STRENGTHENING PRIVATE PROVIDER ENGAGEMENT TO IMPROVE TB OUTCOMES IN INDONESIA An institutional review The lead author of this report was Boston Consulting Group (BCG), supported by the National TB Program (NTP) in the Ministry of Health, Indonesia, and by the US Agency for International Development (USAID) Indonesia, USAID/Washington TB Team, and USAID’s Center for Accelerating Innovation and Impact (CII). The report was commissioned by USAID Indonesia.
The authors wish to thank the participants of this review, including selected Dinas Kesehatan officials, private sector facilities, professional associations, and other civil society organizations, for their support and insightful inputs.
Boston Consulting Group (BCG), United States Agency for International Development (USAID), and National TB Program (NTP) Indonesia; 2018. Strengthening private provider engagement to improve TB outcomes in Indonesia: An institutional review. Jakarta, Indonesia.
To download Strengthening private provider engagement to improve TB outcomes in Indonesia: An institutional review, please visit https://pdf.usaid.gov/pdf_docs/PA00THHS.pdf Table of Contents
Executive Summary...... 4 Annex section...... 50
Glossary...... 9 A. Methodology...... 50 A.1 Geographic focus and district selection...... 50 1. Context, objectives, and methodology of A.2 Approach to qualitative research and this review...... 12 insight generation...... 50 1.1 Context...... 12 A.3 Institution selection...... 53 1.2 Objectives and methodology...... 13 1.3 Key questions...... 15 B. District summaries...... 54 B.1 Tulungagung...... 62 2. Findings: State of the private sector B.2 North Jakarta...... 64 health system...... 16 B.3 Medan...... 66 2.1 State of BPJS-K and DPPM implementation B.4 Kabupaten Tangerang...... 68 in the private sector...... 16 B.5 Kota Tangerang...... 69 2.1.1 Introduction to BPJS-K...... 16 B.6 Makassar...... 70 2.1.2 Payment for TB in BPJS-K...... 16 B.7 Surabaya...... 72 2.1.3 Variation of payment mechanisms in BPJS-K...... 17 C. Inputs from district findings for 2.1.4 State of district-based PPM (DPPM) proposed recommendations...... 73 implementation...... 17 2.1.5 Role of Challenge TB in DPPM D. Analysis of private sector TB drug sales implementation...... 18 to estimate private TB caseloads...... 73 4.2 Typologies of private sector health providers...... 18 D.1 Introduction...... 73 4.3 State of play by district...... 23 D.2 Methodology...... 75 D.2.1 Data collection...... 75 3. Findings: Implications of current market D.2.2 Analysis...... 76 and policy incentives for future private D.3 Findings for North Jakarta and Surabaya...... 77 provider engagement...... 25 D.4 Potential limitations of the analyses...... 85 3.1 Institutional relationships and referrals...... 25 D.5 Recommendations for future use of 3.2 Overall business landscape, including TB drugs sales data in Indonesia...... 89 incentives and barriers to quality care...... 27 D.6 The inventory study methodology as 3.3 The DHO role and implementation a possible inspiration for improved of DPPM...... 33 programmatic approaches...... 90 3.4 Role of Non-Public Stakeholders...... 35 E. Additional insights...... 90 4. Summary of implications...... 38 F. Interview guides...... 90 5. Potential solutions and variations by district...... 40 G. Linkage between objectives, research framework, and key questions for 5.1 Inputs from district findings for proposed implementation...... 90 recommendations...... 40 5.2 Proposed interventions...... 40 H. List of interviewed facilities...... 100 5.3 District and implementation variations...... 48 6. Conclusion...... 49 Endnotes...... 109 Executive Summary
Introduction Objectives and Methodology
uberculosis (TB) continues to be a pressing health The objective of this review was to more fully understand problem in Indonesia, which in 2017 ranked third the behaviors and underlying motivations of private highest – behind India and China – in global TB sector institutions in order to identify potential ways to Tburden. The Global TB Report 2018 estimated a total of improve the quality of TB services in the private sector. 842,000 new and relapse TB cases per year in Indonesia, The intent was also to provide information to support while only 53% of estimated cases in 2017 were reported the implementation of future initiatives to increase uptake to the National Tuberculosis Program (NTP)1. Indonesia’s and improve the quality of TB services, particularly National Tuberculosis Prevalence Survey (NPS) in 2014 opportunities to use JKN – the National Health Insurance indicated that 74% of initial care-seeking for TB and nearly system – as a lever to change the behaviors of private half of all TB treatment occurs in the private sector among sector providers (note that in this report the term JKN, general practitioners, clinics, and hospitals operating referring to the insurance system, will be used somewhat outside the public health care system. Despite the large interchangeably with BPJS-K, the government insurance role of the private sector in TB treatment however, only agency in Indonesia that operationalizes JKN). The results 13% of TB cases reported to the NTP in 2017 originated of this review – in conjunction with the findings from from private providers2. The rapid expansion of Indonesia’s the previous individual provider/patient review – will be JKN (Jaminan Kesehatan Nasional) insurance coverage is used to inform USAID’s upcoming Tuberculosis Private also clearly impacting diagnostic pathways and client and Sector (TBPS) activity, which will serve as USAID’s main provider behaviors. Finally, the NTP’s district-based public- investment in supporting Indonesia in improving TB private mix (DPPM) is prioritizing TB connections at two services in the private sector. levels: between GPs and Puskesmas; and between hospitals and Dinas Kesehatan (the District Health Office, or DHO). Specifically, this review addressed five study objectives, as noted in the Terms of Reference (ToR). The complete In response to this situation, as well as to support study objectives can be found in Section 3.2 of the report; NTP’s DPPM strategic objectives, the US Agency for the following is the condensed version of the study International Development (USAID) commissioned objectives: this review to deepen understanding of the institutional relationships and incentives of private sector health 1). Understand the business case for providing TB facilities and organizations in TB care in Indonesia (or services and drugs in private sector “institutional review”). This report builds on a previous review commissioned by USAID which focused on 2). Understand attitudes among private sector understanding the key behaviors of individual private providers toward participation in JKN and potential providers and patients in private sector TB care in interventions that could be implemented through Indonesia (or “individual provider/patient review”3). JKN
4 3). Develop district-level estimates of unreported TB 3). How do we incentivize institutions to report? cases treated in private sector 4). How do we incentivize institutions to ensure 4). Develop a landscape of key district-level actors treatment completion?
5). Socialize findings with Dinas Kesehatan and others 5). Where should patients access government-funded FDCs? Objectives one and two will be addressed in the findings section of the review. Objective three is an analysis based 6). How do we further enable or incentivize DHO/ on data collected by IQVIA, a provider of data analytics Puskesmas to perform more of their public health on the health care industry, that attempts to estimate function (e.g. increase PPM participation, follow-up TB cases treated in the private sector at the district on TB patients in the private sector)? level. The detailed findings and a discussion of this effort to address objective three, along with the landscape of The links between the study objectives, research key district-level actors (objective four), can be found framework, and six key questions for implementation can in the Annex of this report. A socialization meeting was be found in section III of the Annex. conducted with key stakeholders to address objective five. Institutional typologies, relationships, and referrals. Although the behaviors and the extent of the This review focused on seven districts – North Jakarta, relationships for each facility type are influenced by Medan, Tulungagung, Kabupaten Tangerang and Kota different factors, there are two common drivers that Tangerang, Makassar, and Surabaya – with some of the affect all typologies: the size of the facility and level of districts participating in the USAID-funded Challenge TB participation in the BPJS-K program. Hospitals, clinics, (CTB) program. Within each district, the review team and labs all have size-based classifications from the conducted qualitative fieldwork that included one-on-one MoH, with the higher class facilities typically having more structured interviews or focus group discussions with advanced diagnostic capabilities (for labs and hospitals), the DHO, management team and/or TB team of private higher quality standards, and lower stock-outs (for labs health facilities (i.e. hospital, clinic, lab, and pharmacy), and pharmacies). These facilities are also more likely Professional Associations, and relevant civil society to have more extensive relationships or networks with organizations (CSOs). other facilities or commercial organizations, and are more likely to be more linked to government financing and government programs. This review also observed Key Findings indications that larger facilities and chains are expanding. For example, the compound annual growth rate (CAGR4) Based on the district interviews and focus groups, the of Apotek K-24 was 4.4% from 2014 to 2018, while findings of this review follow a research framework Prodia and Siloam had CAGRs of 4.1% and 16% from reflecting four lenses: (a) institutional typologies, 2015 to 2018, respectively. relationships, and referrals; (b) overall business landscape, including incentives and barriers to quality care for TB and Facilities that participate in the BPJS-K program are more in general; (c) the DHO role and institutional attitudes to likely to participate in TB programs (e.g., district-based the implementation of DPPM; and (d) the role of other PPM) as compared with facilities that don’t participate non-public stakeholders. While JKN is an overarching in the BPJS-K program. The BPJS-K affiliated facilities topic across the four lenses, it is covered in a deep dive are also more likely to have more established referral within the overall business landscape topic. The key networks with other BPJS-K facilities. It is important to findings for each lens are highlighted in this section. note, however, that while there is movement toward more formal relationships between facilities, including The findings using this research framework address six non-exclusive discounts between some facility types critical questions for implementation, which drive the and some vertical integration, the private sector health potential recommendations of this review. These six system in Indonesia overall remains highly informal and questions are: fragmented with limited relationships between facilities and organizations, and a continued predominance of 1). Where should patients get diagnosed? standalone facilities in some sectors such as pharmacies.
2). How do we make sure hospitals down-refer Overall business dynamics and the incentives and uncomplicated TB patients? barriers to quality care. TB contributes to less than
5 5% of revenue for private sector institutions. TB is and clients. However, they are heavily reliant on funding also costly to treat given the multi-step diagnostic from donors, with few if any instances of public funding process and lengthy treatment. Thus, given challenging of CSOs (leaving the CSOs with an unfunded mandate). TB economics and the need to optimize profits, Efforts to increase such public funding come up against private sector hospitals and clinics are responding with the decentralized administration of Indonesia, requiring behaviors that have a significant cumulative effect in action in each individual district. The private sector is driving uncomplicated TB patients to secondary care for not currently willing to pay for CSO cadre services, since diagnosis and treatment. Regulations to curb unnecessary the private sector is not being incentivized or being held up-referrals or retention of uncomplicated TB patients accountable for active case finding or ensuring treatment in hospitals exist, but to date have been ineffective or completion, which are seen as public health functions not enforceable. Furthermore, existing incentives in the more suited to direct public financing. market including access to government-funded FDCs for clinics and hospitals and subsidized GeneXpert placement in hospitals, are likely insufficient. In some cases, such as Discussion: Potential interventions government-funded FDC access for hospitals, perverse incentives for TB care may be created. This includes This review generated four potential interventions that hospitals being further incentivized to keep patients as address the six critical questions for implementation: opposed to down-referring, as FDCs allow hospitals to three longer-term solutions that involve changes to the treat patients at a lower cost, which in turn increases their BPJS-K purchasing system and one short-to-medium term margin. The introduction of BPJS-K has shifted patients’ solution that builds on the current health system. The care-seeking preferences to one-stop shop facilities which solutions are not mutually exclusive; while each addresses results in declining demand for pharmacies’ and labs’ specific priority areas, in some cases combinations could services, especially for the smaller facilities. As a result, have a synergistic effect on outcomes. these pharmacies and labs are not willing to invest in TB drugs and/or services, nor are they as willing to invest in The potential interventions and the implementation the quality of care. questions they address are highlighted in the diagram below (see Figure 1). DHO role and state of DPPM. District-based PPM (DPPM) is still in the early stages of implementation in Potential intervention A: Conditional Fee for Service Indonesia. While the National TB Program currently does for TB diagnosis (longer-term). This intervention not have defined metrics or a scorecard to measure suggests a fee-for-service (FFS) payment mechanism for the true state of DPPM implementation across districts, TB diagnostic tests for hospitals and Puskesmas units this review found variation in implementation across on the condition that institutions report test results to districts. Successful implementation of DPPM hinges the DHO and down-refer uncomplicated TB patients to on leadership of the DHO and other multiple factors primary care. For hospitals, the reimbursement amount including funding and resource availability and DHO should be sufficient enough not to incur losses in order to ability and effectiveness in mobilizing existing resources. incentivize down-referrals. For Puskesmas units, the FFS DHOs cite the lack of human and financial resources as for TB tests is expected to prevent them from rejecting a key challenge that negatively impacts their effectiveness clinic-based patients or requiring clinic-based patients to in carrying out TB programs. This review also found that transfer capitation. the time allocation of Wasor was neither systematic nor standardized across districts and that considerable time Potential intervention B: Inclusion of TB in an expanded may be spent on maintenance activities such as re-training “Program Rujuk Balik (PRB)” (longer-term). This TB teams in DOTS-certified facilities or fixing reporting intervention calls for the inclusion of TB in the current system issues (e.g., Sistem Informasi Tuberkulosis Program Rujuk Balik with some modifications. This Terintegrasi (SITT)). involves appointing PRB labs in each district to conduct TB diagnostic tests for GPs and private clinics and would Role of other non-public stakeholders. The review eliminate the need for primary health care institutions to focused on two non-public stakeholders: professional send patients to secondary care for treatment. Placement associations and CSOs, and found that only a few of publicly funded GeneXpert machines in these locations associations have TB-specific education programs or would presumably be prioritized. In addition, this solution advocacy support. CSOs typically focus on case finding could potentially be expanded to include PRB pharmacies or treatment support for both DS- and MDR-TB patients as distribution points for government-funded FDCs where and could serve as a valuable resource in filling a gap in pharmacies would be reimbursed for drug handling fees. providing public health functions for private providers (Note: In some districts, either intervention A or B may
6 Figure 1: Potential interventions address six key questions Long term Short-to-medium term
INTERVENTION A INTERVENTION B INTERVENTION C INTERVENTION D Conditional Fee for Inclusion of TB in PRB Treatment completion PPM implementation Service for TB diagnosis (“Program Rujuk Balik”) incentives acceleration
Increase Designate private labs to Q1 conduct TB diagnostics as diagnosis access Implement conditional part of the PRB program fee-for-service (FFS) payment mechanism Incentivize for TB diagnostic Improve the functionality Q2 based on hospital/PKM and interoperability of reporting 2 reporting and (for SITB uncomplicated TB), on hospital down-referral Ensure Q3 down-referrals1
Enhance FDC Supply “PRB Pharmacies” Q4 with government-funded access FDCs
Incentivize PHC with Ensure treatment pay-for-performance (P4P) Q5 completion rewards to ensure treatment completion
Empower wasor role and Further DHO/ Implement conditional Implement P4P to increase the quality Q6 FFS to incentivize incentivize Puskesmas’ PKM public of M&E3 of DPPM Puskesmas’ role in DPPM role in DPPM health role implementation
1 For uncomplicated TB 2 Sistem Informasi TB (TB information system) 3 Monitoring and evaluation be selected for implementation, but not both. However, mechanism to ensure that these TB patients receive high further study is required to assess feasibility in each district. quality completed treatment will then be critical. Intervention A sets up a general payment mechanism, but intervention B (by identifying and equipping priority facilities) Potential intervention D: Accelerate DPPM also helps on the supply side, so the two could be somewhat implementation through DHO and Puskesmas complementary. Finally, they could be combined into a incentives and/or investments (short-to-medium composite approach: districts with limited supply for TB term). The acceleration of DPPM implementation at diagnostics may consider leveraging Puskesmas to perform primary and secondary care levels is essential to drive the PRB labs’ role to keep patients at primary level). high quality private sector TB care. This intervention bundles several initiatives to further support and equip Potential intervention C: Treatment completion DHOs and Puskesmas units in fulfilling their public health incentives (longer-term). Ideally this intervention would function for patients receiving TB care from private be combined with either intervention A or B. It introduces providers. The proposed interventions are divided into a pay-for-performance (P4P) payment scheme in which three themes: people, performance management, and health care facilities – whether primary or secondary technology. Within each of these themes, there is one care – are rewarded based on treatment completion. priority intervention recommended: the empowerment Secondary care facilities (i.e. hospitals) would need to of wasors and mobilization of Puskesmas staff (People); provide evidence that the patient suffers from complicated increased quality of monitoring and evaluation of DPPM TB, as uncomplicated TB should be down-referred to a implementation (Performance management); and the primary health care facility, and an audit function would revamp of SITT as it is replaced by SITB (Technology). need to be in place. The P4P payment scheme is an important intervention to consider because this review Other potential short- to medium-term interventions: anticipates that, as reporting improves, a higher number Leverage BPJS-K database and KOPI-TB. As BPJS-K of TB patients will be notified. As a result, an incentive matures, there are several potential opportunities to
7 leverage the system, and particularly the data, to improve This review is one piece of a bigger puzzle that should TB services. For example, the BPJS-K system could be be considered by further implementers, such as the NTP, linked with SITB, the upcoming replacement for SITT, to BPJS-K, Pusat Pembiayaan dan Jaminan Kesehatan (PPJK streamline private sector case notifications. BPJS-K claims or Health Insurance Payment Centre)5, and the USAID data could also be used to get a more accurate estimate TBPS Activity and Results for Development (R4D)6 of the unnecessary cost that BPJS-K incurs as a result of Strategic Health Purchasing project, in a concerted effort inefficiencies and disincentives in the current system. In to eradicate TB in Indonesia. These solutions should also addition, more funding to train GPs in TB primary care be considered as a set of priority areas to further test and would be valuable to increase awareness, confidence, and explore as Indonesia’s NTP and KOPI-TB further define competence in presumptive TB management and case their private provider engagement strategies. As specific reporting. The newly formed KOPI-TB, which is currently solutions are developed and refined by the NTP, private developing a TB training module and strengthening DPPM sector patients, providers, and BPJS-K should be at the implementation under catalytic funding from the Global core of the development process. Fund (GF), could also help accelerate TB knowledge- building and improve quality TB care for GPs and the medical professionals in private hospital and clinics.
Conclusion
This review has provided a set of potential solutions – many of which require changes to the BPJS-K health purchasing system – to incentivize the private sector to diagnose and treat TB patients more cost effectively. These interventions are longer-term by nature and a deeper study is needed to ensure that the eventual solutions are feasible and the key stakeholders involved are aligned for successful implementation.
8 Glossary
Acronyms Definition
APBD Anggaran Pendapatan Belanja Daerah (Provincial Development Budget)
ARSSI Asosiasi Rumah Sakit Swasta Indonesia (Association of Indonesian Private Hospitals)
ASKLIN Asosiasi Klinik Indonesia (Association of Indonesian Clinics)
Badan Penyelenggara Jaminan Sosial Kesehatan (Social Security Management Agency— BPJS-K Health), which administers JKN
CTB Challenge TB project funded by USAID
DHO District Health Authority (or interchangably referred to as Dinas Kesehatan or “Dinkes”)
DM Diabetes Mellitus
DOTS Directly observed treatment-short course
DPPM District-based public-private mix
DST Drug susceptibility testing
FDC Fixed-dose combination
GFATM The Global Fund to Fight AIDS, Tuberculosis and Malaria
GP General practitioner
IAI Ikatan Apoteker Indonesia (Association of Indonesian Pharmacists)
9 IDAI Ikatan Dokter Anak Indonesia (Indonesian Pediatrician Association)
IDI Ikatan Dokter Indonesia (Indonesian Medical Association)
Interferon Gamma Release Assay (blood test to detect immune response to TB IGRA infection)
ILKI Ikatan Laboratorium Kesehatan Indonesia (Association of Indonesian Medical Lab.)
Indonesian Case Base Group, a payment system made by BPJS-K for hospitals, based on INA-CBGs average payment needed for type of disease
ISTC International Standards for TB Care
JEMM Joint External Monitoring Mission
Jaringan Kesehatan/Kesehatan Masyarakat, an organization aimed at enhancing JKM community responses to TB, MDR-TB, and TB-HIV among susceptible groups
JKN Jaminan Kesehatan Nasional (national health insurance system)
Regency (a type of second-level administrative subdivision in Indonesia, referred to as Kabupaten “districts” collectively with kotas [see below])
KOPI-TB Koalisi Organisasi Profesi-TB, a professional organization coalition to fight TB
City (a type of second-level administrative subdivision in Indonesia, referred to as Kota “districts” collectively with kabupatens [see above])
MDR-TB Multidrug-resistant TB
MoH Ministry of Health
NTP National Tuberculosis Program
PAPDI Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia (Association of Internists)
PATELKI Persatuan Ahli Teknologi Laboratorium Medik (Association of Medical Lab Technicians)
PCR Polymerase Chain Reaction, one method of TB diagnosis using molecular biology
PDPI Perhimpunan Dokter Paru Indonesia (Association of Indonesian Pulmonologists)
PDSPatklin Perhimpunan Dokter Spesialis Patologi Klinik Indonesia (Association of Pathologists)
PERSI Perhimpunan Rumah Sakit Seluruh Indonesia (Association of Indonesian Hospitals)
PESAT Organization focused on helping MDR-TB patients
PETA Pejuang Tangguh (Association of Ex-TB MDR patient)
10 Perhimpunan Klinik & Fasilitas Pelayanan Kesehatan Primer Indonesia (Association of PKFI Indonesian Clinics and Primary Health Care)
PME Pemantapan Mutu Eksternal (external quality assurance)
Pengawas Menelan Obat (Person appointed by health care facilities to look after TB PMO patient medication, usually family member of the patient)
Puskesmas Pusat Kesehatan Masyarakat (public community health center)
SITB Sistem Informasi TB (TB Information System)
SITT Sistem Informasi Tuberkulosis Terintegrasi (Integrated Tuberculosis Information System)
TB Tuberculosis
USAID US Agency for International Development
11 1. Context, objectives, and methodology of this review
1.1 Context pathway (from care-seeking, to effective diagnosis and notification, through treatment completion and reporting). he Indonesia TB prevalence survey found that of JKN offers a major lever for potential change in the 3,200 participants who had sought medical care private sector, but additional data is required to help for TB symptoms (cough of two weeks or more), understand the opportunities and challenges. T60% sought that care in the private sector.7 A recent patient pathway analysis conducted in Indonesia used The previous individual private provider/patient review, this and other data sources to conclude that an even which drew on interviews and focus groups with 204 higher proportion of care seeking (74%) was to the private sector TB patients and 395 private sector private sector.8 In addition, a 2009 survey of TB drug sales providers (including GPs, internists, pulmonologists, showed that the volume of TB drugs sold in Indonesia’s pharmacies, and laboratories) across four districts in private sector was larger than the volume of TB drugs in three provinces (Jakarta, East Java, and North Sumatra), the public sector – indeed, large enough to treat 430,000 identified seven key opportunities to improve private patients with full six to eight month regimens.9 Despite sector TB care, listed below, and highlighted the the large role of the private sector in TB treatment, importance of monetary and non-monetary incentives however, only 13% of TB cases reported to the NTP in in influencing behaviors of patients and providers in the 2017 originated from private providers.10 private sector. Key opportunities included:
While Indonesia has seen significant economic advances • Improve public awareness of TB symptoms and over the last two decades, total health expenditure reduce time for people with TB symptoms to seek remains low at approximately 3.1% of GDP in 2013. treatment from a physician. Despite this, the Government of Indonesia made significant progress toward universal health coverage in • Increase the number of referrals of presumptive 2014 by rolling out its social health insurance scheme TB cases from private labs and pharmacies to (JKN). Under JKN, the government has pledged to cover physicians. all citizens, estimated at 275 million people, by 2019. Thus far, ~195 million11 people are covered, of whom • Improve diagnostic options for patients at private 94.5 million receive subsidized premium payments from GPs or clinics to help keep TB patients in primary the government. JKN aims to provide a comprehensive care where appropriate. package of health care services to all, and members are currently accessing services through both public and • Further streamline and reduce barriers to case private facilities. reporting.
Additional actions are required to improve the effective • Adjust patient, hospital, and GP incentives to ensure involvement of the private sector in the full TB patient down-referrals.
12 • Facilitate access to program drugs for private 4). Develop a landscape of key district-level actors that physicians. are contributing or have the potential to contribute to improving the provision or uptake of TB services • Increase the attention paid to treatment adherence in the private sector (e.g. private pharmacies and and completion. labs, private clinics and hospitals, other local NGO or community health care organizations). This landscape includes data such as commercial or more informal 1.2 Objectives and methodology relationships between different types of institutions that might affect TB-related solutions, the TB services To support the Indonesia NTP’s District-based Public- they provide, and the typical profile of their client. Private Mix (DPPM) strategic objectives, USAID commissioned this review as a continuation of earlier 5). Socialize findings with Dinas Kesehatan and other studies of TB care in Indonesia, specifically the individual stakeholders to inform the national dialogue on PPM private provider/patient review,12 which focused on for TB in Indonesia. understanding what drives key behaviors and decisions for TB patients and individual health care providers in the Objectives one and two will be addressed in the findings private sector in Indonesia. section of the review. Objective three is an analysis based on data collected by IQVIA, a provider of data analytics The objective of this current institutional review was to on the health care industry, that attempts to estimate TB build on the individual private provider/patient review and cases treated in the private sector at the district level. to develop an understanding of private facilities’ behaviors The detailed findings and discussion of this effort to and underlying institutional motivations, in order to identify address objective three, along with the landscape of key solutions for improving TB care quality in the private district-level actors (objective four), can be found in the sector. In addition, this review focused on understanding Annex of this report. Objective five is a key step in this current market and policy incentives for private health care review process. A socialization meeting was conducted facilities and how different policies or interventions might with key leaders from the DHO, Provincial Health Office affect incentives at an institutional level. The intent of this (PHO), professional associations, and CSOs from each institutional review is to provide information to support the of the districts that participated in the review as well as implementation of future initiatives to increase uptake and members from the NTP. Feedback from the socialization improve the quality of TB care, particularly opportunities meetings has been integrated into the review. to use JKN as a lever to change the behaviors of private sector providers. More specifically, the results of these This institutional review may also be used to inform (or two reviews will be used to inform USAID’s upcoming highlight collaboration opportunities with) other ongoing Tuberculosis Private Sector (TBPS) activity, the agency’s TB efforts, including but not limited to: main investment in supporting Indonesia’s efforts to improve TB services in the private sector. • Indonesia’s National Tuberculosis Program (NTP): This MoH program sets standards for the TB Specifically, this review addressed five study objectives, as response across the country and reports to the noted in the Terms of Reference (ToR): Director General of the Center for Disease Control. The current institutional review provides NTP with 1). Understand the business case for providing TB- potential market-based interventions and solutions related services and drugs in the private sector, to improve TB outcomes in the private sector. including commercial and non-commercial incentives and disincentives. • KOPI-TB: A coalition of 13 professional medical organization, initiated by MoH. The purpose of 2). Understand attitudes among private sector KOPI-TB is for each medical association to ensure providers toward participation in JKN and potential quality TB care delivered by its members, to help interventions that could be implemented through with outreach for case-finding and patient treatment, JKN (such as fee-for-service payments aimed at and to collaborate with the government in providing private labs and pharmacies). education for providers and the public.
