setiati & Azwar, 2020). On 2 March 2020, the first two confirmed cases of COVID-19 infection were reported in the country, with a dramatic increase to 1,790 confirmed cases, with 170 deaths and 112 recoveries one month later (Djalante et al., 2020). By 7 May 2020, the country had recorded 12,438 confirmed cases, with 895 deaths (WHO, 2020c). The confirmed cases had risen to 37,420, with 2,091 deaths until 13 June 2020 (Yurianto, 2020). Unfortunately, underreporting cases due to the lack of testing, limited access to healthcare services, and fear and stigma of seeking help contribute to the increase in COVID-19 cases every day (BNPB, 2020;Setiati et al., 2020;WHO, 2020e;Yurianto, 2020).
Aceh, a western province in Indonesia, recorded 17 confirmed cases of COVID-19 from January until 7 May 2020 (after one confirmed case died in Banda Aceh hospital) (BNPB, 2020). Of these 17 confirmed cases, 1 person died, 7 were hospitalized, and another 9 people recovered (Gani, 2020). In addition to that, 89 people were monitored for potential COVID-19 infection (Gani, 2020). As of 30 May 2020, the confirmed cases increased to 20, and 106 people were monitored for possible COVID-19 infection, two days after the local government introduced the new normal era on 28 May in the province (Dani, 2020).
The confirmed cases in Aceh (though only 1 COVID-19 death as of May 2020) increased due to bordering North Sumatera province (labelled as a red zone), which had 5,690 confirmed cases, with 249 deaths until 17 August 2020 (BNPB, 2020;Rachmawati, 2020). Further, North Sumatera borders another red zone province (West Sumatera) which had 1,375 confirmed cases, and 41 deaths until 16 August 2020 (Yurianto, 2020). In addition, as Aceh is located in Sumatera Island, many people from Aceh can freely travel to North Sumatera province especially Medan for holiday and business purposes, and people from other provinces can easily travel to Aceh for tourism purposes. Only those travelling by air are required to show a rapid test certificate (with a nonreactive result) before boarding to the airplane.
Understanding the role of provincial government and relevant agencies in response to this outbreak is crucial to curb the cases from spreading. In fact, as emphasised by Shaw et al. (2020), even though the pandemic is global, the response must have a strong local element such that decisions consider local governance, socio-economic and cultural context (UNDRR, 2020).
This study aims to investigate the Indonesian government and Aceh province response to COVID-19 pandemic in the period of January to May 2020 (since the early COVID-19 was identified until a new normal era was introduced in Aceh). Focusing on Aceh province, the objective of this study is to examine the Aceh government and its relevant agencies' responses to COVID-19 pandemic based on the established policies, regulations, official reports and the researchers' observation from January to May 2020. This paper firstly describes key response actions based on the current established regulations at national and provincial levels in response to the global COVID-19 pandemic focussing on Aceh province. It further analyses the opportunities and gaps based on these responses using COVID-19 Infection Prevention and Control (IPC) general principles published by the World Health organisation (Strategic Preparedness and Response Plan for  focusing on imposing country and local lockdown strategy (WHO, 2020a). Finally, the paper provides recommendations to enhance the effectiveness of COVID-19 pandemic responses in Aceh province moving forward and consider ways of strengthening the pandemic preparedness and response system.

Lockdown approaches and goals
One important strategy utilised to prevent the spread of infectious diseases is lockdown (WHO, 2020b). It has been utilised to different degrees worldwide in response to COVID-19 (Sault, 2020). According to the Imperial College London COVID-19 Response Team, a lockdown strategy that restricts people's movement consists of two 13 important approaches: mitigation and suppression (Anderson et al., 2020;Sault, 2020). It aims to reduce reproduction numbers of the average COVID-19 confirmed cases below one person (Sault, 2020).
