As a partner of the Indonesia Health Economics Association (InaHEA), ThinkWell is excited to showcase its achievements in the last year at the 8th Biennial InaHEA Scientific Meeting. Our USAID Health Financing Activity (HFA) is one of our most influential projects in Indonesia and will be featured in several topic areas.

HFA is a five-year project that provides technical assistance to strengthen local capacity in financial analyses, stakeholder engagement, learning, and decision-making in Indonesia. Our HFA team collaborates with Indonesian leaders and institutions to strengthen health financing and propel Indonesia towards achieving universal health coverage. Our team is participating in eight presentations at the conference covering a vast range of topics; our presentations are detailed below. If you are unable to attend, on the last day of the event, the titles of the presentations will link to the presentation materials.

Anita Damayanti Putri, a Pubic Health Analyst with ThinkWell working on Strengthening Strategic Purchasing for Primary Health Care, will be presenting “Assessing Readiness for Service Delivery Redesign in Indonesia for Emergency Obstetric and Newborn Care Services.” Her presentation will be linked below following the conference.

InaHEA has released a series of potential topics for the meeting that includes demographic transition and economic challenges, non-health-related determinants of health, post-pandemic health issues, health behaviors and financing, and tobacco economics. Find the full list, sub-topics, and more information on the meeting here.

Sarah Saragih, Firdaus Hafidz, Aditia Nugroho, Agnes Caroline, Adwoa Twum, Laurel Hatt, Cheryl Cashin, Nana Tristiana, Tiara Pakasi, and Hasbullah Thabrany

This study, initiated in 2020, aimed to simulate a pay-for-performance model in tuberculosis (TB) service delivery, with “strict” and “flexible” payment scenarios based on guideline adherence, using TB service delivery data in 2019 at one Puskesmas and one clinic in Medan. Recommendations for the government include considering flexible reimbursement standards and conducting additional research on payments to hospitals for referred patients.

Ruli Endepe Al Faizin, Miftakhun Nafisah Yannis Putri, Iko Safika, and Hasbullah Thabrany

The purposes of this study are as follows:

• To document the prevalence of e-cigarette consumption in Indonesia.​
• To identify the effect of smoking on various groups and poverty levels among households in Indonesia.​
• To compare and contrast the spending on e-cigarette and food consumption  among households in Indonesia.​
• To show the trend of e-cigarette consumption among vulnerable populations (e.g., late teens and young adults).

The research team recommends additional data collection on e-cigarettes and their effects, a higher tobacco tariff on e-cigarettes and a ban on aromatic and flavored e-cigarettes, and a government-led campaign on the health and economic risks of smoking both cigarettes and e-cigarettes.

Rizki Tsalatshita Khair Mahardya, Yudistira Permana, Ririn Ariani Dewi, Putri Listiani, Muhammad Akmal Farouqi, Naufal Mohamad Firdausyan, Astara Lubis, Yosinda Arsy, Inraini Syah, Maria Hotnida, Iko Safika, and Hasbullah Thabrany

This analysis aimed to demonstrate improvements in access and the quality of maternal and newborn health (MNH) services with the new tariff stated in the Minister of Health Decree (Permenkes) No. 3/2023). The decree was on new standard tariffs for health services under the National Health Insurance (JKN) scheme and the implementation of non-payment interventions. The team concluded that continued monitoring of the governance process around MNH services provision would ensure better communication between health providers, local health offices, and BPJSK branch offices and improve MNH outcomes.​

Mutia Astrini Pratiwi, Iko Safika, Anita Damayanti, Halimah Mardani, Febriansyah Budi Pratama, Made Anggarawati, Rahmad Asri Ritonga, and Rahma Anindita

Though Ministry of Health Decree No. 64/2016, mandated that JKN tariffs, both at the hospital and primary levels, should be adjusted every two years, the tariff has not been adjusted since its introduction eight years ago. Operating costs continue to increase, so, to promote fairness at primary health care centers (PHC), this team used age and gender as risk factors to calculate a new, risk-adjusted tariff. Ultimately, they recommend that the tariff be regularly evaluated and adjusted, an M&E dashboard should be used to analyze use trends, and another payment mechanism should be determined for PHCs in remote areas.