3). Develop a district-level estimate of unreported TB • Implementers under the Global Fund to Fight cases treated in the private sector that can be used Aids, Tuberculosis and Malaria (GFATM) TB grant: as a baseline to assess the effect of interventions to The GFATM incentive funding includes activities improve case notification. to increase DPPM uptake and private provider
13 notifications, with the Respirology society (PDPI) of private health facilities, professional associations, and and Yayasan KNCV Indonesia (YKI) as the lead relevant CSOs. The goals of both types of fieldwork implementers. (i.e. one-on-one structured interviews and FGDs) were to understand behaviors, motivations and incentives; to • World Bank and Results for Development (R4D): identify what is currently working well and challenges that The World Bank is collaborating with USAID to could undermine patient or public health outcomes; and support discussions on strategic health purchasing to determine the dynamics that would need to change to in Indonesia, with TB as a specific focus. Under this address challenges. effort, R4D is the implementing organization that helps structure the discussions among Indonesian The review team generated insights from the interviews institutions such as NTP, PPJK and BPJS-K on and focus group discussions in six (sometimes iterative) strategic purchasing options. World Bank also steps: pre-planning, pre-research hypothesis generation, supports other TB-related activities, expecially on interview guide development and pre-work, interview analytics around health financing and supply-side completion, insights capture and hypothesis refinement, readiness. and synthesis.
Approach and Methodology Socialization
This review was undertaken in three stages: district Throughout this effort, the review team engaged closely selection, qualitative fieldwork, and socialization of with NTP and representatives from the relevant district findings. Each stage is briefly described in the following health authorities to ensure that the findings were overview; more detailed methodology is included in the considered in the local context and that the solutions Annex. under consideration would be feasible, sustainable, and could build on existing structures. District selection and geographic focus The review included an initial workshop with NTP to In partnership with NTP, the review team developed discuss perspectives on private provider engagement and applied a methodology to select seven districts and to generate initial solution ideas. Before conducting with a large number of opportunities for private sector qualitative fieldwork, the review team also held a meeting engagement. The districts included three districts with the relevant district government health authority that were part of the USAID-funded Challenge TB to gain a better view and context for each district. program and four districts that were not. A four-stage After conducting district interviews, the team shared methodology13 was used to identify the final districts preliminary, interim findings with each DHO. A final from an initial set of 16 Challenge TB districts and 498 workshop was also held with stakeholders, including non-Challenge TB districts: 1) Screen out districts outside NTP and DHO representatives, to socialize the overall USAID CDCS14; 2) Screen out districts with population findings of the review, discuss possible interventions under 450,000; 3) Screen out districts with 13 or fewer and to identify potential next steps on private provider hospitals; 4) Test final selected districts for feasibility. engagement.
Based on the methodology above, seven districts were Institutional focus jointly selected and aligned with NTP: Medan in North Sumatera; North Jakarta in the special capital region, DKI This review focused on four types of private health Jakarta; Tangerang regency and Tangerang city in Banten; institutions – hospitals, multi-GP clinics, laboratories, and Tulungagung and Surabaya in East Java; and Makassar in pharmacies – with additional participation from other South Sulawesi. non-public stakeholders (i.e. professional associations, health facility associations, and CSOs). Standalone, Qualitative fieldwork individual GPs were not part of the interview set given the institutional focus of the review; any views regarding Qualitative interviews with owners, managers, persons- standalone GPs included in this report were based solely in-charge, and TB teams of private providers (i.e., private on interviews with multi-person private institutions. hospitals, multi-GP clinics, pharmacies, and laboratories) in all seven selected districts formed the basis of the review’s In each of the seven districts, this review aimed to findings and recommendations. Fieldwork included one- interview: four to five hospitals; four to five clinics; eight on-one structured interviews15 or focus group discussions to ten pharmacies; four to six labs; select professional (FGDs) with DHO, management team and/or TB team associations including ARSSI, ASKLIN, IAI, IDAI, IDI,
14 ILKI, PAPDI, PATELKI, PDPI, and PKFI; and select CSOs After using the research framework to drive inquiries and including AISYIYAH, PPTI, JKM, LKNU, PESAT, and PETA. discussions, the final recommendations were focused on These associations and CSOs are spelled out and defined answering six key implementation questions that reflect in the glossary section of this report. key priority areas for driving the quality of TB provision:
The facilities selection process aimed to ensure a varied 1). Where should patients get diagnosed? and balanced, if not statistically representative, set of facilities. The review team, NTP, and DHO (with PHO for 2). How do we make sure hospitals down-refer Surabaya) identified a mix of facilities based on covering uncomplicated TB patients? a variety of facilities of different sizes, types (e.g. A/B/C/D for hospitals; pratama/utama for clinics and labs; chain 3). How do we incentivize institutions to report? vs. standalone), anticipated levels of TB capabilities and resources, BPJS-K affiliation, and clientele served. The list 4). How do we incentivize institutions to ensure of interviewed facilities can be found in section VIII of the treatment completion? Annex. 5). Where should patients access government-funded 1.3 Key questions FDCs? 6). How do we further enable or incentivize DHO/ This review used a research framework using four lenses Puskesmas to perform more of their public health to inform its findings: (a) institutional relationships and function (e.g. increase PPM participation, follow-up referrals, (b) business landscape, including incentives TB patients in private sector)? and barriers, (c) DHO role and implementation of PPM, and (d) role of non-public stakeholders. While JKN is an overarching topic across the four lenses, it is covered in a deep dive within the overall business landscape topic.
15 2. Findings: State of the private sector health system
ndonesia’s private sector health system is multifaceted independent private practice are designated as primary and complex, characterized by a growing number of care and are compensated through monthly capitation private sector institutions, increasing private sector payments. The amount of capitation is based on the Iempanelment in JKN, and continued implementation of number of patients registered with the provider, the district-based PPM (DPPM). Understanding the current total number of doctors and dentists in the practice, the state of the health system across these dimensions is ratio of doctors to BPJS-K members for that practice, critical context for assessing the behaviors and motivations and the practice’s service hours. This payment is subject of private sector institutions and for identifying and to adjustment to reflect performance targets, including implementing effective solutions to improve the quality of the proportion of registered BPJS-K members who TB care. engage with the primary care provider, the proportion of nonspecialist up-referrals, and the ratio of patients with The following section provides an overview of the current chronic disease. Primary care is expected to diagnose and state of BPJS-K and DPPM implementation in the private treat patients with any of the 144 diseases listed, which sector, discusses the role to date of Challenge TB in includes uncomplicated TB. DPPM implementation, describes specific typologies for key district-level private sector institutions, and highlights Hospitals and utama clinics are designated as advanced the current ‘state of play’ in each district in focus for this care facilities and are reimbursed through INA-CBG claims review. This section combines contextual background with based on charges per episode of care. BPJS-K patients findings from district interviews to address these topics. are required to visit their primary care provider first to obtain a referral to secondary care for diagnosis and to be qualified for treatment in secondary care – a requirement 2.1 State of BPJS-K and DPPM that holds for all patients whether they are presumptive implementation in the private sector TB patients needing a general initial visit or patients referred with a specific diagnosis. The only exception to 2.1.1 Introduction to BPJS-K this requirement is if the patients are in an emergency situation (e.g. high fever, premature rupture of the fetal Indonesia has a rapidly growing national health insurance membrane) BPJS-K hospitals and advanced care clinics system with a current enrollment of ~195 million16 submit claims to BPJS-K, which verifies claims according to people, or almost 75% of the population. The government its guidelines before reimbursing the health facilities. aims to cover all 275 million citizens by the end of 2019. 2.1.2 Payment for TB in BPJS-K For facilities or practices under contract to BPJS-K, there are two primary payment mechanisms: capitation Primary care is expected to perform diagnostic tests on and Indonesian Case Base Groups (INA-CBG) claims17. presumptive uncomplicated TB in their in-house lab, or Services provided by a pratama clinic18, Puskesmas, or an to refer to either Puskesmas units or private laboratories
16 under the partial referral scheme19. The cost of a partial number of PRB labs and PRB pharmacies is expected referral is expected to be borne by the referring facility to expand to cover the increasing demand from since there is no special payment outside of capitation patients, and in line with Presidential Instruction No. for TB in primary care, but in practice, there are seldom 8, 2017 (Instruksi Presiden no. 8 tahun 2017). financial relationships between the referring and receiving facility, so costs may be borne by the receiving facility or • Midwifery service and neonatal care: includes pre- the patients themselves. After receiving a TB diagnosis, and post-childbirth check-ups and childbirth service. uncomplicated TB patients may continue their treatment in primary care by using either private-sector drugs • Cervical cancer screening: Includes IVA test, pap (technically covered by clinics) or government-funded smear, blood glucose level test. FDCs (covered by the national TB program). • Family planning: Includes contraception implant and Patients with extrapulmonary TB, TB with complications, injection. multidrug-resistant TB (MDR-TB), and those in special situations, e.g. pregnancy or TB with negative smear result • Ambulance service: Fees vary by district. (only under the following criteria: TB symptoms don’t go away after patients take broad spectrum antibiotics, or • Inpatient service: Only applicable for facilities with patients are in serious condition, such as high fever and inpatient services, paid based on length of patient’s coughing up blood) can be referred to secondary health stay. care for further diagnosis and treatment. Hospitals receive reimbursement through the INA-CBG scheme, with the 2.1.4 State of district-based PPM (DPPM) amount dependent on hospital type (A/B/C/D), location implementation and the patient’s medical condition (e.g. inpatient or outpatient, and the INA-CBG diagnostic category). Since 2017, NTP has been implementing the district- based PPM (DPPM) model, which is a network of public Provincial Health Offices (PHOs), based on input from and private health care facilities, professional associations, the DHOs, deploy GeneXpert machines in select and CSOs. It is under the supervision of the district health hospitals to run diagnostic tests for presumptive MDR- office (DHO), which aims to coordinate and increase the TB (and for all presumptive TB in a few districts such quality of TB service provision. All health care facilities as in Makassar and Tulungagung as a way to increase are expected to participate in the network so that all GeneXpert utilization). MoH and The Global Fund to TB patients can be detected, diagnosed, and treated Fight AIDS, Tuberculosis and Malaria (GFATM) cover properly, and be notified in the National TB information the cost of procuring the machines and cartridges20, and system. Under this model, the kecamatan Puskesmas units the cost of maintenance, and GFATM provides an IDR (sub-district Puskesmas23) are expected to coordinate 25,000 incentive21 to GeneXpert sites for each test run, as TB service provision in private clinics and by individual GeneXpert sites are not allowed to charge people being practitioners, whereas the DHO has direct responsibility evaluated for MDR-TB. There is some lack of clarity over for both public and private hospitals. the future financing modality for these costs (such as who pays and through which financing channel) after GFATM The DPPM network involves several components for funding ceases. Each district typically assigns a Class A/B implementation: the diagnosis pathway (i.e., where and public hospital to treat MDR-TB patients, with MDR-TB how patients access affordable and quality diagnostic drugs funded by the government. services); the logistics network (access to government- funded FDCs); the reporting process; the tracking 2.1.3 Variation of payment mechanisms in of loss-to-follow-up patients; and clear supervision, BPJS-K monitoring, and evaluation processes. The DHO performs key enabling activities such as mapping and identifying In addition to capitation payments, primary care providers care providers and CSOs, conducting socialization are entitled to non-capitation payments (or fee-for- meetings, training all facilities, and engaging and potentially service) for the following six services22: compensating professional organizations for their activities in the DPPM effort. • Drug and laboratory service for Program Rujuk Balik (PRB): Reimbursement for drugs and laboratory tests Indonesia is early in its DPPM implementation process, for chronic diseases (e.g. diabetes, hypertension, with varying degrees of progress in establishing the asthma); this program applies to a limited number fundamental DPPM components by district. For example, of standalone labs and standalone pharmacies. The access to government-funded FDC varies across districts.
17 In Medan and Makassar, less than 10% of the multi- however, general awareness of DPPM varies greatly provider private primary care clinics (described as “clinics” and is lower among other stakeholders (e.g. GPs, labs, in this review) have participated in DPPM and have access and pharmacies). Expansion of these meetings to other to government-funded FDCs to treat TB patients, while stakeholders will require funding – a key challenge for 40% of clinics in Kabupaten Tangerang already have access DPPM implementation. For example, one DHO did not to government-funded FDCs. The varying degrees of have funding specifically allocated to DOTS training and DPPM progress across districts is also evident in the case therefore had to wait for PHO-organized trainings, which reporting contribution of private sector as percentage of had a limited quota. Kabupaten Tangerang, for example, total TB notifications in the district (Kab. Tangerang 56%, only received four slots for the training annually, despite Medan 41%, Makassar 5%, and Kota Tangerang 0%) and needing ten. While facilities could pay to secure additional the proportion of private hospitals with a DOTS corner slots, they usually are not motivated to do so because (North Jakarta 71%, Tulungagung 55%, Kota Tangerang there are no financial incentives to participate in DPPM. 31%, Makassar 9%).24 In addition, differences in the state of GeneXpert referral network development can be 2.1.5 Role of Challenge TB in DPPM seen across districts. In Tulungagung, GeneXpert sites implementation can accommodate referrals from all facilities in-district and from neighboring districts such as Kediri, Blitar and As expected, districts with direct support from Trenggalek. In Kota Tangerang, GeneXpert sites currently Challenge TB are further along in DPPM implementation. do not accept referrals from other facilities as MoUs Examples of Challenge TB staff participation in DPPM between facilities (and thus a culture of collaboration) implementation activities are wide-ranging and include have not been established. As a result, people being Challenge TB coordination of (and often funding for) evaluated for MDR-TB are required to register as patients workshops with providers and socialization meetings at of the GeneXpert facility before getting access to the the district level with the DHO, the DPPM team, and GeneXpert machine. Puskesmas.
The extent to which a DHO fulfills its DPPM activities Challenge TB has helped DHOs set up the DPPM and also varies across districts. One fundamental area is the GeneXpert referral network, and develop District Action mapping and identification of care providers and CSOs Plans (RAD is the acronym in Bahasa Indonesia), which around Puskesmas, including baseline data such as the helps districts create a more systematic plan for DPPM number of TB cases. Although some districts are making and other TB approaches and, in some cases, results progress (the wasor in Kabupaten Tangerang, for example, in additional TB funding from the district’s provincial completed the district’s mapping in August 2018), development budget (APBD). Three Challenge TB mapping has not yet been completed in many districts. districts interviewed had completed their 2017-2021 Until each DHO can complete this important initiative, RAD, while RAD in all non-Challenge TB districts was it will be challenging to be able to target and measure still in process, according to interviews with the DHOs. efforts. Through RAD, the Tulungagung DHO reportedly secured IDR 1 billion in 2018 in funding from APBD for TB control DHOs are progressing in their stakeholder outreach, efforts, a significant increase from the district’s previous engagement, and training activities, but to varying degrees. budget of ~IDR 100 million in 2017. Although the actual Interviewees report that the engagement of professional allocation for DPPM activities is not specified within this organizations in DPPM efforts is not yet systematic. increased budget, the DPPM strategy was taken into For example, PDPI was engaged by DHOs at times to account during the RAD process. support trainings or provide public awareness campaigns, while participation of other associations relevant to TB Such examples of how additional support and resources were largely absent. The USAID-supported Challenge have been pivotal to DPPM implementation will be TB project has provided seed grants for associations in important to consider when determining how to continue several districts to participate in DPPM, but the ability and accelerate DPPM rollout. to transition these grants to sustainable district-based financing is unclear. 2.2 Typologies of private sector In Challenge TB districts, DPPM socialization meetings health providers and trainings for the private sector are being conducted using a staged approach, with hospitals and clinics This review identified 11 typologies of key district-level targeted first – a logical starting point as these facilities health providers critical for delivering and improving TB see a higher concentration of TB patients. As a result, care in the private sector (see Figure 2 for summary list).
18 Figure 2: Typologies of key district-level health providers
INDIVIDUAL PRIVATE CLINICS / HOSPITALS / PHARMACIES LABS PRACTITIONERS PRIMARY CARE SECONDARY CARE
#1: Standalone General #3: Non-BPJS-K #5: BPJS-K hospitals and #7: Program Rujuk Balik #10: Medium-to-large Practitioners (GPs) pratama multi-GP clinics BPJS-K utama clinics (PRB) Pharmacies labs
#2: Standalone #4: BPJS-K pratama #6: Non-BPJS-K #8: Medium-to-large #11: Small-to-medium pulmonologists clinics hospitals and non- pharmacy chains labs BPJS-K utama clinics #9: Standalone pharmacies
Not included in interview set for review; reference typology only
Each of these typologies is defined by characteristics that The majority of standalone GPs (~90%) are not inform the institutions’ incentives and behaviors and shape empaneled in the BPJS-K program (assuming ~5,00025 how they provide care. These characteristics include of GPs are BPJS-K empaneled out of at least 55,000 business practice drivers (such as ownership type, size, GPs26 overall in Indonesia). It is expected that BPJS-K target customers, infrastructure), engagement in BPJS-K and standalone GPs will behave similarly to BPJS-K pratama DPPM, the nature of relationships with other institutions, clinics (Typology #4) as they are both operating and TB capacity and quality. Not all characteristics are under the capitation model. One key difference is that relevant to each typology; only those that are most BPJS-K standalone GPs currently do not have access to distinctive for a given typology will be highlighted. government-funded FDC drugs as doctors are prohibited from dispensing drugs without the presence of a While all typologies were present in the districts pharmacist. interviewed in this review, the proportions differed by district. Less prominent in the findings and This review deprioritized potential interventions involving recommendations in this review were the standalone GPs standalone GPs since standalone GPs generally refer (Typology #1), and standalone pulmonologists (Typology patients for diagnostic tests, including for TB, to private #2), since this reviews focuses on institutions rather than labs with whom they have an established referral individual providers. In addition, there were fewer non- relationship, with patients paying out-of-pocket (OOP). BPJS-K clinics (Typology #3) and non-BPJS-K secondary This typology also generally does not have an in-house care (Typology #6), as there was either a limited number pharmacy or referral relationships with pharmacies of providers/institutions in the focus districts or they serve and thus patients typically purchase drugs OOP at the a very specific and limited segment of the market that is pharmacies most convenient to them. willing to pay out-of-pocket (OOP). Increased JKN penetration may encourage standalone Individual Private Practitioners GPs to empanel in group rather than individual practices under BPJS-K due to the higher capitation rate for the (Note: Not included in interview set for this review; reference latter (IDR 8,000 per member for individual practices; typology only) IDR 9,000 per member for group practices without dentists or IDR 10,000 per member for practices with Typology #1: Standalone General Practitioners (GPs) dentists). However, it will likely take a while for BPJS-K empanelment to reach a significant proportion of this This review defined individual GPs as medical doctors group of practitioners. who practice individually in clinics without the presence of other medical doctors. Our findings on private GPs were Typology #2: Standalone pulmonologists solely based on interviews with health institutions and CSOs, as private GPs were not part of the interview set Note: This review included only a limited number of interviews for this review. with standalone pulmonologists
19 Most pulmonologists in bigger cities seemed to practice Based on a limited sample, this review observed that exclusively in secondary care as their work typically non-BPJS-K clinics generally referred patients to labs requires advanced facilities available only in secondary (standalone) and pharmacies (in-house and standalone), care. In more rural districts (e.g. Tulungagung), with patients paying OOP for ancillary services. The pulmonologists also practice as standalone physicians. limited sample of non-BPJS-K clinics reported that they do not have referral agreements with standalone labs and do Specialists in individual practices have similar institutional not get compensation from labs. Patients of this typology and referral relationships to those of standalone GPs are not referred or directed to specific labs, but instead (including referring patients to private labs for diagnostic are free to choose whichever labs are most convenient to tests) because they are not empaneled in BPJS-K (i.e., them. patients pay OOP). In contrast with standalone GPs, all standalone pulmonologists in the interview set have an Typology #4: BPJS-K pratama clinics in-house pharmacy where they stock mostly branded TB drugs, both loose and FDC, and refer patients to the in- BPJS-K pratama clinics comprised the majority of the house pharmacy to purchase their drugs OOP. clinic interview set for this review. While these clinics are more likely to participate in DPPM, participation is still This review deprioritized identifying interventions oriented low. to standalone pulmonologists as there was a limited number of this typology in districts interviewed. In contrast to non-BPJS-K pratama clinics, this typology typically refer presumptive TB to hospitals or Puskesmas Clinics/Primary Care units for TB diagnostics as they are aware that the cost is covered by BPJS-K (in hospitals) or the Puskesmas Clinics are divided into two classes: pratama and utama. units’ operating budget. This is in part driven by the fact For JKN, pratama clinics are paid under the capitation that BPJS-K clinics do not want to pay private labs out model while utama clinics are paid under INA-CBGs, of their own capitation (and typically lack the financial similar to hospitals. Given this similarity, this review arrangements to do so efficiently), nor will they ask groups utama clinics in the secondary care category patients to pay OOP as they are prohibited from doing with hospitals, and only discusses pratama clinics in this so. A limited number of the BPJS-K pratama clinics have section. access to government-funded FDCs or treat their TB patients directly, but the majority of patients stay at The business structure of pratama clinics requires the Puskesmas units or hospitals depending on where they employment of at least two GPs and/or dentists while were diagnosed. Access to government-funded FDCs is utama clinics need to employ at least one specialist from particularly important given that clinics typically refuse to each type of specialized services provided (though there stock private TB drugs out of their capitation since it is a are no specific/defined type of specialties required to significant cost for clinics (i.e., multiple drugs taken for a be designated as an utama clinic). Clinics can either be long period of time). owned by an individual (doctor or non-doctor) or by a business entity. Clinics owned by business entities are Hospitals/Secondary Care typically larger or have several branches. This review categorizes primary care clinics into two typologies, with Hospitals are classified by the Government of Indonesia BPJS-K empanelment as the key distinction that influences into four key classes: A, B, C, D (Class A hospitals being their behavior. the biggest, and Class D hospitals being the smallest). This review focused on Class B and C private hospitals as Class Typology #3: Non-BPJS-K pratama multi-GP clinics A are usually public hospitals and there are very few Class D hospitals in the focus districts. Note: This review included a limited number of interviews with non-BPJS-K clinics (four out of 36 clinics overall) as Utama clinics are also included in this hospital/secondary BPJS-K clinics are more likely than non-BPJS-K clinics to have care category because this review expects similar behavior developed relationships with DHO and are more readily from them as with hospitals. Only a few utama clinics available for interviews. were interviewed (2 out of 36 clinics overall), as there is a limited number of this typology in the focus districts All of the non-BPJS-K pratama clinics interviewed in this – district interviews indicated much smaller number of review do not participate in DPPM and are less likely to utama clinics vs. pratama clinics (e.g., ~30 utama clinics report TB cases to the public sector, an activity which is vs. ~340 pratama clinics in North Jakarta). As a result, this part of the DPPM arrangement. review did not include this set as a major focus.
20 Similar to primary care clinics, BPJS-K empanelment is a a DOTS corner to satisfy accreditation requirements. key distinction that influences the behavior of hospitals. However they usually only focus on the care delivery aspect, such as ensuring sufficient infrastructure and Typology #5: BPJS-K hospitals and BPJS-K utama a standardized regimen, but not on DPPM-oriented clinics activities, such as notifying the public sector or providing government-funded FDCs. The choice of secondary care institutions to be empaneled in BPJS-K is usually driven by their market strategy, with This review deprioritized identifying interventions institutions prioritizing empanelment if they are targeting oriented to non-BPJS-K secondary care level as they a broad spectrum of customers that includes the lower serve a more specific and limited market segment willing socioeconomic status segment. Only 10% of all BPJS-K to pay OOP. empaneled private clinics are utama clinics, while ~90% of the BPJS-K empaneled clinics are pratama clinics27. Faith- Pharmacies based institutions and institutions with a social mission are also reported to be more likely to empanel in BPJS-K. Note: This review excluded drugstores and community pharmacies as they are not allowed to sell prescription drugs. An MoH guideline requires secondary care facilities to have a basic in-house laboratory. Although the guideline Like clinics and hospitals, pharmacies are also classified does not require hospitals to have sputum smear test based on level of service or capability. According to capability, 33 of 35 (94%) of interviewed BPJS-K hospitals Government of Indonesia (GoI) regulation no. 51 year are capable of running sputum smear tests in-house; 2009, there are six type of pharmaceutical service facilities: in addition, those facilities with pulmonary or internist drugstores, pharmacies outside of curative facilities29, departments have chest x-ray capability. Secondary care hospital pharmacies30, clinics31, puskesmas units32, and institutions typically run TB diagnostics in-house and use pharmacists group practices. Except for drugstores, which standalone labs to run diagnostics for lower volume, can sell only OTC drugs, other types of facilities need at generally more advanced, tests. least a licensed pharmacist and can sell both OTC and prescription drugs. However, pharmacists are allowed to BPJS-K hospitals are more likely to participate in the DPPM work in (up to) three different facilities33, and there are no program and establish a DOTS corner within the institution regulations requiring the fulltime presence of a licensed to help accumulate enough points for accreditation28 – a pharmacist during a facility’s operating hours. Thus, there prerequisite for BPJS-K empanelment. BPJS-K hospitals that are periods where the pharmacies are being supervised by have a DOTS corner and that satisfy other prerequisites, personnel without a pharmacy license – the review team such as being linked to DHO, have access to government- observed this practice during the interviews (however, this funded FDCs; those who do not have such access either was not the case where the pharmacy was owned and treat patients with non-government-funded drugs procured operated by a pharmacist). by the hospital as part of the INA-CBG package, or down- refer patients to primary care. The typologies of pharmacies in this review (typology #7, #8, and #9) focus on pharmacies that operate outside Typology #6: Non-BPJS-K hospitals and non-BPJS-K of curative facilities. Pharmacies that are contained within utama clinics private facilities with curative services are covered within those curative providers’ typologies. Note: This review included a limited number of interviews with non-BPJS-K hospitals and non-BPJS-K utama clinics Pharmacies dispense medications, ensure the safety and appropriateness of the prescribed therapy, and may According to the DHOs and all of the interviewed sell over-the-counter (OTC) drugs. The proportion of non-BPJS-K secondary care institutions, these secondary prescription vs. OTC drugs stocked for both chain and care institutions typically target more affluent customers standalone pharmacies is primarily driven by the prevalence who are willing to pay OOP for services. As a result, this of GPs and clinics (without in-house pharmacies) within the typology does not rely on – and may even avoid – BPJS-K pharmacies’ catchment area. The primary characteristics of empanelment as they want to maintain a perception of this typology are size and PRB empanelment. exclusivity. Typology #7: Program Rujuk Balik (PRB) pharmacies These hospitals are likely to have the highest accreditation (“Paripurna”) to boost credibility and to attract more BPJS-K Program Rujuk Balik (PRB) pharmacies provide affluent customers. Therefore, they are likely to establish drugs for patients with specified chronic conditions who
21 are down-referred by hospitals under the PRB program. (sometimes a pharmacist) and have local presence only The drugs are reimbursed by BPJS-K according to BPJS-K (i.e., no branches). e-catalogue34 pricing with an additional mark-up for services. TB is not considered a chronic condition and is In contrast to medium to large pharmacy chains, not currently included in this program. standalone pharmacies are likely to have more challenges in (and fewer incentives for) maintaining quality standards. Quality standards for PRB pharmacies are likely higher, as They are less likely than larger pharmacies to have systems this is an important aspect of the accreditation required for monitoring inventory and may face higher likelihood of for PRB participation. Pharmacies are evaluated using stock-outs. They tend to have looser hiring requirements metrics such as the attendance level of the pharmacists (e.g., they can employ vocational high school graduates and quality control standard applied by the facilities. with only on-the-job training).
