This piece originally appeared on P4H here

Written by Ryan Rachmad Nugraha, Anooj Pattnaik, Catherine Connor, Hasbullah Thabrany

The spread of Covid-19 around the world has provided a litmus test on the strength and resilience of every country’s health system. Indonesia has been no exception. As of November 6, 2020, there have been 421,731 positive confirmed cases with a devastating 3.38% mortality rate, putting tremendous pressure on the Indonesian health system.[1]

To ensure routine essential services are provided as usual and ballooning Covid cases are covered, the Government of Indonesia (GoI) rapidly mobilized its purchasing system to provide funding, as well as technical and operational guidance, to its health system actors. Special attention was given to hospitals, as they were hit especially hard with their highest recorded bed occupancy of 77-79% within the last 3 months.[2] In order to meet this surge in demand, the GoI used public funds to cover all Covid-19 treatment, based on the bylaw 6/2018 of the Health Quarantine, including at hospitals.

How hospitals now submit Covid claims

The government passed Decree 238/2020 in April 2020[3], which established that the Ministry of Health (MOH) would be the main purchaser of a Covid-related package that covers all hospitalized patients dating back to January 2020. The Covid package reimburses hospitals on a fee-for-service basis for specific services, ventilators, drugs and consumables, per diem for accommodation, as well as mortuary care. As explained in a related blog, the GoI chose to use the MoH to disburse funds rather than use the existing but young JKN national health insurance scheme. In turn, the MoH is assisted by BPJS-K, the agency that runs JKN, to manage and verify the Covid claims. All hospitals, regardless of being contracted by JKN or not, submit claims for Covid through this newly established system.

The decree also clarified the process for hospitals to submit claims for Covid-19 care. The MoH decided to utilize an e-claim application that was previously established for JKN, before they moved on to a new claims system that pays a fixed amount per case. Hospitals are required to submit Covid patient claims and supporting documents through this revived application. After the claim is submitted, the MoH pays hospitals 50% of the claimed amount up front. The submitted data is then reviewed by verifiers from BPJS-K and once approved, the MOH pays the remaining balance to the hospital.

Challenges hospitals face (so far)

While the rapidly enacted policy has been fairly accommodating of hospital costs thus far, it has presented several challenges. First, the server of the e-claim application has been down often due to several bugs and errors, causing hospitals to often postpone submission and hindering the claim reimbursement process.[4] Many hospitals also feel that they have no feedback mechanism to the purchaser about any challenges with the application.

Second, many hospitals perceive the claims requirements to be quite rigid, especially as the rate of claim submission is high and the process is so new. For instance, hospitals noted instances of approval delay or denial from verifiers because they had not received the full range of completed documents from actors outside the hospital, such as a letter for proof of swab from the lab centre (outside the hospital).

Third, many of the hospitals that are now submitting Covid claims are new to the system. Out of 2,813 private hospitals, 390 were not already contracted with JKN and had no experience with the e-claim system, let alone these Covid-related claims.[5] Even if training was provided, this took much time and had to be done over videoconferencing. On the disbursement side, many of these hospitals note significant delays in receiving reimbursement for the many Covid claims they have submitted.

Fourth, there have been several problems that have bubbled up between the MoH as the main purchaser of Covid services and BPJS-K, who are verifying the claims. These include:

• Claims are verified by BPJS-K verifiers at the district level. Hospital administrators noted that different verifiers within the district seemed to have variable levels of competency and/or standards for verifying Covid-related claims.
• The MoH is paying fee-for-service for Covid hospital care. In contrast, for all other hospital patients covered by JKN, the BPJS-K pays a fixed amount per case, similar to Medicare in the United States. BPJS-K staff verifying Covid claims must review an itemized bill for each service, lab test, drug, and hospital day, which is quite different from verifying the patient’s diagnosis and paying a fixed amount.
• There has been a lack of clarity on how to handle Covid patients who have one or more comorbidities, which drives up the cost. Especially as a new disease, it is not always clear which parts of the claim apply to the MoH system (Covid-services) and which parts belong to JKN (all other services).  In July, the MOH revised the Decree 446/220[6] to accommodate disputes associated with patients with comorbidities and other issues. However, there are many cases where the hospital is still unclear which purchaser to submit a claim to, and continued disagreement between the MoH and BPJS-K on these more complicated claims. These challenges have slowed down claim submission and verification.