Mentari Widiastuti, Abigael Wohing Ati, Lambang Wahyu Nugroho, Shita Dewi, Yuli Farianti, Mazda Novi Mukhlisa, Elvina Diah, Iko Safika, Ruli Endepe Al Faizin, and Hasbullah Thabrany

The research question for this study was “how much did the patient pay out of pocket at a facility for the current visit for the following items: registration, laboratory/radiology examination, medical procedures and consultation, medicines, preventive services, and a bed.” Based on responses to this question, the team recommends enhancing the coverage of JKN and reassessing membership types, expanding JKN’s connections with PHCs, and conducting further qualitative studies and data triangulation.

Iko Safika, Yuli Farianti, Ackhmad Afflazir, Hasbullah Thabrany, Sushanty, Sarah Straubinger, and Ritu Kumar

​The goal of this study was to examine the challenges and opportunities of improving the capacities of Government of Indonesia, which is HFA’s main counterpart, specifically the Center of Health Financing and Decentralization Policy (Pusjak PDK). The researchers concluded with two recommendations:

• With the introduction of new laws, organizational changes, and subunits within the establishment, a concentrated effort is needed to foster enhanced analytical skills and understanding of health financing concepts. Additionally, it is essential to develop capacity for creating evidence-based policy briefs that effectively communicate ongoing progress in health financing and information reform initiatives.
• Continued capacity building can be achieved through on-the-job training, coaching, and mentoring. These strategies will effectively address the high turnover and demanding schedules of staff members, allowing them to participate in training sessions.

Diah Eva Sari Husnul Khotimah, Ruli Endepe Alfaizin, Dini Kurniawati, Mutia Astrini Pratiwi, Iko Safika, Nurhalina Afriana, Romauli, Indah Budiarty, Maria Hotnida, Amalia Zulfah Dani Hari Wijaya, Windi Haryani, Nana Tristiana Indriasari, and Hasbullah Thabrany

This team aimed to calculate the cost of viral load (VL) testing per patient per year, including the cost for specimen transport, at health facilities. They applied unit costs to inform a budget impact analysis and estimate the costs of covering comprehensive HIV services, including VL testing, under JKN. The researchers recommend that further expansive of VL test coverage at the PHC level should be targeted, regional variations of VL testing machines should be considered when determining reimbursement rates for such services, and necessary specimen transport costs should be included in these rates.

Dini Kurniawati, Iko Safika, Hasbullah Thabrany, Ackhmad Afflazir, Tri Indah Budiarty, and Lanny Luhukay

This study was conducted to understand the demographic status of respondents, understand access and adherence to antiretroviral treatment (ARV) among JKN members, and explore factors associated with access and adherence to ARV treatment among members. The researchers recommend health care providers consider implementing multi-month dispensing of ARV to ensure that PLHIV have an adequate supply and offer counseling services aimed at reducing internal stigma and encouraging ARV adherence.

How USAID HFA assisted the Government of Indonesia in improving COVID-19 health financing efficiency.

For more than three years, citizens and governments around the world have endured COVID-19. It has posed a unique challenge to national governments to rebalance the three dimensions of everyday life that it most impacts: economy, society, and health. In the face of continuous uncertainty brought on by this unprecedented crisis, Indonesia’s leaders have created strategies to ensure efficiency and economic resilience while also safeguarding the wellbeing of communities. One of these strategies is identifying the most effective health financing system. Efficient and equitable health financing not only saves money, but it also increases coverage for patients otherwise neglected by outdated systems.

To identify and hone this system, the Government of Indonesia (GOI) collaborated with USAID Health Financing Activity (HFA) to build evidence and consensus among stakeholders across the government and health sector. Building on the powerful partnership between USAID and the Ministry of Health (MOH), countless hours of research, discussion, and revisions were conducted to adapt the health financing system to the nuances of a pandemic.

