Nearly 200 attendees convened on October 19th and 20th for the Second Annual Health Campaign Effectiveness Coalition Meeting. The goals of the meeting were to identify promising practices and build consensus around actions to foster learning, collaboration, and systems to effectively plan and implement campaigns to deliver health services to priority populations. More than 50 speakers, moderators, and presenters, including ThinkWell economist Laura Boonstoppel, came together to share their knowledge and experiences in health campaigns around malaria, NTDs, polio, vaccine-preventable diseases, and nutritional supplementation.

Laura was part of the panel for an open discussion on the economic aspects of campaign integration alongside Dr. Alan Hinman of the Task Force for Global Health and Dr. Deborah McFarland of Emory University. This session included a rich conversation on the implications of campaign integration for health worker incentives and motivation, and how benefits and costs for households and beneficiaries are included in economic analyses. The recording of this session can viewed below and recordings of all of the other presentations and discussions can be viewed here.

Christina Banks and Flavia Moi presented a poster on findings from two costing studies on immunization campaigns in Nigeria and Sierra Leone which showed the potential financial efficiencies of campaign integration and the effect of volume delivered on cost per dose. This presentation prompted interesting discussions on how the cost of campaigns with multiple antigens or integrated nutritional interventions compares to single-antigen or vaccine-only delivery and the different staffing requirements of both. The poster can be viewed here and the full Sierra Leone study report can be read here.

For more information on ThinkWell’s campaign costing work, please visit the Immunization Costing Action Network page on immunizationeconomics.org

On September 21, 2021, the USAID Health Financing Activity (HFA), which is implemented by ThinkWell, sponsored the 7^th Indonesian Health Economics Association (InaHEA) Biennial Scientific Meeting. This three-day gathering of some of the greatest minds in health economics in Indonesia presented an opportunity for attendees not only to share ideas to optimize resources under Indonesia’s national health insurance scheme, Jaminan Kesehatan Nasional (JKN), but also to frame these ideas around an urgent topic: COVID-19.

Researchers, academics, and policymakers from across various socioeconomic, geographic, and industry backgrounds discussed challenges the Ministry of Health of Indonesia (MOH) faces and how policymakers can tie health and finance together to find bold solutions.

COVID-19 in Indonesia

After an astronomical spike in COVID-19 cases in July, the MOH is diligently working to make sure JKN has the capacity to withstand the aftershock of such an unprecedented health crisis. Creating efficient policy around pandemic response requires an understanding of who needs COVID-19-related care and how much the care will cost per capita.

For the last year, Ryan Nugraha, one of ThinkWell’s Program Analysts in Indonesia; Ery Setiawan, Health Financing Specialist in Indonesia; and Ruli Endepe, ThinkWell’s data analyst consultant; have taken a deep dive into these two areas of health financing and they presented their findings at the conference. The following is an overview of key points from each presentation.

COVID-19 Cost of Primary Care Service

Ryan R. Nugraha and Ery Setiawan

In 2020, the Government of Indonesia passed a decree that makes all costs associated with COVID-19 treatment eligible to be reimbursed by JKN under a specific MOH payment mechanism using a cost-per-day rate. Though this policy was a quick response to the crisis, more information is needed in order to create a reimbursement rate that doesn’t lead to over- or under-provision of services and prevents significant differences in service delivery between public and private providers.

To find the exact cost of primary care services for COVID-19, HFA collected costing data on human resources for health, inventory, and visits. They then spoke with 48 public and private providers to calculate the total costs related to treating one COVID-19 patient.

HFA found that private facilities are using significantly less resources than public facilities for COVID-19 treatment because they often only provide screening for mild cases, whereas public facilities receive referrals to public hospitals and worse cases that require reactionary treatment. This means that allocating more money to screenings at public facilities could reduce public hospital burdens and costs. This finding could also expose a discrepancy in what public and private providers consider a severe case, consequently leading to over-spending at public facilities and differences in treatment when seeking care at public versus private providers. HFA’s study suggests that a standard for mild, moderate, and severe COVID-19 cases should be set among all providers to make reimbursement less varied and smoother.

Utilization and Portrait of COVID-19 Care in Secondary Health Facilities: Evidence from National Survey, 2020

Ryan R. Nugraha and Ruli Endepe

COVID-19 has put stress on each level of the Indonesian health system. As the disease changes and new variants present themselves, hospitals must continue to adapt to waves of patients and their symptoms to provide the best care possible. This change is rapid and requires a rolling analysis of best practices in order to have a full view of the finances involved. The HFA team conducted a study of 814 patients experiencing mild to severe cases of COVID-19 and what kind of care they required to give MOH a holistic view of standard practices. Here is a snapshot of what they found:

The use of the antiviral medication Oseltamivir for moderate cases was disproportionately higher than other studied medications which created supply issues. Ultimately, the researchers suggested that, while variations in care are warranted, the MOH should create clinical pathways to formalize treatment standards and eventually payment methods. A standard care package that includes an array of resources like medications will both give providers treatment options to tailor to each patient and provide a flat reimbursement rate for each case, making it easier for providers to file costs with MOH.

Estimation of Actual COVID-19 Health Care Cost in Hospital

Ery Setiawan

To round out the background knowledge of COVID-19 treatment and coverage under JKN, HFA estimated the actual cost of COVID-19 treatment and presented it at InaHEA. Having a tangible number gives health economists and policymakers in Indonesia a vision for the financial future of JKN, especially in crises like COVID-19. Here’s what the team found:

Based on a study of cost drivers including length of stay, case severity level, treatment procedures, and past cost references, the findings of this study were used to produce a cost to charge ratio. This estimate eventually informed the per capita tariff (or charge) for COVID-19 treatment. With a clear picture of what it costs to treat the disease, MOH can build budgets with the proper capacity for treatment in the future.