Overcoming the Challenges

Dealing with a rapid response and in such a pressurized environment, it is rather unsurprising that the system to pay for Covid patients has experienced several implementation challenges. At this point, it is now essential that the MOH learn from these early challenges and adapt accordingly at three levels:

Short term

With the inputs from hospitals, it is evident that the MOH must first improve the e-claim application itself, particularly in building its database, resolving the bugs and connectivity issues, and making its interface more user-friendly. User feedback needs to drive these improvements and thus, the MoH needs to establish more easy-to-use feedback mechanisms that they actually take into account.

The MOH and BPJS-K need to establish better communication and coordination on comorbidities and ‘splitting the bill’. There needs to be clear definitions and criteria for cases and simple decision rules for who pays.[7] Finally, the MoH needs to widely and transparently communicate this to not only the rest of MoH and BPJS-K, but to hospitals and verifiers, as well. Moreover, the GoI needs to set up mechanisms for the two bodies to communicate and handle confusion and disputes.

To reduce the variability in BPJS verification of Covid claims, verifiers need to be better monitored to identify those that are having issues and then more training and supervision can be targeted to them. The information given to verifiers, including decision rules on disease pathway and verification, needs to be communicated as simply as possible to avert confusion and ease the verification process.

Medium-term

Once Covid-19 is classified as an endemic infectious disease and not a pandemic emergency, the GoI will transition financing of Covid-related services from the MoH to the JKN scheme. Covid-related services will then be purchased the same way as other services covered by JKN. Once this happens, purchasing of Covid services will benefit from the established instruments of BPJS-K and its six years of experience in purchasing a wide range of services from both public and private hospitals. Thus, it is critical that the Covid-19 benefit package is carefully to ensure its coverage is sustained for the long term. This process should take in the lessons learned from the last 9 months of implementation through the MoH system.

Long Term and the way forward

The purchasing decisions, and the lessons from Indonesia’s Covid-19 response, must be applied to future crises. The standard procedure for emerging disease purchasing needs to be updated and laid out should any future pandemic arise. This should take into account the unique health system arrangements in Indonesia and the lessons of implementing the Covid response within that system.

For instance, while the government’s rapid decision to establish the MOH, rather than BPJS-K, as the main purchaser of Covid services was understandable, it established several novel processes and systems, including a new e-claims application, purchasing from private hospitals that are not contracted with BPJS-K, and having BPJS-K staff verify newly established Covid claims. It also relied on close coordination between two massive agencies across overlapping purchasing systems and regulations. Thus, it is no surprise that there has been several growing pains embedded throughout this process.

To prepare for that next crisis, the GoI needs to take a step back and review objectively the choices they made during the response and shine a light on what worked and what could be improved within its health system with all its unique quirks and ever-evolving nature. That way, next time, their rapid response will be built on the scaffolding of the lessons learned from Covid.

[1] The Ministry of Health GoI. Covid-19 daily infographics. Retrieved from https://infeksiemerging.kemkes.go.id/

[2] Minister of Health. Covid-19 containment and National Economic Recovery. Undisclosed presentation, October 2020.

[3] T The Ministry of Health, GoI. The Decree of the Ministry of Health HK.01.07/MENKES/238/2020 on Technical Guidance on Claim Submission to Cover Specific Emerging Infectious Disease for Hospitals Providing Care for Coronavirus Disease 2019. Jakarta, April 2020.