Only 15 of the 55 private pharmacies reviewed in Additional note on pharmacies this review were empaneled in the PRB program, as only ~104 of the ~3,130 pharmacies across the seven It is worth mentioning the role of “wholesale” pharmacies districts were PRB (8%), and roughly half of those ~104 in the health care system, as these pharmacies may PRB pharmacies are under the state-owned pharmacy, provide private GPs, nurses, and midwives retail access Kimia Farma. No national data on the number of PRB to TB drugs, enabling these practitioners to “unlawfully” pharmacies was available. dispense and treat TB patients. Wholesale pharmacies are not included in this review as a primary typology, as these Typology #8: Medium -to -large pharmacy chains institutions do not directly interact with TB-symptomatic clients. This typology includes pharmacies with regional or national branches, including franchise pharmacies. Apotek K-24 was Labs the only pharmacy chain included in this review’s interview set. Of the ~27,00035 pharmacies in Indonesia (including Labs are divided into three classes: pratama, madya, pharmacies in hospitals), Apotek K-24 has ~400 outlets and utama (utama being the biggest or having the most (1.5% of total pharmacies). Other fully private pharmacy comprehensive offerings, pratama being the smallest or chains include Apotek Century Pharma with ~300 outlets having the most limited offerings). This review provides (~1% of total), but they are typically located inside malls. two lab typologies based on size and reach, as these Kimia Farma36 has one of the biggest networks with characteristics are the most important in defining lab more than 1,000 outlets (~4%) in Indonesia, but they are behavior. government-associated businesses and thus are not included in this review set (please note the caveat in the footnote). Typology #10: Medium to large lab chains
These medium to large pharmacy chains are more likely Medium to large lab chains are characterized by regional to have higher quality standards compared with smaller or national presence via branches, and typically cater to chains. They are generally more established and more affluent, higher socioeconomic status customers who likely to have resources for preventing stock-outs, such pay OOP for diagnostics. These labs usually offer more as computerized systems to monitor drug stock across comprehensive test offerings than smaller and medium branches and patient purchase history. They also tend to labs and are thus usually categorized as utama or madya be more professionally staffed – such as requiring all staff labs. to have a pharmaceutical background – which may lead to higher quality assurance. Compared with smaller labs, this typology has higher revenue contributions from hospitals (e.g. from test Some of these pharmacies have mutual relationships with outsourcing) and the corporate sector (e.g. medical GPs, such as providing space within the pharmacies for check-ups), in addition to referrals from standalone GPs. GPs or specialists to practice with hopes of capturing Given their customer segment, and as a way to remain prescriptions from these providers. They are also more competitive, larger labs are more incentivized to perform likely to have financial resources to market to nearby GPs rigorous internal and external quality assurance schemes, to build relationships. which sometimes include international quality assurance. As a result of higher quality standards, this typology is Typology #9: Standalone pharmacies more likely to be designated for the BPJS-K fee-for- service Prolanis program37, which provides reimbursement Standalone pharmacies are typically owned by individuals to specific labs to run diagnostic tests for designated
22 chronic conditions (e.g., hypertension and diabetes). biggest fully private pharmacy chain, Apotek K-24, In this program, each district appoints private labs to increased the number of outlets from 337 in 2014 to 400 run diagnoses for chronic diseases (referred to as “PRB in 2018 (4.4% compound annual growth rate/CAGR). In labs” in this document); the number of labs involved is the laboratory clinical testing industry, Prodia, the largest unknown, but they are typically regional or nationwide chain lab in Indonesia, also increased its number of outlets chains that have participated in a quality assurance from 251 in 2015 to 283 in 2018, representing ~4.1% program. In addition, larger chains are also more likely to CAGR. Siloam hospitals, one of the largest hospital chains have international partnerships to expand test offerings, in Indonesia, increased its number of hospitals by ~16% although serving a very specific and limited segment of the (in CAGR terms) from 20 in 2015 to 31 in 2018. market.
Typology #11: Small -to -medium standalone labs 2.3 State of play by district
This typology usually includes local standalone labs There are several key characteristics that illustrate the with no branches, where the majority of revenue is current state of play in each of the districts in the review. predominantly from referrals from standalone GPs or These include demographic and socioeconomic factors, specialists. These labs usually have more limited/basic level of TB case reporting, state of DPPM implementation, testing capabilities compared with medium to large labs private and public sector TB capacity, state of BPJS-K (e.g., tests referred from GPs are usually simple tests empanelment, and CSO presence. Table 1 captures such as blood tests) and are thus typically categorized current data for each district. as pratama labs. If these labs accommodate more complicated tests, they will usually outsource to bigger As the state of DPPM implementation and BPJS-K labs and act as a sample collector. Smaller labs are empanelment in the districts are particularly struggling since patients are more aware of the BPJS-K important context for understanding the findings and scheme and seek “free” diagnosis at clinics. Two labs recommendations of this review, a deeper dive on each in North Jakarta mentioned that they were considering of these topics is provided in the next section. Highlights integrating with clinics to survive the changing market of the variation between Challenge TB and non-Challenge dynamics. TB districts – as delineated in Table 1 – is also discussed.
As business is typically from standalone GPs or specialists As a whole, the districts in the review cover 6% of the who seek less demanding proof of quality compared with national population but some other coverage indicators corporations or hospitals, these labs are less incentivized are much higher. For example, these districts include to perform rigorous internal and external quality 16% of private hospitals that participate in BPJS-K and assessments. As a result, this typology is less likely to be more than 25% of total outpatients in all private hospitals appointed for the BPJS-K Prolanis program. nationally. In terms of TB notification, the districts in review only include 8% of total notified TB cases, but they Summary capture 19% of total private notification and close to 30% of notification by private clinics.38 However, both the TB In general, the larger facility typologies (hospitals, labs, treatment coverage (number of notified TB/number of pharmacies) have more quality control and are more estimated TB) and the percentage of private notification linked to government financing and government programs. across the districts in review vary substantially (26-82%, There is also an indication that the larger facilities and and 0%-56%, respectively). chains are on the increase. For example, one of the
23 Table 1: State of Play for focus districts
Challenge TB Districts Non-Challenge TB Districts
North Kab. Kota Medan Tulungagung Makassar Surabaya Jakarta Tangerang Tangerang
Population (in thousands) (‘15) 1,747 2,211 1,021 3,371 2,047 1,449 2,849
Size (km2) (various years) 147 265 1,056 1,012 154 176 351 District demographics % Rural Population (‘10) 0% 0% 54% 18% 0% 1% 0%
Avg. HH expenditure (in mn IDR) (‘15) 7.8 4.6 2.7 4.2 5.4 4.9 6.6
Reported TB cases (‘17) 4,897 8,224 1,043 7,900 1,829 4,926 6,601 TB Notification Rate per 100k Population 280 372 102 234 89 340 232 ('17) TB treatment coverage (# of 76% 58% 32% 66% 26% 82% 66% (4,897/ (8,224/ (1,043/ (7,900/ (1,829/ (4,926/ (6,601/ TB statistics notified TB/# of estimated TB) (‘17) 6,471) 14,141) 3,242) 12,000) 7,000) 6,040) 9,953) % report from private (‘17) 33% 41% 23% 56% 0% 5% 20%
% case reporting No case 95% 63% contribution from Data not 64% reporting 100% Data not (1,548/ (2,750/ private hospitals vs available (154/241) from private (222/222) available 1,624) 4,400) private clinics sector
Private Hospital with 70% 40% 45% 66% 31% 8% 49% DOTS corner (12 /17) (29 / 72) (5 / 11) (15 / 25) (8 /26) (3 / 34) (23 /47) GPs can ~40% of None as 5 clinics None; clinic ~7% of ~5% of access private DHO’s have access State of PPM Clinics with access PPM effort private clinics private government- clinics have PPM focus to FDCs, all to government- only started have access to clinics have funded FDCs access to is currently other clinics funded FDCs in H2 of government- access to through WiFi- government- only can refer to 2018 funded FDCs FDCs TB39 funded FDCs hospitals PKM One in a One in a One in a One in a faith-based large chain large chain faith-based GeneXpert in private sector hospital None None None hospital (RS hospital (RS hospital (RS (RSIJ Siloam) Awal Bros) Ibnu Sina) Sukapura) Puskesmas40 with ~18% of ~85% of 100% of 100% of 100% of sputum smear 58% of PKMs 100% PKMs microscopy PKMs PKMs PKMs PKMs PKMs Public sector capacity and DHO resources capability Ratio of wasor 2 : 442 4 : 214 1 : 69 1 : 362 1 : 229 1 : 200 2 : 337 number: (24+49+ (85+39+ (13+32+ (28+34+ (29+32+ (50+46+ (67+63+ HP+PKM+Clinic 369) 9041) 24) 300) 168) 104) 207) facility numbers
Private hospitals in the district 70% 53% 73% 64% 96% 59% 51% contracted by JKN (12 / 17) (38 / 72) (8 / 11) (16 / 25) (25 / 26) (20 / 34) (24 / 47)
All Several assoc. Several associations lack All All All Presence of Professional associations lack presence presence (ILKI, ARSSI) and associations associations associations associations have (PDPI, ILKI, some share same staff have have have presence presence IDAI, PAPDI) members (IDI, IAI, PATELI) presence presence
24 3. Findings: Implications of current market and policy incentives for future private provider engagement
nterviews with private sector institutions as well as NTP, This inefficiency of care is consistent with what was DHO officials, and CSOs focused on understanding four observed in the individual provider/patient review, aspects of the health system: where a number of patients (64% of 204 interviewed I patients) mentioned that they visited multiple providers • Institutional relationships and referrals before finally getting a TB diagnosis. In addition, in this institutional review, none of the standalone pharmacies • The business landscape, including incentives and or standalone labs interviewed had formal, exclusive barriers relationships with primary care or secondary care facilities for patient referrals, leaving patients to seek treatment • The role of DHO and implementation of DPPM from health providers of their own choice, when and if they were motivated to do so. While this review does • The role of non-public stakeholders not include specific recommendations about treatment- seeking behavior, given the institutional focus, we believe The following section discusses the key insights for each that efforts to increase awareness and reduce stigma – aspect, as well as the implications for improving the quality per findings from the individual provider/patient review – of TB care. are a critical part of the answer and should be considered in further solution development. 3.1 Institutional relationships and referrals “We never recommend, suggest, or direct our customers to specific doctors or The private sector health system in Indonesia remains highly informal and fragmented. Based on 2016 facilities – it is solely patients’ discretion. data from the Ministry of Health, the top 15 private We won’t know if they actually seek hospital organizations in the country only accounted proper care afterwards” for ~10% of total private sector beds42; the biggest player only accounted for ~2% of total private beds. — Medium-to-large regional lab chain, Private institutions largely operate as isolated entities Medan with limited networks of peer facilities or referral relationships. The following section describes the current state of relationships and referrals which, compounded by the lack of incentives to provide The fragmentation and absence of established integrated or coordinated care, often results in patients relationships in the private health care system is driven seeking and receiving treatment inefficiently and in part by the lack of a culture of – and mechanisms for ineffectively. – information sharing among health facilities. Currently,
25 handover of TB patients is intended to be done manually via hard copy public sector TB forms (TB-04 and TB-09), “When we send our patients to other a process which is unreliable, as patients may move to a different facility without notifying their current facility. institutions, we usually don’t get responses As a result, physicians (both standalone and working in or feedback from the receiving institutions. institutions) may have to reorder tests already performed Maybe because the information gets elsewhere or restart their patient’s treatment regimen due to lack of information. buried as there are a lot of unimportant information in the WhatsApp group; there is no quality control to maintain what can “A few patients of mine who were once or cannot be discussed in the groups.” treated using government-funded FDCs in — BPJS-K Class C hospital, Medan Puskesmas and potentially other private providers, restarted their treatment regimen with me.” The WiFi-TB version two pilot rollout may offer helpful — Senior pulmonologist, Makassar technology for these issues. Clinics and GPs in select Challenge TB districts involved in the pilot have already starting using the tool to access public sector FDC drugs. Although the app has not fully replaced manual Increasing DPPM penetration may provide a new avenue documentation in the pilot phase, version two enables for communication and information sharing between recording of presumptive TB test results, reminds doctors participating facilities (public and private) and the DHO. to update patients’ lab results in the database to ensure This trend was observed largely through institutions monitoring of clinical progress and treatment outcomes, using informal WhatsApp groups to track the movement allows clinics to notify Puskesmas or the DHO of TB of referred patients, monitor reporting adherence, diagnosis and treatment outcomes, and allows automatic and facilitate treatment adherence. However, there is SMS/email appointment reminders to be sent to patients a mixed response on the effectiveness of WhatsApp and facilities. In addition, Wi-Fi TB has also simplified groups. According to interviewed hospitals and DHOs, reporting by reducing the number of fields compared the WhatsApp groups are an effective tool for reminding with the manual public sector TB form. Version two of private providers to submit TB reporting forms or to WiFi-TB, however, does not allow clinics to request labs fix incomplete documents, but hospitals and clinics to conduct a TB test, nor does it allow labs to return do not think it’s an effective tool for transfering health results to clinics or notify Puskesmas or the DHO of information between facilities. Hospitals and clinics positive test results. It is important to note that WiFi-TB mentioned that information in WhatsApp groups tends has received mixed reviews. While GPs who leverage to get overlooked, possibly inadvertently, due to the nurses for WiFi TB data entry regard the tool positively, flurry of exchanges and information – some of which those whose use the application themselves report are random and irrelevant (e.g., daily news) — and that spending time and effort on the app that could be spent may bury important information. This issue is magnified on patient care. Further exploration and evaluation may if the WhatsApp Group get too big. Moreover, hospitals be needed to fully realize the potential for effective and may not receive feedback from the institutions they are efficient data flow. sending their patients to.
“Our clinic has been using the application “DHO constantly reminds hospitals who since the version 1 pilot (letting nurses to forget to submit TB06 forms and request handle the data entry) and I think it’s a those who submit incomplete documents great tool. However, I think the second to fix them through the WhatsApp group.” version of WiFi TB seems to be much — BPJS-K Class C hospital, Kota slower vs. the first” Tangerang — BPJS-K pratama clinic, Tulungagung
26 There are some examples of relationships or more formal 1). Help bridge the potential tension between clinic and networks that have the potential to directly influence the Puskesmas over capitation (further discussed in the patient pathway and shape treatment outcomes. These next section) relationships, found in larger districts such as North Jakarta, Medan, and Makassar, include: 2). Allow individual providers to respond more quickly to potential loss-to-follow-up patients 1). Vertically integrated hospitals and clinics, including Siloam, RSU Delima, in North Jakarta and Medan 3). Create potential champions for the DPPM effort in the private sector 2). Pharmacies acting as buffer stock for nearby hospitals, such as Apotek SanaFarma in Makassar
3). Sample collection centers at doctors’ offices, such as “We refer our patients to the nearest Prodia deploying phlebotomists inside participating Puskesmas, which happens to be my own, doctors’ offices (more common in DKI Jakarta). because the Puskesmas has a network for In addition, transportation networks for lab samples patient monitoring which can respond supported by the public sector are developing, but are faster in case patients drop out.” limited to the transport of sputum to public or private GeneXpert machines, with no sustainable funding stream — Pratama clinic, Tulungagung. beyond the current SITRUST program funded by the Global Fund. The program currently supports sample specimen transportation in 50 districts, increasing to 86 districts this year. 3.2 Overall business landscape, This review also observed several non-TB-specific including incentives and barriers to examples of relatively widespread, formalized relationships quality care involving private labs and pharmacies. Labs provide institutional providers (clinics, hospitals) with non- The review team found that TB contributes less than 5% exclusive discounts for outsourced tests or compensation of revenue/patients for private health care institutions for referrals. Hospitals, in particular, typically outsource (except clinics with pulmonologists). TB is also costly more uncommon (usually lower volume, more to treat given the multi-step diagnostic process and sophisticated) tests to labs (generally larger labs with the lengthy treatment, putting pressure on clinics that advanced capability). Smaller labs, which tend not to have are relying primarily on fixed capitation payments from sputum test capability in-house, may have agreements BPJS-K. The challenging economics associated with to send samples to larger labs, eliminating the need for TB are compounded by the rapid expansion of the patients to travel between facilities. Larger national labs, national health insurance program, which has had a like Prodia and Pramita, have created a commercial profound impact on hospitals, clinics, and pharmacies. network through agreements with third party logistics These business dynamics – and the resulting behaviors, companies to transport sample specimens via ground incentives, and barriers – will be examined in the following or air shipment between their hub and spoke facilities. section, first for hospitals and clinics, then for pharmacies, Additionally, each of their branches typically has in-house and finally with labs. messengers or couriers to pick up samples from or deliver samples to hospitals or clinics within a 5 to 10km Finding 3.2a: Profit pressure from the catchment area. Select pharmacies also provide space BPJS-K system, in addition to incentives in onsite to GPs or specialists to practice, hoping to capture the private sector, lead to up-referral of the presciptions from these providers. uncomplicated TB patients to secondary There are also examples of informal relationships care for diagnosis and treatment between the public and private sectors. In smaller districts (Tulungagung), where the cross-pollination of staff For the hospitals and clinics reviewed, the BPJS-K scheme between public (Puskesmas) and private sector (clinics) has led to higher-volume, lower-margin practices, with was greatest among districts visited, informal relationships overall higher total profits. But profit pressure is still across sectors may be more easily facilitated. These prevalent and growing. Since the inception of JKN, informal relationships may: capitation rates received by clinics have not increased
27 despite increasing operational costs driven by ~3- cumulative effect showing clinics are losing other kinds of 4% inflation and increasing labor costs. There are patients (i.e., non-TB patients) to Puskesmas. also specific pressures for institutions associated with treating TB. For example, the estimated cost for a typical Type C BPJS-K hospital to run diagnostics tests for TB “We have in-house sputum microscopic outpatients is estimated to be 20-25% higher43 than the test, but we always send presumptive TB BPJS-K reimbursement rate (using the general outpatient consultation Q-code described below). Similarly, clinics to Puskesmas or hospitals, where the that are paid based on capitation have limited incentives diagnostic cost is covered by government.” to treat TB patients who require more intensive care. — Deputy Director, BPJS-K pratama clinic, Medan “From 2014-2018, there is inflation each year, and also increases in wage for staff, but there is no equivalent increase of “Each capitation matters – we’ve gone to BPJS-K capitation rate.” any length to find patients for this clinic. So — Pratama clinic, Kabupaten Tangerang I don’t want to lose any, even though only for six months.” — BPJS-K pratama chain clinic, Kota The stated aim of BPJS-K is to diagnose and treat Tangerang uncomplicated TB at the primary care level, but this aim is challenged by TB economics and the need to optimize profits, plus the relatively lower TB diagnostic capacity at the private primary care level, in terms of both instrument Based on multiple interviews with hospitals, DHOs, availability and diagnostic confidence of providers (see and clinics across districts, hospitals accept referrals for the individual patient/provider report). Therefore, uncomplicated TB patients and have limited incentive to hospitals and clinics are responding with behaviors that down-refer after diagnosis since they are able to receive have a significant cumulative effect in driving patients per-visit reimbursement, even though the intention of to secondary care for diagnosis and treatment. Hospital the BPJS-K is reimbursement per episode. As a result, incentives, along with patient preferences and clinics’ lack hospitals use subsequent TB patient visits to make up for of desire to treat TB patients, result in patients staying losses incurred on the initial diagnostic visit. Interviews with hospitals for treatment. These findings are consistent with clinics across districts also revealed that clinics avoid with those of the individual private provider/patient treating patients requiring more intensive care and/or review44, where significantly more patients completed multiple visits if they don’t have a designated chronic treatment in private sector secondary care (80% of condition that comes with BPJS-K “top up” and instead patients interviewed) as compared with those who started refer these patients back to secondary care. Non- seeking treatment in private sector secondary care (24% DPPM clinics without government-funded FDCs are of patients interviewed). not willing to pay for a long course of TB drugs out of capitation. Interviewed clinics across districts reported The behavior of clinics is driven in part by an unwillingness that hospitals are also not incentivized to down-refer to pay private labs out of capitation and a preference for patients with other chronic diseases, such as diabetes or refering presumptive TB to Puskesmas units or hospitals hypertension, presumably so that hospitals could get more for “free” diagnosis instead45. But clinics end up referring reimbursement from multiple patient visits. more patients to hospitals than Puskesmas units due to tensions with Puskesmas over capitation. Puskesmas don’t In response, DHOs are imposing different solutions by want to diagnose and treat patients without capitation district, including asking clinics to move their capitation being transferred over, while clinics are fighting to keep to a Puskesmas during the TB treatment period of capitation of the patient and their family. The motivation six months (Makassar) or asking the Puskesmas to for clinics to keep capitation seems to be largely driven assist clinics without capitation transfer (Medan). In by principle and not a real bottom-line impact associated Tulungagung, none of the interviewed clinics reported any with presumptive TB alone, given that TB patients are resistance from Puskesmas to run TB diagnostic tests or relatively low-volume and there doesn’t seem to be a treat TB patients from private clinics.
28 “My patients (whom I already referred to hospital) came back to the clinic and said “The Puskesmas complained about having that he was being asked obtain another to diagnose and treat clinic-based patients referral from the clinic only to go to without getting anything in return. We another department in the hospital, requested clinics to transfer their possibly because the hospital wants to get capitation over for the duration of an extra reimbursement.” treatment.” — Pratama clinic in Tulungagung — DHO, Makassar
Finding 3.2b: Regulations to curb unnecessary up-referrals and over- While institutional examples vary from district to district, hospitalization and maintain quality of care it is important to consider patient preference as an additional driver for patient diagnosis and treatment in exist, but to date have been ineffective or secondary care. In larger cities such as North Jakarta and not enforceable Medan, clinics feel encouraged to refer their patients to secondary care facilities due to patients’ strong preference As in many other countries, regulation is an important for hospitals. Patients in Tulungagung, however, do not but challenging tool to manage health systems.46 In seem biased toward secondary care over primary care. Indonesia, enforcement of official regulations and policies is difficult, and systems are not yet in place for consistent Hospitals and clinics are also responding to the incentives monitoring and compliance. Any enforcement effort created by the BPJS-K system in other ways, including: requires coordinated action across multiple stakeholders and therefore is rare and only occurs in the most egregious • Some clinics include a complication or other special cases. Consistent with the findings of the individual private conditions (e.g. diabetes, hypertension) in the referral provider/patient review47, regulation is not a sufficient letter for presumptive uncomplicated TB, allowing lever for driving behavior change in the private sector. In them to 1) refer patients to secondary care and 2) interviews for this review, hospitals across districts reported avoid paying for diagnostic cost out of capitation. that they still earned reimbursement for uncomplicated TB patients despite BPJS-K rules stipulating that uncomplicated • Some hospitals run tests sequentially so that they TB should not be reimbursable by secondary care – a clear can charge separately for both (e.g., TB tests on one illustration of the challenges associated with oversight and day, and HIV tests on the next day). enforcement in the Indonesian context.
• Many hospitals use Q-code (Q-05) “Consultation “There seems to be inconsistent result and other diagnosis” to claim multiple reimbursements for uncomplicated TB outpatients from BPJS-K auditors regarding on a per-visit basis. reimbursement for uncomplicated TB. Even for our hospital, sometimes it gets • Some hospitals require patients to return to primary care sites for another referral for reimbursed, sometimes it’s not, so we will conditions identified by another department in the try our luck every time.” hospital (unlike internal referrals between hospital departments, which do not generate revenue, — Type C hospital in one of the referrals from primary care can be claimed by the interviewed districts hospital as a new episode of care for another BPJS-K reimbursement). Regulations can be combined with financial consequences, • Some hospitals have up-referral agreements where but the current mechanism for this in Indonesia may be they pay clinics for every referral. ineffective for TB specifically. As noted earlier in this
29 review, clinics’ capitation payments are subject to departments to the DOTS corner; and lack of hospital adjustment to reflect performance targets, which include, management committment. In general, there is no among others, the proportion of nonspecialist up-referrals. standard procedure for knowledge handover when Clinic capitation is discounted when nonspecialist up- TB-trained staff leave the facility, and this affects case referrals are greater than 5%. However, this penalty is not reporting. Wasors also reported that the lack of reporting effective in preventing up-referrals for uncomplicated TB by physicians from other departments (e.g., pediatrics) patients as they typically constitute less than 1% of the to DOTS corner – compounded by low management total referral base for a given provider. engagement – may put the burden of TB data collection on one person in the DOTS corner who is likely already over capacity. For example, a nurse in Medan had to “Last month we sent approximately five personally visit each hospital department to collect TB presumptive TB to secondary care out of case finding records on top of other responsibilities such more than 2,000 referrals – the number is as attending the clinics and preparing administration documents for accreditation or other administrative so small that I don’t think it would have activities mandated by the hospital. Additionally, any impact on our capitation rate.” enforcement is limited as DHOs will only give verbal notice when institutions fail to deliver the completed — Clinic pratama, Kabupaten TB reporting forms properly, in part due to a belief that Tangerang accountability lies with the institutions.
