ThinkWell is pleased to virtually join over 2,000 policymakers, practitioners, and researchers from more than 100 countries at the Sixth Global Symposium on Health Systems Research (HSR2020) from November 8-12, 2020.

This year, the gathering aims to, “explore how we can build health systems which improve people’s health and are socially just.” We’re thrilled that the theme aligns well with ThinkWell’s mission to ignite system-level transformation for lasting improvements in the health and well-being of society. A broad ecosystem of factors influence health, so we’re looking forward to participating in conversations about how to break down old silos and boundaries.

You can view the full program and register here. We hope to see you there!

ThinkWell’s posters and presentations that will be featured at HSR2020 are briefly summarized below.

A Stakeholder-based Approach to Assessment of Barriers to Climate Change Adaptation (CCA) of Local Health Systems in an At-risk Province in the Philippines: Health system adaptation to climate change (CCAH) requires building on core health system functions and working with actors outside the health sector. Jemar Anne Sigua, Geminn Louis Apostol, Mary Camille Samson, and Leoncio Abiera Jr. mapped the Filipino health system stakeholders involved in CCAH to understand their relationships and to identify the barriers and facilitators to implementing CCAH strategies in a provincial health system. Based on their findings, the authors proposed recommendations in strengthening health system awareness and action towards CCAH. The presentation was be presented at HSR on November 25. It can be viewed here.

Facilitators and Barriers to Engaging Private Primary Care Providers in the Delivery of Family Planning Services in the Philippines: In the Philippines, the supply of family planning services has not kept up with rising demand. The country’s 2019 UHC Law presents an opportunity to improve family planning access. The government can do this by leveraging the country’s vibrant private reproductive health sector that currently offers limited clinical family planning services. Geminn Louis Apostol, Viviane Cen Apostol, Kate Sheahan, and Matt Boxshall’s research presents recommendations that can help make this potential a reality. ThinkWell will continue to work with partners in PhilHealth, PhilHealth, the Ministry of Health (DOH), and others to develop, test, and learn from these interventions. The poster can be viewed here.

Reproductive Health Voucher Schemes in Uganda: Key Lessons for the Future: Over the past decade, Uganda has used voucher schemes to improve low-income people’s access to family planning (FP) and maternal, newborn, and child health (MNCH) services. In early 2020, ThinkWell and the Uganda Ministry of Health (MOH) collaborated to study the latest two voucher initiatives’ experiences. Tapley Jordanwood, Angellah Nakyanzi, Espilidon Tumukurate, Eric Tabusibwa, James Mwaka, Anooj Pattnaik, Sarah Straubinger, Flavia Moi, and Sarah Byakika captured what the voucher schemes have achieved and distilled what can be taken forward to future health system purchasing reforms. The poster can be viewed here.

Purchasing Arrangements at County-level in Kenya: ThinkWell’s Strategic Purchasing for Primary Health care (SP4PHC) team in Kenya supports a program that combines strategies at the national and county levels to improve how public funds are used to pay for primary health care (PHC) services. Boniface Mbuthia, Felix Murira, Shano Guyo, Daniel Koech, and Nirmala Ravishankar completed a rapid situation analysis to understand county-level purchasing practices. The full report can be viewed here and the poster can be viewed here.

Development of a Competency Certification Framework for Primary Care Providers in the Context of Universal Health Care in the Philippines: The Philippines’ UHC Law presents an opportunity to strengthen primary care. To do this, primary care providers must be adequately supported. Louella Patricia D. Carpio, Madeline Mae Ong, Viviane Cen Apostol, and Maria Eufemia Yap created a guidance framework for the primary care certification of health care providers. This framework can help produce primary care providers who will effectively promote health and make the health system more responsive to the population’s needs. The poster can be viewed here.

Understanding Health-Seeking Behavior for Inpatient Care in Antique and Guimara: Christian Nuevo, Pura Angela Co, Helena Alvior, and Mary Camille Samson from ThinkWell’s Philippines team completed a study to describe inpatient care health seeking behavior patterns in the provinces of Guimaras and Antique. They explored factors that affect utilization of inpatient healthcare services. Their study also aimed to assess the potential role of healthcare provider networks in improving access to and delivery of health services. The poster can be viewed here.