The initial shock of a global pandemic

In March 2020, Indonesia reported its first confirmed case of COVID-19. In the following weeks— characterized by a sense of uncertainty, fear, and rapidly evolving circumstances—almost every aspect of life was impacted. In an instant, the government’s top priority became providing care to COVID-19 patients as quickly as possible. The GOI took measures to protect citizens and finance their medical services. But hospital beds rapidly filled, and access to vital resources dwindled. Normal or routine health procedures quickly became untenable under the burden of COVID-19.

As hospital reimbursement claims piled up, the need for a formulation of a more efficient payment system was clear. Guided by reimbursement and cost data from four large hospitals—Dr. Soetomo Regional Public Hospital Surabaya, Sulianti Saroso Infectious Disease Hospital, Fatmawati Central General Hospital, and Persahabatan Central General Hospital—the GOI decided on a per-diem scheme for reimbursement.

The system reimbursed health care providers or hospitals for all treatment they provide patients—medication, equipment, tools, consumables—in a single day. The reimbursement amount, or “tariff,” was set by MOH. The per-diem tariff scheme served as a quick fix to ensure the GOI was fully reimbursing hospitals as they cared for an overwhelming patient load as the patients arrived. Over the coming months, however, the weight of cases exceeded expectations and the system couldn’t keep up.

A method for better spending and faster care

Cases continued to increase, and so did the costs of reimbursements. The costs doubled to IDR 204.9 trillion (nearly US$13.5 billion) between December 2021 and December 2022, leaving public health officials wondering if the high charges from hospitals were a true reflection of the upward trend in cases. MOH requested USAID HFA to perform an evidence-based task analysis to support its decision-making process.

For two years prior to COVID-19, USAID HFA, implemented by ThinkWell, had been working to build evidence and capacity within the GOI to support MOH in generating and utilizing evidence to inform policy processes, including optimizing the National Health Insurance Scheme (NHIS). When the MOH tapped USAID HFA, the program immediately began assisting the government to generate a robust, timely, and efficient health financing payment scheme for the COVID-19 response in Indonesia.

“Calculating how much the correct real cost was for COVID-19 needs actually required finding the real costs for each unit,” said Dr. Yuli Farianti, MOH Center of Health Financing and Decentralization Policy (Pusjak PDK) Head. Between 2020 and 2021, HFA carried out a study to determine the actual costs of treating COVID-19. “That’s when we began to see the relevance of how the case-based groups (CBGs) might work in this situation,” she said.

The COVID-19 CBGs scheme was modeled after the CBGs payment method that has been applied for other disease areas since 2014. The system charges health care expenses in a package, per instance of care. Each package covers the entire treatment cycle from when a patient tests positive for COVID-19 until their discharge from a health facility. The amount of reimbursed expense per package varies based on severity level, which incentivized hospitals to treat patients quickly and according to each patient’s unique needs

USAID HFA’s technical and analytical assistance made it possible to reconfigure the reimbursement formula so that public funds were utilized effectively, and openness and transparency were promoted among hospitals. The new tariff was enacted in an MOH decree on October 1, 2021.

A policy that changes with the circumstances

Dr. Yuli highlighted that shifting to CBGs improved spending patterns and budgeting. “Before CBGs, [the rates] were calculated unit by unit, from masks to medicine, and beyond,” said Dr. Yuli. “Afterwards, [the expenses were] added to the daily rate of medical service. At the end of the day, expenses surged. CBG is a package service. They take everything into account, from equipment to medical consumables to services and others all under a particular CBG package code.”

COVID-19 continued to rapidly evolve, epidemiologically and clinically, and the development of less severe variants, vaccination, and herd immunity led Pusjak PDK to seek further revisions to the CBG tariff amounts. The Omicron variant required fewer resources, so USAID HFA worked with MOH to adjust the tariffs to reflect the provided health treatment.