There is also a regulatory framework for hospital “Our TB reporting is not yet centralized; I accreditation (conducted by the Hospital Accreditation Committee or “KARS”) intended to drive improvement will need to proactively go to each in quality of care, including in TB services. The motivation department, ask for each department’s TB of hospitals to have a DOTS corner – especially for those case findings, and input the data in SITT facilities aiming for the highest “Paripurna” status – is strongly linked to accreditation. myself.” — Nurse, Class C hospital, Medan
“We probably would not have a DOTS corner if they were not tied to hospital accreditation.” “When we train them on DOTS function and implementation, we make sure they — Class C, BPJS-K hospitals, Medan understand that all departments in hospital need to report TB cases to the DOTS corner. However, there seems to be However while hospital accreditation standards cover the lack of follow up of what we have already existence of a TB standard operating procedure as well as infrastructure and mandatory TB staff, they do not cover delivered in training.“ outcomes. The accreditation process is not very rigorous — DHO, Kab. Tangerang and, according to the 2017 JEMM report48, accreditation surveyors lack capacity both in quantity (impacting the ability to reach all hospitals) and in level of TB knowledge. As a result, hospitals can still pass DOTS accreditation Three out of 37 DOTS hospitals49 reviewed, reported even though they may not have the required supporting that they under-report TB cases and do not trace infrastructure (e.g., sputum corner) or may not properly loss-to-follow-up patients. However, interviews with report TB cases to DHO exhaustively. DHOs indicate a potentially higher proportion of under- performance. For example: The wasors interviewed report that there are multiple factors that contribute to improper DOTS • The Kab. Tangerang wasor noted that one hospital implementation (e.g., under-reporting): staff turnover; reported 100 TB patients (exclusively from the lack of active reporting from individual physicians and pulmonology department) out of the over 500 TB
30 patients identified based on the hospital’s overall days of income – or wait to get a slot in one of the medical records. Although such evaluation has not infrequent PHO-funded trainings. been done across all hospitals, the wasor believes that a similar magnitude of underreporting is likely Access to government FDCs in secondary care, however, occuring in other DOTS hospitals. may create perverse incentives for hospitals to further keep and treat uncomplicated TB patients as opposed • One hospital in Kota Tangerang reported that staff to down-referring to primary care. This is because don’t have enough time or resources to complete government-funded FDCs allow hospitals to treat patients the reporting or follow-up on their TB patients. at a lower cost, which in turn increases their margin. Yet allowing access to government FDCs in private hospitals is likely necessary in the short term due to the “Actually, the reporting is not difficult but I lack of government-funded FDC access in private clinics don’t always have the time to do it; and existing tensions between clinics and Puskesmas. Otherwise, patients might be referred between multiple sometimes I would leave out some primary care facilities in an attempt to access FDCs or information in the form. When I have to to complete a TB loose drugs regimen, risking a delayed submit the forms, I have to go back to the treatment or loss-to-follow-up. files to check but they are no longer to be For example, in Kota Tangerang many reviewed found.” pharmacies (five of eight) did not stock a complete TB regimen due to the difficulties of keeping a consistent — Nurses in hospital Kota Tangerang inventory of the numerous TB drugs, especially generics. According to reviewed pharmacies, this was probably driven by the tendency of drug distributors and BPJS-K Finding 3.2c: Existing incentives are e-catalogue to prioritize distribution of their limited insufficient to motivate desired behaviors stocks to government hospitals and bigger facilities for high quality TB care in the private with larger purchase orders. As a result, patients would usually be able to secure only part of their prescription sector, and, in some cases, might create in one pharmacy and then would need to search for the perverse incentives remaining drugs in other pharmacies, potentially causing delayed treatment and/or general inconvenience for the There are existing incentives provided by the public patients. sector to engage private providers in driving TB-related quality of care for both the primary level and secondary level. They include: 1) access to government-funded FDCs “We are put in a difficult situation for clinics and hospitals, allowing them to provide costly because we are not supposed to treat TB medications for “free,” and 2) subsidized GeneXpert uncomplicated TB patients. But at the placement in secondary care. same time we know that if we refer them Across reviewed districts, however, less than 10% back to their clinics, the clinics won’t have of private clinics participated in DPPM with access the capability to treat the patients. It is to government-funded FDCs (with the exception of Kab. Tangerang with a 40% participation rate). While further complicated if patients don’t want this could be partly attributable to the early stages of to be treated in a Puskesmas. As a DPPM implementation, we anticipate that participation consequence we will treat these patients may continue to lag, as clinics may not be motivated to participate in DPPM because treating TB patients is at the hospital.” resource intensive, without any additional revenue, even if — Chain, type C hospital in Kota the drugs are covered by the government. The perceived lack of incentives is exacerbated by the high barrier to Tangerang government-funded FDC access as GPs need to be certified for TB by completing either a multi-day training or a lengthy IDI-developed online course. Attending these Hospitals reviewed across districts reported that they only trainings is a burden, as GPs often have to pay for the report TB cases where the patients were treated using training registration fees out-of-pocket and forgo several government-funded FDC drugs, which are administered
31 under the NTP-recommended intermittent regimen. A recent study50 on enhancing TB notification in hospitals, however, shows that public and private clinicians prefer “Two out of three public GeneXpert hosts prescribing a daily regimen to complicated TB patients, are not ready to invest in the necessary using loose drugs that are procured by the hospitals. infrastructure to diagnose presumptive This prescribing behavior makes it harder to identify and audit data for missing TB cases because while it is easy to MDR-TB; these two hospitals refer extract data for patients under the intermittent regimen presumptive MDR-TB to the only hospital from the hospital information management system, doing currently putting the machine under so for patients under a daily regimen is more complicated and time consuming. While the use of the two regimens operation.” should not be a barrier for notification at diagnosis, — DHO, Medan on public hospitals the key challenge is that mandatory notification is not currently enforced and there are no penalty clauses for that were not using the GeneXpert non-compliance or incentives for notification. machine
Existing incentives to increase the use of GeneXpert in the private sector by subsidizing their use and placement in secondary care may also be insufficient. Even though Finding 3.2d: Given declining overall GeneXpert sites benefit from the machine, cartridges, and business and low TB drugs sales as a result maintenance being funded by the Global Fund and the of BPJS-K, standalone pharmacies are not additional reputational benefit from being a GeneXpert site, interviewed facilities and DHOs cited examples of incentivized to stock or dispense TB drugs private hospitals that refused to be GeneXpert sites due to the potential additional necessary investments required. The introduction and scale-up of BPJS-K has significantly Although the GeneXpert setup is designed to operate reduced overall sales for most standalone pharmacies across a wide range of temperatures and environments, (by ~20-40%), since primary clinics are now stocking and and should not require a separate room, hospitals selling their own drugs, amplifying already competitive perceived that extensive infrastructure is required to be market dynamics. For example, competition among a GeneXpert site – such as additional real estate and a pharmacies in Medan and Makassar has resulted in a lower temperature-controlled isolation room – while providing profit margin (10-15% for Medan, 5-10% for Makassar vs. limited incentives of about $2 per test run. This reasoning ~20% in other districts). was also apparent in a few examples of public hospitals that received GeneXpert but did not operationalize the The declining demand in retail pharmacies for drugs in machine. Although this is not a representative view of general and TB drugs in particular has been driven by all private hospitals – given that the reviewed private patients’ increasing awareness of BPJS-K coverage of FDCs GeneXpert hosts seem to appreciate the subsidy – this at clinics, Puskesmas units, and hospitals – an attractive finding indicates that future expansion of GeneXpert alternative to paying OOP at standalone pharmacies. As deployment in private facilities may face resistance in some demand is being fulfilled elsewhere, private pharmacies locations and incentives may need to be further assessed. are reducing stock of TB drugs, either partially or All of the reviewed private hospitals have an MOU with completely, and interviewed pharmacies stated that GeneXpert sites, whether private or public sites. they often only stocked drugs on request or for partial regimens (e.g., Rifampicin (R) and Isoniazid (H)).
Pharmacies may participate in the PRB scheme in order “Even with current incentives, they are still to secure additional revenue (note that the BPJS-K not ready to fulfill the requirement to contract for pharmacies only applies to specific chronic provide the supporting GeneXpert diseases under PRB and does not cover TB treatment). In Makassar, two PRB-enrolled private sector pharmacies infrastructure and requirement.” interviewed solicited nearby Puskesmas units and clinics to — DHO on a hospital that rejected refer PRB patients from primary care to the pharmacies by offering payment-in-kind such as phone credit top-up GeneXpert placement (~IDR 100K) to the physicians and nurses. Within our interview set, there were a limited number of private pharmacies that enrolled in the PRB scheme, reportedly
32 due to the higher capital requirement necessary to keep this set of labs declines, however, and more tests get all of the chronic disease drugs in stock. referred to bigger labs, incentives and enforcement efforts should focus on medium and large labs. Finding 3.2e: Changing business dynamics affected labs differently based on size, with This review found several examples of increased implications for quality assurance engagement in quality assurance, particularly in bigger cities such as North Jakarta, Medan, and Makassar, where Similar to standalone pharmacies, the rollout of BPJS-K large chain players are more dominant. Likely as a result has impacted business for labs, primarily local, smaller of the increased infrastructure and resources, and more labs without the resources or infrastructure to weather concern about protecting brand and reputation, these labs the changing business dynamics. Patients who used to go are engaging in more comprehensive internal and external to private GPs (the main source of revenue for smaller quality assurance procedures. labs) are more aware of the BPJS-K scheme and now seek “free” diagnoses at clinics. According to reviewed clinics and labs, clinics are more likely to partner with medium- 3.3 The DHO role and to-large labs to run more basic lab tests since these labs implementation of DPPM provide more quality assurance and generally higher discounts. However, for TB, as previously discussed, clinics DHOs across districts cited the lack of human and typically refer patients to Puskesmas or secondary care financial resources as a key challenge, hindering their to avoid incurring the cost of diagnostic tests. In some ability to effectively implement DPPM and carry out the instances in North Jakarta and Kota Tangerang, the DHO TB program more broadly. The lack of financial resources reported that some labs have been driven out of business seems particularly acute for those DHOs that rely only on altogether. APBD (i.e., no additional funding received from donors or Challenge TB). For example, the wasors in Medan (despite For medium-to-large labs (including regional and it being a Challenge TB district) reported that they nationwide chains), however, the net effect on the have to pay for all of their transportation out-of-pocket bottom line has been limited and overall business even when they need to travel to organize trainings reportedly remains stable (or grew at a slower pace). This and socializations or to visit facilities. The Kabupaten is likely due to the more affluent, OOP-paying customer Tangerang DHO reported that they receive the same segment served by these labs. Additionally, increased funding from the PHO as other much smaller cities (e.g., test volume from rising awareness of preventive health Cilegon, with ~10% of Kab. Tangerang’s population and care within this customer base helped to offset the shift fewer facilities) and less in comparison to other DHO of customers to government-funded services. These labs health programs. also had the means to continue paying GPs referral fees/ commissions to refer patients. As most patients referred by GPs pay OOP and are not BPJS-K patients, this may provide more stability for the medium-to-large labs. “For comparison, DHO funding for Leprosy of IDR200mn is almost the same as our Labs receive most of their test volume (70-80%) from TB funding IDR240mn, while HIV receives individual GP referrals, with the remaining 20-30% from walk-ins, hospital outsourcing, or the corporate sector. As approximately three to four times of our medium-to-large labs have greater diagnostic capabilities funding at IDR800mn.” and are better equipped to establish institutional relationships, it is expected that the composition of test — DHO, Kabupaten Tangerang volume from walk-ins, hospital outsourcing, and corporate sector would be higher for this typology.
The shifting business dynamics for labs has important In addition to impacting district-based activities, financial implications for quality. Establishing quality assurance barriers may also influence DPPM progress at the for smear tests in the private sector continues to be a secondary level. An insufficient quantity of DOTS training significant challenge due to a lack of incentives and loose was cited by DHOs as a key barrier in implementing enforcement of mandatory quality assurance. This has the TB DOTS program under DPPM. Trainings were been particularly evident in smaller labs where low test usually coordinated and funded by the PHO, either by volumes provide limited incentives for investing in internal APBD or by donors such as the Global Fund. However, and external quality assurance. As services provided by these trainings usually have very limited slots and are
33 only held once a year. Those DHOs who rely solely on This review also found that wasor time allocation was this PHO-organized training or expect private facilities neither systematic nor standardized across districts. to pay out-of-pocket to attend – sometimes done to In Makassar and Kota Tangerang, the wasor spent the incentivize accountability –may face constraints when majority of time interacting with health facilities – primarily trying to accelerate DPPM participation rate (for example, on less value-added activities such as troubleshooting SITT in Makassar, where the private hospital participation rate problems in Puskesmas units and hospitals – and only is 9%). 10-20% of his/her time on training or socialization to non- DPPM health facilities. In contrast, the wasor in Kabupaten Tangerang allocated ~70% of time on data analysis of “We are unable to enroll all ten non- case-finding achievements in Puskesmas units, and the DPPM hospitals since we only received balance of time interacting with facilities. four slots in the PHO-led DOTS training. At this rate, we will only reach 100% participation in two to three years.” “I have been going to hospitals and puskesmas fixing and troubleshooting the — DHO, Kabupaten Tangerang latest version of SITT, but I feel I could add more value doing other activities.” — DHO, Kota Tangerang “We expect hospitals to pay out-of-pocket for the DOTS training, so they have more ‘skin in the game’ and would be more Wasors across districts might also allocate time differently incentivized to implement DOTS properly.” between private and public facilities. This determination is driven by several characteristics including (1) the — DHO, Makassar proportion of public versus private facilities in the district, (2) the proportion of facilities already participating in DPPM, and (3) the amount of time spent on private The challenges for DHOs in effectively mobilizing existing sector training and socialization. Although there were resources are seen in particular in the role of wasor. some variations across interviewed districts, the majority While the wasor is intended to play a critical role in of each wasor’s time was usually spent on public facilities, accelerating DPPM implementation, wasor effectiveness particularly with Puskesmas units. is currently hindered by heavy capacity loads and a focus on non-value-adding activities. On average, each wasor in Wasor capacity utilization for DPPM rollout may be the reviewed districts handles ~70-440 facilities (which improved with more effective utilization and mobilization includes private hospitals, clinics, and Puskesmas units), of Puskesmas who, in the DPPM model, are intended to which is far from the ideal 1 to 20 ratio as stipulated in serve as the coordinator for private clinics and individual the MoH regulation Permenkes 67, 2016 Bab XI (in part practitioners. This review found that DHOs who were because this ratio was originally conceived to cover only able to better mobilize Puskesmas for clinic outreach public facilities). This ratio has limited wasors’ ability to commonly had higher rates of clinics participation – interact with all health facilities frequently and may be a which also then allowed the wasor to focus on hospital barrier for wasors to reach out to individual hospitals to outreach as intended. In Kab. Tangerang, for example, participate in and maintain DPPM or TB DOTS activities. 40% of private clinics have MoUs with Puskesmas units, as the wasor was constantly monitoring each Puskesmas’ achievement in case finding and clinic DPPM participation “It is hard to supervise all facilities in the rates. The Kab. Tangerang wasor seems to be personally district with limited number of human motivated, especially considering that she is also resources. There’s only one wasor per 80+ pursuing her doctorate degree in TB. In Surabaya, the DHO developed an MoU template and then leveraged facilities, that’s four times more facilities Puskesmas to visit clinics and individual practitioners to than the ideal.” get them to join DPPM. In contrast, districts that have not systematically leveraged their Puskesmas, such as — DHO, Kabupaten Tangerang Kota Tangerang, have not been able to gain traction from clinics or the private sector in general.
34 Understanding opportunities for mobilizing other key support for both DS-TB and MDR-TB patients, such as stakeholders will also be critical for effective DPPM PETA (a patient survivor group in N. Jakarta), PESAT implementation. This review found that aligning TB (a patient survivor group in Medan), and religion-based indicators to the performance of key actors influenced organizations focused on case-finding, such as AISYIYAH DPPM traction. In Kab. Tangerang, TB case finding and (nationwide) and LKNU (Tulungagung). treatment outcomes became part of the KPIs for both the Head of Regency and Head of DHO and were tied Findings 3.4a: Professional associations to their performance-based bonus. The wasor in Kab. could play three roles in increasing quality Tangerang reported that, as a result, the Head of the of TB care, but very few organizations are DHO was keen to provide monetary support (higher TB budget) and non-monetary support (reinforcing case currently fulfilling these roles for TB notification targets with Puskesmas, and issuing warning letters to Puskesmas units that do not meet TB case Professional associations are well-positioned to play three finding targets). This is a national scheme, but other roles to increase quality of care: wasors outside of Kab. Tangerang did not bring this up as a key DPPM driver. • Education: Ensure continuous medical education (CME) of their members.
“The head of the DHO helped me issue a • Advocacy and negotiations: Represent their members warning letter for a Puskesmas that does in negotiations, primarily on BPJS-K related topics (e.g. BPJS-K empanelment endorsement, BPJS-K not meet or improve its TB case-finding tariffs) or to provide professional inputs to guide KPI.” disputes with customers. — DHO, Kabupaten Tangerang • Implementation: Play an active, publicly funded role in DPPM implementation (e.g. supporting the public health functions provided primarily by Puskesmas This review suggests the need for further evaluation and DHOs). of how to more effectively use human resources – in particular, an assessment of wasor utilization and time While this review found that associations are generally allocations – as it may enable important mechanisms active in fulfilling these leadership roles outside for accelerating the DPPM effort. Challenge TB has of TB, there were limited instances of TB-specific developed a draft51 of tasks for wasors within the context activity. Without being compensated financially by of DPPM implementation, which is available upon the government, associations are unable to amplify request. However, this effort did not assess wasors’ time the reach of government. Such funding (plus funding allocations. Additionally, a systematic gathering of best for CSOs to drive DPPM implementation; see next practices from Puskesmas that are effectively driving section) can only reach nationwide coverage if there is DPPM participation would also be valuable and could be a way to cascade this expectation of funding through conducted – and applied in districts – in the immediate Indonesia’s decentralized governance structure, so that term. the implementation happens in all or most districts. CTB’s idea to address this was the district action plans (RAD), but it may be a tough process to expand; future 3.4 Role of Non-Public Stakeholders implementers should continue engaging GoI and other stakeholders to develop solutions to this. Two primary non-public stakeholder organizations were interviewed in this review: professional associations and Understanding the decentralization environment – CSOs. Professional associations can be categorized into where responsibility for planning and managing service two groups based on membership: those whose members delivery was shifted from the central MoH entities to are health care personnel and those who represent local governments following the decentralization reform institutions. All health care personnel are obligated to be in 1999 – is also important for coordination purposes. members of their respective associations (for example, all The relationship among MoH, PHO, and DHO is not internists need to be members of PAPDI) while joining a hierarchical; each level has its own mandates and areas professional organization is optional for institutions. CSOs of authority. A recent study52 highlights the complexity of include non-profit organizations with a social mission who the communication lines for TB technical changes. The are typically focused either on case-finding or treatment study recommends clear communication and expectation-
35 setting for all stakeholders and providers, initiated by the philanthropic organizations. In some districts, the key leads Directorate General of Communicable Disease Prevention or the head of the associations are also part of the DHO, and Control to ensure coordination at all levels. which helps the associations obtain funds from the DHO to cover the aforementioned activities. Education The focus of IAI (the pharmacists’ association) is on All the associations reviewed provide members with drug usage, and the topic of antibiotics is relevant for knowledge-building programs, seminars, trainings, and TB. In Kota Tangerang, IAI participated in a drug usage conferences, but only PDPI includes TB on its learning government campaign “Gema Cermat” (smart usage agenda. These knowledge building programs are typically of medicine) which includes education on proper TB sustainable since they are funded by both membership drugs usage funded by DHO. In Kabupaten Tangerang, and registration fees from participants. The limited TB IAI – along with BPOM, Indonesia’s food and drug agency focus across associations is likely a reflection of the – plays an enforcer role by conducting unannounced priorities and interests of the organizations and members. inspections to make sure pharmacies are following facility requirements and drug dispensing guidelines. In this program, violating pharmacies are given two “We are very unlikely to organize sputum warning letters before having their license suspended. It is important to note that the head of IAI in Kabupaten test training for our members. First of all, Tangerang was also a civil servant in DHO which we don’t think our members are willing to might explain his motivation to conduct unannounced pay OOP (unlike phlebotomy). Secondly, inspections through IAI. we don’t allocate any portion of our Advocacy and negotiation funding for sputum microscopic training.” There is evidence of associations advocating on behalf — PATELKI (Association of Medical of their members on issues such as how to gain Lab Analysts), Makassar endorsement for BPJS-K empanelment, how to receive timely BPJS-K payment, and other implementation issues. Several examples include:
• Clinics associations ASKLIN and PKFI worked “Programs or initiatives with SKP [credit with DHO to evaluate whether new clinics meet points used for license renewal] as prerequisites for opening, and also provided clinics incentives are not attractive; my colleagues with recommendations for BPJS-K credentialing and re-credentialing. and I could easily get the associations to approve our request for a small gathering, • Hospitals associations (e.g. PERSSI) have successfully rewarding us with SKP accordingly.” put pressure on BPJS-K to disburse late claim payments for member hospitals. — GPs and Pharmacists, Tulungagung • ARSSI in Kabupaten Tangerang helped to arbitrate a dispute with a BPJS-K patient who was perceived to have been denied admission due to full occupancy. In addition, associations may provide education to health care professionals beyond their members. PDPI and Only one example of TB-specific advocacy was found in IAI are the only two organizations found in this review this review. PDPI in Kota Tangerang negotiated with both that are engaged in TB-related topics. PDPI worked DHO (to provide government-funded TB loose drugs to with the DHO across districts to provide TB treatment hospitals) and BPJS-K (to ensure that patients diagnosed training to GPs as well as for socialization to increase by radiology and not sputum test can still be reimbursed public awareness. For example, PDPI members in Medan by BPJS-K). provided TB treatment training for GPs, while in Kota Tangerang, members served as a “hotline,” answering Implementation questions on TB from GPs (particularly those in Puskesmas). These associations may receive an allowance This review did not find observable activities in support of or compensation from either the government or DPPM implementation being carried out by professional
36 organizations aside from the day-to-day practices of the have the opportunity to request and receive government members. These activites include a clinician encouraging funding, and be held accountable for a set of predefined the establishment of a well-functioning internal TB targets for specific activities or outcomes. network or facilitating the improvement of TB capacities of health service within his or her hospital. Challenge Finding 3.4c: While potentially valuable TB has given mini-grants to some associations in the resources, CSOs are constrained by limited Challenge TB-assisted districts to do this, but sustainability funding and the private sector is not is a major concern. Professional associations should utilize donors’ funds with an eye toward self-funding, currently willing to pay for their services for example partnering with corporations through CSR (Corporate Social Responsibility) programs. The CSOs interviewed typically focus either on case- finding or treatment support for both DS-TB and MDR- Finding 3.4b: KOPI-TB is perceived TB patients. PETA (N. Jakarta) and PESAT (Medan) positively, with the potential to increase provides support to MDR-TB patients and Aisyiyah participation and coordination in TB care (Medan and Makassar) focuses on case-finding. Given that CSOs have TB cadres trained as case-finders, treatment between siloed, non-public TB actors supporters, and/or contact tracers, these organizations could serve as valuable resources in TB care delivery. For This review observed that professional associations example, facilities could recruit them to perform those largely operate in silos and, given their individual agendas functions. and priorities, do not heavily invest in the TB agenda – behaviors that compound a fragmented TB care system. In The challenge in utilizing these organizations, however, an effort to address this challenge, the Ministry of Health is their reliance on donor funding for sustainability. This established KOPI-TB in 2017 to develop a common goal review observed that the CSOs whose funding was for TB and unite 13 professional organizations in an effort terminated – for example Aisyiyah in Tulungagung and to increase participation and coordination in TB care53. Kabupaten Tangerang, and LKNU in Tulungagung – were no longer active. While the private sector could pay for The KOPI-TB concept builds on the PPM committees the cadre services offered by the CSOs, there was a that were long established under TB CARE I54, a general unwillingness expressed in the interviews given a global cooperative agreement funded by USAID, but lack of incentives and accountability for case finding and it has been unclear what the committees can actually treatment completion achieve. Although KOPI-TB, as a committee, could help make decisions, Indonesia is still lacking well-funded organizations that are well positioned to implement “I don’t think our hospital, or other private DPPM and the TB agenda more generally. Although the sector facilities in general, will have any representatives of associations across districts that were need or recruit trained cadres from interviewed were happy with the creation of KOPI-TB, they were unsure how exactly KOPI-TB would make Aisyiyah and the likes.” tangible impact on the ground. Other countries have — TB team lead, BPJS-K Class C equipped local organizations to become implementing entities, but through significant funding and a clear hospital, Kota Tangeran mandate. For example, Taiwan heavily invested in the . Centers for Disease Control (CDC) to implement the public-private mix activities. In South Korea, an association received government funding to fulfill the function played in Taiwan by the Taiwan CDC.
For DPPM acceleration, it is critical for the Government of Indonesia and other stakeholders to both support better coordination and enable well-funded implementing organizations. In order for KOPI-TB to further aid in DPPM, there must be clear funding streams to enable KOPI-TB (and/or other actors) to effectively implement the TB agenda. KOPI-TB, or other implementing organizations that may emerge out of KOPI-TB, should
37 4. Summary of implications
his review identified several dominant behaviors private GPs to pharmacies and labs have dropped. and forces at work in the private health care system with important financial and health outcome On the other hand, there are several financial and health Timplications for TB care. Overall, several positive trends outcomes ‘costs’ that the system is incurring as a result for TB care are observed that are particularly driven by of the TB care challenges identified in this review. These momentum from both BPJS-K and DPPM. There are include the BPJS-K system overpaying for uncomplicated also several consequences of current TB diagnosis and TB patients, care not occurring in the optimal places treatment breakdowns that need to be addressed to (leading to worse patient outcomes) and impeded DPPM improve the efficiency and effectiveness of TB care. implementation. Each of these implications is discussed in more detail below. One important positive trend is the increased access to affordable care as a result of the growing number of BPJS-K overpaying to treat uncomplicated TB private providers contracted by JKN. Patient access to patients, given the incentives and disincentives government FDCs in primary care has also expanded as created by the JKN system more private primary care providers participate in DPPM and more clinics receive government-funded FDCs. It is BPJS-K is incurring unnecessary costs to treat important to note, however, that access to government- uncomplicated TB patients, especially those treated funded FDCs is still at an early stage with significant room by hospitals, as they have to make two payments for for improvement55. The simplified treatment regimen of uncomplicated TB treatment – once via capitation to FDCs over single anti-TB formulations and the removal clinics and once via INA-CBG to hospitals. of previous OOP payments for loose drugs by supplying government- or DHO-funded drugs should result in This double payment is driven by clinics up-referring better treatment outcomes, although this transition of presumptive TB to hospitals due to the multiple factors private providers to government-funded drugs would discussed in this review – for access to “free” diagnosis be far easier if NTP were to adopt the internationally and treatment of TB, the tension with Puskesmas over recommended daily regimen. transfer of capitation, and the patient preference to be treated in secondary care. Moreover, hospitals that In addition, the quality of TB care may improve as receive referrals from PHC may not necessarily down- providers and patients reduce their use of lower-quality refer because 1) they are trying to claw back losses pharmacies and labs for TB drugs and services. The influx incurred during the initial diagnostic visit, and 2) there of BPJS-K affiliated providers has driven business away is not yet full FDC penetration in BPJS-K clinics. While from small pharmacies and labs (which are more likely to hospitals may alternatively send patients to Puskesmas have lower-quality standards in order to minimize cost) as for treatment, this only occurs if clinic-based patients are patients have become more aware of government-funded willing and there is no tension over capitation between services and drugs and the prescriptions or referrals from Puskesmas units and clinics.
