The Challenge
Indonesia is the largest economy in Southeast Asia and the tenth largest economy in the world. Aligned with strong economic growth, the country has witnessed steady gains in overall population health. While performance in health areas such as life expectancy and under-5 mortality has improved, performance in some health areas has been stagnant or less than satisfactory. Indonesia ranks as the third country in terms of absolute number of estimated TB cases (845,000), and TB remains the leading cause of death by communicable diseases. Notification of TB cases is a challenge in Indonesia – only 67% of estimated TB cases are notified compared to 73% in the combined other South-East Asia and 78% in the West-Pacific. A second challenge is that an excess of TB treatment is being provided in hospitals, where care is more expensive, TB medication monitoring is poor, and treatment outcomes are consistently worse compared to outcomes at the primary health care (PHC) level. The payment arrangements applied in JKN may partially explain the dominance of hospital-based treatment. Optimizing contracting arrangements and payment methods in a way that creates stronger incentives for providers to increase case finding and notification and avoid excessive use of secondary care would achieve more value for money for TB care in Indonesia
The Opportunity
Services in priority programs such as TB create nuanced health financing issues and may require tailored strategic purchasing approaches. There are growing concerns that covering TB through capitation payments is creating an incentive for PHC providers to refer TB cases inappropriately to secondary and tertiary hospitals, and to avoid case-finding and reporting. Any consequences of shortcomings in service delivery affect not only individuals seeking care but have spillover effects on others in the community. Financial incentives must align to include preventive services and ensure appropriate and high-quality diagnostic and curative services.
Our Work
Under the USAID Tuberculosis Private Sector (TBPS) activity and in partnership with the Indonesian Ministry of Health Center for Health Financing and Insurance, R4D will lead the design and implementation of a strategic health purchasing pilot for TB with a goal of increasing the number of care-seeking clients in the private sector who are correctly diagnosed, notified, and have successfully completed TB treatment.
Working with FHI360 as the prime contractor for the TBPS project, R4D will design the technical elements and implementation arrangements for the TB pilot. This includes analytical support for the Technical Working Group to inform decision making on included services, payment methods and rates, contracting arrangements, institutional relationships, as well as monitoring and evaluation.
R4D will then conduct a budget impact analysis that would provide insight into which providers may gain or lose revenue under any purchasing changes. The next steps would then be to prepare and implement the strategic purchasing pilot.
Strategic Purchasing of TB Services through National Health Insurance in Indonesia
R4D is examining the link between incentives for TB diagnosis and treatment, provider behavior, and service delivery patterns and designing strategic purchasing solutions under Jaminan Kesehatan Nasional (JKN), Indonesia’s national health insurance payment system.