A mitigation approach aims to slow or reduce case numbers, often called "flattening the curve," to reduce the healthcare burden (Bruina et al., 2020). This approach protects those most at risk of infections (most vulnerable groups) through isolating the suspected cases, their families, and social distancing the elderly and those with the highest risk of comorbidities. The mitigation approach does not necessarily halt COVID-19 transmission but controls the epidemic by allowing populations to acquire herd immunity to interrupt virus transmission over the longer term (James et al., 2020;Sault, 2020). However, acquiring herd immunity is likely to be very high risk, unproven, uncertain, and may take years (James et al., 2020;Vergne, 2020). According to Vergne (2020), mitigation strategies that protect the elderly (e.g., 60% reduction in social contacts) can save 20 million lives from 7.0 billion infections with 40 million deaths worldwide this year. The Netherlands, for example, has selected a mitigation strategy since 16 March 2020.
A suppression or total lockdown approach attempts to stop epidemic growth directly to reduce case numbers to the lowest level through social distancing to whole populations (including asymptomatic populations) within an unlimited period and closing schools, universities, offices, and other public facilities (Hochberg, 2020;James et al., 2020;Vergne, 2020). The suppression measure is a more aggressive strategy than mitigation since it eradicates the virus to push rapid reproduction numbers below one and flatten the epidemic curve (Vergne, 2020). The Chinese government immediately imposed this strategy in the major cities of the Hubei province after 23 January 2020 (Anderson et al., 2020). They stopped transportation in and out of cities and prohibited millions of people from working, going to schools, and closed all shops except those essential retailers (i.e., food, fuel stations, and pharmacies). As a result, no new confirmed cases in Hubei were reported after 19 March 2020 (Vergne, 2020).
Similarly, Italy and Spain applied nationwide suppressions from 9 to 15 March 2020. Lodi city, Italy, for example, showed a flattening of the curve (levelling off cases) following the city lockdown on 23 February, in contrast to Bergamo city who did not lockdown until 8 March 2020 (Sault, 2020;Vergne, 2020). Following the detection of a large number of infections, at least 42 countries worldwide (e.g. Italy, France, Spain, and India) have placed their people under lock downs (James et al., 2020). In summary, a combination of suppression measures and strong border closure can lead to reduced confirmed cases. When the cases can be reduced to a very small number, the lockdown or suppression can be relaxed (Askitas et al., 2020;James et al., 2020).

Methods
This study utilized a qualitative content analysis to analyse text data (Roller, 2019) from various sources, including documents from central and provincial government regulations, official reports and speeches, online official COVID-19 websites, national and local newspapers were focusing on COVID-19 update information at national and Aceh province, and social media observation (e.g., Facebook from government postings) concerning early government responses to COVID-19 at central and Aceh province from January to May 2020. The stage of content analysis for this study is shown in Figure 1.

Keyword searches
The search process using various keywords included grey literature (government documents) published in Indonesian or English from January to May 2020. In addition, searches were performed on various databases and websites. Detail search terms using various keywords through databases and websites are presented in Table 1. Table 1. Search terms included in the content analysis process The keywords were translated into English to investigate the current government responses to COVID-19 in Aceh based on its local regulations or policies. Then, these regulations were reviewed and analysed. The exclusion criteria were non-academic literature, including Wikipedia, personal opinions written by certain interest groups.

Inadequate early responses by the central government to COVID-19
On 2 March 2020, the Indonesian President, Joko Widodo, announced the first two confirmed cases of COVID-19 in the country. The Ministry of Health (MOH) conducted surveillance training for Provincial Health and Port Health Officers across 34 provinces from 9 to 11 March 2020 (Djalante et al., 2020). The training aimed to reinforce containment measures, e.g., identifying and isolating cases, tracing contacts, and quarantining contacts (Ministry Of Health, 2020a). On 13 March, the government established an operational task force for COVID-19, led by the National Agency for Disaster Management (BNPB), and announced 227 referral hospitals across the nation.
Additionally, two days later, the President encouraged people throughout the country to work, study and worship at home and suspended all activities that involve many participants (Ministry Of Health, 2020b). Further, by 20 March, the Governor of Jakarta proclaimed a state of emergency in the capital for two weeks to stop the COVID-  (WHO, 2020c). However, within 24 days after the government reported the first two cases, a sharp increase of COVID-19 infections to 893 confirmed cases with 78 deaths throughout 34 provinces was reported (WHO, 2020d). These 893 confirmed cases were initially spread across 27 provinces, including Aceh province. At this stage, the remaining seven provinces of Bengkulu, Bangka Belitung, North Kalimantan, West Sulawesi, Gorontalo, East Nusa Tenggara, and West Papua provinces did not appear to have infections (WHO, 2020d).