38 The higher the number of uncomplicated TB patients on the system. In addition, while private sector access to being treated in hospitals, the more BPJS-K needs to government-funded FDCs is growing, it is not yet fully pay secondary care for services that should be able to accessible, thus motivating patients to stay in secondary be treated in primary care. Given the limited supply of care where drugs are “free.” diagnostics (especially GeneXpert), it may be necessary to refer for diagnosis, but completion of treatment is better Impeded DPPM implementation given Puskesmas handled at the primary care level (see below). This review disincentives (or lack of incentives) to fully perform estimated that BPJS-K unnecessarily incurs expenses of at their role least IDR 850,000 per uncomplicated TB patient treated in secondary care56. This overpayment for uncomplicated The role of the Puskesmas is critical for effective DPPM TB patients in secondary care could be redirected to and for enabling strong linkages between the public fund the potential interventions detailed in Section 7. and private sectors – a role that may be ineffective Note that the assumptions for this estimation are based given tension between Puskesmas units and clinics on qualitative interviews with limited real-world data over capitation. In several districts interviewed (Medan, around inpatients and outpatients, and therefore may not Makassar), this was a more prominent issue, potentially represent the true extent of inappropriate behaviors. hindering Puskesmas units from proactively conducting DPPM outreach and socialization (providing clinic training Poorer patient outcomes due to TB care not and access to government-funded FDCs) and potentially occurring in the optimal places impacting Puskesmas’ willingness to perform public health function (tracing loss-to-follow-ups) for private clinics. Evidence indicates that uncomplicated TB patients treated in secondary facilities have worse treatment outcomes In addition, DHO interviews indicated that because public than those treated in primary facilities57. In general, this health functions are not tied to specific financial incentives, is because adherence partly depends on factors such Puskesmas’ ability or willingness to fully perform their as distance from the health care facility, availability of public health role could be insufficient. At both Puskesmas transport, and patients’ physical condition. And since and DHO, the public health functions – especially to patients usually reside closer to primary care facilities, cover the entire health sector including private providers they are able to visit clinics more regularly than hospitals. – remains insufficiently recognized and resourced, both In addition, clinics are more likely to track their few TB financially and in terms of human resources. DPPM patients more closely, whereas patients often get lost in a currently rests on unclear assumptions about resourcing, large and complex hospital. with a risk that DHOs are overloaded, and associations inherit an unfunded mandate. There is a need for clearer The same forces and behaviors described above that estimates of financial and human resource requirements lead to negative financial consequence may also lead to to achieve DPPM at scale. worse health outcomes – creating even more burden
39 5. Potential solutions and variations by district
he linkages among the study objectives, 5.1 Inputs from district findings for research framework, and six key questions for proposed recommendations implementation can be found in table 11 in Tsection III of the Annex. Through the input from private There are several key findings from the district sector institutions, as well as NTP, DHO officials, and interviews that serve as the basis for the four proposed CSOs, this review generated four potential interventions recommendations. For example, Intervention A that address the key implementation questions that (conditional fee-for-service for TB diagnosis) and B are critical to driving high quality private sector TB (inclusion of TB in PRB program) are built on the existing provision (outlined in Section 3.2). These potential links between labs and providers, and designed to interventions are highlighted in the diagram (see Figure create a compelling business case and incentivize private 3 below). These include three longer-term solutions hospitals and labs to invest in and provide TB diagnosis, that involve changes to the BPJS-K purchasing system while reducing tensions with Puskesmas. Intervention C is and one short- to medium-term solution that builds on constructed not only to motivate private clinics to treat the current health system. It is important to note that TB patients, but also to further enable Puskesmas units solutions are framed as longer-term given the time likely to fulfill their public health function. Lastly, the finding required to build necessary political will to change the of wasors’ limited attention to private sector and lack of existing system; once the decision is made, however, empowerment to rollout DPPM, along with associations’ implementation may be relatively quick. Several additional lack of funding and organization to drive private provider short- to medium-term solutions have been identified engagment to support Intervention D. that may help improve TB case findings in both the private and public sectors. Table 11 in the Annex provides more detailed linkages between the findings and implications, and the proposed This section will first highlight the key findings from solutions, including those from the “individual private the district interviews that are used as inputs for the provider/patient review.” proposed recommendations. A detailed review of each of the four proposed interventions will then follow, including the intended impact on the TB private sector 5.2 Proposed interventions system and the key enablers required for implementation. A discussion of the key variations across districts The four potential interventions identified should not highlights districts’ characteristics and makeup that should be considered mutually exclusive. While each addresses be considered for implementation, and implications for specific priority areas, in some cases combinations could district prioritization. including the state of BPJS-K and have a synergistic effect on outcomes. PPM, private and public sector service capacity, patient preference, presence of professional associations, and The set of recommendations was developed using guiding level of DHO’s resources for TB. principles for solution design consistent with those from
40 Figure 3: Potential interventions address six key questions Long term Short-to-medium term
INTERVENTION A INTERVENTION B INTERVENTION C INTERVENTION D Conditional Fee for Inclusion of TB in PRB Treatment completion PPM implementation Service for TB diagnosis (“Program Rujuk Balik”) incentives acceleration
Increase Designate private labs to Q1 conduct TB diagnostics as diagnosis access Implement conditional part of the PRB program fee-for-service (FFS) payment mechanism Incentivize for TB diagnostic Improve the functionality Q2 based on hospital/PKM and interoperability of reporting 2 reporting and (for SITB uncomplicated TB), on hospital down-referral Ensure Q3 down-referrals1
Enhance FDC Supply “PRB Pharmacies” Q4 with government-funded access FDCs
Incentivize PHC with Ensure treatment pay-for-performance (P4P) Q5 completion rewards to ensure treatment completion
Empower wasor role and Further DHO/ Implement conditional Implement P4P to increase the quality Q6 FFS to incentivize incentivize Puskesmas’ PKM public of M&E3 of DPPM Puskesmas’ role in DPPM role in DPPM health role implementation
1 For uncomplicated TB 2 Sistem Informasi TB (TB information system) 3 Monitoring and evaluation the previous individual private provider/patient review: • Given the timeline and effort required to pilot and implement certain interventions, proposed solutions • Potential solutions and interventions should build should include a mix of “quicker wins” and longer- on existing systems to ensure ongoing sustainability. term, more transformational interventions. They should also consider the possible roles played by different actors in the existing health system. • Potential solutions need to have the right balance between incentives and regulations, aiming to be • Uncomplicated, drug-sensitive TB should be incentives-focused, and apply regulation strategically treated at the primary-care level. Patients who where incentives are cost-prohibitive. A strong seek treatment for uncomplicated, drug-sensitive regulatory and policy framework lays an important TB at the primary-care level should be kept there, foundation by clarifying expected standards and with a minimum of up-referrals. Down-referrals from behaviors. However, on its own, it is not enough secondary care should be encouraged whenever to change behavior in Indonesia’s private sector. appropriate. Note, however, that the current review Conversely, not only are incentives effective in suggests greater flexiblity around the location of changing behavior, they also entice the private diagnosis, given supply-side constraints. sector to invest their own resources in building the knowledge or tools they need to ensure that they • Guidance for TB care and potential interventions will reap the benefits of that incentive. should be patient-centric—designed around patient and provider preferences—and, whenever The proposed interventions were informed by the possible, should work in concert with (rather than behaviors and motivations of institutions selected from fight against) existing incentives, such as low-cost seven districts for this review and were developed to and convenient interventions that allow patients to serve as an input to inform broader efforts in driving remain in the private sector if desired). quality TB care. It will be important to use additional
41 initiatives, such as the ongoing Strategic Health providers’ economic incentives while (1) reducing Purchasing (SHP) discussions and the upcoming USAID the overall BPJS-K financial burden, (2) extending the TBPS Activity, to further test, evolve, and build on this service reach of the public sector (notification, contact set of interventions. It will also be helpful to further investigation, loss-to-follow-up tracing), (3) improving case assess the likely costs required to implement these notification rate, and (4) encouraging down-referrals. interventions, and to determine how much could be offset by savings from the reduction in unnecessary Since hospitals can already profit from the patient’s up-referrals and secondary care treatment (as described first visit, the FFS scheme is intended to curb, or in Section 6) and reduction of other inefficiencies that even eliminate, the hospitals’ behavior of keeping these interventions could help address (e.g. averting uncomplicated TB patients in secondary care, thus MDR-TB cases). reducing the BPJS-K financial burden. Should clinic-based patients prefer to be diagnosed in Puskesmas, the FFS Potential intervention A: Conditional Fee-for-Service should also alleviate Puskesmas’ concern about getting for TB diagnosis (longer-term) commensurate rewards for providing care to non- Puskesmas-based patients – reducing existing tension with This intervention would involve adopting a fee-for-service clinics. payment mechanism for TB diagnostic tests for hospitals and Puskesmas units, with a reimbursement amount that In addition, by tying FFS reimbursement to notification is sufficient to cover costs within a reasonable margin, adherence and down-referrals (for example, via on the condition that the institutions report test results submission of public sector paper “rujuk balik” form TB-09 to the DHO and, in the case of hospitals, down-refer as evidence, or preferably a simpler reporting mechanism uncomplicated TB patients to primary care. As opposed via BPJS-K data systems or WiFi TB), an increase in case to forcing (or funding) clinics to have TB diagnostic notification and down-referrals is anticipated (otherwise capabilities, this recommendation allows clinic-based there will be a lower TB diagnosis reimbursement cost). patients to choose whether to seek a TB diagnostic at Puskesmas units or hospitals. Enablers required to implement recommendations This intervention is built on current referral relationships For hospitals, the reimbursement amount should be without significant changes to the system, while allowing sufficient to prevent them incurring losses that would for patient preferences to access diagnostic tests either disincentivize either testing or down-referrals of at hospitals or Puskesmas units. This is consistent with uncomplicated TB patients. Regulatory enforcement to the current positive trend of more diagnosis capabilities prevent up-coding of patients (that would allow patients in Puskesmas units and hospitals, where higher quality is to remain in secondary care for treatment) will still be more likely than in smaller standalone labs and there is necessary. For Puskesmas, the fee-for-service for TB more likely to be access to GeneXpert and to physicians diagnostic tests is expected to prevent their rejection more experienced in TB diagnosis. However, this of clinic-based patients and the requirement for clinic- intervention will require a new fee-for-service payment based patients to transfer capitation. Moreover, the scheme and potentially additional funding to ensure the reimbursement will also serve as an additional funding enforcement of proper reporting and down-referrals (or resource – especially for capacity-constrained Puskesmas alternatively, the deployment of government-funded case units – to expand their capabilities, for example by hiring managers). additional lab analysts or procuring additional microscopes to help Puskesmas serve a higher number of presumptive Enhancements to the existing reporting systems are TB patients outside of their capitation. required to ease the burden on hospitals, which currently need to report similar data in several different platforms. Sputum sample transport also could be promoted through Linking the SITT and BPJS-K systems could allow hospitals this intervention by including transport cost as one of to report and claim in one platform and do so in a more the FFS components, eliminating the need for patients timely manner58. to travel between facilities. This may become especially relevant as GeneXpert machines becomes more available Potential intervention B: Inclusion of TB in an and the standard of care shifts even further toward using expanded “Program Rujuk Balik” (longer-term) Xpert to diagnose TB. In this intervention, TB would be included in the Anticipated impact of intervention current Program Rujuk Balik, with some modifications. The fee-for-service scheme for TB diagnostics is intended This involves appointing PRB labs in each district to accommodate patient preference and account for to conduct TB diagnostic tests for GPs and private
42 clinics and addresses a key driver for institutions to Anticipated impact of intervention send patients to secondary care in the first place (the The main intended impact of this intervention is to keep lack of appropriate diagnostics in many primary care clinic-based patients with TB symptoms out of hospitals settings). The appointed labs would be reimbursed at from the start, so hospitals are not able to keep patients concessionary pricing, lower than list price, given the for the full treatment duration. TB symptomatics will high volume benefit expected from this arrangement also be assured of access to TB tests at defined facilities, and the possible capital contribution from the public which will help prevent delayed diagnosis of presumptive sector (such as to cover the upfront cost of procuring TB due to excessive shuttling among facilities. From a GeneXpert machines). This will eliminate the need systems perspective, this intervention minimizes the costs for clinics to pay out of pocket for lab services (which of monitoring hospital up-coding or the lack of down- currently is largely non-functional), avoid patient OOP, referrals, although considerable promotion of this scheme and minimize unnecessary up-referrals from clinics to will be needed to shift clients away from hospitals (their hospitals. current favored destination) and toward PRB sites. It also strengthens the role of labs and pharmacies, creating a It is important to note that Interventions A and B have more robust holistic, synergistic system at the primary a similar aim of increasing diagnostic access. Either one care level, where each actor takes a more active role in or both may be implemented – deciding between these providing TB care. In addition, diagnostics volume will be options requires discussion about how best to achieve concentrated where, theoretically, capability is higher and a reasonable level of diagnostic access, and the answer where quality can be managed. may differ from district to district. Patient preference is also an important consideration, since intervention A Enablers required to implement recommendations directs patients to public primary care or public or private This recommendation requires funding to cover diagnostic secondary care, while intervention B keeps patients in costs and margin for private labs (possibly including public or private primary care for diagnosis. Intervention upfront procurement of GeneXpert machines for these B may be preferable to intervention A if modification of labs) as well as for drugs, distribution costs, and incentives BPJS-K using the PRB model as a jumping off point is the for PRB pharmacies. However, this review expects that easier path and/or if the control of quality of diagnosis in the additional funding would at least in part be offset by this system would be easier. the declining number of inappropriate up-referrals and the reduced use of hospitals. This solution might also include the participation of PRB pharmacies as distribution points for government-funded Another key enabler is ensuring the increase of FDC FDCs, where the pharmacies would be reimbursed access in primary care providers to ensure that clinics are for a drug-handling fee. This is similar to the existing able to treat and retain TB patients through treatment PRB payment incentive, but potentially with a higher completion. Therefore, the acceleration of the DPPM reimbursement or “top up” to cover the costs of more effort for private clinics is a critical interdependency; frequent drug handling fees. The distribution of FDCs in further explanation of DPPM implementation is presented PRB pharmacies would be an advantage in increasing FDC in the fourth intervention (Intervention D). access at primary care level since FDC penetration via clinics is happening slowly. Potential intervention C: Treatment completion incentives (longer-term) The selection of PRB labs and PRB pharmacies in each district could build on the existing PRB mechanism, This intervention would ideally be combined with ensuring that only quality-certified facilities are entitled intervention A and/or B. It introduces a pay-for- to provide TB services. It is also a recognition that the performance (P4P) payment scheme in which health volume of TB services is not sufficient to maintain all care facilities, whether primary or secondary care, are service provision outlets as TB diagnostic and drug rewarded based on notification of treatment outcome. specialists – so the system would be better off selecting Secondary care facilities would need to provide evidence a certain number as specific TB providers, with general that the patient suffers from complicated TB to receive clinics left with the less specialized task of overseeing the P4P reward. treatment completion. One measurement of quality for labs could be participation in external quality assurance for Ideally, this reward would incentivize the private sector TB tests; for pharmacies, historical stock-out rates could to invest in ensuring treatment adherence and to support be a potential metric. Existing job aids could be used to current efforts to increase access to full regimens. Given further assist partner labs and pharmacies in providing the that DPPM assumes that Puskesmas are responsible for highest quality of service. patient tracing and follow-up, the Puskesmas would retain
43 the full reward for Puskesmas-based patients; but clinics outcomes through ensuring treatment completion. It and Puskesmas would split the reward for clinic-treated is anticipated that the introduction of P4P will be a patients where the Puskesmas role is limited to public compelling proposition to the private sector and would health functions. Health care facilities would need to be accelerate penetration of FDCs in primary care and able to show proof of treatment completion. pharmacies. In addition, the intention is also that this intervention will motivate primary care institutions to track Performance-based incentives for TB have been their patients up-referred to secondary care and generate implemented in many countries with multiple studies a “pull” to treat uncomplicated TB patients in primary demonstrating higher treatment adherence as a result59. care. Similar to the FFS for diagnosis recommendation For example, in 2001, Taiwan implemented a pilot P4P (Intervention A), this review also expects the intervention program for TB and several other illnesses (including will further incentivize Puskesmas to more actively fulfill asthma, diabetes, breast cancer, and cervical cancer). their public health role as they will receive a (shared) As Taiwan has a universal coverage health care system, treatment completion reward for clinic-treated patients. payments were made by national insurance. The P4P program increased the participation of health care Enablers required to implement recommendations providers in TB control from 68 institutions nationwide in As with recommendations A and B, this recommendation 2002 to 751 hospitals and clinics in 200460. would require the development and introduction of a new payment scheme, presumably through BPJS-K. In addition to the rewards, Taiwan also developed an In addition, for this recommendation to be successful, electronic information-sharing platform to enable both Puskesmas would need the capacity and resources to health care providers and public health officials to access fulfill their public health functions, such as implementing up-to-date information regarding the treatment plans of on-the-ground tracing of lost-to-follow-up patients in the individual TB patients, such as visit records, side effects private sector. In addition, there would need to be strict experienced, prescription records, and follow-up status. monitoring of reimbursement processes to prevent a This information helped smaller health care facilities with perverse incentive, where hospitals would try to treat as minimal internal system infrastructure or capacity to many uncomplicated TB patients as possible to generate properly track patients. Such a system might be relevant P4P rewards. in Indonesia as patient handover may be unreliable due to limited infrastructure and a lack of a data-sharing In addition, technology61 could support this incentive. This culture. could include the usage of automated SMS to patients or treatment supporters (termed PMO62) for treatment Notification from a private provider under the Taiwanese reminders and two-way SMS chat if patients have any P4P system triggers an immediate and substantial input issues or questions (some of these functions are already from the public sector around patient education and present in WiFi TB v2), which would reduce the burden adherence support. This public health support for private of TB nurses manually following up on each patient. patients is a common and important element in many Potential partnerships with telecommunications providers middle and higher income countries, and may be far more could minimize the cost incurred by health facilities or important than the actual financial reward. This highlights patients. the importance of potential intervention D (see below), and the synergistic nature of the various interventions Potential intervention D: Accelerate DPPM suggested in this report. implementation through DHO and Puskesmas incentives and/or investments (short-to-medium term) As a benchmark for the financial inputs required, financial incentives for private providers in the Philippines amount The acceleration of DPPM implementation at primary to ~IDR1.1 million (although this is seen as too low), and secondary care levels is essential to drive high quality and a proportion is awarded on completion of the entire private sector TB care. The following intervention bundles course of TB treatment. Using a comparable rate in several initiatives to further support and equip DHOs and Indonesia, the estimated savings from one unnecessary Puskesmas units in fulfilling their public health function up-referral TB patient could be used to fund eight for patients receiving TB care from private providers. P4P cases. A pilot approach could further assess the The intent is to encourage more proactive efforts to appropriate incentive amount and validate the anticipated engage the private sector in order to accelerate DPPM impact of intervention. participation.
Anticipated impact of intervention The proposed interventions are divided into three This intervention is primarily aimed at improving TB components: people, performance management, and
44 technology. It is recommended that all three components responsibilities should be reflected in the wasor’s KPIs to are implemented. There are five essential interventions ensure accountability. across the three components. The priority people interventions are the empowerment of wasors and the Standardization of wasor qualifications such as education mobilization of Puskesmas. The priority performance background and skills is another important element management intervention is increased quality of to ensure optimal wasor utilization and performance, monitoring and evaluation of DPPM implementation. however standard qualifications for wasor do not And the priority technology intervention is the continued currently exist. As a result, each wasor has a different improvement of SITB. The rest of the interventions are level of capability and ability to drive DPPM progress. illustrative and not exhaustive. The standardization of wasor qualifications is especially important since wasors are required to interact with People senior staff of hospitals and clinics (such as heads of the The proposed people interventions address the role of institutions) which might necessitate a more relevant three key actors in the implementation of DPPM – the experience (MD or PhD) and/or senior presence wasor, Puskesmas, and KOPI-TB. The DHO should focus to secure buy-in. In addition, upgrading the wasor’s on the empowerment of the wasor and the mobilization capabilities through training is critical since their role has of Puskesmas as priority initiatives. The effectiveness evolved from being a data collection and analytics officer and number of wasors are critical for driving the DPPM to an overall representative of the TB program in the program, and Puskesmas are necessary for scaling up of district, which requires communication and presentation the program at the primary care level. In addition, KOPI- skills. To further equip the wasors to perform their roles TB could serve as another resource for training and effectively, the provision of project management tools driving cross-sectoral cooperation in DPPM. could also be considered.
Empowerment of the wasor role To implement this intervention, a deeper study of current As the primary actor spearheading the TB program wasor activities, roles and responsibilities, and time in a district, the wasor is critical for the success of the allocation should be conducted to further understand TB program, and, in particular, DPPM implementation. the opportunities and challenges for optimization and For increased effectiveness, the wasor role should be standardization. This assessment will likely reveal the enhanced and empowered in four key ways: clarifying need for substantial numbers of additional wasors, the wasor’s roles and responsibilities, standardizing wasor and the DHO will need to reassess the number of qualifications and skills, developing tools to support the wasors required to optimally drive the TB program in wasor, and ensuring a sufficient number of wasors. the districts. Of note, wasor numbers were originally determined based only on public facility numbers, but Based on district observation, the wasor role and time there is a clear need to reassess this so that wasors can allocation of activities varies significantly across districts, fulfill their new mandate of governing both public and impacting the level of effectiveness in each district. private facilities. Clarifying the roles and responsibilities of the wasor, including the appropriate time allocation across activities, Enhance mobilization of Puskesmas is required. This will ensure that the wasor’s time is As discussed in the findings section of the review, the spent on the most important and value-added activities districts that were able to mobilize the Puskesmas for for the provision of quality TB care, while minimizing outreach to clinics garnered more clinic participation in time spent on performing less important activities. DPPM. Therefore, to ensure the scale-up of the DPPM Additionally, ensuring an appropriate time allocation program, further efforts to mobilize Puskesmas are likely between the private and public sectors is important to required. The DHO will first need to regularly engage ensure sufficient private sector engagement. These roles Puskesmas units and give them the responsibility to and responsibilities should be codified into a formal coordinate with clinics within their area. In order to job description that can be applied nationally to reduce effectively perform this role, the Puskesmas need to district variation. be equipped with the necessary training, materials, and tools for private sector engagement. This could include Ensuring clear roles and responsibilities (which can be communication training to manage private facilities, MoU discussed using the RASCI63 framework) between the templates, or a pitch deck for socializing the program wasor, other DHO staff, puskesmas staff, CSOs, and and the partnership. To motivate clinics to participate professional organizations is also necessary to ensure and engage in DPPM, the DHO could provide monetary appropriate coordination between the wasor and other and/or non-monetary incentives, which will be further parts of the organizations. Lastly, the updated roles and discussed in the performance management section.
