This piece originally appeared in P4H here.

Written by Shamima Akhter, Anooj Pattnaik, Callum Pierce, Afroja Yesmin, and Pak Trihono

In the early days of the COVID-19 pandemic, Dr. Helal, the manager of a busy health facility in Bangladesh’s sprawling capital city of Dhaka was faced with an unexpected challenge: how would he pay for the hand gel and masks that were needed to keep his staff and patients safe? “The list of things I needed to pay for grew rapidly,” says Dr. Helal, “the Government acted quickly to mobilize money to my facility but to access that money I had to send dozens of forms and make several trips to the local admin office. Anytime my request changed, the process started all over again.” Like Dr. Helal, front-line responders around the world faced similar challenges in accessing and spending the money allocated to them for COVID-19. To understand why, we need to dive into the world of public financial management, or ‘PFM’.

PFM refers to the laws, regulations, and systems that govern how public funds are allocated, spent, and accounted for, including in and by the health system. In theory, a good PFM system ensures that money gets to where it is needed and is only spent on its intended purpose. In practice, however, PFM rules can be complex and hard to navigate, particularly for health managers from clinical backgrounds with limited training in administration and finance. When it works well, PFM directly supports the attainment of Universal Health Coverage (UHC) because it minimizes waste, directs resources to areas of greatest impact, and maximizes the value for money spent on health. The efficiency of good PFM is particularly valuable in settings where government spending on health is relatively low. In this blog, we shine a spotlight on some of the most important PFM barriers that front-line responders faced when responding to COVID-19. These insights draw from the experience of Bangladesh and Indonesia, where the authors have been working closely with the government to identify and address some of these “plumbing” challenges.

Indonesia is an upper-middle-income country with a decentralized health system and the world’s largest national health insurance scheme, Jaminan Kesehatan Nasional (JKN). Still, the national and subnational governments play a substantial role in financing health providers in the public sector, even as both public and private facilities receive payments under JKN.  Since Indonesia decentralized its health authority in the early 2000s, District Health Office (DHO) priorities do not always match the national ones, and PFM capacities vary across the districts.

When COVID-19 struck in March 2020, Indonesia’s Government mobilized significant resources for the response, including reallocating money away from other front-line services. However, the lack of PFM capacity at the district level to revise budgets according to national government guidelines led to pools of funds for COVID-19 sitting at the national level. Moreover, the central ministries in charge of essential health services (EHS) like family planning (FP), maternal, new-born, and child health (MNCH), immunizations, and nutrition delayed issuing budget revision guidance (and even when they did, they revised it five times) to DHOs and frontline providers, leading to confusion on how to balance COVID-19 services with routine EHS ones. With a lack of funding and guidance flowing from the central and district levels, most frontline providers were left to manage their responses on their own. Those who had special autonomy status, known as BLUD, were able to flexibly use JKN capitation funds in their emergency and routine EHS provision. However, only 20% of over 10,000 public PHC facilities have BLUD status and thus, often did not have the funds at hand to respond in the way they needed to.

This resulted in a chaotic response at the frontline, with each provider charting their own course, and contributed to a large decline in EHS service use with slow recovery. For instance, basic immunization services reduced considerably in 2020 compared to 2019. The largest dip in coverage between the two years was in May (34.5%) and remained at least 20% lower than the previous year’s level until November 2020 where the coverage difference between the two years reduced to 13.9%.

Bangladesh has an extensive primary health care system, supporting the delivery of “good health at low cost.” Resources for the health sector run through the PFM system and has a standard set of rules for all budget planning, execution, and procurement. Though PFM rules give health managers some autonomy over how budgets are spent, decision-making is largely centralized. PFM in the health system is characterized by complexity, with fragmented funding flows and diversity of financing agents at each level of the health system.

When the COVID-19 pandemic struck in Bangladesh, the Ministry of Health and Family Welfare (MOHFW) explicitly set out to conserve funding for essential health services while ramping up spending on the pandemic response. In support of this goal, the Government launched a large economic stimulus package which included hundreds of millions of dollars of additional financing for the health sector. In addition to overall increases in funding, the MOHFW authorized facilities to reallocate some of their unspent budgets toward COVID-19 related activities and issued detailed technical guidance to facilities on how to reconfigure services in a way that would balance the pressure of COVID-19 response with routine service delivery.