The central government had been criticised for not being transparent in announcing the COVID-19 cases since many cases were undetected due to the lack of accurate diagnoses, leading to underreporting of actual infection numbers by the authority (Carina, 2020). An epidemiologist from Indonesian University, Pandu Riono, argued that the COVID-19 cases had been detected in Jakarta since January 2020 instead of March 2020. He also acknowledged that the COVID-19 death toll in Jakarta was higher than the national numbers released (from 2 to 26 March 2020) by the government (Carina, 2020). Delayed early detection measures of imported cases and imposing travel restrictions, especially on direct flights from Wuhan to Indonesia, were also criticised for increasing the case numbers in the country (De Salazar et al., 2020;Setiati et al., 2020). In contrast, the government (based on the MoH data) announced zero cases in Indonesia before travel bans were implemented (De Salazar et al., 2020). Consequently, it can be argued that this early lack of transparency, poor border closure, and disease surveillance affected the future response platform for COVID-19 at central and local government levels, including Aceh province.
The other response timeline worthy of noting for COVID-19 is that on 31 March, the President issued a Presidential Decree No. 21/2020 on "Large Scale Social Restrictions (PSBB, known as Pembatasan Sosial Berskala Besar) to accelerate COVID control" and on the same date, a Presidential Decree No. 11/2020 on "public health emergency status" was formulated. Further, on 7 April, the MoH established decree No. 239/2020 to implement PSBB in Jakarta. However, the PSBB was not effective, for instance, during its implementation, national or local agencies did not strictly impose the restrictions (Gorbiano et al., 2020).
To overcome the impact of the social restriction policy and to encourage community compliance, the government provided financial aid to informal workers and disadvantaged people (WHO, 2020c), and by 1 April 2020, the government allocated IDR 405 trillion for healthcare expenditure, social security, tax incentives, and economic recovery programs. In the healthcare sector, the funds were prioritised for purchasing medical equipment, establishing referral hospitals, and compensation for medical personnel (OCHA, 2020). For instance, on 2 April 2020, over 349,000 pieces of personal protective equipment (PPE) had been distributed for medical personnel to several provinces (Riau, Jambi, Bengkulu, South Sumatra, Gorontalo, and Central Sulawesi), though the confirmed COVID-19 cases in the country had by then reached 1,790 cases with 170 deaths and 112 recoveries across 32 provinces (OCHA, 2020). Java islands and South Sulawesi province recorded the highest number of cases while only two provinces were free from the COVID-19 infections namely Kupang and Gorontalo (WHO, 2020b) (as shown in Figure 2).
Despite this PPE distribution, many referral healthcare facilities at local levels faced a PPE shortage (e.g. medical masks, gloves and suits) forcing many medical personnel to wear raincoats (HRW, 2020). Consequently, 31 medical personnel, including 20 medical doctors and 4 nurses had died (among 280 total deaths from 3,293 total cases within 33 provinces) during the period January to 9 April 2020 (Adjie, 2020).
COVID-19 case numbers continued to rise across all 34 provinces (of 5,516 of total COVID-19 confirmed cases, 496 deaths as of 16 April) leading to widespread socio-economic impact, and by 13 April, the President declared COVID-19 as a national disaster, and local governments were instructed to follow the central government's guidelines for controlling the pandemic (WHO, 2020c). He also demanded an increase of rapid tests to 10,000 per day, and improvement in the capacity of polymerase chain reaction (PCR) testing, after being criticised for having the lowest testing rates in the Southeast Asia (WHO, 2020b).