45 Involvement of KOPI-TB to train facilities facilities. For example, in Surabaya, all hospitals (both The DHO should also consider supporting the DOTS-certified and non-DOTS-certified) are invited to development of KOPI-TB in each district. Moving forward, meet every quarter to check the accuracy and quality the DHO could engage KOPI-TB as an additional resource of their reporting and to receive additional updates to scale-up training efforts for health workers in hospitals, regarding the TB program in the district. The DHO clinics, pharmacies, and labs. PDPI in Surabaya has could also increase engagement and communication launched similar initiatives in which selected association with facilities using the already-established WhatsApp members are certified to provide hospital DOTS training group to disseminate any new information that could be and the association can organize DOTS training and relevant for the facilities. charge facilities for the registration fee. This has increased the Surabaya DHO’s capacity and enabled trainings to TB DPPM performance-based incentives for Puskesmas be delivered to more facilities, circumventing the issue Incentives could be introduced to encourage the DHO around the limited quota of the annual PHO-led DOTS and Puskesmas to fulfill their public health functions. training. In addition, representatives of KOPI TB could be Puskesmas units should be motivated to drive the scale- given the responsibility of advocating for more regular up of TB by ensuring they are being held accountable education regarding TB in their professional organizations, for their TB achievement and by providing them with as currently this education is still very limited. appropriate incentives. For example, the DHO could recognize the Puskesmas units with the highest case Performance Management notifications or create an award for the most innovative Two potential interventions related to performance engagement method with clinics. Further examination of management will be discussed. The first intervention – a the most effective reward system for Puskesmas should priority initiative – is to increase the quality of DHO be pursued as this review did not include them in the monitoring and evaluation in order to increase the quality interview set. of DPPM implementation. The second is performance- based incentives to motivate Puskesmas to achieve their Technology TB metrics. Continued improvement of SITB As the main tool for TB reporting, SITB (the system that Increase the quality of monitoring and evaluation of DPPM will shortly replace SITT) will be essential to ensuring implementation quality TB surveillance and enabling effective planning, To increase the quality of monitoring and evaluation of implementation, and evaluation of the TB program. This DPPM implementation, the central NTP should develop review identifies the continued improvement of SITB as a scorecard that should be cascaded down to PHOs and the priority technology intervention and highlights several DHOs and used to evaluate the DPPM implementation opportunities for increasing the effectiveness of the in each facility and within/across districts. Currently, system. measurement of the success of the TB program focuses only on end results such as case detection rate or The first opportunity is to enhance SITB’s functionality treatment success rate. However, particularly in private to enable the DHO/PHO to perform monitoring across sector engagement, there are no metrics or tools available facilities or districts in order to identify high and low to inform the DHO on the leading indicators for these performing sites and then formulate the appropriate results. To evaluate compliance according to the DPPM action plans. During the district socialization effort for guideline as well as achievement of DPPM targets, this review, one of the PHOs mentioned that he had to the scorecard should include a checklist of the ideal manually open 30 different files for each of the districts in implementation criteria, leading indicators, and a scoring his province to understand the state of TB, an inefficient mechanism.64 One example of a leading indicator is process for analyzing data and making decisions. private notifications as percentage of estimated incidences to assess progress of private provider engagement. The second opportunity is to enable the interoperability Another example is the percentage of privately notified of the SITB and BPJS-K systems. During the first pulmonary cases successfully treated (requiring treatment Technical Working Group session for TB Strategic outcome on each privately notified case) to assess the Health Purchasing facilitated by R4D in August 2018, the quality of treatment for private patients. The scorecard group (including PPJK, BPJS-K, and representatives from and tool could report on these metrics to help with health facilities) suggested that TB cases in the BPJS-K monitoring and evaluation. system were likely higher than those in SITT. This is especially true given that BPJS-K is an essential revenue Any monitoring tool should be accompanied by stream for facilities, as compared with SITT, which has sufficient, regular interaction between the DHO and no financial implications. Therefore, ensuring integration
46 of the TB and BPJS-K systems may help to reconcile and digital chest X-rays), and digital vouchers for drugs and ease the case notification burden for facilities. BPJS-K diagnostics. Such systems require substantial, continuous claims data could also be utilized to get a more accurate investment, including an ongoing institutional “owner” estimate of the unnecessary cost that BPJS-K incurs as of each system, and access to outstanding technical a result of the inefficiencies and disincentives in the resources. In addition, some of these functions such as current system, such as unnecessary clinic up-referrals payments for clinical services (either by cash transfers or and hospital up-coding of TB patients. In addition, given vouchers) are already taken care of in Indonesia via JKN. the increasing number of BPJS-K providers, this database Innovations should build on these existing systems rather could potentially be used in the future as a more cost- than duplicating them. effective way to estimate TB national incidence via improved notification, reducing the need for a resource- Anticipated impact of intervention D intensive method such as an inventory or prevalence The bundling of the above-mentioned interventions is study. The greater timeliness of data entry into a BPJS-K meant to increase both the level and quality of DPPM system, driven by financial incentives that are already implementation. The people, performance management, present in JKN, would also increase the timeliness and technology components are complementary and of data going to the NTP and allow a more dynamic should be implemented in parallel to achieve optimal decision-making process for the government. SITB has impact. been designed with interoperability as a priority, so the replacement of SITT by SITB should provide a clearer It is anticipated that the combination of an empowered path toward integration with BPJS-K systems. However, wasor together with motivated Puskesmas could help to multiple challenges remain, including the current lack of scale-up the DPPM effort significantly by ensuring more a TB-specific code in the INA-CBGs for uncomplicated facilities are engaged by the public sector. In addition, TB. the presence of KOPI-TB (or other implementing organizations) with clear mandate, financing, and targets A global landscape analysis65 highlighted that NTPs, with could provide additional capacity for the DHO to deliver partners and any intermediary agencies, should be in a TB training to facilities and help drive DPPM participation. position to routinely monitor progress and take action The quality of DPPM (i.e., proper and complete case accordingly, using timely and valid data that captures both reporting and treatment completion) is expected to coverage and quality. Analysis of coverage, yield, and increase with improved monitoring and evaluation sustainability of provider engagement requires access to of participating facilities. Lastly, interventions around a reasonably complete and up-to-date facilities register technology are expected to increase the effectiveness covering all types of health care providers, and it benefits of the wasors and TB teams by reducing the burden of from the use of case-based TB registers that automatically manual work currently experienced by both the public tag those provider types. Efforts should be made to and private sectors. measure referrals as well as notifications. Analysis of the quality of care requires that TB outcomes be tracked by Enablers required to implement recommendations type of provider. Sufficient financial and human resources will be required to implement the above-mentioned recommendations. Other uses of technology A proper budgeting and HR requirement assessment is As previously mentioned, technology66 could be a needed to determine the level of resources required. powerful support tool for increasing the effectiveness of Completion of a RAD (District Action Plan) is an enabler the TB program. Such technology could facilitate tasks for increasing the budget allocation to the TB program. like digital payment of the incentives and enablers in DHOs can also look for opportunities to use the recommendation C (treatment completion incentives increasing capitation-based funds available at Puskemas, for Puskesmas and clinics), the usage of automated and any newer sources of DHO financing, such as the SMS to patients or treatment supporters (PMO) for example of the Surabaya DHO using tax money from treatment reminders, and two-way SMS/chat if patients cigarettes to fund training for clinics. have any issues or questions. Following this theme, further rollout of WiFi TB is encouraged as a way to Summary simplify reporting for smaller institutions such as clinics Together, the interventions outlined above and in Figure and individual practitioners. Digital technologies can 3, address private provider engagement in Indonesia also enable innovations that further facilitate private on multiple fronts. Payment reforms address access to provider engagement at scale, such as digital payments to diagnostics, down-referral, and treatment completion; and patients (cash transfers in India), adherence monitoring enhancement of the people, performance, and technology technologies, distance learning, remote diagnostics (like for DPPM address the complementary interventions
47 that support and provide the framework for private qualitative district variations and how the implementation provider engagement. These interventions and more will of potential interventions would vary based on each be needed to address the multiple challenge of private district’s characteristics can be found in section II of the provider engagement for TB in Indonesia. annex
5.3 District and implementation variations
It is important to recognize that variations across districts could have implications for implementing the proposed interventions. An overview of the key quantitative and
48 6. Conclusion
he purpose of this review was to understand patients. This function remains severely under-resourced the challenges and opportunities in working with in Indonesia in terms of both finances and human private provider institutions to improve TB health resources. Toutcomes, building on the findings of the individual private provider/patient review. The interviews revealed This review is one piece of a bigger puzzle that should the attitudes of private sector institution toward TB be considered by further activities, such as the NTP’s and participation in public sector programs, which are DPPM rollout, the USAID TBPS Activity and R4D substantially driven by financial incentives but also by the Strategic Health Purchasing project, in a concerted effort current lack of public health supports provided to private to eliminate TB in Indonesia. These solutions should be provider institutions. The review identified a number of considered as a set of priority areas to further test and opportunities, particularly focused on keeping presumptive explore as NTP and KOPI-TB continue to define their TB in primary care (and improving treatment outcomes at private provider engagement strategies. A deeper study primary care), encouraging down-referrals from hospitals, is needed to ensure that the solutions are feasible and all increasing access to government-funded FDCs, and the key stakeholders involved are aligned. reducing tension between Puskesmas and clinics. As specific solutions are developed and refined, a Addressing the access of government-funded FDCs for collaborative process will be needed that draws in private private primary care providers should continue to be sector patients and providers, along with NTP, PPJK, a key leverage point in treating TB patients in primary BPJS-K professional associations, and other important care. Pay-for-performance incentives for each treatment actors. This will ensure that solutions developed meet completion is expected to increase clinics’ participation in the needs of patients and providers and are grounded DPPM, but other countries have seen that it is even more in an understanding of how each intervention works important to strengthen the public-health-supporting in the context of current preferences, incentives, and initiatives – the interventions such as DPPM that are institutional relationships. provided via public sector financing for private sector TB
49 Annex section
A. Methodology A.2 Approach to qualitative research and insight generation A.1 Geographic focus and district selection The findings from this review stem from district research The objective of the district selection process was to with private sector hospitals, clinics, pharmacies, and labs identify districts with a large number of opportunities for using a multi-step process. This process was adapted from private sector engagement. The seven selected districts BCG best practices for conducting qualitative interviews. included three districts that were part of the USAID- funded Challenge TB (CTB) program and four districts At a high-level, there were six key steps in this process: that were not. Selection criteria for Challenge TB districts included at least two provinces, a mix of cities and 1). Pre-planning regencies, and at least one district with substantial middle- income population. Criteria for non-Challenge TB districts 2). Pre-research hypothesis generation included representation across two different provinces and at least one city and one regency. 3). Interview guide development and pre-work
A four-stage methodology67 was used to identify the final 4). Interview conducting* districts from an initial set of 16 Challenge TB districts and 498 non-Challenge TB districts: 1) Screen out districts 5). Insights capture and hypothesis refinement* outside USAID CDCS68, 2) Screen out districts with population under 450,000, 3) Screen out districts with 13 6). Synthesis or fewer hospital, and 4) Test final selected districts for feasibility. *Note that steps four and five were iterative in that they informed each other throughout the process. The following figures highlight each stage in the methodology for selection of Challenge TB districts Each step of the process is explained in more detail in the (Figure 4) and non-Challenge TB districts (Figure 5). following sections. To clarify the process, the example of hospitals is used. A similar process was used for all facility Based on the methodology and framework above, seven types. districts were jointly selected and aligned with NTP: Medan in North Sumatera; North Jakarta in the special capital Step 1: Pre-planning region, Daerah Khusus Ibukota (DKI) Jakarta; Tangerang regency and Tangerang city in Banten; Tulungagung and The review team engaged in pre-planning to set the Surabaya in East Java; and Makassar in South Sulawesi. objectives of the district research, determined the number
50 Figure 4: Detailed methodology for Challenge TB districts selection
Districts excluded 16 CTB districts Jayawijaya Exclude districts with population < 450,000 Mimika Jayapura 13 remaining districts Exclude districts with >63% rural population 1 OR >73% rural Desas (villages) None 13 remaining districts Jakarta Barat Exclude districts with average HH expenditures >5M IDR/month AND GINI coefficient <= 0.41 Jakarta Pusat Jakarta Timur 10 remaining districts
Exclude districts with < 8 private hospitals Jember
2 9 remaining districts Exclude districts with > 42% of case Kota Bandung notifications from private providers Surakarta 7 remaining districts Rank districts on private sector 3 reporting and # of private hospitals
Assess and select 4 districts
Figure 5: Detailed methodology for non-Challenge TB districts selection
Districts excluded 498 non-CTB districts
Exclude districts outside 14 USAID health priority provinces in Indonesia CDCS OR population < 450,000 394 districts 13 remaining districts Exclude districts with >63% rural population 1 OR >73% rural Desas (villages) 52 districts 13 remaining districts Exclude districts with average HH expenditures > 5M IDR/month AND GINI coefficient <= 0.41 3 districts 10 remaining districts
Exclude districts with < 8 private hospitals 33 districts
2 9 remaining districts Exclude districts with > 8% of case reporting from private providers 2 districts 7 remaining districts Rank districts on private sector 3 reporting and pop. per hospital, GP
Select districts, 4 incorporating feasibility
51 and type of hospital interview participants, and developed hospitals may be performing currently in diagnosing, the selection methodology and the location of the treating, and reporting TB; the nature of their interviews (for hospitals, the interviews were conducted relationships with other facilities and providers; and the at each of the hospitals). rationale for this behavior. It was critical to do this prior to developing interview guides as well as ensuring that For hospitals, the key research objectives were to the research was structured and delivered in a way that understand the sphere of influence of hospitals in TB could meet objectives and enable the team to identify care; identify strengths, weaknesses, and opportunities the most effective levers and incentives to affect change. of institutional relationship between hospitals and other The hypotheses were informed by existing literature and TB care providers; and highlight institutional incentives research, findings from past efforts and the perspectives and disincentives to providing high quality, effective TB of experts in the field (including hypotheses shared by treatment, including via participation in district PPM. For DHO in introduction meetings). In generating these each district, this review targeted interviews with four hypotheses, the review team also considered relevant to five directors or managers or the TB team of private ‘root causes’. hospitals. In order to be able to see meaningful distinctions in behaviors and incentives for hospitals, this review sought For hospitals, specific ongoing hypotheses included: a balanced set of hospitals based on characteristics such as: • Hospitals serving a high percentage of clientele with • Class and size: broader socioeconomic status, especially lower ones, »» A mix of different hospitals including Type may be more reliant on BPJS-K reimbursement in (A/B/C/D); and/or order to cover their cost (given the lower ability of patients to pay) and, therefore, careful consideration »» Varying numbers of beds and outpatients; and/or of the impact of BPJS-K is vital to driving positive » changes for TB care especially in rural, less affluent » Varying numbers of reported TB cases areas.
• TB-service capabilities: • Chain hospitals, such as Rumah Sakit Hermina, »» A mix of facilities with in-house labs with and might be an important opportunity for impact in any without advanced TB diagnostic tools (GeneXpert, change initiative due to the sheer number of facilities DST, and Culture) and with and without in-house within the network, assuming there was a strong pharmacies disbursing TB drugs (FDC vs. loose) central command model. »» Aimed to include all facilities within the district • Hospital groups with feeder clinics, like Rumah Sakit with GeneXpert if possible Siloam and Klinik Siloam, have a larger sphere of influence and are less likely to be worried about • BPJS-K empanelment: Mix of BPJS-K-affiliated and potentially losing clients from down-referrals, as non-BPJS-K affiliated reimbursement payments would still be captured in the broader hospital-clinic network. • Business model: Mix of chain and non-chain facilities • Hospitals that are part of a group with other • Clientele served: Mix of higher and lower business, such as Mitra Keluarga owned by the socioeconomic status clientele (proxy by % largest pharmaceuticals company in Southeast Asia, of BPJS-K patients or affluence level of the Kalbe Farma, are likely to present both challenges neighborhood) (they may prefer their own drugs to government- funded FDCs in their hospitals) and opportunities The review team selected the facilities with input from (ability to better monitor care over the patient NTP, Challenge TB, and DHO to identify those hospitals pathway). seen as technical and moral leaders in TB as well as to ensure feasibility (i.e. ability to secure interviews). (See • Hospitals that are part of a strong broader network Section I.1.3 for details on facility selection). of care (such as referral agreements with labs and pharmacies, with Puskesmas or civil society Step 2: Pre-research hypothesis generation organizations (CSOs), or professional health associations, as well as commercial service providers Prior to conducting research in the districts, the review such as sample transporters) as opposed to those team developed theories about how private sector that act independently, may be more effective
52 and efficient in delivering convenient, consistent • What were the key themes and takeaways related care because they have institutions that can help to our project objectives? supplement care delivery or reinforce behaviors of the providers and patients. This process enabled the review team to refine and focus pre-research hypotheses as needed. Step 3: Interview guide development and pre-work Step 6: Synthesis The review team developed an interview guide to help direct the interview discussion, ensuring that the questions After conducting district research, the review team were aimed to test the pre-research hypotheses and synthesized the findings and identified key themes overarching project objectives. including:
Step 4: Interview conduct • Areas of convergence and divergence across interview findings (also highlighted the findings that For each of the districts, the interviews with hospital were expected and unexpected and why). directors/managers/TB team took place in stages over the course of one to two weeks as opposed to • Areas most useful in answering the overarching all of the interviews for hospitals being conducted in project questions. one condensed, discrete time period (note that for most districts it took up to ten days to complete all • Insights on the rationale for why challenges were interviews for that district including hospitals, clinics, labs, occurring. pharmacies, DHO, and professional associations). This staged approach was deliberate in order to enable the A.3 Institution selection team to reflect, adjust, and refine in between interviews. Specifically, the initial set of interviews was used as The review team interviewed three groups of exploratory interviews to test (prove/disprove) initial stakeholders: government (Dinas Kesehatan or DHO), hypotheses and understand the range of responses from private providers (hospitals, clinics, pharmacies, and labs), participants. Once initial patterns emerged, the team used and non-public stakeholders (professional associations the interviews to a) continue to validate patterns and and CSOs). The set of institutions selected across probe deeper on understanding the “why”, b) to probe the stakeholders was not meant to be statistically in-depth on specific concepts emerging as critical, and/or representative, but to provide a balanced qualitative c) to close any remaining gaps in information. view of overall TB care and health system in the private sector within Indonesia. As such, the targeted The evolution of interviews occurred over the course of mix of institutions included a range of typologies and the research in each district as well as across districts. This characteristics as highlighted in Figure 6. Due to data ongoing refinement was informed by the step to capture limitations, especially for private clinics, pharmacies, insights as outlined in the next section. and labs, institution selection was not by a solely data- driven approach and included supplemental feedback Step 5: Insights capture and hypothesis refinement from District Health Offices (DHO) and the district- level Challenge TB teams (for North Jakarta, Medan, The review team captured insights during the interview and Tulungagung). Local knowledge of the DHO and as well as after the interview in addition to an Challenge TB team in each district helped to identify audio recording. Key insights of the interviews were facilities and organizations considered relevant actors documented and shared with the broader team, and the in providing TB care while ensuring feasibility to secure audio recordings were listened to in order to ensure key interviews. points were captured. After each interview (or at the end of each day if interviews were scheduled back-to-back), Several notes on the institutions selected: the review team discussed key themes and tested several areas including: • No Class A hospitals were interviewed as there were no Class A private hospitals in the interviewed • Were the interviews providing the type of insight we districts. need? If not, what needed to be adjusted? • Only 2 out of 36 interviewed clinics were of • What were we learning that might prove or “utama” classification due to the limited numbers of disprove our hypotheses? this type in participating districts.
53 • A higher proportion of BPJS-K clinics (32 out of 36 many non-BPJS-K hospitals in the districts were interviewed clinics) were interviewed, as BPJS-K tertiary hospitals, such as eye hospitals or cancer clinics are more likely than non-BPJS-K clinics to have hospitals, which typically do not have TB patients. developed relationships with DHO and are more readily available for interviews. Due to limited data • Only those professional associations and CSOs with on TB mapping by facility, the review team accepted district-level presence or offices were interviewed in the skew toward BPJS-K clinics, as the results from each district. the individual provider/patient review suggested that most TB patients use BPJS-K for their treatment. B. District summaries • Similarly, a higher proportion of BPJS-K hospitals (35 out of 40 interviewed hospitals or ~88%) were This section includes summaries for each of the seven interviewed to reflect the proportion of BPJS-K focus districts. It captures key findings and observations empanelment in each district (~50-90%). In addition, from interviews with the facilities, DHOs, professional
Figure 6: Variation of typologies and characteristics for institution selection
Professional Associations and Civil Hospital Clinic Pharmacy Lab Criteria Society Organizations (n=4-5 per district) (n=4-5 per district) (n=8-10 per district) (n=4-6 per district) (based on district availability)
Mix of size, based on Mix of size of clinics1, Mix of size, based on Mix of size, based on • Type (A/B/C/D), based on • # of pharmacists, or • # of TB diagnostics and/or • Type (pratama and • # of TB drugs sold, performed, or Size • # of beds and utama), and/or or • # of laboratory outpatients, and/or • # of doctors and/or • # of TB cases technicians • # of reported TB • # of patients referred Professional Associations: cases • IDI (doctor association) • IAI (Pharmacist association) • IDAI (Pediatrician Mix of labs with and Mix of labs with and Mix of pharmacies Mix of labs with and association) without advanced without advanced selling more FDC and without advanced • PAPDI (Internist TB diagnostic tools TB diagnostic tools selling more loose drugs TB diagnostic tools association) (GeneXpert, DST, (GeneXpert, DST, (GeneXpert, DST, TB care • PDPI (Pulmonologist Culture) and in-house Culture) and in-house Culture) service association) pharmacy disbursing TB pharmacy disbursing TB • PATELKI (lab tech. capabilities drugs (FDC vs. loose) drugs (FDC vs loose) association) • ILKI (lab associations) Include all facilities with Include all facilities with Include facilities with • PKFI (Primary health GeneXpert if possible GeneXpert if possible GeneXpert if possible care association) • ASKLIN (clinic association) Not applicable (Not • ARSSI (private hospitals BPJS-K affiliated with BPJS-K, association) affiliation Mix of BPJS-K-affiliated and non-BPJS-K affiliated except for preventive diagnosis, e.g. cervical CSOs cancer pap smear) • AISYIYAH • LKNU Business • PESAT model Mix of chain and non-chain facilities • JKM • PETA • PPTI Clientele Mix of higher and lower SES clientele (proxy by % of BPJS-K patients or affluence level of served neighborhood)
Qualitative (For CTB district only) Level of engagement or participation of facilities in enhancing/supporting TB assessment care in the area
54 associations, and CSOs. Each district summary covers The variations we observed are the result of three topics: a) institutional relationships and business decentralized governance in Indonesia, along with the landscape, b) DHO role and implementation of DPPM, demographic composition of each district and local and c) the role of non-public stakeholders. While the key care-seeking behavior. Since decision-making is primarily findings across districts – as presented in Section 5 of the conducted at the district level, the individual districts have review’s main report – are included as context where developed different practices and emphasize different important, the primary focus of the following summaries is actions. There appear to be limited, if any, efforts to to highlight unique findings for each district. identify and spread best practices among the different districts in a province, let alone to districts in other Before diving into the individual district summaries, this provinces. section first presents an overview of the key quantitative and qualitative district variations. The quantitative data, Overview of key district variations – Quantitative as shown in Table 2, was collected from interviews with the DHOs and from secondary desktop research, with Table 2 below summarizes the key demographics and the purpose of providing more context to readers on key TB service statistics across the seven reviewed districts. aspects such as district demographics and TB statistics. The Several statistics in this table, such as TB capabilities and section on quantitative district variations is then followed detailed breakdown of DOTS function, are not available by the qualitative overview, which stems from observations at the district-level and thus only data69 for interviewed from the district interviews and includes additional insights facilities is included. Unless otherwise noted, all data into potential implications for implementation. represented is for the entire district.
