Piloting Non-Payment Interventions in Tuberculosis Strategic Health Purchasing: Early Experience from Indonesia

Abstract

Although there has been a 19% decline in Tuberculosis (TB) mortality from 2007 to 2017, TB remains a major health challenge in Indonesia. In 2021, the country issued a Presidential Decree No. 67 to provide guidance on the National Health Insurance (JKN) utilization of control. In 2022, Ministry of Health Decree No. 1936 mandating primary care facilities to comprehensively treat uncomplicated TB case. However, the existing payment structure of JKN does not encourage primary-level TB service delivery. O’Connell and colleagues conducted a study in 2022 that revealed that a significant proportion (81%) of uncomplicated TB patients covered by JKN were unnecessarily referred to hospitals, resulting in suboptimal treatment outcomes and increased healthcare costs.

To address these challenges, a TB strategic health purchasing (SHP) pilot program was proposed in 2019. Its objective is to incentivize primary health facilities to deliver quality TB services for individuals with drug-susceptible TB through a combination of nonpayment and payment interventions. Two districts, Medan and Denpasar, were selected to implement these interventions, and the pilot began in 2021. The non-payment components, including health facility certifications and modifications to the JKN contracting process, were successfully implemented in Medan and Denpasar districts from 2021 to 2022. Regulations governing the JKN payment mechanism require substantial modifications before implementing the payment components.

Several learnings emerged through implementation and this report summarizes the learnings as a guide for government stakeholders and partners for scale up to other districts in 2023. Amongst these, is the significant level of advocacy and support from high-level government stakeholders, both at the national and sub-national levels, required to reform the regulatory environment to pave the way for implementing the complete interventions. For example, successful implementation of the non-payment components at the sub-national level relied heavily on improved coordination and engagement between the District Health Office (DHO), the BPJSK Branch Office and the health facility associations. This coordination was responsible for the increased involvement of primary care facilities in the DPPM networks.

BIMTEK technical trainings and facility TB certification, led by the DHO, are critical inputs into the JKN credentialing process, beginning with facility self-assessments to determine the capacity to provide TB care and the level of training required to raise the capacity of health workers. This certification process has demonstrated positive outcomes in terms of increased engagement, commitment, and adherence to guidelines among private primary health facilities providing TB services. 94% of JKN-empaneled private primary health facilities in Medan and 87% in Denpasar obtained certification, demonstrating increased commitment and capacity to deliver comprehensive TB care from diagnosis to treatment to reporting.

The report also outlines other recommendations for policymakers, including adapting the primary health center accreditation scheme as a baseline to continue the health facility readiness certification process, as well as suggestions related to the ongoing TB payment reforms.