As at 30 April 2020, the number of confirmed COVID-19 cases had reached 10,118 with 792 deaths (EKONID, 2020), even with increased efforts to contain the cases. For example, the Transportation Minister imposed domestic travel bans on 23 April to prevent people from travelling in the upcoming fasting month and Idul Fitri festival and the BNPB (Badan Nasional Penanggulangan Bencana) distributed medical supplies such as surgical masks, medical gloves, PPE, PCR reagents, and ventilators throughout the country on 26 April (Adjie, 2020).
By the end of April, WHO (2020b) indicated that only one province (East Nusa Tenggara) was categorised as a green zone (two confirmed cases were found), categorising other provinces as red, orange or yellow, depending on case numbers (as shown in Figure 3). Aceh province was classified yellow since 18 confirmed cases had been detected as of 30 April (Nugraheny, 2020). Also, it is important to note that the other provinces with yellow categories were being identified as likely to change to red categories due to proximity to red zones and lack of border restrictions (WHO, 2020c).
According to Andriyanto (2020), Underreporting has also been an issue. the number of deaths from confirmed COVID-19 cases exceeded 1,000 (four times the formal number reported by the government) as of 12 May 2020.
The COVID-19 taskforce only included fatalities from cases confirmed by PCR tests in their reports (WHO, 2020d).
The casualties from patients under surveillance (PDP) and people under observation (ODP) were not included even though the corpses had been buried following COVID-19 procedures (Andriyanto, 2020).
The other response timeline was that on 28 May, the government introduced a "new normal" by relaxing the

Inconsistent lockdown implementation as central government policy dominates decision-making processes
The Indonesian government's response to COVID-19 infection control is different from that of imposing a lockdown approach across the whole country. For instance, the President utterly rejected an official letter from the Jakarta governor to impose a partial lockdown in the provincial city (Gorbiano et al., 2020). Eventually, the city administration only kept the PSBB in place after assessing the outbreak conditions in the city in partnership with the COVID-19 local task force. Further, the governor indicated that Jakarta would need to avoid and prepare for a sharp increase in infections when the government relaxed the restrictions (Adjie, 2020). The West Java Governor had also arranged lockdown plans for the most populated province in the country (which has the second-highest number of COVID-19 infections after Jakarta). However, the lockdown planning was not imposed as it was not permitted by the President (Dipa, 2020).
Other provinces opposed the President's instructions and made their arrangements. For example, the Central Java province, along with its mayor, imposed a lockdown in the city by closing its borders from 30 March to 31 July2021 (Suherdjoko, 2020). Similarly, Papua province applied a tougher measure through restricting entry points to the province such as seaports and airports for two weeks from 26 March 2020. The Maluku administration also limited access to seaports and airports of the province and urged people to stay at home and practice physical distancing (Gorbiano et al., 2020). Meanwhile, in Aceh, although the Banda Aceh House Representative Chief and Banda Aceh Mayor planned to impose a partial lockdown in the provincial capital on 27 March 2020, their planning was not implemented as the central government did not allow it (Nurdin, 2020). Eventually, on 29 March 2020, by their own initiative, some village chiefs along with their villagers around Banda Aceh locked down their villages' borders and blocked entry to streets to the village (as shown in Figure 5) (Nasir, 2020a). Timeline and early responses for COVID-19 by the Aceh government Aceh province (Banda Aceh as the provincial capital) is located in the westernmost part of Indonesia, and bordered by the North Sumatera in the South; Malacca Straits to the North and East; and Indian Ocean in the West (Aceh Bureau of Statistics, 2017). The province is divided into 23 districts, 289 subdistricts, and 6,497 villages (as shown in Figure 6) (Aceh Bureau of Statistics, 2017).
In relation to early responses for COVID-19 in Aceh, on 20 March, the Aceh government directed the Banda Aceh RSUDZA hospital and Cut Meutia hospital in Lhokseumawe district as the referral centres for COVID-19 cases (Ramadhan, 2020). The province reported that 45 people were monitored (ODP/Orang Dalam Pemantauan) and 28 patients were supervised (PDP/Pasien Dalam Pengawasan) though the confirmed cases were zero as of 20 March (Ramadhan, 2020). Details of early responses for COVID-19 taken by the Aceh government in relation to confirmed case numbers is presented in Figure 7.  Figure 7. Early responses for COVID-19 by Aceh government, and changes in case numbers from January to May 2020. Source: Authors, collected from different sources (2020) On the first day that the governor's instruction took effect (23 March), Banda Aceh city was quiet, many coffee shops were closed and government employees worked from home (WFH) (Azman, 2020) However, the government was criticised for not closing airports and seaports, potentially allowing COVID-19 positive cases to enter the province through travellers (Nasir, 2020b).