This piece originally appeared on P4H here

Written by Hélène Barroy, Federica Margini, Joseph Kutzin (World Health Organization), Nirmala Ravishankar  (ThinkWell), Moritz Piatti-Fünfkirchen (World Bank Group), Srinivas Gurazada (PEFA), Chris James (OECD)

COVID-19 has been a well-recognized stress test for public financial management (PFM) systems in most countries. It exposed the overall weaknesses of PFM systems across countries but also helped to pinpoint the PFM mechanisms and approaches that make it easier for countries to respond to epidemics. Emerging evidence shows, however, disparities in the readiness of PFM systems. Some countries have budgeting modalities which allowed them to rapidly reprogramme expenditure toward the emergency health response. In other countries, spending procedures have stymied the rapid release of funds to subnational entities and prevented health service providers from quickly accessing necessary resources. In this blog, we delineate some of the enabling features of PFM systems that engendered an effective health response to COVID-19 (“PFM system readiness”) and some of the challenges and bottlenecks that have required major adjustments to existing systems (“PFM system adjustments”).

This work builds on inputs from the WHO Survey on PFM & COVID-19 containing information for 183 countries (updated in September 2020), the World Bank COVID-19 response tracking portal (developed in July 2020), the OECD Joint Network of Senior Budget and Health Officials, and regional and country consultations in 17 low- and middle-income countries (Argentina, Australia, Brazil, Chile, China, Costa Rica, Dominican Republic, Ecuador, Indonesia, Lao People’s Democratic Republic, Malawi, Mexico, Mongolia, Peru, Philippines, South Africa, Ukraine) conducted between June and September 2020 by WHO.

PFM system readiness for COVID-19

A pre-existing flexible budget structure—that is, a budget that plans and releases funds by programmatic envelopes linked to policy objectives, instead of by detailed line items—has proven to be helpful for budgeting for COVID-19 and for tracking emergency health expenditures when the structure is accompanied by a robust accountability framework.

Several countries, across income levels, leveraged existing programme-based budgeting approaches by adding a COVID-19 budgetary programme to their health budgets or by using existing programme envelopes to redirect expenditure toward the emergency response. In these cases, COVID-19 targets were defined within existing performance monitoring frameworks to ensure expenditure tracking. In Mexico, New Zealand and South Africa, where programme budgeting has long been standard practice, this approach clearly enabled an agile response to the crisis.

In Mexico, programme budgeting was introduced in the 1970s. When COVID-19 emerged, Mexico’s budget structure facilitated a rapid response by the health sector. A COVID-19 subprogramme was added to the Ministry of Health (MoH) budget to cover secondary and tertiary care. A new budgetary programme for other individual and community-related support was added to a special fund, the Fondo de Aportaciones para los Servicios de Salud (FASSA). As a result, MoH health spending increased by 61% in the first quarter of 2020 and spending by the Ministry of Labor and Social Welfare increased 58% during the same time period to match funding needs for the health response.

In South Africa, where programme budgets have been in place for nearly twenty years, flexible reallocations were made possible through several existing budgetary programmes (i.e. communicable and noncommunicable diseases, primary health care, and health system governance and human resources). At the subnational level, provinces were also allowed to reprioritize up to 1 billion South African rand in existing programme envelopes for COVID-19 expenditure. The budget structure, which has supported an integrated service delivery approach since 2019, facilitated the inclusion of COVID-19 services into service delivery platforms that cut across diseases and levels of care.

In New Zealand, the government established the COVID-19 Response and Recovery Fund (CRRF) as part of the 2020 budget. The CRRF provided additional funds for the response, consistent with and using the same core principles as its overarching programme budgeting framework, which has been in place for decades. All budget appropriations in the health sector were allocated by output, with the MoH having the flexibility to choose the most suitable input mix and delivery mechanisms for each given output.

