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Written by Andrea Bare (Program Director, ThinkWell)

According to the World Health Organization (WHO), universal health coverage (UHC) means that all people have access to the health services they need, when and where they need them, without financial hardship.

Cervical cancer elimination is one of countless areas to be addressed through UHC, but noteworthy given that the disease can be prevented through vaccination against human papillomavirus (HPV), which is a main cause of cervical cancer, as well as through early screening and treatment for precancerous lesions. Yet, preventative care coverage for services like HPV vaccination, HPV testing, and Pap smears are not prioritized when governments build their health budgets.

Building on ThinkWell’s health financing expertise, particularly in oncology, UICC commissioned ThinkWell to investigate cervical cancer financing challenges and how governments can create policy to close this gap in care and strive for the WHO elimination targets. This work was conducted within the scope of the Scale-Up Cervical Cancer Elimination with Secondary prevention Strategy (SUCCESS) project, funded by Unitaid, led by Expertise France and implemented in partnership with Jhpiego. It seeks to provide key stakeholders and civil society with an understanding of how financing can and must be leveraged across different country contexts to drive progress towards elimination.

ThinkWell conducted stakeholder interviews and literature reviews of health financing for cervical cancer in the four countries where the SUCCESS project is established: Burkina Faso, Côte d’Ivoire, Guatemala, and the Philippines. The profiles include policy recommendations that can support advocacy efforts to advance progress towards more comprehensive and accessible cervical cancer prevention and control financing and implementation strategies.

Pushing for UHC

As the global health community moves towards UHC as an international standard, low- and middle-income countries are leading the way in terms of policy goals; with that, addressing gaps in coverage and accessibility and health budgets will be essential to tackle ambitious yet attainable goals like eliminating cervical cancer. The four-country analysis revealed common themes while also highlighting the unique conditions within each country.

In the face of political and economic volatility, the Government of Burkina Faso has dedicated greater spending on health in pursuit of UHC, but cervical cancer elimination is not a financing or implementation priority. Côte d’Ivoire lacks funding for the national HPV vaccine program as well as screening services, though there is strong evidence that these prevent the development of cervical cancer. In Guatemala, access to services and knowledge about prevention and treatment are often determined by social, Indigenous, and economic status, as well as physical access to care and health facilities (e.g., urban vs. rural areas).

Access to early detection and screening for cervical cancer is limited and often requires out-of-pocket payments (OOP), marginalizing women who are unable to afford these services. In the Philippines, OOP accounted for 44.7% of health expenditures in 2020, and, while this is improving, the percentage of OOP costs spent on health impacts 13 million Filipino women living below the poverty threshold.

Financing for UHC

Working with both national and local policymakers to increase funding and allocation for health is necessary to reach people and get them the care they need. Advocates can encourage policymakers to intensify focus on issues like cervical cancer in several ways:

  • Support increased government funding for cervical cancer elimination rather than relying on external donor support
  • Highlight how effective prevention and control can prevent disease, free up health resources, and contribute to national development objectives
  • Engage trusted local-level governmental and non-governmental organizations that work with communities, to ensure they have the funds, tools, and capacity to support implementation of financing and policy advances

What’s next?

The financing barriers facing all countries, including Burkina Faso, Côte d’Ivoire, Guatemala, and the Philippines, are multifaceted and complex. Furthermore, while each government faces unique challenges, the overarching conclusion is that expanding fiscal space for health and preventable diseases such as cervical cancer should continue to be a top priority in the future.

Each country has context-specific development goals, but greater investment in diseases such as cervical cancer which can be eliminated is an investment not only in future generations but also in the stability and growth of each nation. This is about women’s health but also their ability to be productive members of society and there for their own daughters and sons.

 

On September 21, 2021, the USAID Health Financing Activity (HFA), which is implemented by ThinkWell, sponsored the 7th 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.

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.

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