In addition, based on the authors' observation, another 11 designated referral hospitals appeared to lack trained personnel or appropriate protective equipment (e.g. medical or surgical masks, face shields, gloves and gowns).
This is consistent with survey results from 23 districts across Aceh province involving 1,132 selected respondents across 12 health professions categories, which suggested that although health care staff understand the risk to COVID-19 exposure in their workplaces (primary health care facilities and referral hospitals), inadequate personal protective equipment (PPE) and trained staff were identified (Ichsan et al., 2020).
Furthermore, the government did not take the important and firm actions sufficiently early to contain the virus from spreading throughout the province (Zairi, 2020). For instance, the Aceh easternmost entry point bordering with North Sumatra was not closed; and visitors or residents returning from outside Aceh crossed the border freely without health examination (Zairi, 2020). Further, the government did not trace the prior history of health conditions of visitors to Aceh.
Although some early efforts were taken by the government in the early period (Figure 7), the number of confirmed cases increased from one on 26 March to five as of 1 April, with another four (PDPs) hospitalised (Info COVID-19, 2020). Also, the Aceh Provincial Health Office (PHO) reported that, 620 ODPs and 44 PDPs were recorded across 23 districts. Of 44 PDPs, eight were hospitalised, and one of them died before the lab result was released (Hasyim, 2020). Figure 7) is identified in the province. For instance, although the Governor Instruction on the closure of public facilities especially coffee shops and markets was issued on 22 March, it was implemented only for seven days (as shown in Figure 7), before the coffee shops, for example, reopened with patron wearing no masks, or maintaining physical distancing. This is similar to what has been surveyed by the Syiah Kuala University Research Centre; in which more than 75% of total respondents admitted that they still conducted their activities outside of their home, and the most frequent visited locations were markets (35%) and coffee shops (40%) (Rizal, 2020). Further, on 6 May, the Banda Aceh Mayor instructed people in the city to wear masks in public areas, with the penalty for non-compliance being removal of their identity card (Nashrullah, 2020). However, this regulation only applied for people living in Banda Aceh not for newcomers or visitors and based on the authors' observation, there was little evidence of identity cards being removed on the spot, despite many people not wearing masks.

Inadequate implementation and reinforcement of established regulations (as shown in
In response to the increase in COVID-19 positive cases, ODPs and PDPs in the province, the governor established a COVID-19 taskforce on 1 April 2020 (as shown in Figure 7) . The taskforce, led by two authorities namely the Aceh Disaster Management Agency/BPBA chief and a provincial secretariat was a timely and significant action since it played an important role in improving COVID-19 prevention and control (Aceh Governor, 2020). Based on a Governor Decree No. 440/1028/2020, in coordination with relevant agencies, the taskforce is responsible for formulating and implementing action plans for COVID-19 prevention and control; establishing COVID-19 checkpoints; and instructing relevant agencies to speed up the implementation of COVID-19 prevention and control measures (BNPB, 2020).
However, based on the authors' observations, only some districts had COVID-19 checkpoints with inadequate personnel (e.g., medical teams) and equipment such as masks and thermometers. In relation to COVID-19 action plans, only one district (Benermeriah) had developed action plans for COVID-19 eradication (Oktabina, 2020).
Further, although the government stated that 4,181 villages (6,497 of total villages) had established COVID-19 Alert Teams within their villages as of 15 April 2020 , only some established Alert Teams and fulfilled the required actions mentioned on the Ministry of Village Circulation Letter No. 8/2020 on Village Response for COVID-19 (e.g. the alert team must conduct spray disinfectant and provide hand sanitizer in public places such as community centres; provide isolation rooms; and conduct first aid treatment/management for COVID-19 suspects). In reality, based on the authors' observations, some alert teams within certain villages only provided weak guidance or enforcement, using simple encouraging statements in banners related to COVID-19 precautions (as shown in Figure 8). For example, the banner illustrated in Figure 8, encourages villagers who have recently returned from other provinces or overseas to notify a village head.