Some pre-existing spending modalities have also facilitated financing of the COVID-19 health response, especially in moving money quickly toward the frontline service providers. The ability to quickly transfer funds to subnational levels through robust transfer mechanisms and formula-based allocations has been instrumental in many instances.

In at least 15 of 37 OECD countries, subnational governments received transfers from central government for COVID-19 health spending. In Argentina, the pre-existing conditional grants for subnational levels provided a suitable environment to accelerate transfers to the provinces: having well-established central-subnational transfer mechanisms in place was an enabler to moving funds down for the COVID-19 health response. In April 2020, the government created the Provincial Financial Emergency Program which allocated 60 billion Argentine pesos to the provinces through the ATN fund (Aportes del Tesoro Nacional) and another 60 billion pesos through a trust fund managed by the Ministry of Economy. The Provincial Development Trust Fund distributes funding based on the poverty index (Necesidades Basicas Insatisfechas), the number of self-employed, and the COVID-19 infection rate per 100,000 inhabitants.

In some countries, a pre-existing accountability system has enabled the establishment of a robust tracking system for COVID-19 health expenditure. While some countries set up parallel systems for reporting COVID-19 spending, others made rapid adjustments to existing financial management information systems (FMIS) to integrate expenditure tracking for COVID-19. South Africa developed a robust accountability system, building on their pre-existing framework. Special templates were created to report expenditures related to COVID-19 and a new category was added to the standard chart of accounts.

PFM system adjustments since COVID-19

While some countries had their PFM systems ready for emergency response, several other countries had to introduce major adjustments to their regular systems to enable a more rapid budgetary response to the crisis and the speedy allocation and disbursement of public funds. Some countries introduced broad adjustments related to resource programming and use, going beyond traditional emergency clauses.

A few countries with line-item budgets introduced new programme-type lines for COVID-19 to support more flexible spending for the emergency response. This may be considered a pseudo form of programme budgeting. In Nigeria and in Liberia, for example, a lump sum to finance the COVID-19 response was introduced into the input-based formulation of the federal/central budget to generate more flexibility. In other African countries (e.g. Niger, Chad), special earmarked accounts (comptes d’affectation spéciale) consolidating all COVID-19 spending were established to overcome the limitations of line item budgeting.

These temporary measures are worth exploring to see whether they could be further adapted and institutionalized over the long run. COVID-19 has shown that programme-based structures can make allocating funds by purpose easier and can improve expenditure tracking accordingly. Moving forward, countries with budgets historically formed and controlled by line item, with no clear links to results, are encouraged to institutionalize programmatic classifications. This approach would link resources to health outputs, improve flexibility in resource use and potentially provide a framework for accountability with predefined sector targets.

Since the start of the COVID-19 crisis, several countries have also explored alternative spending modalities within their regular PFM systems. These have, in some cases, simplified and accelerated spending by frontline health service providers for the response.

In several countries, fast-track spending authorization procedures were introduced to accelerate the release of funds for COVID-19. For example, China introduced a package of accelerated disbursement mechanisms that allowed for advance appropriations (i.e. no further approval required to release funds) and fast-track payments (i.e. reducing the timeline to final payment) to meet health spending needs. Colombia temporarily excluded medical devices and personal protective equipment (PPE) from the general public procurement regime, allowing public buyers to purchase these items without formal tender procedures.

Many countries also introduced advance payments to health service providers to compensate them for the increase in demand due to COVID-19. When purchasing agencies were able to operate outside of the regular PFM rules with flexible spending modalities and the ability to reallocate funds across existing budget lines, health service providers were able to access funds more easily and the overall response was generally more agile. This was the case in the Philippines where hospitals were able to benefit from advance payments from PhilHealth, the purchasing agency. PhilHealth frontloaded funds using a case-based mechanism. The amount was estimated by multiplying the average value for claims during the previous year by 90 days. As of August 2020, a total of LCU 9.3 billion had been provided in cash advances to hospitals and health facilities to relieve financial pressures.

