Indonesia: Strategic purchasing strategies and early results

INDONESIA COUNTRY TEAM

JANUARY 2020

Indonesia: Country Context

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SELAMAT DATANG DI INDONESIA

▪ Indonesia is the largest archipelago in the world. Over 17,000 islands make up this diverse nation but only 6,000 islands are inhabited.

▪ Indonesia is the fourth most populous country in the world, and its population is expected to keep growing (1.1% annually).

▪ The country is facing the double-burden of communicable and non-communicable diseases.

▪ Although GDP is increasing (5.2% annually), many Indonesians still live below the poverty line (5.7% of total population).

Indicator Value

Total population (million) 267.7

Population growth (annual %) 1.1

Urban/Rural divide (% of pop.) 45/55

Population ages 0-14 (% of total) 26.6

Population ages 15-64 (% of total) 67.6

Population ages 65 and above (% of total) 5.9

Life expectancy at birth (years) 71.3

GDP growth (annual %) 5.2

GDP per capita, PPP (current international $) 13,079.60

Poverty headcount ratio at $1.90 USD/day (% of population)

5.7

Human Development Index Rank (2019) 111 (out of 189)

Source: World Bank Development Indicators, 2020

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FAMILY PLANNING (FP) CONTEXT: STAGNATION OF PROGRESS

▪ The modern contraceptive prevalence rate (mCPR) has increased from 5% in the early 1970s to 57% in 2002, and mCPR has not changed in the 15 ensuing years.

▪ The unmet need among married women is still at 13.8%.

▪ Due to many milestones having been met, there is a risk that local stakeholders no longer view FP as a health priority even though many FP indicators have not continued to improve.

Source: IDHS, 2017

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FP CONTEXT: METHOD MIX AND WHERE WOMEN ACCESS SERVICES

▪ Among the modern methods, injectables and oral contraceptives are the two most popular FP options.

▪ Similar to Maternal, Neo-natal, and Child Health (MNCH), a large proportion of women access FP services from the private sector.

Source: IDHS, 2017Source: Family Planning, 2020LAM = Lactational Amenorrhea MethodIUD = Intrauterine Device

Modern Contraceptive Method Mix in Indonesia

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MNCH CONTEXT▪ Indonesia did not reach the Millennium Development Goal for maternal health.

▪ While neonatal, infant, and under-5 mortality have reduced significantly over the last 20 years, the maternal mortality ratio (MMR) remains stubbornly high.

▪ This is in the face of high coverage rates for most MNCH services, including antenatal care (ANC) visits and skilled birth attendance (SBA). For example, 93.6% of births are assisted by a skilled birth attendant.

Trends in MMR, ANC, SBA, facility deliveries, & C-sections in Indonesia, 1981 – 2017Trends in neonatal, infant, and under-5 mortality, 1997-2017

SDG MMR Target

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MMR SDG MMR Target ANC +4

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Source: IDHS Series, 1987-2017

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MNCH CONTEXT: SUB-NATIONAL VARIATION

▪ There is high variation of MMR across the many islands of Indonesia, from the lowest MMR in urbanized Bali (47 out of 100,000 live births) to the highest MMR in the more rural province of Gorontalo (371 deaths).

▪ The maternal mortality ratio in Indonesia is high compared to other countries in the region.

Maternal mortality ratio by province (per 100,000 live births)

Source: MOH, 2017

Regional comparison of MMR, 2017

Source: Cameron, L., D.C. Suarez, and K. Cornwell. 2016

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PRIVATE PROVIDERS, PARTICULARLY MIDWIVES, ACCOUNT FOR A LARGE PROPORTION OF MNCH SERVICE PROVISION

OB-GYN, 27.8

GP, 1.5

Midwives, 51.9

Village Midwives, 15.2

Nurse, 1.2

Traditional Birth

Attendant, 0.4No ANC, 1.8

Distribution of ANC by type of health personnel (%)

Source: IDHS, 2017 Source: IDHS, 2017

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Public Hospital Private Hospital PHC Center Private GP/midwife Home

Percentage of deliveries by provider type and wealth quintile

Lowest Second Middle Fourth Highest

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HEALTH FINANCING CONTEXT▪ Jaminan Kesehatan Nasional (JKN) is a single-payer scheme managed by the Social Insurance Administering Body for Health (BPJS-K).