Written by Pura Angela Wee-Co (Country Manager, ThinkWell), Ileana Vilcu (Program Manager, ThinkWell), and Marissa Maggio (Communications Specialist, ThinkWell)

The COVID-19 pandemic has stifled nations across the globe in their pursuit for Universal Health Care (UHC)—and the countries that make up the Association of Southeast Asian Nations (ASEAN) are no exception. For many, the pandemic has introduced additional barriers to high-quality health care at a low cost. To highlight how ASEAN nations are rising to new challenges, the Center for Strategic and International Studies (CSIS) held a webinar in August 2021 to discuss a path towards sustainable health care financing in the region. Joined by other experts, Dr. Marife C. Yap, Senior Technical Advisor at ThinkWell Philippines, discussed how the country has responded to COVID-19 challenges and several strategies that national health systems can employ to make UHC a reality.

Following the passage of the Universal Health Care Act in 2019, the Philippine Health Insurance Corporation (PhilHealth) was tasked with putting the law into practice and launched KonSulTa, a primary care benefits package that provides access to comprehensive outpatient services under one affordable, fixed rate. However, with multiple lockdowns, widespread mobility restrictions, and a reduced budget, PhilHealth has faced several challenges in ensuring equal access to care. For instance, PhilHealth experienced hurdles in quickly and sufficiently reimbursing coverage payments—such as those for COVID-19 testing—to hospitals, which limited the delivery of essential health services.

Faced with these new obstacles, what can the Philippines do to improve UHC? Dr. Yap touched on several key approaches, including:

1. Integrate across the health system. The key to making the UHC rollout successful, Dr. Yap says, is three types of integration—managerial, clinical, and financial; managerial to ensure capable province-wide health systems, clinical to provide a comprehensive set of health services from preventative to curative, and financial to lessen the fragmentation of fund pools. By ensuring integration across the health system, PhilHealth can establish a smooth delivery of health services under province-wide networks.
2. Simplify membership. Prior to the 2019 UHC law, there were five categories of PhilHealth membership, which led to confusion and limited enrollment. Now, membership has been simplified to just two categories, direct and indirect contributors, which is envisioned to help increase enrollment and access to a universal primary care benefits scheme.
3. Increase and consolidate health funding. Despite increased health budgets during the COVID-19 pandemic, the Philippine Department of Health (DOH) has only disbursed 141 billion pesos out of the 205 billion allocated to tackle diverse health needs. To achieve UHC, the DOH needs to remain accountable for the proper allocation of funds and continuously demonstrate the value of maintaining a substantial health budget. This will help the DOH and PhilHealth to improve health service delivery to all Filipinos.
4. Promote utilization. Some health packages offered in the Philippines have experienced low utilization due to a lack of awareness or trust in government agencies. For instance, PhilHealth has offered the ‘Z benefits package’ since 2014, which aims to support health programs that require costly treatments—such as cancer care—and may be delivered through outpatient services. However, despite the support available, a 2020 study shows that the Z benefits package was not widely used, suggesting that awareness must be raised to improve program utilization.
5. Close gaps in coverage. There are several policy gaps that need to be addressed in order to achieve UHC. Foremost among these is the need to change people’s perspective on accessing PhilHealth benefit packages. Because PhilHealth provided mostly inpatient services—or when people are admitted to a hospital—prior to the 2019 UHC law, many are still not aware that more outpatient services are available to them, particularly KonSulTa’s comprehensive outpatient benefit package. This further exacerbates gaps in coverage. In addition, PhilHealth can improve the capacity of health care purchasers to finance both COVID-19 and non-COVID-19 services. Not all hospitals are accredited by PhilHealth, leaving many patients that seek care to pay out-of-pocket for health services. And while there has been a slight decrease in paid claims in 2020, down from those received in 2019, there are still many unpaid claims that must be settled. To provide a comprehensive set of services under UHC, strategic health care financing can close these gaps and ensure costs are covered.

Looking to the rest of the ASEAN region, other panelists touched on several core ideas to improve the sustainability of health care financing during and beyond the COVID-19 pandemic, including:

1. Build awareness. COVID-19 has introduced a unique opportunity to promote awareness of the need for UHC. Although UHC is meant to ongoingly provide essential health services, this pandemic has shown that people need affordable, effective health coverage most in times of crisis. Therefore, this is the best time to hold ASEAN governments accountable to bolster UHC programs and prepare for future emergencies. Moreover, the pandemic response has also lent many lessons that can inform new processes and innovations across health systems. For example, community health workers (CHWs) in the Philippines are not considered part of the official health system. However, the COVID-19 response has revealed the monumental role that CHWs play in managing local, frontline emergency response teams, clearing a permanent space for them in the Philippine health sector.
2. Encourage better health behavior. In addition to addressing pandemic and disease-related challenges, ASEAN governments should seek to promote better health behavior, all the way from health prevention and screening to rehabilitation. For instance, governments can encourage healthy behavior—such as routine immunization—and discourage high-risk behavior—such as high tobacco or alcohol consumption—to keep health costs low and balance the availability of funding across the entire health system.
3. Invest in better treatment. As COVID-19 becomes endemic, or a routine disease found globally at a reduced rate, ASEAN nations must continue to invest in better health solutions that will last beyond the current pandemic. Governments must work towards UHC while accepting that the COVID-19 disease will remain, in some capacity, and continue to innovate better health technologies to improve quality of life for all.

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