In China, a total of 19.4 billion yuan in advance payments was allocated from local insurance funds to health service providers as of May 2020, including 3.7 billion yuan for Hubei. China also adjusted its global budget payment policy. All expenses for treating COVID-19 were excluded from the hospitals’ annual budget quota and were covered separately by the insurance funds. In Germany, federal measures were introduced to support hospitals and expand the capacity of intensive care units (ICUs), including bonuses for hospitals that expanded ICU capacity and compensation payments for loss of earnings due to a lower bed usage

The ability to hire and manage staff more flexibly has been a key factor for success in some countries. In Portugal, National Health Service facilities were given the authority to directly hire health workers using renewable four-month contracts. In Uganda, the Ministry of Health was provided with supplementary funds to contract and deploy surge staff for an initial period of three months. Though flexible staff management can be challenging to achieve, it is among the most instrumental factors for efficient health service delivery.

Key policy actions

Simply allocating more funds from budgets will do little to make PFM systems more responsive to health needs. Countries must instead use their systems smartly to address bottlenecks, enabling funds to be quickly directed towards health priorities, executing budgets effectively, and ensuring accountability for health results.

Moving forward, some of the mechanisms introduced during the emergency response to COVID-19 may be considered for non-emergency health needs—needs that, by nature, will keep evolving and require PFM flexibility. The positive experiences of the countries in which programme budgeting is well-established, as well as those with effective and accountable inter-governmental transfer mechanisms, suggest that these features need to be part of the “build back better” agenda for more resilient health financing arrangements in the longer-term. In addition, mechanisms that allow for direct facility transfers can be explored to empower providers as they respond to health needs, whether during epidemics or in more normal times. Examples of these mechanisms include those mentioned previously in this blog post and those that have been implemented in other contexts prior to COVID-19 (e.g. in the Tanzania Direct Facility Financing mechanism primary health centres directly receive, manage, and account for public funds).

We recommend three key policy actions to integrate or scale up successful PFM approaches used during COVID-19 to make systems more adaptable, flexible and resilient:

1. where detailed line item planning prevents the effective use of resources, accelerate efforts to tailor health budget structures to allow for more flexible programming;
2. to remove bottlenecks to health budget execution, sustain formula-based approaches for intergovernmental transfers and agile payment methods to frontline providers;
3. to enhance accountability in the health sector, make reporting systems more user-friendly and responsive to health expenditure tracking needs. 

Acknowledgments

We appreciate inputs received from Claudia Pescetto (WHO Regional Office for the Americas) for Argentina, Chile, and Dominican Republic; Ding Wang (WHO Regional Office for the Western Pacific) for China; Gao Chen (WHO China) for China; Ronald Tamangan (WHO Regional Office for the Western Pacific) for the Philippines; Marife Yap, Ian Nuevo and Pura Angela Wee-Co (Thinkwell) for the Philippines; Jonatan Daven (National Treasury, Republic of South Africa) for South Africa; Neil Cole (Collaborative Africa Budget Reform Initiative) for South Africa; and Kingsley Addai Frimpong (WHO Ghana) and Ernest Sekyere (Ministry of Finance, Ghana) for Ghana.

This article originally appeared in Health Systems Governance Collaborative here

Our current situation – living through the COVID-19 pandemic – highlights the critical role of local governments in securing the health of communities. Since the confirmation of the Philippines’ first COVID-19 case last January 30, 2020, the disease has heavily strained the health system of the country. The early stages of the pandemic had local government units (LGUs) and different sectors scrambling to address various concerns with “survival” strategies on their own because of unclear directives from central government. In the Western Visayas region, the provinces imposed border restrictions and requested airlines to temporarily suspend flights coming in from areas with known positive cases. Despite these, COVID 19 entered the region with the first confirmed case on March 20.