[4] Based on (limited) inputs by hospital administrators

[5] BPJSK. JKN Report 2019

[6] The Ministry of Health, GoI. The Decree of the Ministry of Health HK.01.07/MENKES/446/2020 on Technical Guidance on Claim Submission to Cover Specific Emerging Infectious Disease for Hospitals Providing Care for Coronavirus Disease 2019. Jakarta, July 2020.

[7]  Three examples of decision rules: 1) Active Covid infection with or without potentially related comorbidities: MOH pays 100%. 2) Active Covid infection with clearly unrelated comorbidity like injury or mental illness: MOH + JKN split cost. 3. Re-admission of previous (not currently active) Covid case: JKN pays 100% .

Written by Prastuti Soewondo, Halimah Mardani, and Nadhila Adani

ThinkWell’s Indonesia team presented research findings from three studies at the Annual Scientific Forum of the Indonesian Public Health Association on November 24-26, 2020. The conference was conducted by the Indonesian Public Health Association, Ministry for National Development and Planning, UNFPA, and Faculty of Public Health University of Indonesia. The studies stem from primary research conducted by ThinkWell’s Indonesia team, in partnership with the Indonesian Vice President’s Office, as part of the Strategic Purchasing for Primary Health Care (SP4PHC) project, supported by the Bill and Melinda Gates Foundation. Comprehensively, the research explored how the government’s response to Covid-19 affected essential services like family planning (FP), maternal and newborn health (MNH), and nutrition.

We’ve summarized our presented studies below. The conference’s steering committee selected two of three our submitted papers as the ten best papers at the conference.

“How did Family Planning Service Providers Respond to the Covid-19 Pandemic in Indonesia: A Case Study in Eight Districts/Cities?”

Presenter: Nurul Maretia Rahmayanti

The conference’s steering committee selected this paper as one of the ten best papers at the conference

The team aimed to answer this research question by analyzing how PHC providers (e.g., public and private PHC facilities, midwives, and volunteer cadre workers) adjusted how they provided FP services during the pandemic. Using qualitative methods, we found several challenges that FP providers faced during their response to Covid. First, the central government did not provide clear guidance about how FP services should be adjusted after the Indonesia’s initial Covid cases. Instead, FP providers had to wait three months before they received guidance. Because of that, much of the providers’ initial Covid response was scattered.

The guidance they eventually received included recommendations that FP providers shift towards distributing short-term contraceptive methods (i.e., contraceptive pills and condoms), rather than long-acting reproductive contraceptives (LARCs), that could be more quickly given at the facility and easily distributed in the community. Usually, this type of policy change would require the government to provide socialization and training of PHC providers to implement this policy change. However, this socialization was poorly implemented largely due to the halting of in-person trainings and supervision. In addition, there were many technical issues, such as limited access to internet services among these PHC providers.

Other key policy changes that PHC providers made during Covid was to reduce their opening hours, mandate appointments before visits, and shift as much as they could to telemedicine (mostly via WhatsApp).  Again, the central government’s lack of detailed guidance, socialization, and poor access to internet led to a very scattered response among PHC providers.

Another challenge was that the FP budget was reduced during Covid, which impacted provider’ ability to maintain FP service provision. Many noted that out-of-pocket (OOP) payments among FP patients likely increased, which probably further perpetuated a dip in FP access, use, and a potential increase in unwanted pregnancies.

During the Q&A following the presentation, there was a question on the impact of the FP budget reallocation process on FP service delivery. According to our findings, the government tried to keep an adequate budget for maintaining contraceptive logistics, but reallocated the FP activity implementation budget for the Covid-19 response. This could affect FP services provision, which could lead to a potential increase in FP unmet need and unwanted pregnancy. The research team recommended that the budget reallocation leaders should consider the urgency of adequate program implementation funding, not only funding for the logistics of contraceptive distribution.