Table 2: Key district demographics and TB service statistics across 7 districts
Challenge TB Districts Non-Challenge TB Districts
Jakarta Kab. Kota Medan Tulungagung Makassar Surabaya Utara Tangerang Tangerang
DISTRICT-WIDE DATA
Population (in thousands) ('15) 1747 2211 1021 3371 2047 1449 2849
Rural population (%) ('10) 0 0 0.54 0.18 0 0.01 0 District demographics Size of district (km2) (Various Years)70 147 265 1056 1012 154 176 351
Average monthly HH expenditure (in million IDR) 7.8 4.6 2.7 4.2 5.4 4.9 6.6 ('15)
# Est. annual TB Cases (+) ('17) 6,471 14,141 3,242 12,000 7,000 6,040 9,953
# reported annual TB cases71 4897 8224 1043 7900 1829 4926 6,601 ('17), split by (Private + Public) (1,624+ (3,407+ (241+ (4,400+ (0+ (222+ (1,344+ 3,273) 4,817) 802) ,500) 1,829) 4,704) 5,257) TB statistics Under-reporting (%) in a year 24% 42% 68% 34% 74% 18% 34% (under-reported case over est. (1,574/ (5,917/ (2,199/ (4,100/ (5,171/ (1,114/ (3,352/ TB cases) 6,471) 14,141) 3,242) 12,000) 7,000) 6,040) 9,953)
Private sector reporting over 33% 41% 23% 56% 0% 5% 20% total reported TB case per year (1,624/ (3,407/ (241/ (4,400/ (0/ (222/ (1,344/ (%) 4,897) 8,224) 1,043) 7,900) 1,829) 4,926) 6,601)
55 Table 2: Key district demographics and TB service statistics across 7 districts (Continued)
Challenge TB Districts Non-Challenge TB Districts
Jakarta Kab. Kota Medan Tulungagung Makassar Surabaya Utara Tangerang Tangerang
DISTRICT-WIDE DATA
Total: 12/17 Total: 38/72 Total: 8/11 Total: 16/25 Total: 25/26 Total: 20/34 Total: 24/47 A: 0/0 A: 0/0 A: 0/0 A: 0/0 A: 0/0 A: 0/0 A: 0/0 # BPJS-K private Hospitals / B: 3/6 B: 11/13 B: 0/0 B: 3/3 B: 5/5 B: 9/10 B: 7/11 # of private hospitals (with C: 7/9 C: 24/40 C: 3/6 C: 11/19 C: 19/20 C: 10/22 C: 13/25 breakdown of Class A/B/C/D/ D: 0/0 D: 3/7 D: 5/5 D: 2/2 D: 1/1 D: 1/1 D: 4/6 not yet classified) Not yet Not yet Not yet Not yet Not yet Not yet Not yet classified: classified: classified: classified: classified: classified: classified: 2/2 0/12 0/0 0/1 0/0 0/1 0/5
Total: 7/7 Total: 8/13 Total: 2/2 Total: 3/3 Total: 3/3 Total: 17/17 Total: 15/20 A: 0/0 A: 1/2 A: 0/0 A: 0/0 A: 1/1 A: 3/3 A: 3/6 Number of # BPJS-K public Hospitals / B: 1/1 B: 4/4 B: 1/1 B: 2/2 B: 0/0 B: 9/9 B: 5/6 BPJS-K # of public hospitals (with C: 2/2 C: 2/3 C: 1/1 C: 0/0 C: 2/2 C: 4/4 C: 4/4 facilities breakdown of Class A/B/C/D/ D: 4/4 D: 0/1 D: 0/0 D: 1/1 D: 0/0 D: 0/0 D: 3/3 not yet classified) Not yet Not yet Not yet Not yet Not yet Not yet Not yet classified: classified: classified: classified: classified: classified: classified: 0/0 1/3 0/0 0/0 0/0 1/1 0/1
Total: Total: Total: 102/ Total: Total: Total: 129/300 49/369 No data Total: 13/27 69/168 90/104 93/207 # BPJS-K private clinics / # of Pratama: Pratama: Pratama: Pratama: Pratama: Pratama: Pratama: private clinics (Pratama/Utama 129/No 48/342 100/100 13/27 65/No data 89/No data 86/140 classification breakdown given) data Utama: Utama: 2/ Utama: 0/0 Utama: 4/ Utama: 1/ Utama: Utama: 0/ 1/27 No data No data No data 7/67 No data
# Puskesmas 49 39 32 43 33 46 63
# Pharmacies72 Total: 430 Total: 506 Total:128 Total: 183 Total: 656 Total: 252 Total: 820 Number of PRB: 5 PRB: 19 PRB: 6 PRB: 0 PRB: 4 PRB: 1 PRB: 20 facilities # Private Labs 25 No data 10 No data 13 12 86
# Public Labs73 0 2 1 0 1 2 2
Private hospitals (as % of all 71% 85% 85% 89% 90% 67% 70% hospitals) Private: Public (17/24) (72/85) (11/13) (25/28) (26/29) (34/51) (47/67) facilities proportion Private clinics (as % of all clinics 88% 46% 87% 80% 69% 77% No data + Puskesmas) (369/418) (27/59) (300/343) (168/201) (104/150) (207/270)
# Beds in hospitals, split by 3,131 8,681 908 2,679 3,010 6,048 7,667 (Private + Public) (2,068+ (6,125+ (415+ (2,036+ (2,475+ (2,615+ (3,509+ 1,063) 2,556) 493) 643) 535) 3,433) 4,158)
0.62 0.98 # Outpatients in hospitals (in 1.7 1.5 0.59 1.5 4.3 Facility Size (Data not (Data not mn), split by (Private + Public) (1.0+0.7) (1.1+0.3) (0.4+0.2) (1.3+0.16) (2.5+1.8) available) available)
% Private hospital with DOTS Corner (as % of all private 71% 40% 55% 56% 31% 9% 70% hospitals) (12/17) (29/72) (6/11) (14/25) (8/26) (3/34) (33/47)
56 Challenge TB Districts Non-Challenge TB Districts
Jakarta Kab. Kota Medan Tulungagung Makassar Surabaya Utara Tangerang Tangerang DISTRICT-WIDE DATA # Total GeneXpert machines (public+private hospitals+ 8 4 1 3 2 4 9 Puskesmas) GeneXpert # GeneXpert machines in profile private facilities 1 0 0 1 1 1 0 % Puskesmas with GeneXpert 4% 0% 0% 0% 0% 0% 8% (as % of all Puskesmas) (2/49) (0/39) (0/32) (0/43) (0/33) (0/46) (5/63) % Puskesmas Rujukan Mikroskopis75 (as % of all 12% 0% 0% 21% 0% 0% 100% (6/49) (0/39) (0/32) (9/43) (0/33) (0/46) (63/63) Puskesmas74 Puskesmas) Service % Puskesmas Pelaksana Mandiri76 (as % of all 0% 85% 100% 58% 100% 100% 0% availability and (0/49) (33/39) (32/32) (25/43) (33/33) (46/46) (0/63) TB capabilities Puskesmas) % Puskesmas Satelit (Satellite 88% 15% 0% 21% 0% 0% 0% PKM)77 (as % of all Puskesmas) (43/49) (6/39) (0/32) (9/43) (0/33) (0/46) (0/63) DATA FROM INTERVIEWS ONLY (non-representative data)
Yes: 83% Yes: 83% Yes: 83% Yes: 40% Yes: 33% Yes: 50% Yes: 67% % Private hospital with DOTS (5/6) (5/6) (5/6) (2/5) (2/6) (3/6) (4/6) certification from DHO (as % In process: In process: In process: In process: In process: In process: In process: of interviewed hospitals) 0% (0/6) 0% (0/6) 0% (0/6) 40% (2/5) 50% (3/6) 0% (0/6) 0% (0/6) No: 17% No: 17% No: 17% No: 20% No: 17% No: 50% No: 33% (1/6) (1/6) (1/6) (1/5) (1/6) (3/6) (2/6)
Yes: 100% Yes: 83% Yes: 83% Yes: 40% Yes: 83% Yes: 83% Yes: 67% % Private Hospitals (6/6) (5/6) (5/6) (2/5) (5/6) (5/6) (4/6) with supporting DOTS Partial: 0% Partial: 0% Partial: 0% Partial: 20% Partial: 0% Partial: 17% Partial: 0% infrastructure78 (as % of (0/6) (0/6) (0/6) (1/5) (0/6) (1/6) (0/6) interviewed hospitals) No: 0% No: 17% No:17% No: 40% No: 17% No: 0% No: 33% (0/6) (1/6) (1/6) (2/5) (1/6) (0/6) (2/6)
% Private Hospitals with Yes: 67% Yes: 17% Yes: 83% Yes: 60% Yes: 83% Yes: 50% Yes: 83% centralized TB recording in (4/6) (1/6) (5/6) (3/5) (5/6) (3/6) (5/6) Interviewed facility (as % of interviewed No: 33% No: 83% No: 17% No: 40% No: 17% No: 50% No: 17% hospitals) Hospitals (2/6) (5/6) (1/6) (2/5) (1/6) (3/6) (1/6) DOTS corner Yes: 33% Yes: 83% Yes: 50% Yes: 40% Yes: 33% Yes: 33% Yes: 83% profile % Private Hospitals reporting (2/6) (5/6) (3/6) (2/5) (2/6) (2/6) (5/6) TB data to public sector (as % Partial: 50% Partial: 0% Partial: 33% Partial: 40% Partial: 50% Partial: 17% Partial: 17% of interviewed hospitals) (3/6) (0/6) (2/6) (2/5) (3/6) (1/6) (1/6) No: 17% No: 17% No: 17% No: 20% No: 17% No: 50% No: 0% (1/6) (1/6) (1/6) (1/5) (1/6) (3/6) (0/6)
% Private Hospitals using Yes: 67% Yes: 83% Yes: 83% Yes: 60% Yes: 33% Yes: 50% Yes: 50% public sector drugs (as % of (4/6) (5/6) (5/6) (3/5) (2/6) (3/6) (3/6) interviewed hospitals) No: 33% No: 17% No: 17% No: 40% No: 67% No: 50% No: 50% (2/6) (1/6) (1/6) (2/5) (4/6) (3/6) (3/6)
% Private Hospitals conducting Yes: 0% Yes: 0% Yes: 0% Yes: 0% Yes: 0% Yes: 0% Yes: 0% drug intake monitoring (as % of (0/6) (0/6) (0/6) (0/5) (0/6) (0/6) (0/6) interviewed hospitals) No: 100% No: 100% No:100% No: 100% No: 100% No: 100% No: 100% (6/6) (6/6) (6/6) (5/5) (6/6) (6/6) (6/6)
57 Table 2: Key district demographics and TB service statistics across 7 districts (Continued)
Challenge TB Districts Non-Challenge TB Districts
Jakarta Kab. Kota Medan Tulungagung Makassar Surabaya Utara Tangerang Tangerang
DATA FROM INTERVIEWS ONLY (non-representative data) % Private hospital with sputum microscopy capability (as % of 100% 100% 83% 100% 100% 100% 83% interviewed hospitals) (6/6) (6/6) (5/6) (5/5) (6/6) (6/6) (5/6) Interviewed % Private hospital with IGRA Hospitals capability (as % of private 17% 0% 0% 0% 0% 0% 0% (1/6) (0/6) (0/6) (0/5) (0/6) (0/6) (0/6) TB capabilities hospitals) % Private hospital capable of culture test (as % of private 0% 0% 0% 0% 0% 0% 33% hospitals) (0/6) (0/6) (0/6) (0/5) (0/6) (0/6) (2/6) % Clinics in PPM (as % of 20% 20% 25% 33% 0% 40% 83% Interviewed Clinics) (1/5) (1/5) (1/4) (2/6) (0/5) (2/5) (5/6) % Clinics reporting TB data 60% 40% 25% 33% 0% 40% 83% Interviewed to public sector (as % of Interviewed Clinics) (3/5) (2/5) (1/4) (2/6) (0/5) (2/5) (5/6) Clinics % Clinics using public sector DOTS corner drugs (as % of Interviewed 20% 40% 25% 33% 0% 40% 50% profile Clinics) (1/5) (2/5) (1/4) (2/6) (0/5) (2/5) (3/6) % Clinics conducting drug intake monitoring (as % of 20% 0% 0% 0% 0% 20% 0% Interviewed Clinics) (1/5) (0/5) (0/4) (0/6) (0/5) (1/5) (0/6)
% Clinics with X-ray capability 40% 20% 25% 0% 0% 40% 0% (as % of interviewed clinics) (2/5) (1/5) (1/4) (0/6) (0/5) (2/5) (0/6)
% Clinics with IGRA capability 0% 0% 0% 0% 0% 0% 0% (as % of interviewed clinics) (0/5) (0/5) (0/4) (0/6) (0/5) (0/5) (0/6) % Clinics with in-house 40% 80% 50% 100% 60% 33% pharmacy (as % of interviewed 100% (5/5) Interviewed clinics) (2/5) (4/5) (2/4) (6/6) (3/5) (2/6) Clinics % Clinics with in-house lab (as 40% 40% 50% 33% 40% 80% 33% TB capabilities % of interviewed clinics) (2/5) (2/5) (2/4) (2/6) (2/5) (4/5) (2/6) % Clinics with pulmonology unit (as % of interviewed 0% 0% 0% 0% 0% 20% 0% clinics) (0/5) (0/5) (0/4) (0/6) (0/5) (1/5) (0/6) % Clinics with practicing internist/s79 (as % of 20% 0% 0% 17% 0% 20% 0% interviewed clinics) (1/5) (0/5) (0/4) (1/6) (0/5) (1/5) (0/6) Interviewed % Pharmacies that stock TB Pharmacies drugs80 (as % of interviewed 88% 86% 75% 100% 100% 88% 63% (7/8) (6/7) (6/8) (8/8) (8/8) (7/8) (5/8) TB stock profile pharmacies) % Labs with Sputum test capability (as % of interviewed 80% 100% 75% 80% 33% 80% 100% lab) (4/5) (4/4) (3/4) (4/5) (1/3) (4/5) (4/4)
% Labs with X-ray capability (as 80% 50% 50% 80% 33% 80% 100% Interviewed % of interviewed lab) (4/5) (2/4) (2/4) (4/5) (1/3) (4/5) (4/4) Laboratories TB capabilities % Labs with IGRA capability (as 40% 25% 0% 0% 33% 0% 75% % of interviewed lab) (2/5) (1/4) (0/4) (0/5) (1/3) (0/5) (3/4)
% Labs with Culture test capability (as % of interviewed 0% 25% 0% 60% 0% 40% 0% lab) (0/5) (1/4) (0/4) (3/5) (0/3) (2/5) (0/4)
58 Overview of key district variations – Qualitative or Puskesmas. This variation is particularly interesting for Surabaya as there was no patient objection to Puskesmas Institutional relationships and business landscape observed, which make it an outlier compared with other urban districts. This is likely in part due to a more Patients’ care-seeking behavior developed relationship between clinics and Puskesmas Patients’ care-seeking behavior in TB varies across districts as a result of the DHO mandate for all Puskesmas to and is influenced by multiple institutional and patient- provide free TB service for Surabaya residents, regardless related factors including demographic composition (urban/ of where the patient’s BPJS-K membership is registered. rural) and degree of DPPM implementation. Table 3 provides an overview of how the two factors interplay It was reported that patients and clinics in more rural with each other. Note that clinics are not included as an districts such as Tulungagung prefer treatment in option since they generally are unable to diagnose TB Puskesmas, since Puskesmas are more accessible and and therefore refer patients to either secondary care or considered better equipped than clinics and are willing to Puskesmas (PKM). accept clinic patients without requiring clinics to transfer their capitation. Even though DPPM implementation Overall, interviewees reported that patients in more is still in its early stages in Tulungagung, the DHO and urban districts such as North Jakarta, Medan, and Makassar interviewed providers (clinics and hospitals) mentioned were more likely to seek care directly in secondary care, that the accepting, non-confrontational, and hospitable bypassing primary care as a gatekeeper. In addition, local culture may also be the motivation for Puskesmas there were several reinforcing factors in each district to behave in this way. In addition, this could also be which further drove this tendency. In Medan, there was influenced by the relatively low access patients have to a particular perception around the inhospitable attitude secondary care (ratio of one bed per ~1,125 people) in of Puskesmas staff which reportedly discouraged patients comparison with more urban districts such as Jakarta (one from private clinics from seeking TB care there. In bed per ~558 people) or Surabaya (one bed per ~372 North Jakarta and Makassar, patients had to move their people). capitation or pay out-of-pocket when being referred to Puskesmas. This combination of factors thus drove the Profile of private labs clinics we interviewed in these districts to refer their TB Another variation observed across the districts was the patients to secondary care. composition of private players, particularly the private labs. In bigger cities such as North Jakarta, Medan, and The behavior observed and reported in Kota Tangerang, Surabaya, labs are primarily the large chain players that Surabaya, and Kabupaten Tangerang was different – there typically have more sophisticated internal and external was no clear orientation toward secondary care, hospitals quality assurance processes. A good illustration of this is
Table 3: Patient preference mapping across districts
Demographic DPPM progress and District Preferred location for TB diagnosis and care composition (% urban) implementation81
North Jakarta 100% Med Secondary care82
Medan 100% Low Secondary care83
Makassar 99% Med Secondary care84
Kota Tangerang 100% Low Neutral (no objection to PKM)85
Surabaya 100% High Neutral (no objection to PKM)86
Kab Tangerang 82% Med Neutral (no objection to PKM)87
Tulungagung 46% High Puskesmas (PKM)88
59 that all of the labs interviewed in North Jakarta were large organizations (KOPI TB) or lower its effectiveness in lab chains, potentially because the DHO’s relationships are driving initiatives aimed at aligning different actors in TB concentrated on the bigger labs that make up so much of treatment. This implies that the DHO in smaller districts the market (in 2015 Prodia was the largest lab chain with may need to focus on the key associations that exist in the 35% market share, and the next five key players make district (which is typically the doctors association, IDI) and/ up another 33% of market share89). Meanwhile in smaller or look for alternative ways to deliver services, like training cities, such as Tulungagung and Kab. Tangerang, there were and education, that associations often provide. only one or two large lab chains in the whole district. The majority of the players were smaller standalone labs or No observeable difference in CSOs across districts regional chain labs, which typically don’t have the same was observed. All CSOs were typically funded by quality standard as the larger chain players. donor organizations and faced the challenge of funding sustainability. DHO role and implementation of DPPM Implementation variations by intervention Degree of DPPM implementation/overall progress of TB program The following section describes how implementation of The state of DPPM implementation is another key each intervention might vary based on the characteristics variation observed across districts that should be of each district. considered as interventions are designed and implemented. Readers can refer to the summarized view of the Intervention A: Conditional fee-for-service for TB differences in section 4.1.4 and the discussion in section diagnosis 5.3. One factor contributing to the variation in DPPM implementation is the direct support from Challenge TB, There are two dimensions that influence this intervention: which can be observed in the three Challenge TB districts patient preferences for primary versus secondary care interviewed – North Jakarta, Medan, and Makassar. Further and the level of Puskesmas capability. As discussed detail of progress in each district can also be found in the previously, patients in more urban districts such as Medan summary of each district in the annex. and North Jakarta tend to gravitate toward secondary care as compared with patients in more rural districts Presence of informal or authorized health care personnel such as Tulungagung, likely resulting in higher BPJS-K A particular challenge faced by regions with higher rural reimbursements on a per TB-patient basis for the urban populations, such as Tulungagung, is to curb informal or districts. For the other districts where patients have unauthorized health care personnel – such as traditional no strong resistance toward Puskesmas (such as Kab. healers, midwives, and nurses – from treating TB patients, Tangerang), it is particularly important to facilitate the who may not have the expertise or clinical tools to introduction of fee-for-service TB diagnosis for Puskesmas diagnose and treat TB properly. This challenge is more units in addition to hospitals. pronounced in the more rural areas of these districts where informal health care personnel are likely more Implications for TBPS implementers: Implementers should accessible than registered GPs, clinics, or hospitals. work with the DHO to pilot fee-for-service for TB Utilization of these providers is expected to decrease diagnosis for hospitals and Puskesmas. Implementers once people get used to “free” services through BPJS-K should also consider patients’ preferences when facilities – and have the funds to pay for transport to get calculating or validating the cost-benefit analysis of this to these facilities – although this transition may still take intervention. some time. Intervention B: Inclusion of TB in PRB (“Program Role of other non-public stakeholders Rujuk Balik”)
Most professional organizations are present in the larger The inclusion of TB in PRB hinges on the assumption that districts of North Jakarta, Medan, and Surabaya. In smaller there are quality-assured private labs with enough capacity districts, such as Tulungagung and Kota Tangerang, there to run TB diagnosis tests for individual practitioners is a lack of professional associations and the districts rely and private clinics. However, in smaller and/or more on the provincial-level organizations instead. Associations rural districts such as Tulungagung, private labs may not without district-level presence may not have an established necessarily have the appropriate equipment or capacity network or relationships with the district-level facilities to run tests for the clinics and/or GPs. For example, one or the DHO. This may potentially either slow down the of the biggest labs in Tulungagung – Prodia – had sputum establishment of the local TB coalition of professional microscopy test capabilities (with unknown throughput
60 capacity), but lacked x-ray machines, and thus referred Intervention C assumes a sufficient level of Puskesmas TB symptomatics to hospitals instead. Another private lab units’ resources to fulfill their public health functions, such interviewed had both sputum test and x-ray capabilities, as on-the-ground tracing of loss-to-follow-up patients but did not participate in the quality-assurance scheme from the private sector. Puskesmas resources and (PME) for TB. Conversely, Prodia and other nationwide capacity, however, vary by district and will need to be lab chains such as Pramita in bigger districts such as further verified in future studies. Medan or North Jakarta have sputum microscopy test capability and x-ray equipment with 15 to 30 lab analysts. On a more tactical level, implementers can also expect Whatever capacity exists already, adding Xpert capacity Challenge TB-assisted districts to demonstrate faster will remain a priority. adoption of the intervention and a higher rate of treatment completion given the rollout of the WiFi-TB This intervention also expects participation from application in primary care. These districts could leverage PRB pharmacies as additional distribution points for the functionalities of WiFi-TB (second version), such as government-funded FDCs. Districts with a higher sending SMS and notification emails to patients to remind proportion of the PRB pharmacies being public or state- them of their treatment schedules and to Puskesmas and owned (i.e. Kimia Farma), such as Kab. Tangerang, Kota the DHO to report presumptive TB and TB patients. Tangerang, Surabaya, and Makassar (percentage of PRB pharmacies that are public are 100%, 71%, 57%, and Implications for TBPS implementers: Implementers may 50%, respectively), may demonstrate a faster adoption need to work alongside the DHO to determine the level of the intervention given the central command model of resources and capability of Puskesmas units to perform as compared with districts with a lower proportion their public health functions, which goes hand-in-hand of the PRB pharmacies being public, such as North with intervention D. Implementers could also encourage Jakarta, Tulungagung, and Medan (29%, 25%, and 10%, the deployment of the WiFi-TB application in non- respectively). In the former category of districts, PRB Challenge TB-assisted districts to facilitate easier reporting pharmacies are typically dominated by state-owned Kimia and ensure higher treatment adherence for primary care Farma. facilities.
Less than 30% of interviewed private pharmacies across Intervention D: Accelerate DPPM implementation all districts were empaneled in the PRB program and through DHO and Puskesmas incentives those that didn’t empanel in the PRB program cited two reasons for not participating in the PRB program: a long Efforts to accelerate DPPM implementation will be reimbursement cycle from BPJS-K that may put cash flow influenced by two dimensions: DHO resources for TB and constraints on the pharmacy, and instances of stockouts the presence and strength of professional organizations. in the e-catalogue system that forces the pharmacy to The level of both DHO funding and human resources are purchase the drugs from higher-priced distributors (non important drivers for accelerating DPPM intervention are e-catalogue) to fulfill the orders and thus settle for a constrained in most districts. In the absence of additional lower profit margin. resources, districts that are able to fund TB programs from alternative funding, such as cigarette tax collection Implications for TBPS implementers: Implementers should in Surabaya and increased budget from APBD through check the quality and capacity of private labs in the district action planning in Tulungagung, are likely better districts before implementing this intervention. In the positioned to accelerate DPPM implementation and event that there is an insufficient number of facilities continue engagement with private facilities. that meet the criteria to run quality TB diagnosis tests for clinics or GPs, implementers may engage and assign Weak district-level presence of professional associations Puskesmas units to do so under a similar payment scheme may impede the DPPM implementation in the district for private labs (concessionary pricing for the tests). because it translates to a lack of an established network Implementers should also work with BPJS-K to ensure PRB and weaker influence of these associations on the facilities pharmacies can access drugs on time, on demand, and are in the district. As a result, implementation in smaller being reimbursed on time, or that FDCs are sufficiently districts such as Kab. Tangerang, and Tulungagung may accessible via other providers in the private sector. be challenging, as they typically rely on the provincial- level professional organizations or engage in clustered Intervention C: Treatment completion incentives associations with several neighboring districts. In Tulungagung, for example, several common professional Puskesmas units’ capability and willingness to perform associations including ILKI, IDAI, and PAPDI were not their public health function is a relevant dimension as very active in the district, primarily because they didn’t
61 have enough resources or there were too few relevant For intervention B, implementers could start their efforts specialists in the district. in any of the seven districts, but may want to make sure Tulungagung has sufficient capacity from quality-assured Implications for TBPS implementers: Implementers should private labs first before executing the intervention. anticipate slower DPPM implementation for districts Implementers may also want to make sure that there without a sufficient level of DHO funding and human are sufficient number of PRB pharmacies that are resources. Implementers should also expect that for willing to serve as government-funded FDC distribution districts with low district-level presence of professional points, especially in districts where the majority of PRB associations, engaging and influencing private sector pharmacies are private, such as Medan (90%), although providers (and potentially the management of the private the assumption that public or state-owned pharmacies are facilities) may be less effective and the introduction of easier to engage and more open to participating in such regular TB education programs within organizations programs was not tested or proven in this review. (through KOPI-TB) may take longer than in districts with a stronger presence of professional organizations. B.1 Tulungagung
District prioritization Of the seven districts in this review, Tulungagung has the highest rural population (54%) and the lowest average District variations may not only influence how monthly household expenditure (IDR 2.7 million). The implementers should approach implementation, but large rural population, along with the perceived capability may also impact which district should be prioritized first of the public sector health care system, contributes to for implementation. In particular, the state of DPPM a positive attitude toward public sector health care and implementation in each district varies and thus each may influence the care-seeking behavior of patients. TA district’s readiness to adopt and implement interventions has a high proportion of BPJS-K hospitals (~80% of public may also differ. and private hospitals), which allows patients to access government-financed care in the district. The number of Districts with low private sector DPPM participation TB cases reported by the private sector is rather low at such as Kota Tangerang, Makassar, and Medan may 23% (~1,000) potentially due, in part, to the high number take longer to implement Intervention A or may need of cases being treated in public facilities. As one of the a manual workaround. For example, non-PPM enrolled Challenge TB-assisted districts, Tulungagung has ongoing hospitals may not have established the SITT system for initiatives to better engage private sector in the DPPM reporting and thus would need to rely on manual TB program. These characteristics, along with the market case documentation/submission as a condition for fee- environment, the resulting institutional relationships, and for-service reimbursement. Potential enhancements to the progress of the TB program, are examined in the the existing system to ease the reporting burden (e.g. following sections. linking SITT and BPSJ-K systems to merge claims and reports in one platform) may take longer in districts with Institutional relationships and business landscape a low percentage of BPJS-K affiliated facilities, such as Medan and Makassar. Implementers may want to focus As this review found across the districts, institutional their efforts on districts that have a higher percentage relationships in Tulungagung are relatively weak of facilities using SITT, such as North Jakarta (71%) and with limited formal agreement among facilities and Surabaya (70%), or recognize that the path to impact will organizations, except for more widespread relationships be longer. Note that all of this work will also need to be with private labs. We observed three examples in coordinated with the expected rollout of SITB (to replace Tulungagung where staff were employed at both public SITT) during 2019. and private primary care facilities, allowing for improved referral relationships and information exchange between Similarly, Intervention C requires the participation of clinics facilities. Referral relationships between private and public in PPM and a willingness to treat TB patients in-house. facilities in Tulungagung are further reinforced by patients’ Implementers should expect a slower ramp-up for districts general inclination to be treated at Puskesmas for TB. with low clinic PPM participation such as Makassar and Kota Tangerang where PPM participation is less than 10%. Unlike in other districts, Puskesmas in Tulungagung Instead, implementers may want to focus their efforts on were willing to accept referrals for clinic-based patients districts with higher clinic PPM participation first, such as for sputum tests and for treatment without requiring Kab. Tangerang, which has 40% participation. The concept the patient to transfer capitation. This could be a result of introducing and testing P4P schemes initially into higher of, according to the Tulungagung DHO, the values of performing sites is another lesson from Taiwan. the Tulungagung community that help create a more
62 Table 4: Tulungagung District Demographic Snapshot
Private sector Avg. HH Population TB Notification (hospitals vs. clinics) Reported TB Size (km2) % Rural expenditure (in thousands) Rate per 100k case reporting over cases (‘17) (various years) Population (‘10) (in million IDR) (‘15) Population (‘17) total reported TB case (‘15) per year (‘17)
1,021 1,043 102 1,056 54% 2.7 23% (15% + 8%) accepting, non-confrontational, and hospitable culture – a drug dispensing alternatives to in-house pharmacies, culture more commonly observed in smaller districts. serving patients who preferred to get their medications None of the interviewed clinics had TB diagnosis more quickly by paying out of pocket. The pharmacies capability, but they all could access FDC drugs as long mentioned that some BPJS-K patients were willing to pay as the GPs working in the clinic had received WiFi-TB out-of-pocket to avoid the minimum three to four hour training90 and recorded their TB patients’ information wait for drugs in BPJS-K hospitals that resulted from the via the Challenge TB-developed WiFi-TB application. As high number of patients served. in other districts and consistent with guidelines, clinics typically referred patients to hospitals for complicated TB, DHO role and implementation of DPPM including MDR-TB suspects. With help from Challenge TB, the Tulungagung DHO The only GeneXpert machine in Tulungagung is in a public developed a District Action Plan (RAD) and secured IDR hospital. It was reported that this facility required referred 1 billion in funding from APBD for TB control efforts, a patients to first register as a patient of the hospital, as significant increase from the district’s previous budget opposed to accepting a sputum sample referral or letting of ~IDR100 million. The DHO is planning to use this patients go to the lab directly for testing – an extra step increased funding to conduct activities currently supported that could make GeneXpert use inconvenient for patients. by Challenge TB (e.g. monitoring and evaluation for MDR- TB cases, setting up socialization meetings, and advocacy As this review found across districts, private labs in for DPPM implementation), as well as to cross-collaborate Tulungagung often provide non-exclusive discounts with other programs and departments. The Tulungagung to institutional providers (e.g. clinics, hospitals) for DHO expects that the RAD, contained within the local outsourced tests or compensation to individual providers regulation (Perbup Nomor 36 tahun 2017), will help to (e.g. GPs, specialists) for referrals. Of the four interviewed accelerate DPPM participation within the private sector. standalone labs, TB diagnostic capabilities were mixed. Although the Tulungagung-specific regulation and decree Only one lab provided both sputum microscopy and chest supposedly provide a stronger legal basis for the private X-ray tests in-house; two labs ran sputum microscopy sector to join DPPM, the Tulungagung wasor still needs tests in-house but without chest X-ray capabilities, and to proactively engage the private sector to participate in one lab had chest X-ray capability, but without any DPPM and monitor its implementation. Tracking DPPM sputum microscopy capability. The lab that did not have implementation across ~40 health facilities is reportedly a sputum test capability referred any walk-in customers key challenge for the wasor, given time constraints. to Puskesmas for sputum microscopy tests. This lab’s rationale was that it would be redundant to maintain a Although the DHO wants more TB patients to be treated sputum microscopy capability if it were already available in Puskesmas, interviews highlighted a lack of monitoring (and covered by the government) in Puskesmas. and enforcement to prevent nurses and midwives from treating TB patients in their own practices. In Tulungagung, Pharmacies reviewed in Tulungagung do not have this action takes place in the more rural parts of the formalized relationships with other institutions and district, where there is limited access to clinics and private operate as standalone operations. Of the eight GPs. While patients in the rural areas can more easily interviewed pharmacies, only one was a chain with more access these nurses and midwives for TB diagnosis or than one branch and none of them was part of other treatment, quality is unknown and not regulated. Nurses relevant business/activities. There were two pharmacies and midwives are typically revered and trusted by the (of the eight) that were located close to other care community; they usually set up practices in their home providers (e.g. hospitals, clinics) and inadvertently became and get patients through word of mouth. Although
63 other districts mentioned a similar challenge, this was a related diseases; a common practice this review observed more prevalent issue that was raised multiple times in across districts. interviews in Tulungagung. To curb nurses and midwives from dispensing drugs unlawfully, the DHO is considering The main CSO AISYIYAH was no longer active in ways to limit distribution of drugs from pharmaceuticals Tulungagung as funding from the Global Fund ended manufacturers and distributors to these providers (for in the beginning of 2018. Previously, AISYIYAH cadres example, requesting manufacturers and distributors to successfully identified around 100 TB symptomatics/ report their sales data and who they sell the drugs to). month with around 20% of those individuals testing positive for TB and with an 80-85% treatment completion The Tulungagung DHO demonstrated significant support rate. AISYIYAH reported that the Global Fund was for this review and Tulungagung was the most responsive shifting funding to another global health organization district to the request for participation, including the P2P Lembaga Kesehatan Nahdlatul Ulama (LKNU), a former (“Control and Prevention) team providing the review USAID implementer, who will pick up this work. team with a venue to conduct interviews. The DHO’s willingness to understand their strengths and learn from B.2 North Jakarta other districts is an indication of their recognition of TB as a key priority and a commitment to advancing public and North Jakarta is one of the five administrative cities in private programs for quality TB care. the Special Capital Region of Jakarta, Indonesia. Among the seven selected districts for this review, North Role of non-public stakeholders Jakarta has the highest average monthly household expenditure (IDR 7.8 million) and no rural population. Given the smaller size of Tulungagung (population of These demographic characteristics shape the nature of around1 million people) relative to other districts, there institutional relationships in the districts and may influence were many professional associations that were not the preference of patients to seek care in hospitals that present in Tulungagung. Instead, Tulungagung relied on was reported in interviews. Private and public hospitals the provincial-level professional organizations or engaged contribute to ~64% of TB reporting (contributions of in cluster organizations with several neighboring districts ~32% from each sector), with the remaining 35% from such as Kediri and Trenggalek. For example, several Puskesmas and 1% from private clinics. North Jakarta is common professional associations including ILKI, IDAI, also one of the three Challenge TB districts which has and PAPDI are not very active in the district because assisted the DHO’s effort in DPPM implementation, they don’t have enough resources or there are too few particularly in terms of garnering political commitment specialists in Tulungagung. The lab associations were not through the launch of legislation in form of governor’s present in Tulungagung and the clinic association was only decree to support the DHO’s activities. recently formed and did not yet have a program. Institutional relationship and business landscape There were a few associations in Tulungagung that had a TB agenda and conducted TB-oriented activities; however, Although institutional relationships in North Jakarta are, Tulungagung had an outsized amount of activity relative as found elsewhere, relatively weak; the district has some to size. This included the Nurse Association PPNI and vertically integrated facilities, with connections such as Doctors Association IDI, along with the DHO, focusing between hospitals and clinics or clinics and pharmacies, on reducing the risk of MDR-TB patients by educating that operate under one business roof. The vertically their members and enforcing regulations to prevent integrated facilities in North Jakarta reportedly referred unlawful dispensing of drugs by private GPs and nurses 100% of their patients to their partnering facilities and have as previously discussed. This review also found that mechanisms to track patients throughout care delivery. IDI in Tulungagung offered a more unique approach to incentivize better TB diagnosis, reporting and treatment While many hospitals in North Jakarta began enrollment in by rewarding doctors with professional credits for DOTS in 201291, DHO did not begin TB engagement with license renewal. In addition to collecting professional clinics until the second half of 2018. Among the clinics credits through seminars and workshops, members reviewed in North Jakarta, only one had an agreement were rewarded one additional point for every 25 TB with a Puskesmas for TB treatment and reported their TB suspected patients found and another point for every TB patients’ data to Puskesmas in exchange for government positive patient reported. Additionally, the pulmonologist FDC drugs. It is important to note that this agreement association PDPI, despite only having two members in may be a bit of an anomaly as it was made on the clinic’s the district, assisted the DHO in conducting a public initiation five to ten years ago due to the high number of awareness campaign related to TB and other respiratory- presumptive TB patients in their facility (up to 100 per
64 Table 5: North Jakarta District Demographic Snapshot
Private sector Avg. HH Population TB Notification (hospitals vs. clinics) Reported TB Size (km2) % Rural expenditure (in thousands) Rate per 100k case reporting over cases (‘17) (various years) Population (‘10) (in million IDR) (‘15) Population (‘17) total reported TB case (‘15) per year (‘17)
1,747 4,897 280 147 0% 7.8 33% (31% + 2%) month). As in most other districts, other reviewed clinics the TB agenda and supporting the eradication of TB. The in North Jakarta typically referred their TB patients to governor of DKI Jakarta has issued legislation (Peraturan hospitals as they did not have the capability to diagnose or Gubernur no. 28, 2018) that requires all health facilities in treat them themselves. This behavior was likely magnified DKI Jakarta to report their TB patients and by strong patient preference for hospitals, as facilities and the DHO reported that patients perceived they to adhere to national treatment guideline for TB with would receive higher quality care due to the presence of several consequences – ranging from verbal reprimands to specialists and the overall hospital facilities. One clinic in license suspension – if they fail to do so. North Jakarta even mentioned that it saw its role as more of a referral facility, since most patients (even those with The DHO, in collaboration with Challenge TB, has also conditions other than TB) visited the clinic only to request finished the District Action Plan (RAD) which was also a referral letter to a specialist in a hospital, including in the included in the governor’s decree. The completion of case of uncomplicated TB. RAD paved the way for a request to increase DHO budget for TB threefold in 2019. The DHO plans to use Out of the eight GeneXpert machines in North Jakarta, the additional budget to procure INH as prophylaxis one is hosted by a private hospital (RSIA Sukapura), with for children exposed to TB (e.g. when parents are the rest in public hospitals and Puskesmas. Similar to other TB patients) and HIV patients, and fund TB-DPPM districts, all costs related to the GeneXpert machine are socialization (e.g. pharmacy and labs together with borne by the PHO, and the hospital is given a payment professional organizations), among others. In addition, the per test of IDR25,000. RSIA Sukapura was chosen as the DHO has enrolled all of their departments in pulmonary private hospital GeneXpert host due to its long-standing TB ISO certification management to ensure the commitment to TB and strong reputation as a center for synchronization of the TB program and appropriate level TB treatment in North Jakarta (~250 patients reported of competency in TB management across departments in per year). DHO.