As the confirmed COVID-19 cases increased in the region, panic and fear set in. Rising numbers of confirmed positive cases globally and nationally coupled with limited and confusing information about how the virus spreads, and the haphazard implementation of the community quarantine heightened the negative sentiment of the people towards the national government response. In addition, there was widespread news that personal protective equipment (PPE), especially for health workers, were limited. Rural health units and hospitals across the region grappled to put protocols in place, reorganizing patient flows in services and establishing referral protocols for COVID-19 and non-COVID-19 patients. Making matters more problematic was the fact that there was no testing laboratory in the region and all swab samples had to be flown to the central laboratory in Manila. On top of these health concerns was the foreseeable impact of the pandemic to the economy and livelihood of the people.

LGUs became proactive in their campaigns against the COVID-19 pandemic, especially in engaging both public and private stakeholders. Harnessing the combined efforts of the local government, the regional Department of Health (DOH), the academia, and the private sector led the facilitation of the availability of necessary laboratory equipment and supplies. Health human resources were mobilized and capacitated such that within a week time, the first COVID-19 testing laboratory in the region became functional. From big businesses to pooled efforts of groups of friends, food and donation drive initiatives to support front liners overflowed. To augment PPE supplies, science and technology schools produced alcohol, designed and built face shields, aerosol boxes, and even prototyped ventilators. Local fashion designers collaborated and redirected skills to producing hazmat suits with film-inspired designs to bring some positive light amidst uncertainties. When community quarantine prevented the ingress of supplies coming into the region as well as the transport of economic products outside, efforts to save agricultural products were initiated. For example, tons of world-class Guimaras mangoes were in danger of being unsold and wasted but a new market for the mangoes emerged from the neighboring provinces and cities within the region aided by social media marketing and online platforms. This ensured that none of these agricultural products were wasted and provided much needed funds to the farmers.

Local civil society organizations partnered with academia in generating context-specific evidence to inform decision makers and spur action across all sectors for a coordinated and effective COVID-19 response. This effort was initiated by ThinkWell Philippines, through its field-based team that has been providing technical assistance in Western Visayas for the implementation of Universal Health Care (UHC) reforms in the region. Due to COVID-19, most of the UHC reform activities halted, and support was redirected to help in the strengthening of the region’s pandemic response. The team started with a simple contact tracing analysis of the first few COVID-19 cases in the region with data sourced and consolidated from local official bulletins and news articles, and then shared these with networks in the health sector and in academia. This eventually led to a collaboration with public health experts from the University of the Philippines Visayas (UPV) for a series of policy notes (linked below) anchored on the detect-isolate-treat structure with epidemiological analysis of local data supported by various issuances from the national government and the World Health Organization.

With strong collaboration among local leaders who chose to adapt a local and contextualized approach to pandemic response, Western Visayas was recognized as one of model regions in terms of COVID-19 response. ThinkWell and UPV, both well-regarded in their own fields, gained the trust of regional partners and were agents in influencing the COVID-19 response in the region through the endorsement of the policy notes. The regional DOH and LGUs appreciated the analyses, used the findings as talking points in both the national and local arena, and considered the recommendations put forth during task force meetings. Mass media and social media platforms facilitated the sharing of documents to the public, drawing the interest of non-government and private organizations to use these as guides in planning and decision-making.

This experience of LGUs taking charge and stepping up to protect the people emphasizes that deeper trust can indeed be fostered by quick inclusive action of local leaders. The spirit of togetherness is very much alive. This realization is a call to build on local strengths. Moving forward, local health systems should invest in taking stock of capacities, expertise, resources, influence, and networks, keeping in mind that multi-sectoral approaches should not only focus on health challenges but also promote good governance across sectors that impact health.    

Multi-sectoral actions create space for people to come together, breaking down silos to think out of the box and design new interventions or arrangements that could lead to more sustainable and comprehensive results. The UHC Law of 2019 seeks the implementation of province-wide integrated health systems. In Western Visayas these efforts were underway, especially in pushing for strong and independent health systems led at the provincial level. The COVID-19 pandemic highlights the glaring fragmentation of the current health system. This situation is an opportune time to reflect on this experience and harvest learnings to ensure a more prepared local health system as we adjust to the “better normal”. Responding to the COVID-19 crisis is not the sole responsibility of government alone, the Western Visayas experience illustrates that local governments that have the capacity and willingness to proactively engage multi-sectoral partners are a cut above the rest.