The other early response for COVID-19 taken by the Aceh government was the conduct of a mass rapid testing program in public areas such as coffee shops and markets (the most crowded places and frequent visited sites where few people wear masks). 3,000 samples from both places were collected to confirm the presence of the virus, though it has been acknowledged that the rapid test is not the most accurate method to confirm a COVID-19 case  with a nasopharyngeal swab test (Real Time Polymerase Chain Reaction/RT-PCR test) the gold standard method (Gani, 2020). Despite this activity intended to ascertain prevalence, the testing now only focuses on certain areas especially in cities, and initially individuals were required to pay IDR 650,000 for the rapid test and IDR 1.5 million for the PCR test (Setyadi, 2020). However, based on the author contact with COVID-19 taskforce personnel, the rapid test and RT-PCR tests are free only for those who are required medically. According to Muhajir (2020), the payment for rapid and RT-PCR tests should be waived because referring to the circulation letter No. 903/5467/2020, on 27 March, the government has allocated a large amount of money (IDR 1.7 trillions) for COVID-19 infection prevention and control measures focusing on three main sectors namely health, economy and social safety nets.
The number of confirmed COVID-19 cases in Aceh from March to April remained low at 10 as of 30 April 2020. In addition, 85 PDPs were recorded until 30 April 2020; and a detailed distribution of the positive cases, PDPs and ODPs across different districts is shown in Figure 9. The figure indicates that Banda Aceh city represented the highest positive cases (3) followed by Aceh Besar district (2); this is because both areas have large populations and the increase of new inhabitants.
Other districts, bordering with Medan city, North Sumatra province (labelled as a red zone), namely Tamiang and Langsa districts had 1 positive case and 1 PDP respectively as of 30 April 2020. Since then, because of less attention by the government to both these districts and inadequate imposition of a firm regulation on people to stop COVID-19 transmission (e.g., practice physical and social distancing, wearing masks, stay at home, and regular hand washing), the number of confirmed cases significantly increased. For example, as of 6 May, the total confirmed cases in the province reached 17, in which, Tamiang and Langsa districts accounted for the highest number (4 cases), taking over from Banda Aceh. This spatial case trend continued (5 cases were reported from both districts) when 20 total confirmed cases were recorded as of 28 May in the province.
Unfortunately, even though confirmed COVID-19 case numbers continued to increase in Aceh, on 28 May, the governor declared "a new normal era". At the same time (as shown in Figure 7), the local government issued many regulations in relation to guidelines for COVID-19 infection prevention measures for the public during the new normal situation which then allowed the district governments to resume public activities such as offices, schools, markets and other businesses as usual by following the established guidelines (Ifdhal, 2020). In this context, the local government followed the central government policy, despite the fact that case numbers were still growing.

Discussion
It is clear that no full lockdown was implemented either at central government or Aceh provincial levels and the new normal era, which eased restriction, was introduced at a time when COVID-19 cases were still increasing.
This could be considered a failure of policy as lock down (suppression) has been identified as a critical measure to stop COVID-19 transmission (WHO, 2020b). For example, as shown in New Zealand, a tough nationwide lockdown (indicated by alert level 4) for five weeks reduced COVID-19 cases rapidly, then the country relaxed the lock down and restriction measures by moving to the alert level 1 when new cases were zero (Baker et al., 2020).
Further to a countywide lockdown, other important strategies to reduce infection transmission at the community level include case detection, contact tracing, and isolation of those at risk (Askitas et al., 2020). Closure of mass gathering such as schools, places of worship, markets, social events (sports, festivals, and meetings) is also critical to slow down the virus transmission (Atalan, 2020;Khanna et al., 2020). It is only when numbers are low via stringent lockdowns at a national level that other strategies like testing and tracing and introduction of more targeted local lockdowns will be effective as demonstrated in Australia (Australian Government, 2020).