Although the Government acted quickly to authorize funding reallocations, health managers faced many barriers in accessing this money for service delivery as they could not follow the PFM process requirement needed for the additional funding. If a manager wanted to use the funds to purchase essential commodities, procedures to comply with the current MOHFW “delegation of financial authority” rules, hindered rapid approval and utilization of funds. For health managers, this represented hours of time they could ill-afford in a crisis. It also meant that the Central Government needed to review hundreds of procurements plans from facilities across the country, which presented a formidable administrative burden. Additionally, because of years of centralized control of financing functions, many health managers did not have the training nor expertise to navigate the complex PFM requirements and unlock the funding available to their facility. Most health managers were largely unaware of the increased procurement flexibility attached to the reallocation of funds for the COVID-19 pandemic.

These pre-existing challenges further contributed to the severe disruption of essential health services delivery in Bangladesh during the early months of the pandemic. For instance, antenatal care visits declined by 34% in April 2020 compared to the previous year, with a gradual and uneven trend toward recovery in the period since.

So, what can the experiences of Bangladesh and Indonesia teach us about PFM in a pandemic context?

Lesson 1: PFM challenges cut across country contexts

Both Indonesia and Bangladesh experienced major constraints with their PFM system in the pandemic context, even though both countries have completely different health systems and health financing arrangements. While the chain of events and specific bottlenecks for accessing and utilizing the funds efficiently differed slightly across the two countries, similar PFM challenges resulted in the same outcome: front-line responders were blocked from rapidly receiving and spending funds that could have augmented their response and saved lives in both countries.

Lesson 2: Writing cheques is not enough in emergency situations like the COVID-19 pandemic

Governments and development partners mobilized massive amounts of domestic and external financing in both countries to respond to COVID-19. Despite these commitments of additional and reallocated funding, poorly set-up and executed PFM meant that much of the money failed to reach the front-line, where it was needed the most.

Lesson 3: PFM reforms don’t have to be difficult to be impactful

In Bangladesh, simple reforms like a more efficient and regionalized approval process for procurement plans, as well as increased support and training for those health facility managers engaging with the PFM system could help to address some of the major bottlenecks to efficient fund flow in the pandemic context and beyond. In Indonesia, the complexity of funding flows to district health offices, each with its own budget revision processes, needs to at least be reduced during a crisis response. The Government of Indonesia also needs to make the longer-term investment of strengthening the PFM capacity of these districts, especially in the more rural, Eastern part of the country. Finally, on the provider side in both countries, financial autonomy for facilities needs to be expanded, at least temporarily during a crisis and with the right accountability measures.

PFM is essential to the efficient and equitable functioning of any health system, even more so now when COVID-related economic disruption and the increasing demands of the pandemic response put health budgets under intense pressure globally. The shared experiences of Bangladesh and Indonesia shows that the importance of PFM cuts across contexts and have exposed opportunities for relatively simple reforms that can lead to potentially large gains in the capacity of the health system to deliver at speed and scale in both a crisis and steady state.

Written by Andrea Bare (Program Director, ThinkWell) and Martha Coe (Program Manager, ThinkWell)

Routine immunization is not clearly and consistently prioritized—nor is it sufficiently funded—in many countries across the income spectrum. Yet, the evidence has spoken: the benefits of immunization are undeniable. Not only is immunization successful in warding off disease—it is also a cost-effective health intervention. Economic and scientific studies continue to sing the praises of immunization’s value for preventing disease, however, this strong evidence base is not consistently reflected in health policies and budgets.

On September 15, 2021, ThinkWell convened the second event in its Counterpoint webinar series, where four experts were invited to discuss why routine immunization programs struggle to obtain sufficient and sustained funding, and how health advocates may respond to this challenge. Moderated by Margaret Cornelius, Deputy Director of the Private Sector Team at ThinkWell, the four panelists included Eduardo Banzon, Principal Health Specialist at the Asian Development Bank; Ulla Kou Griffiths, Senior Advisor on Immunization Financing at UNICEF and Honorary Associate Professor at the London School of Hygiene & Tropical Medicine; Catherine Goode, Founder of Goode Strategies; and Stefan Swartling, Professor of Global Transformations for Health at the Karolinska Institute. Each provided their unique perspective and expert recommendations on how to elevate financing for routine immunization, including:

  1. Tell the full story of vaccination success to generate societal and political demand.
  2. Create and maintain a shared agenda across the health advocacy spectrum.
  3. Articulate the shared needs of the products, systems, and people involved in immunization.
  4. Integrate immunization into primary health care.