Policy notes:

• Policy Note 1
• Policy Note 2
• Policy Note 3
• Policy Note 4

Authors’ Bionote

Written by Helena Marie Lagon Alvior, Mary Camille Samson, and Jemar Anne Sigua. The authors are affiliated with ThinkWell under the Strategic Purchasing for Primary Health Care (SP4PHC) Project in the Philippines. Dr. Helena Alvior, Technical Advisor, and Camille Samson, Program Analyst, are assigned in two provinces in Western Visayas, Philippines to provide technical assistance in the implementation of the Universal Health Care Law. They work together with Jem Sigua, Program Coordinator, who oversees the development of knowledge products and analyses.

The authors would also like to acknowledge Dr. Maria Eufemia Yap and Ian Nuevo of ThinkWell, and Dr. Philip Ian Padilla of the University of the Philippines Visayas for their inputs.

To know more about the project: https://thinkwell.global/projects/sp4phc/

This article originally appeared in Health Systems Governance Collaborative here

Expanding technical capacity

When Covid-19 hit the Philippines last January 2020, a lot of the science behind the disease response was still unknown. Testing was prioritized, and the Department of Health (DOH) grappled with increasing the number of capable testing laboratories and personnel, whilst balancing proper regulatory and safety standards.  At the same time DOH had to understand a wave of potentially game-changing new technologies in pandemic management and response.

As a response, DOH formally convened a Covid-19 Laboratory Expert Panel (CLEP)[1], composed of experts in fields of chemistry, biochemistry, molecular biology, pathology, medical technology, laboratory management, and public health. These individuals have strong and trusted relationships with the DOH and the Department of Science and Technology (DOST) as experts and consultants in former projects. The ad hoc panel provides evidence-based, independent, technical assessment and advice to the agency on all matters related to Covid-19 testing.

Translating expertise to decisions and actions

DOH engagement with CLEP has resulted to significant gains in policy and governance for COVID-19 testing:

• Interdisciplinary expertise complemented field experience to create a responsive strategy arc for expanded testing capacity. The CLEP hit the ground running by recommending strategies focused on (1) standardizing processes that ensure biosafety and accuracy, (2) investing in capacity-optimizing interventions such as automatic testing platforms and mobile pop-up laboratories, and (3) centralizing data management and funding to ensure efficiency and economies of scale. The diverse expertise of the panel allowed comprehensive recommendations.

Members of CLEP have been previously involved in laboratory personnel training and volunteer management. They married field experience with technical proficiency to form policy recommendations grounded in both scientific evidence and practical understanding.

• CLEP objectively reviews new technologies and crafts scientifically based recommendations to guide policy and implementation. With Covid-19 becoming a highly political issue, the DOH is pressured to make immediate decisions on a lot of challenging matters.  The private laboratory sector lobbied strongly to make use of rapid antibody tests as part of return to work clearance protocols. WHO recommended relaxing biosafety standards for GeneXpert facilities targeting poorer and resource-constrained areas. Antigen testing and pooled testing[2] are also being positioned by external stakeholders and other government partners as means to quickly scale-up testing capacity.

In the end, rapid antibody tests were still included in the expanded testing protocol, and standards for GeneXpert facilities were not relaxed. While these were not in accordance with CLEP recommendations, the engagement still resulted positively. The retained standards for GeneXpert facilities were comprehensively explained, shaping a well-rationalized policy. Technical guidance on proper use and disposal of rapid antibody tests were also provided to mitigate risks. Expert advice is currently guiding the strategic roll-out of pooled testing to fully realize its gains.

• Expertise allowed for immediate, continuous discourse on relevant innovation. Given their networks, CLEP members were able to identify two early but promising innovations for a more efficient Covid-19 testing: (1) the use of saliva as specimen for testing, and (2) onsite deactivation of collected samples. Published and unpublished literature were reviewed to guide initial recommendations. Expert discussions with other resource persons from WHO also polished ways forward.