According to Dr. Yuli, the process presented two challenges: formulating the new tariffs and implementing them in hospital operations. At the end of the day, however, hospitals across the nation recognized the public good represented by the new tariff structure and have since implemented the new scheme.

Moving forward and a shift to endemic

The World Health Organization’s Strategic Preparedness and Response Plan: April 2023–April 2025 will end the emergency phase of the COVID-19 pandemic in all countries and shift from emergency response to sustainable comprehensive management of the disease. As she reflected on the current declining trend in COVID-19 deaths and hospitalizations, Dr. Yuli expressed her hope that COVID-19 will be incorporated into the NHIS covered diseases soon. “Notwithstanding future challenges, we have to take into account the sustainability of the NHIS,” she said. Since the time of writing, COVID-19 has been deemed endemic in Indonesia and has automatically been included in NHIS coverage.

Dr. Yuli is grateful for USAID HFA’s assistance throughout its three-year collaborative journey with MOH  to find the most effective COVID-19 financing and adjusting the tariffs accordingly. “It is very significant,” she said. “If we don’t work with USAID, it will definitely be more difficult for us. It was such a great help in many aspects, such as the studies and many more…The process was much faster and more efficient with the help of HFA including the process of revising [the tariff]. Moreover, hospitals and other stakeholders have been supportive. Maybe without their help we wouldn’t be able to finish this fast.”

“HFA helped us do the tariff calculation, they taught us what to formulate, how to release the data, how to conduct analysis, and generate tariff calculation,” Professor Abdul Kadir, Head of the Supervisory Board of the Indonesia Social Security Agency on Health.

The successes of this project will act as an example for the MOH’s policy endeavors going forward. The teamwork fostered by USAID HFA between stakeholders and experts to create efficient policy and improved internal capacity will hopefully benefit the health care system of Indonesia as it continues to grow and adapt to whatever circumstances arise.

Header image: Puskesmas Setiabudi, Jakarta, Indonesia, July 2023; Credit: Ardy Rahmatullah for ThinkWell

In October 2022, the Strategic Health Purchasing Pilot for Maternal and Newborn Health Services (“the pilot”) launched in Serang District of Indonesia. The pilot is a collaborative effort from the Ministry of Health and Indonesia’s Health Insurance Agency (BPJSK) to improve the way that maternal and newborn health services are paid for under the country’s national health insurance program (JKN). It comes in response to challenges with unpredictable service quality and financial strain on JKN. The innovative design of the pilot seeks to strengthen the benefits package, contracting arrangements, provider payment mechanism, and monitoring of maternal and newborn health services. Ultimately, this will reduce spending inefficiencies and promote better health outcomes for pregnant people and their children.

USAID’s Health Financing Activity (HFA)—led by ThinkWell and implemented with Center for Health Economics and Policy Studies at the University of Indonesia, the Center for Health Policy and Management at Gadjah Mada University, and Results for Development (R4D)—is providing technical support to the Ministry of Health and BPJSK. HFA’s collaborative and locally led approach has been instrumental to the success this initiative has seen so far. The pilot fosters active engagement and coordination among policymakers, purchasing agencies, and providers to effectively monitor and support maternal and newborn health service delivery—an achievement that has been lauded widely by those participating in this initiative. Portions of the pilot design are also already being adopted at the national level, and the pilot is now being expanded to include more facilities in the implementation region.

The pilot is ongoing and closely evaluated through implementation research. In a blog posted by ThinkWell’s partner, R4D, HFA experts share three main lessons from the process which they believe led to the successful launch the pilot and has set it up for a lasting impact:

1. Co-creation with local stakeholders has grounded the design in local realities and was fundamental to promoting local ownership of this pilot.
2. Collaboration and established partnership protocols among national and subnational health agencies built a strong foundation for scale-up.
3. Placing local voices in the lead improves pilot performance and leaves a lasting impact.