1. Tell the full story of vaccination success to generate societal and political demand.

The irony is that when vaccination programs are successful, decision makers and the public can take these programs for granted. Instead, a negative press story, such as a gravely ill person in an intensive care unit, gets far more attention than the thousands of individuals who are safe and well because of vaccination. We must be careful not to become victims of our own success.

To champion routine immunization in the long term, advocates and immunization program managers need to provide ministers of health and finance a clear picture of what their countries would be facing without immunization programs. Providing preventive health care is often thankless, and for people to recognize the value of that investment, advocates must continually communicate the value of successful programs and the broad societal and economic benefits that they bring. There is an opportunity during the COVID-19 response to showcase how immunization programs are rising to the challenge of rolling out COVID-19 vaccines while also highlighting investment gaps, ensuring that both the public and policymakers appreciate the risks to population health if routine vaccinations do not continue—or if we do not prepare for future risks.

2. Create and maintain a shared agenda across the health advocacy spectrum.

 Advocates should start with, and come back to, what we have in common. Highlighting the reality that public health priorities compete for scarce resources, panelists emphasized the importance of stepping out of program and funding silos to find common ground. The different programs that make up primary health care, including immunizations, can align under a common agenda to increase broader primary health care funding, thus extending budget benefits across the entire system. Investments that have wider impact are more likely to gain the ears of those who hold the purse strings. As global policymakers come together to discuss funding for pandemic recovery and preparedness, advocates who call for a unified investment in comprehensive primary health care programs will make a stronger case for ongoing immunization funding.

3. Articulate the shared needs of the products, systems, and people involved in immunization.

Broad based investment in immunization involves three components to increase access and uptake: the vaccines, the vaccine delivery system, and vaccine education. Health advocates can better communicate why additional investment is essential by emphasizing the shared needs of the vaccines, systems, and people that sustain immunization programs.

  • Vaccines: Sufficient investment is necessary to ensure that vaccine production capacity can meet both regular and peak demand when needed. Manufacturers make these investments when there is a clear signal of demand and financing for immunization programs from the market. The gap in ability to enable surge capacity to meet demand became abundantly apparent during the global COVID-19 pandemic, when countries experienced an urgent need for vaccine supply, along with the equipment and associated medicines required to treat COVID-19 patients. Although procurement models that can support more resilient manufacturing capacity come at a higher cost, investing sufficiently in immunization pays off. For instance, organizations such as UNICEF have shown that creating a healthy vaccine market can help bring in high-quality manufacturers that are prepared to meet vaccine needs.
  • Systems: The global health care system and workforce have risen to the challenge of quickly and effectively administering available vaccines. Despite quick adjustments by health systems, the pandemic has revealed capacity challenges for delivering both routine and COVID-19 vaccines. The hurdles that vaccine delivery systems have experienced—such as limited points of access or outdated data systems—are often embedded in primary health care delivery and thus have negative effects that extend beyond immunization. Therefore, investments in vaccine delivery systems must be considered essential not only for effective immunization programs, but also for the overall well-being of a resilient primary health care system.
  • People: Ultimately, people are at the heart of health. People drive vaccination demand, and without this demand, prioritization of immunization will be limited. Investments must be made to consistently nurture the value of routine immunization through frequent education and communication, thereby building confidence and cultivating societal demand for impactful vaccination programs.

4. Integrate immunization into primary health care.

Immunization financing must be considered within the broader context. Panelists agreed that primary health care budgets are generally insufficient, meaning that immunization budgets are likewise left scant. The panel discussed the need to better highlight what primary health care is composed of to ensure that immunization is considered central to strong primary health care systems—including vaccinations for children, adolescents, and adults. Additionally, panelists noted that by evaluating other well-funded areas across the primary health care system, advocates can identify opportunities for cost savings and efficiencies. The traditional operating model, particularly for countries that have leveraged donor funding for immunization or other primary health care services, such as HIV or tuberculosis, is to have siloed program funding. However, vaccination services benefit from the investment of other budget lines, including health infrastructure and clinic staff. Maintaining these siloes may harm access to prevention services or primary health care in the long run. Instead, promoting an integrated health delivery approach—which includes vaccination alongside routine primary health care—could provide new opportunities to bolster immunization programs that are prepared to treat a variety of diseases.

If you want to learn more about ThinkWell’s work in sustainable immunization financing, you can read about it here. You may also watch the full webinar recording below.

This blog was produced by ThinkWell in partnership with and funding from Merck Sharp & Dohme Corp. (MSD), a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA. The views and opinions expressed by the panelists are their own and do not necessarily reflect the views and opinions of ThinkWell or MSD.