The use of saliva as specimen and onsite deactivation of collected samples have the  potential to significant resources savings, while also safely scaling up testing capacity. The country’s national reference laboratory, the Research Institute for Tropical Medicine, is in the process of validating the applicability of these innovations in the local setting. The CLEP continues to provide technical guidance in these studies.

Continuing strategic engagements with stakeholders toward effective health governance

Deliberate and well-organized convening of external experts resulted in the swift development of evidence-based policies that offer better ammunition against the pandemic. Although individual members of CLEP work outside the DOH, regular and legitimate platforms of participation allowed strategic harnessing of their knowledge and skills. DOH has used a similar approach in the past – an ad hoc panel of health systems experts that provided technical advice in the drafting of the Implementing Rules and Regulations of the Universal Health Care Act, and more recently the law-mandated, institutionalized Health Technology Assessment Council that provides objective review of technologies for government purchasing. All of which have expanded the government’s capacity for better informed decision-making. Such strategic governance mechanisms should be continued to engage other key experts and relevant stakeholders, even beyond the pandemic. These efforts evidently allow for a more inclusive, collaborative stakeholder engagement that strengthens and facilitates units like the DOH, particularly its key function of providing stewardship over health care service delivery in a rational and efficient manner.

Written by Christian Edward Nuevo (1), Lindsay Orsolino (2), Kim Patrick Tejano (3), Maria Eufemia Yap (1), Matt Boxshall (4)

1. Strategic Purchasing for Primary Health Care (SP4PHC), ThinkWell Philippines
2. Office of the Secretary of Health, Department of Health Philippines
3. Health Regulations Team, Department of Health Philippines
4. ThinkWell United States of America

[1] through Department Personnel Order 2020 – 1348 and its amendment

[2] A means of combining samples for testing from several individuals and combining one laboratory test on the combined batch

This piece originally appeared on P4H here

Written by: Anooj Pattnaik, Deputy Director for Learning; Prastuti Soewondo, Country Director, ThinkWell Indonesia; and Nadhila Adani, Analyst, ThinkWell Indonesia

Purchasing of health services during normal times is rarely done by a single entity. Rather, there are usually many different purchasers in a country’s health system, from ministries of health, subnational governments to national health insurance agencies.  This is certainly the case in Indonesia, where their young national health insurance scheme founded in 2014, Jaminan Kesehatan Nasional (JKN), covers over 80% of the population for individual health services, while the government still plays a substantial role in delivering population health and allocating funds to public providers for expenses like wages and supplies. So how does a mixed purchasing system, like the one in Indonesia, adapt and respond to the advent of a crisis like COVID-19?

A Hybrid Approach

When the virus hit the shores of Indonesia in March 2020, the Indonesian government needed to rapidly adapt its mixed purchasing system to prepare for the potential rapid rise of COVID-19 within its borders. It decided to adopt a hybrid approach between its Ministry of Health (MoH) and BPJS-K, the government agency responsible for implementing JKN.  The MoH would be responsible for defining the clinical pathways for COVID-19, developing the tariff and payment mechanism (cost-per-day), and making the payment directly to the providers.  BPJS-K would be responsible for receiving and verifying claims around COVID-19 from health facilities and submitting to the MoH for payment.  In this way, the Indonesian government aimed to leverage the strengths of each agency: the deep experience and technical expertise of the MoH to set the guidelines and receive/disburse significant amounts of funds, and the strong claims management and verification systems of BPJS-K, as well as their existing contracts with both public and private providers who are delivering COVID-19 services to the population. Once the pandemic is over, the plan is for COVID-19 to be part of the case-based group payment (CBG) system of JKN. Therefore BPJS-K involvement has been crucial in these early stages so they can better devise how they will incorporate COVID-19 coverage in the future.