However, despite the central and Aceh governments in Indonesia following some of the COVID-19 control measures successfully used in other countries, it has never employed the same level of restrictions, adequately enforced them or kept them long enough (Kurniawan, 2020;Sutrisno, 2020). For example, Asfinawati, the YLHBI chief explained that the government only applied PSBB (some restriction efforts e.g. school and workplace closure, restrictions on religious activities and other activities in public facilities/areas) and had never implemented a full lockdown (suppression) or even partial lockdowns in any local government areas and relaxing the restrictions had not been applied optimally (Setiati et al., 2020).
Hence, any countries that takes steps to ease restrictions and move toward a new normal should first ensure the

Recommendations
Other issues that require consideration to reduce cases in Aceh as the pandemic continues include:  The government-led action to lockdown border areas between Aceh and North Sumatra province to avoid importing cases. Provincial governments' decisiveness and political will to make this challenging decision to close the border areas are necessary. It is important to consider that lockdowns restrict people movement only, allowing for transport of goods to the province;  Local government must use allocated funds for the purpose of handling the COVID-19 effectively and accountably based on the existing central government regulations because many issues related to the three key sectors of health, economy, and social safety nets have not been addressed appropriately. The government should not only focus on treating the confirmed COVID-19 cases at hospitals, but that the impact of COVID-19 on vulnerable groups, education, and people's livelihoods need to be taken into account.
Importantly, maintaining the accountability of using the funds is crucial to avoid misuse and enhance transparency;  Strengthening of the role of BPBA as the COVID-19 taskforce chief to enhance the coordination efforts with other relevant institutions in order to accelerate preventive and control measures for the virus transmission;  Strengthening coordination with Islamic leaders in efforts to contain the COVID-19 spread in the province is important to speed up the process of infection prevention and control measures. Further, the role of the Islamic Sharia Agency to engage the Islamic leaders who may be resistant to such efforts is essential to strengthen the teamwork;  Reassess vulnerability across all districts of Aceh to ensure COVID-19 assistance can be delivered to those most in need and to prevent duplication in assistance for some;  Waive the charge for rapid testing and PCR tests for all citizens so as to encourage individuals to voluntarily test in order to improve early detection efforts;  Continued dissemination of preventive information to the community by the government and relevant stakeholders (e.g. military, police and health officers);  Establish a local regulation to reinforce the Ministry of Village circulation letter on village response volunteers (alert teams) on COVID-19, which is currently not available in Aceh province to address workforce capacity issues;  Improve the capacity of health personnel to safely handle COVID-19 cases at Public Health Centres (PHCs) at sub-district and village levels. This is important because the PHC is the frontline in providing health care to communities;  Improve pandemic control infrastructure and supported facilities (e.g., isolation rooms for COVID suspects), personal protective equipment for assigned staff (e.g. masks, gloves and face shields) at land, air and water transportation terminals;  Establish a Pandemic Health Intelligence Plan. Such a plan is essential to continue to assess and analyse COVID-19 related information including epidemiological condition, the capacity of public health and health care systems, as well as community response to the plan (Australian Government, 2020).

Conclusions
This study has examined the current central and local governments and other relevant institutions' responses to COVID-9 pandemic. Focusing on Aceh province as a setting, this research used media content analysis of central and local government regulations, official reports/websites, newspapers and Facebook's postings from January to May 2020.
This study described the timeline and early response actions on COVID-19 taken by the Aceh government and its key relevant agencies based on the current regulations formulated during the COVID-19 pandemic in Aceh province.
The results highlight several issues including late early responses taken by central and Aceh governments and other issues relating to no lockdown implementation (suppression), and no border restrictions at borderland areas, seaports and airports; early introduction of the new normal era; the absence of checkpoints and village alert teams across the entire province and lack of enforcement on the established regulations to prevent and control the spread of the virus in the province. It provides key recommendations for policy and practice in enhancing the effectiveness of responses to COVID-19 infection prevention and control procedures in Aceh province as the pandemic continues, and in doing so contributes to system strengthening for future health emergency events.