A vaccination campaign requires significant resources over a short period of time. Unlike with routine immunization programs, where resource allocations can be fine-tuned over time, a campaign is a one-off opportunity to make an impact. Inadequate funding or late disbursements can derail a campaign completely, and a low-impact campaign may be a considerable waste of resources. Nevertheless, the cost of delivering immunization through campaigns is not well understood. To address this gap, ThinkWell estimated the cost of two measles-rubella (MR) catch-up campaigns in Sierra Leone and India.

In India, the government undertook a large-scale phased campaign from 2017 to 2020, vaccinating over 324 million children aged between 9 months and 15 years in 34 Indian states and Union Territories. In Sierra Leone, a seven day campaign was conducted in June 2019. Just under three million MR vaccines were delivered, alongside oral polio vaccines (OPV) nationwide, and vitamin A supplements and deworming tablets (albendazole) in half of the country’s districts.

Both studies estimated the full financial and economic costs of the campaign in Sierra Leone and the financial delivery costs in three states in India (Assam, Gujarat, Himachal Pradesh) and the full economic costs in one state (Uttar Pradesh). The study in Sierra Leone was the first to generate cost evidence for co-delivery campaigns, which are likely to become more common.

Key findings of the studies included:

  • The financial delivery cost per dose ranged from US$0.16 to US$0.34 across the states in India and was US$0.31 during the integrated campaign in Sierra Leone.
  • Per diems and incentives for staff were the main cost drivers of the MR campaigns in both Sierra Leone and India. Service delivery was a cost driver for both campaigns, followed by training and social mobilization in Sierra Leone and supervision and record keeping in India.
  • The economic delivery costs were estimated at US$0.69 per dose in Sierra Leone and US$0.87 in Uttar Pradesh, mainly driven by the value of paid and unpaid labor.
  • In Sierra Leone, we found that financial cost efficiencies could be achieved through integration. However, the opportunity costs of labor were higher in districts that co-delivered both vaccines and nutrition interventions, indicating the higher burden that co-delivery campaigns place on the existing health system.
  • In India, the delivery cost was higher than the government pre-fixed budget per child for the MR campaign. While this suggests an insufficient budget, the study also found underutilization of the MR budget in two states and use of other sources of funding for the campaign. This indicates a potential need for more flexibility around the use of campaign budgets in Indian states.

The cost estimates from both studies can be used for future planning and budgeting of campaigns in India, Sierra Leone and other countries. To read the full study reports, please click here for India and here for Sierra Leone. These studies were a part of the Immunization Costing Action Network (ICAN), a project supported by the Bill & Melinda Gates Foundation, and helped inform the development of methodological guidance on costing immunization campaigns.

On September 21, 2021, the USAID Health Financing Activity (HFA), which is implemented by ThinkWell, will sponsor and host the 7th Indonesian Health Economics Association (InaHEA) Biennial Scientific Meeting.

The purpose of the meeting is to optimize resources to improve health outcomes, and in the face of new waves of COVID-19, this goal is of the utmost urgency. The 7th InaHEA conference will examine the burden COVID-19 has placed on Indonesia and highlight current research and policies to fight it. ThinkWell has invited researchers, academics, and policymakers from across various socioeconomic, geographic, and industry backgrounds to discuss these challenges and to pool their knowledge to find creative and bold solutions.

Click here to find more information on the event and how to attend.

Several ThinkWell team members will have poster presentations and participate in highly anticipated panel discussions. The following is a full list of topics and presenters from the USAID HFA team for InaHEA.

Satellite Sessions

JKN Financial Modeling

Thursday, 23 September

10:50-13:50 WIB

Since its establishment in 2014, Jaminan Kesehatan Nasional (JKN), Indonesia’s national healthcare program, has been working under a budget deficit. If action is not taken soon, thousands of Indonesians will continue to suffer a lack of healthcare including vaccinations, routine care, and emergency care.

To address this mounting concern, the Government of Indonesia has begun to work with healthcare financing and health economics experts including those at ThinkWell.

The Indonesia Ministry of Health’s Center for Health Financing and Insurance and Center for Health Economics and Policy Studies will collaborate with USAID’s HFA to host this interactive and practical half-day workshop. The purpose of the session is to discuss and analyze the financial structure of JKN. Aside from this overall analysis, the floor will be opened to attendees to break down the results of a recent study of JKN’s revenue and expenditures, create policy scenarios to understand their impact on JKN, and simulate the financial needs of these policies in order to hone JKN’s financial model.