Purchasing Features of the Response

Quickly after COVID-19 permeated Indonesian shores, the MoH clarified key details of how COVID-19 services would be purchased in the emergency response. The first regulation was that local citizens would pay nothing out-of-pocket (OOP) if they met 3 categories: probable (if they were admitted to the hospital due to pneumonia, fever, or respiratory infections at any age), suspected (if they are 60+ and had any symptoms in the last two weeks (e.g. fever, trouble breathing), or confirmed cases.  This regulation was updated in August 2020 to now include those under 60 who show any symptoms.

This coverage extends to only public and private hospitals, not PHC facilities, as the MoH transfers funds directly to the hospital, not the patient.  However, testing for COVID-19 is only free if the person fits under these 3 categories. If not, Indonesians must pay OOP for the test, which is certainly not ideal and has likely led to under-testing of the population. 

The President has implored for COVID testing to be increased across the country. To this effect, the availability of PCR tests has increased tenfold in the last 3 months. However, these PCR tests have been unequally distributed, especially outside Java island.  On the contract tracing side, developing a unified strategy and then implementing it has been a tremendous challenge, resulting in targeted testing being scattered and largely ineffective.  In addition, there is a significant delay (around 10-14 days) for test results due to the limited lab capacity in the country. 

The services that are covered under the new COVID-19 package include administration fees, accommodation (e.g. inpatient, ICU, or isolation rooms), treatments, ventilator use, medical consumables, diagnostic support tests, drugs, referrals, and other related health services. The hospital then submits the claim through the existing JKN claims system and is paid by the MOH via a case-based group (CBG) rate for outpatient care or cost-per-day for inpatient care. There is one fixed tariff for all hospital classes (for both public and private), with a range of severity level from moderate, complex, and critical.  

The Indonesian government also is responsible for procuring and supplying these hospitals with PPE, necessary equipment like ventilators and oxygen, and improving the physical infrastructure of these hospitals to optimally respond to the virus.  These funds and supplies are allocated to health facilities through separate purchasing channels than this COVID-19 claims one. All hospitals that are appointed to receive COVID patients should be able to receive supply assistance. However, in practice, public hospitals and government-related providers (military and police hospitals) have been prioritized with only few selected private hospitals confirming that they received assistance.

Initially, hospitals were only allowed to submit COVID claims once every two weeks. This has been updated recently to allow for a weekly submission.  BPJS-K then is supposed to verify the claim within a week and submit the verified claim to the MoH. When hospitals submit claims to BPJS-K, they should also send the claim to the MOH.  While waiting for approval from BPJS-K, the MoH transfers 50% of the total claim to the provider. The MoH then transfers the rest of the payment to the hospital within 3 days of receiving the verified claim.  

Perhaps unsurprisingly, there have been challenges around this system, as many of the claims submitted by public and private hospitals for COVID still have not received payment, far past the stated payment schedule. This is more of a critical issue for private hospitals who rely on these payments to stay afloat and do not receive government subsidies like their public counterparts.  Rapidly setting up this purchasing arrangement likely has also led to bottlenecks that delay payments, while JKN has had its share of existing challenges with processing payments even before COVID. 

Moving forward

It remains to be seen how effective and efficient this hybrid purchasing arrangement has been for dealing with the COVID-19 crisis in Indonesia. Nonetheless, the Indonesian government clearly aimed to leverage the strengths of its different purchasing agencies in its response. The MoH has decades of experience in this type of fund management and disbursement through programs like Jampersal and previous emergency responses. On the other hand, JKN still is only 6 years old and it could have been a heavy burden for BPJS-K to play this central role in such a massive crisis the way the more experienced PhilHealth has done in the Philippines.  Instead, JKN’s existing claims management infrastructure, routine data systems, and contractual arrangements with both public and private providers (which expand access) were tapped in the response, which may prove to be a more appropriate and considered approach. In any case, this type of joint response and collaboration between the two major purchasers of health services in Indonesia could help to usher in a more coherent approach to achieving UHC once the immediate crisis has receded.

Written by: Anooj Pattnaik, Deputy Director for Learning; Prastuti Soewondo, Country Director, ThinkWell Indonesia; and Nadhila Adani, Analyst, ThinkWell Indonesia