▪ Contributions by all the different types of members (PBI/poor & vulnerable people, formal, and informal workers) are pooled by BPJS-K.

▪ JKN has a tiered referral system to provide health services for members, including primary, secondary, and tertiary care.

▪ JKN applies capitation and non-capitation for primary health care (PHC), while secondary and tertiary health care use case base groups (CBGs).

PBI (National)

Diagram of fund and service flows under JKN

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PROPORTION OF HEALTH EXPENDITURE FROM JKN INCREASING, BUT OUT-OF-POCKET (OOP) STILL HIGH

Trends of Indonesia Health Expenditure 2010-2018

Source: Center of Health Financing and Security - MOH, 2019

JKN starts

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ORGANIZATION OF SERVICE DELIVERY

PHC Facilities in Indonesia (by type of facility, 2018) Referral Hospitals in Indonesia (by type of hospital, 2018)

• Indonesia decentralized nearly two decades ago, transferring the planning, management, and some financial responsibilities for health to the provincial and district government levels.

• Private providers at the PHC and referral levels are a significant source of health services. The proportion of private providers in the health system has grown rapidly since the introduction of JKN in 2014.

• However, the referral system is weak and uncoordinated both horizontally (e.g. public to private providers) and vertically (e.g. PHC to referral levels).

Source: BPJS Kesehatan, 2018Source: BPJS Kesehatan, 2018

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FINANCIAL SUSTAINABILITY CONCERNS IN MNCH: HIGH OOP & JKN PAYMENTS ARE NOT INCENTIVIZED TOWARDS PHC SERVICES

JKN, 41.2

National security for delivery, 4.3

Local security for delivery, 1.5

Private Ins, 3.8

OOP, 53.3

Others, 1.2

SOURCE OF PAYMENT FOR DELIVERIES (% OF TOTAL, 2018)

Source: MOH Health Survey, 2018

456 511

1,005 873

2,821

3,520

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

2016 2017

Source of JKN Claims for Deliveries (in billion IDR)

Normal delivery at PHC Normal delivery at Hospital C-Section

Source: BPJS Kesehatan, 2019

SP4PHC Strategies in Indonesia

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SP4PHC IN INDONESIA: KEY STRATEGIES

Strategy 1

Strategy 2

Strategy 3

Strategy 4

Support JKN to prioritize primary health care

Lear

nin

g ag

en

da

Leverage purchasing to incentivize better quality for PHC services

Increase private provider participation in JKN, especially midwives

Explore how purchasing can improve family planning access

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STRATEGY 1: INCREASE PRIVATE PROVIDER PARTICIPATION IN JKN, ESPECIALLY MIDWIVES

• Indonesia has seen significant reductions in neonatal, infant, and under-5 mortality • Indonesia performs strongly across key FP indicators, although the positive trends have stagnated recently • Despite a variety of efforts (e.g. high skilled birth attendance) and the expanded coverage of JKN, Indonesia suffers from

stubbornly high maternal mortality• Private midwives provide a substantial proportion of reproductive and maternal services across the country, but few

midwives are contracted under JKN• Quality of care varies across the country, and there are poor referral systems among public and private providers of

maternal services

▪ Conduct landscaping assessments to systematically understand the barriers to quality MNCH provision at the PHC level▪ Examining various purchasing strategies for MNH and FP services in PHC under JKN with a focus on the relationship

between: (i) the Government and BPJS-K; (ii) BPJS-K and PHC providers; and (iii) PHC providers and JKN members▪ Collaborating with the MNCH Technical Working Group (TWG), which is led by the Ministry of Health (MOH), to test

policies that offer stronger incentives to PHC providers to join JKN, especially private midwives. These activities include▪ Estimating the budget needed for the MNCH pilot ▪ Designing modules on SP for MNCH & FP for the pilot▪ Helping the TWG and selected pilot areas prepare for pilot implementation

The challenge/opportunity

Our work

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STRATEGY 1: KEY RESULTS

— Integrated with the Ministry of Health’s MNCH Technical Working Group (TWG)