Private Sector Analysis by PJKS-UI

Thursday, 23 September in Indonesia

13:50-15:50 WIB

Based on Indonesia’s National Socio-Economic Survey (SUSENAS), in 2006, only 13% of Indonesians were covered by health insurance. At the end of 2019, this number had increased significantly: more than 80% of Indonesians were covered by health insurance thanks to the implementation of Indonesia’s national healthcare program. While this is a vast improvement, it means that there should be a parallel increase in the availability of qualified private and public healthcare facilities and providers. This has not been the case.

The University of Indonesia’s Center for Social Security Studies, the Indonesia Ministry of Health’s Center for Health Financing and Insurance, and HFA have collaborated on a study titled “Involvement of Private Health Care Providers in the National Health Insurance Program: Barriers, Challenges and Future Potentials.” The purpose of this quantitative and qualitative analysis is to develop evidence-based recommendations for policymakers so they can build incentive for private providers to play a greater part in JKN through claims.

During this session, the team of researchers will present the results of the study, open the floor to discussion and input, and prepare a policy brief that will later be submitted to the Minister of Health to incorporate into actual health policy.

Poster Presentations

This page will be updated once the presentation schedule has been finalized.

Institution Presentation Title Lead Author
ThinkWell COVID-19 Cost of Primary Care Service Ryan R. Nugraha/Ery Setiawan
ThinkWell Utilization and Portrait of COVID-19 Care in Secondary Health Facilities: Evidence from National Survey, 2020 Ryan R. Nugraha/Ruli Endepe
ThinkWell Estimation of Actual COVID-19 Healthcare Cost in Hospital Ery Setiawan
CHEPS NHA Disease Accounts Analysis: Challenges Faced in the Primary Health Care Data Yunita
CHEPS NHA Obstacles on Tracking Expenditure of Early Detection for Non-Communicable Diseases Program: A Case Study in The Ministry of Health Scheme Kurnia Sari/Rita Yuniatun
CISDI A Discourse Network Analysis on Public Discourse of the National Health Insurance (JKN) Premium Hike Amid COVID-19 Pandemic Yurdhina Meilissa/Reyhan Alemmario
R4D JKN Improves Healthcare Access for TB Services: Quantitative Analysis of BPJS-K Data Sample 2015-2018 Firdaus Hafidz
CSSS-UI Perceived Challenges of Private Hospitals Engagement in the Indonesian National Health Insurance Program Ahmad Fuady
CSSS-UI Remaining Out-of-Pocket Payment Incurred in Public and Private Hospitals Despite the Indonesian National Health Coverage Rifqi Abdul Fattah

CHEPS NHA: Center for Health Economics and Policy Studies at Universitas Indonesia, National Health Accounts

CISDI: Center for Indonesia’s Strategic and Development Initiatives

R4D: Results for Development

CSSS–UI: Center for Strategic and Global Studies at Universitas Indonesia

JKN: Jaminan Kesehatan Nasional

BPJS-K: Badan Penyelenggara Jaminan Sosial – Kesehatan

TB: Tuberculosis

Pre-Conference Session

Monday, 20 September

09:00-12:00 WIB Session 1: Room C: Discourse Network Analysis (led by HFA’s subcontractor CISDI)

13:00-16:00 WIB Session 2: Room C: Discourse Network Analysis (led by HFA’s subcontractor CISDI)

Topics Covered Presenter
Introduction to Foresight and Discourse Network Analysis (DNA) Yurdhina Meilissa, dr., MSc
Explanation of DNA Module Reyhan Allemmario
Exercise: Data Mining Reyhan Allemmario
Exercise: Designing DNA Reyhan Allemmario
How to Analyze DNA Yurdhina Meilissa, dr., MSc

Plenary Session

Tuesday, 21 September

15:10-17:00 WIB Plenary 4: Special Session for NHA: What has been achieved and what are the future challenges?

This event is moderated by Prof. Dr. drg. Mardiati Nadjib, MS

Institution Title of Presentation/Role Resource Person (RP)
MOH Latest Figure of NHA dr. Kalsum Komaryani, MPPM
MOH Use of NHA data for policymaking improvement Prastuti Soewondo, PhD
CHEPS Disease account production Dr. Atik Nurwahyuni, MKes
TW The real-time policy use drawing from NHA result Hasbullah Thabrany, dr., MPH, DrPH

We hope to see you at the conference!

Click here to find more information on the event and how to attend.