Prof. Siswanto from the University of Gadja Mada (UGM), one of the premier FP experts in Indonesia, noted that these presentations are important to understand issuers affecting access and quality of care during the pandemic. Still, he noted that there are many aspects outside of Covid’s scope that affect access and quality of MNH and FP services. Most of this analysis was carried out from the providers’ point of view, but there are other aspects that must be considered, such as the psychological and socioeconomic dynamics of the patient themselves. He noted that there is little response from the government to reduce this socio-economic burden.

You can view the presentation as a PDF here.

“How was the Practice of Private Midwifery Continued during the Covid-19 Pandemic in Eight Districts/Cities across Indonesia?”

Presenter: Retno Pujisubekti

The conference’s steering committee selected this paper as one of the ten best papers at the conference

To answer this question, we interviewed private midwives and other health system stakeholders involved in private midwife practice. We analyzed how private midwives, and those that govern them, adjusted their practices during Covid-19, especially around essential services provision. Private midwives are one of the most used and trusted providers of MNH services across Indonesia. Our research found that guidance was delayed, socialization was weak if often nonexistent, and technology challenges hampered effective telemedicine and data reporting. For instance, many private midwives noted that it was very difficult to continue to provide services when they had very little access to PPE or rapid testing. Therefore, especially in the pandemic’s initial stages, many private midwives had to shut down their practices. Naturally, many women did not seek services during the pandemic due to fear of contracting Covid-19. This led to a significant decrease in revenue among midwives, which was not aided with government support. Many midwives feared that the lack of support, whether it be financial or PPE, could have led to a significant decrease in FP, MNH, vaccine, and nutrition services during the pandemic. They see this as a missed opportunity because since many women feared going to health facilities during the crisis, midwives could have been better deployed to fill in the gaps.

After our presentation, the audience discussed the financial sustainability of private midwifery practices, both during and after the pandemic. The audience agreed that the government should evaluate the non-capitation payment under JKN to offer better incentives for midwives, equivalent with the services they provided. Due to the pandemic, there is a decrease in visits to midwives for the range of services (including FP and MNCH), so midwives have been receiving less income. However, midwives are forced to buy their own PPE, which has proven to be quite expensive for them. Private midwives are willing to provide comprehensive midwifery services, from pregnancy stage to childbirth, but several members of the audience stated that they are not given the support they need from the government.

You can view the presentation as a PDF here.

“How Were Nutrition Services Adjusted during Covid-19 Pandemic: Study Cases at Eight Cities/Districts in Indonesia”

Presenter: Dwi Oktiana Irawati

To answer this question, we analyzed how health authorities at the central and district levels adjusted their policies during the pandemic. We then analyzed the impact this had on how PHC providers maintained access to essential nutrition services. Similar to FP and MNH providers, PHC providers faced limited and delayed guidance from the higher levels of government on how to adjust their service provision and meet previously laid out nutrition goals. Not only was guidance delayed, but the national budget for nutrition was reduced by over 23%. This had a rippling effect for districts and PHC providers, often in the form of PHC providers’ reduced ability to track and report on essential nutrition indicators (e.g., malnutrion, child height/weight). It also hampered PHC providers’ ability to provide key services,  like food supplementation to mothers and children.  There was a missed opportunity to empower frontline community health workers like Kaders (volunteer community health workers) and midwives to fill the gaps, as they were not properly equipped with PPE or given incentives for service continuation.

Our findings are very useful for policy makers, especially for decision-making around the national program for stunting reduction. Since this program is one of Indonesia’s national priorities, the government must monitor the budget and ensure implementation at the community level. Active participation from Kaders is important to reach the community and increase knowledge, attitude, and practice among these community members.

At the end of our presentation, conference participants discussed the strategies needed for preserving nutrition services and preventing negative impact on several MCH indicators such as stunting, as well as anemia among adolescent and pregnant women.

You can view the presentation as a PDF here.

ThinkWell is thrilled to participate in the HSR2020 satellite session “Strengthening Capacity for Strategic Purchasing.” Access the full details on this session here.