▪ In coordination with the TWG, assessed MNCH situation through fact finding missions in selected provinces to inform potential strategic purchasing interventions

▪ Lead partner in the TWG tasked with identifying key issues that public and private PHC providers face, clarifying criteria for selecting pilot areas, co-developing the technical design for potential policy options, developing pilot interventions, and advocating to key stakeholders on selected options

— Estimated the budget needed for the MNCH pilot

▪ Developed a budget estimation model for the proposed MNCH pilot and communicated with key stakeholders to gain inputs on the assumptions used in the cost estimation

▪ The potential budget impact and cost savings of a SHP intervention was also incorporated in the model

— Developed landscaping report on private midwives

▪ Used quantitative analyses and qualitative interviews with private midwives and the midwife association (IBI), key national and local government stakeholders, and other PHC providers

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STRATEGY 1: KEY RESULTSREVISED PAYMENTS AND CONTRACTING ARRANGEMENTS AIM TO MEET SERVICE DELIVERY OBJECTIVES

Purchasing Reforms

1. Create stronger incentives for private midwives to engage with BPJS-K

2. Link payment to quality of primary care maternal services (e.g. ANC)

3. Create stronger incentives and mechanisms for networking and care coordination (e.g. among midwives, PHC, and OB-GYNs)

Service Delivery Objectives

1. Improve service readiness at both primary and referral levels

2. Increase the competency of health care providers and adherence to standards

3. Strengthen referral systems and procedures

4. Improve continuity of care during pregnancy and the postpartum period

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STRATEGY 2: LEVERAGE PURCHASING TO INCENTIVIZE BETTER QUALITY FOR PHC SERVICES

• Decision-makers struggle with determining how resources should be used to provide high quality services in a sustainable way

• The design of SHP for MNCH and FP services proposed by the TWG needs to be tested, and the findings need to inform the national dialogue on purchasing MNCH services for PHC

• In collaboration with the MOH, two pilot areas were selected, and the selection criteria included the urban and rural divide, political commitment of local governments, supply side readiness, and other regional considerations

The challenge/opportunity

• Engage with BPJS-K to strengthen their buy-in for the technical implementation plan• Support the process of establishing governance and management arrangements for the pilot at the district level, such as

establishing a District Oversight and Management Team and identifying key stakeholders • Lead the design and implementation of a situational analysis in pilot areas, synthesize results, and ensure realities on

the ground translate into adjustments and/or adaptations of pilot design elements• Provide trainings and other technical support to improve the education, quality of services, and networking of providers• Establish routine checks and feedback mechanisms to assess implementers’ understanding and to address challenges

Our work

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STRATEGY 2

— Engage with BPJS-K to strengthen the buy-in process for the technical implementation plan

▪ Continuous discussions with BPJS-K on the technical strategy to ensure their buy-in and to ensure optimal coordination for the pilot and its future sustainability

— Support the technical design and implementation plan for the MNCH pilot

▪ Providing technical expertise on designing the pilot’s intervention, operational guidelines, monitoring and evaluation plans, and coordination strategies

▪ Continuously support government officials in the pilot areas by advocating, communicating, and building capacity

— Engage with local governments in the pilot areas of SerangCity and Grobogan District

▪ Share our approach of SHP on MNCH and receive inputs on technical issues

▪ Three key resource persons and project staff have participated in these meeting, which include the districts’ health financing, public health, and family health units

KEY INTERVENTIONS

Strategic Health Purchasing Approach on MNH&FP

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STRATEGY 3: SUPPORT JKN TO PRIORITIZE PRIMARY HEALTH CARE

• Barriers to improving efficiency in public PHC facilities (Puskesmas) include multiple, fragmented channels for funding and complex regulations on how to use funds

• The absence of clear guidelines on how different sources of funds can be used leads to uncertainty in use of funds, fear of audit, under-provision of critical services, and underspending of budgets overall (reported as undisbursed capitation funds)

• The funding channels have separate management and reporting systems, which cause additional administrative burden and exacerbate inefficiencies in PHC facilities

• Assess stakeholder perspectives in using the purchasing power of JKN to strengthen the gatekeeper role of primary health care providers

• Conduct analyses using government data to understand trends in health-seeking behavior and funding sources• Understand how various funds in public PHC facilities interact with JKN funds

• A literature review on the utilization of funding sources in PHC, especially JKN capitation funds• Explore the utilization of capitation and non-capitation funds at Puskesmas, including the challenges in Public Financial

Management and the presence of undisbursed capitation funds. The local perspective on the relationship between Puskesmas’ autonomy and the utilization of various funds in Puskesmas will also be assessed

• Evaluate the utilization of the Social Security for Delivery (Jampersal) at local levels, particularly the local policy on how to use this budget and the items that are covered by the Jampersal fund

The challenge/opportunity

Our work

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STRATEGY 3

KEY LEARNING AREASKEY INTERVENTIONS

— Facilitate policy discussions to strengthen the gatekeeper role of primary health care providers

• Facilitate interviews and focus group discussions with key stakeholders and providers to understand the current context

• Organize an international seminar on the role gatekeeping plays in integrating PHC and hospital services under social health insurance, inviting all key stakeholders

— Investigate how JKN is being utilized by analyzing secondary data from BPJS-K claims and SUSENAS

• Use BPJS-K data to get a better understanding on the utilization of and spending for FP & MNH services by provider type (e.g. public/private), level (e.g. midwife), and location, as well as the demographic characteristics of the JKN members accessing these services

• Use SUSENAS data to analyze the source of funds that people access to receive FP & MNH services, including out-of- pocket (OOP) payments for FP & MNH services, disaggregated by socioeconomic status and type of health insurance

— Assess the use of government funds at Public PHC facilities, including JKN payments (capitation and non-capitation funds),Social Security for Delivery (Jampersal), and other national and sub-national funds

Reducing inequality within the JKN program: How is JKN being utilized by people from different socioeconomic status and demographic status? What factors influence the inequalities in level of healthcare utilization within JKN?

Effective funding disbursement to increase the gatekeeper role of PHC facilities: How can the various national and local government funds strengthen PHC services? What policies influence the PHC facilities to disburse funds?

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STRATEGY 4: EXPLORE HOW PURCHASING CAN IMPROVE FAMILY PLANNING ACCESS

• While the total fertility rate has reduced to near replacement levels and mCPR is nearly 60%, progress on increasing mCPR and total demand satisfied has stagnated in Indonesia

• Specific challenges include:• Method mix is not skewed towards long-acting reversible contraceptives (LARCs) • Lack of coherence in the purchasing streams for FP and other commodities between JKN and the government

agency charged with FP (BKKBN) • Low utilization of FP services through JKN despite more than 80% of the population being covered by JKN • Lack of subsidized commodity access for private providers, especially private midwives

• Understand why the FP commodities supply chain is fragmented and how to streamline it using purchasing techniques• Explore how the private sector can be better leveraged to provide quality FP services and incentivize a wider range of

method mix, especially to include Long-Acting Reversible Contraception (LARCs) • Engage with BKKBN to identify and analyze key purchasing challenges

The challenge/opportunity

Our work

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STRATEGY 4

KEY LEARNING AREAS

Institutional set-up: How are current policies encouraging or hindering people from accessing or providing FP? How are various government institutions working together (e.g. BPJS-K, BKKBN, MoH, and local authorities) to ensure efficient delivery systems for FP services?

How can we tap into the private sector to expand access to FP: Identifying the major barriers to the provision of FP services by the private sector and how they can be removed, especially related to method choice and the routine availability of LARCs to Indonesian women.

— Leveraging private providers to increase access to FP commodities

▪ Explore how the private sector can be better leveraged to provide quality FP services and incentivize a wider range of method mix (especially LARCs)

▪ Improve access to FP, quality of care, and JKN member participation for private providers, especially private midwives using national procurement systems through BKKBN

— Analyzing the current supply chain for FP commodities

▪ Engage with BKKBN to better understand their priorities and avenues for building capacity, and to harmonize purchasing approaches with JKN and other MoH schemes

▪ Conduct quantitative analyses using government data to study the supply chain management for contraceptives between BKKBN and private midwives under JKN

KEY INTERVENTION

Thank you!Terima kasih!

https://thinkwell.global/projects/sp4phc/