The quality of private labs in North Jakarta, especially in The percentage of DOTS-certified hospitals is high at the context of TB diagnosis, may be higher than that of ~70% since DOTS is one of the criteria for hospital other districts due to the composition of the players. All accreditation. The proportion of private hospitals in of the interviewed labs were large chains (more than ten the top two accreditation92 status levels (paripurna and branches). DHO did not identify any local non-chain labs utama) in North Jakarta is ~64%. This review observed a in the district that offered TB tests. These large chain labs similar correlation between high accreditation (paripurna report that they run rigorous internal quality assessments plus utama) and the presence of DOTS-certification for and comprehensive external assessments. Specifically for private hospitals in some other districts (for example, TB, the North Jakarta DHO required all labs in the district 61% and 70%, respectively, of private hospitals in to enroll in an external assessment where labs send their Surabaya achieved these standards; and 36% and 40%, test results to government labs for cross-examination. The respectively, for Medan). Given this observation, it seems DHO then provides an evaluation and coaching for labs that hospitals with higher accreditation status are more with unsatisfactory test results. likely to participate in PPM and be DOTS-certified. The wasor in North Jakarta mentioned that a key challenge in DHO Role and implementation of DPPM scaling the DPPM program in the district is ensuring that health facilities can perform the appropriate knowledge The North Jakarta DHO together with DKI Jakarta PHO transfer within their institution and develop effective has reached several important milestones in advancing monitoring and evaluation processes, which was also
65 cited in several other districts. To further scale up monthly household expenditure (IDR 4.6 million, the their effort, the wasor in North Jakarta cited that they third lowest in this review). The private sector is active need to be more effective in performing monitoring in Medan, with private hospitals making up 85% of total and evaluation to ensure sustainable and proper hospitals in the district and the private sector reporting implementation of TB DPPM in health facilities and to ~40% (8.2K) of total TB cases (the second highest rate minimize time on less value-added activities for TB such across the seven interviewed districts). BPJS-K hospitals as re-training facilities. empanelment, however, is the second lowest among the interviewed districts at 54%. Interviewed clinics and Role of other non-public stakeholders hospitals mentioned that patients in Medan generally have a positive attitude toward the private sector, for While all professional organizations in the interview both primary and secondary care. The review team set were present in North Jakarta (as this review also also observed more unique business models evident observed in other bigger districts such as Medan and in Medan as compared with other interviewed districts Makassar), most had a very limited TB agenda, with such as clinics outsourcing non-clinical functions (for the exception of PDPI and IDI. PDPI in North Jakarta, example the recruitment of physicians and nurses, similar to PDPI in other districts, was the most active marketing, and day-to-day management), and pharmacies organization with a focus on TB. Using funding from their boosting OTC sales utilizing pharmaceutical company’s membership fees as well as program enrollment fees, sales representatives. These characteristics – and the PDPI ran an education program (including seminars and resulting institutional relationships, Challenge TB support, doctor’s trainings) both independently and with the DHO. and progress of the TB program – are examined in the IDI was active with a program unique to North Jakarta following sections. where 185 volunteer physicians in Posyandu – a cadre- run community health center – conducted public health Institutional relationship and business landscape functions such as immunizations and vaccinations as well as referred TB suspects found in Posyandu to the nearest Public and private primary care facilities are generally Puskesmas. operating as isolated entities in Medan due to tension over capitation which is further magnified by patients’ One CSO reviewed, PETA, currently receives funding preference for private sector facilities. To capitalize on from the Global Fund to focus on MDR-TB patients. Its patients’ preferences, the reviewed private facilities in main activities were conducting home and hospital visits Medan have deployed a variety of business models in to educate MDR-TB patients and their families on the order to expand business and edge out competitors, importance of MDR-TB treatment and its completion, giving rise to a more competitive market environment and since this is an MDR-TB patient survivor organization. a more robust set of relationships (as opposed to other Similar MDR-TB related activities were observed in reviewed districts) between private facilities, albeit still other districts, although they might be led and organized limited. by different CSOs (e.g. PESAT in Medan or PPTI in Tulungagung). More than half (three out of five) of the interviewed clinics generally sent their TB suspects to secondary B.3 Medan care for diagnosis rather than to Puskesmas. This was in response to patient preferences, reportedly due to Like North Jakarta, the population of Medan is the perception that Puskesmas’ were inhospitable to completely urban, but Medan has a much lower average clinic-based patients. Meanwhile, for MDR-TB suspects,
Table 6: Medan District Demographic Snapshot
Private sector Avg. HH Population TB Notification (hospitals vs. clinics) Reported TB Size (km2) % Rural expenditure (in thousands) Rate per 100k case reporting over cases (‘17) (various years) Population (‘10) (in million IDR) (‘15) Population (‘17) total reported TB case (‘15) per year (‘17)
41% 2,211 8,224 372 265 0% 4.6 (breakdown not available)
66 all clinics and hospitals referred to public hospitals, given such practice is deemed illicit and the DHO reported that that all four GeneXpert machines in the district were the ongoing DPPM implementation should address this hosted by public hospitals. For TB treatment, two of the issue going forward. interviewed clinics had access to government-funded FDC drugs. However, unlike other districts where The DHO anticipates that the RAD and the decree will paper/online reporting is sufficient for clinics to access support accelerated DPPM implementation. Although the government-funded FDCs, clinic staff in Medan needed Medan DHO added a fourth TB wasor in 2018, the wasor to accompany TB-positive patients to a Puskesmas interviewed was still handling a facility case load beyond before the clinic could obtain government-funded FDCs the recommended standards, resulting in not being able for the patients. to spend time on value-added activities. For example, the wasors in Medan often have to re-train DOTS-certified Although relationships of private facilities with the public hospitals due to staff turnover rather than spending time sector are generally weak, private clinics in Medan on outreach to and training other non-DOTS-certified seemed to have stronger relationships with other private hospitals. facilities, both at the primary and secondary level. Two reviewed clinics entered into a capitation-sharing split There are no GeneXpert hosts in the private sector in agreement by taking over the operations of other clinics: Medan, but it is interesting to note that, unlike other the clinics contracting out their operations retained districts, in Medan the maintenance cost for GeneXpert ~30% of the capitation and distributed the balance to the is incurred by the GeneXpert hosts (according to the managing clinics; in return, the managing clinics recruited Medan DHO). This review was not able to secure a and employed the physicians and nurses, and ran the sample of the GeneXpert MoU to verify this agreement. operation of the partnering clinics (such as managing the shift work). Additionally, one clinic had a three-way Role of non-public stakeholders agreement with hospitals and patients (who were willing to pay as non-BPJS-K patients) where both the referring All professional associations are present in Medan with clinics and the referred patients were compensated by the different levels of activity; however, as with other districts, hospital. TB is generally not a focus, with the exception of a few CSOs whose agenda specifically includes TB: AISYIYAH, We also observed some unique behavior among JKM, and PESAT. At the time of this review, AISYIYAH private pharmacies and labs in Medan. One standalone had trained about 40 active cadres out of a total of 120, pharmacy focused on driving OTC sales (80% of through funding from the Global Fund. In addition to their total sales), hosting seven pharmaceutical sales other tasks, it was reported that the cadres stationed in representatives in the pharmacy to market OTC Puskesmas in Medan were sometimes requested to help products. All interviewed private labs in Medan read sputum test results (often with only prior informal participated in external quality monitoring (PME) training by Puskesmas staff). While AISYIYAH’s activity administered by the public sector (BBLK), as opposed to has declined as a result of discontinued Global Fund those assessments organized by the lab association ILKI. funding, the organization is continuing to work at a lower This was suggested by the interviewed labs to be the scale by raising funds through their parent foundation result of the perceived higher legitimacy assurance from Muhammadiyah. the public sector. The main activity of JKM, founded by public health DHO role and implementation of DPPM educators and professionals, was TB-related educational activities (e.g. public awareness campaigns, socialization to Similar to other reviewed Challenge TB-assisted districts community, TB advocacy to Mayor/head of Regency) and (North Jakarta and Tulungagung), the Medan DHO ran on-the-ground activities, such as contact tracing. While developed the District Action Plan (RAD) and secured funding from the Global Fund ended in 2013 and USAID the regent decree (Perwal No 85 tahun 2017) as the legal funding through the CEPAT project ended in 2017, the basis to increase political commitment for TB programs. organization is still supporting its cadres through corporate It is anticipated that this milestone will be impactful for funding (e.g. corporate social responsibility funds) via their advancing local TB capacity, such as implementing DHO’s members’ companies. plan to – by the end of 2018 – equip the remaining 15% of Puskesmas who do not have sputum test capability The focus of KNCV-funded PESAT is MDR-TB patients, in-house. This will be particularly important, as non- and since its founding in 2014, the organization has Puskesmas-based patients reportedly currently need to delivered care to ~400 patients and successfully treated pay Puskesmas IDR 10,000 to run TB diagnosis tests – ~75 patients. PESAT members accompany patients to
67 hospital and serve as an outlet for patients to share their market share and overall capitation income, two clinics experience given the stigma of TB. located near industrial areas worked with the corporate sector (and the associated labor unions) to set up branches B.4 Kabupaten Tangerang inside the factories. However, as BPJS-K empaneled clinics expand their branches within corporations, the competition Of the seven districts in the review, Kabupaten Tangerang to win business may encourage commitments to refer (Kab. Tangerang) has the second highest rural population patients to secondary care, even for services that can be (18%) and the second lowest average monthly household handled effectively at the primary care level. One clinic expenditure (IDR 4.2 million). Even without Challenge mentioned that its competitors promised the unions they TB support and WiFi-TB deployment, Kab. Tangerang will more frequently refer their clients to secondary care has demonstrated strong progress in clinic DPPM as a tactic to win business, as unions may want their clients participation over the past few years (~5-10% in 2016; referred to hospitals due to the perception of higher quality ~40% in 2018 – the highest among interviewed districts) care received. reportedly due to a recent change in the wasor position and unique resourcefulness by the DHO. The high clinic Of the three GeneXpert machines in Kabupaten DPPM participation rate has also helped Kab. Tangerang Tangerang, one was hosted by a large, national chain to achieve a 56% private sector TB reporting rate (7.9k) – private hospital. The hospital received a payment amount the highest among the seven districts. of roughly IDR10,000 per test (lower than the 25,000 fee in other districts) with the costs of cartridges and Institutional relationship and business landscape maintenance borne by the Provincial Health Organization. The private sector hospital saw hosting GeneXpert as The relationship between the public and private sector an opportunity to capture potential clients who may seems to have strengthened recently with BPJS-K clinics not otherwise choose the hospital and may increase working more closely with Puskesmas. Two reviewed the hospital’s reputation as one of the few referral clinics have MoUs with nearby Puskesmas, accessing destinations. government-funded FDCs to treat clinic-based patients and providing TB patient records and TB case reporting DHO role and implementation of DPPM to the public sector. Other than clinics and hospitals, there were also instances of TB case reporting from Unlike other DHOs that have less capacity and resources, private labs in the district. One lab reported its TB results the Kabupaten Tangerang DHO has strong organizational to Puskesmas on a quarterly basis and did so as part of a and staffing power to drive and implement changes reciprocity-based agreement, given the Puskesmas sent to TB care. This includes a supervisor with a personal their patients to the private lab when they did not have interest in TB and the wasor, a PhD candidate in TB sufficient capacity to run the tests in-house. Puskesmas who has students who can support her in conducting reportedly paid the private labs out of their capitation. specific TB-related analyses, and who has built rapport with and secured access to NTP officers in MoH Jakarta. Due to profit pressure from increasing BPJS-K- The Kabupaten Tangerang DHO IT division has also empanelment and stagnant capitation rates despite been engaged in the TB agenda and is collaborating with inflation, clinics in Kabupaten Tangerang reported being the NTP’s IT division to eliminate the need to have two focused on cost efficiency and/or increasing the number separate laptops to enter TB and HIV reports. of capitated clients. To reduce operational cost, one clinic chain was cutting its logistics cost by reducing the frequency As a result of the support from her students and data of drugs shipment to their clinic network. To increase officers, the wasor is able to focus on value-added
Table 7: Kab. Tangerang District Demographic Snapshot
Private sector Avg. HH Population TB Notification (hospitals vs. clinics) Reported TB Size (km2) % Rural expenditure (in thousands) Rate per 100k case reporting over cases (‘17) (various years) Population (‘10) (in million IDR) (‘15) Population (‘17) total reported TB case (‘15) per year (‘17)
3,371 7,900 234 1,012 18% 4.2 56% (35% + 21%)
68 activities such as evaluating Puskesmas’ achievement on Beyond the TB agenda, the Private Hospital Associations getting more clinics to participate in DPPM program and (ARSSI) has reportedly been very effective in resolving providing on-the-job (OJT) DPPM training for hospitals local disputes in the past (e.g. arbitrating disputes from that are not yet officially DOTS-trained. Training is BPJS-K patients who were allegedly rejected admission a critical activity as it is an eligibility requirement for due to full occupancy). In Kab. Tangerang, one hospital’s accessing government-funded FDCs, but space and director is the head of the private hospitals association resources are limited. The wasor has been able to (ARSSI) and thus, given the natural relationship between conduct OJT DPPM training for two non-DOTS-certified the hospital and the association, any concerns of the hospitals in Kab. Tangerang; even though these two hospital and its group can be directed straight to ARSSI, hospitals have not established DOTS corners within the (e.g. negotiating BPJS-K reimbursement rate). facility, they are reporting TB cases to the wasor already. It is important to note, however, that DOTS-certified B.5 Kota Tangerang hospitals may not necessarily report 100% of TB cases in hospitals (for example, TB cases in the pediatrics Kota Tangerang has the third highest average monthly department may not get reported to the DOTS corner). household expenditure (IDR 5.4 million) among the As highlighted in the main report, this reinforces the need districts in this review and does not have a rural for bringing together the data systems of NTP and BPJS-K, population. Private sector participation in DPPM is so that BPJS-K payment is tied to notification. still relatively low in the district – there is no clinic participation and only ~35% of hospitals are DOTS DHO in Kabupaten Tangerang are funding loose drugs certified. There was no private sector TB reporting from their APBD (District’s Budget) as TB loose drugs in Kota Tangerang in 2017, likely because hospital were no longer subsidized by the central budget for DOTS engagement only started in late 2017. These hospital-based complicated TB patients. characteristics, along with the market environment, the resulting institutional relationships, and the progress of the Role of non-public stakeholders TB program are examined in the following sections.
All professional associations, except ILKI, are present in Institutional relationship and business landscape Kab. Tangerang with different activity levels; as in other districts, TB is not a focus of their agenda. None of the reviewed clinics in Kota Tangerang have enrolled in DPPM and thus none of the operating clinics Although the Pharmacist Association (IAI) also doesn’t have access to government FDCs yet. Clinics typically have a TB-specific agenda, their “Gema Cermat” referred patients to hospitals for diagnosis, as clinics are initiatives (smart usage of medicine) includes education required to move their patients’ capitation to Puskesmas on proper TB drugs. IAI plays an enforcer role by upon referring. conducting unannounced inspections to make sure that pharmacies are following facility requirements and drug Unlike in other districts, BPJS-K reinforcement of down- dispensing guidelines, along with DHO and Indonesia FDA referrals in Kota Tangerang is reportedly stricter. Three (BPOM). In 2018, IAI in Kabupaten Tangerang targeted out of six hospitals interviewed in Kota Tangerang ~250 pharmacies (roughly half of the total number of down-referred all of their uncomplicated TB patients to pharmacies) for unannounced inspections to make sure primary care as they feared BPJS-K would reject claims that drug dispensing guidelines were being adhered to. for these patients otherwise, following a warning by Operations that violated the stipulated regulations received BPJS-K representatives in December 2017. The reviewed two warning letters and then had activities suspended. hospitals mainly down-referred patients directly to
Table 8: Kota Tangerang District Demographic Snapshot
Private sector Avg. HH Population TB Notification (hospitals vs. clinics) Reported TB Size (km2) % Rural expenditure (in thousands) Rate per 100k case reporting over cases (‘17) (various years) Population (‘10) (in million IDR) (‘15) Population (‘17) total reported TB case (‘15) per year (‘17)
2,047 1,829 89 154 0% 5.4 0%
69 Puskesmas as they feared any patients sent to clinics are needed to minimize the instances of system would be referred back to the hospitals since clinics in breakdowns and to have a readily contactable help desk Kota Tangerang don’t have access to government-funded so facilities could contact the SITT team instead of the FDCs. No clear rationale was evident for why down- wasor. referral is so much more common in Kota Tangerang than in other districts. The Kota Tangerang DHO had not yet begun engaging clinics in DPPM mainly due to the lack of data on clinics One of the two GeneXperts in Kota Tangerang is hosted (such as the total number of clinics in the district and in the private sector at the large, national chain hospital their potential TB burden) which makes prioritization RS Awal Bros. The hospital was selected because of its of clinics – a necessity given limited DHO resources – strong relationship with the DHO and strong TB reporting difficult to conduct. As a result, clinics in Kota Tangerang track record. Similar to other districts, the GeneXpert had not received any training on DPPM, which hindered machine was provided by the PHO and all expenses their ability to serve as DPPM clinics. In addition, the Kota related to maintenance and cartridges are borne by Tangerang DHO was still focused on engaging hospitals the PHO, with the host receiving payment of ~IDR25k in DOTS since DOTS-accreditation in Kota Tangerang per test. However, a strong referral network among was still relatively low at ~35% (~10 out of 29 public and facilities in the district has not yet been established by private hospitals). the DHO, as the hospitals reviewed did not know that the GeneXperts in the two Kota Tangerang hospitals Similar to other districts, the human resource constraints were operational. To date, they had been sending MDR- at the Kota Tangerang DHO are a key challenge, TB patients to hospitals in a neighboring district (Kota particularly regarding wasor capacity, as only one of the Tangerang Selatan) for tests. two wasor roles was filled. However, the DHO has been creative in finding opportunities for synergies and reducing DHO role and implementation of DPPM overall workload, such as combining the TB and HIV MoU and reporting process and engaging health facilities on DPPM implementation in Kota Tangerang is still in both agendas in one outreach. the early stages, particularly in terms of the level of engagement with hospitals, Puskesmas, and clinics. Similar Role of other non-public stakeholders to other districts, the wasor in Kota Tangerang mentioned the lack of human resources and the volume of non- Similar to other districts, this review found that only PDPI value added activities as key challenges to driving DPPM had an active TB agenda. CSOs such as AISYIYAH, and implementation. several professional associations such as IDI, IDAI, ILKI, and PATELKI are based organizationally in Kabupaten This was particularly evident in the DHO’s challenges Tangerang rather than Kota Tangerang, and do not have in sustaining hospital reporting due to problems with specific activities in Kota Tangerang. The Indonesian the SITT system and high nurse turnover. Even though Clinic Association ASKLIN was just recently formed in all DOTS-certified private hospitals in Kota Tangerang Kota Tangerang and aims to help form more effective have already set up a TB team and DOTS corner since relationships among the DHO, Puskesmas, and clinics. 2017, they only started reporting in SITT in mid-2018 since they had to wait to get access to the system. As a B.6 Makassar consequence, DHO had to manually input hospitals’ TB reports, which increased the workload of the wasor and Makassar is a predominantly urban city with only ~1% data officers. In addition, because of high nurse turnover rural population and a relatively high average monthly (either due to resignation or rotations to other divisions), household expenditure (IDR 4.9 million - the third the lack of handover often caused either lower quality highest of the districts reviewed). Similar to other big reporting or discontinuation altogether, and required the cities, such as North Jakarta, private facilities and the wasor to continuously retrain hospitals. DHO reported that there is a strong patient preference for private secondary care, which is further encouraged To address the nurse turnover challenge, the DHO has given the tension between Puskesmas and private clinics been considering getting medical record staff – who over capitation. Participation of the private sector in typically have lower turnover and more data entry/ government programs is relatively low – for example, reporting knowledge – to perform the reporting role private clinic participation in DPPM is at 7%; 59% of instead. Solutions are still needed to address the SITT private hospitals are BPJS-K empaneled and 8% of private challenges – the issue that has occupied the majority of hospitals are DOTS-certified. This trend is also reflected the wasor’s time this year. In particular, improvements in the low private sector TB reporting rate of less than
70 Table 9: Makassar District Demographic Snapshot
Private sector Avg. HH Population TB Notification (hospitals vs. clinics) Reported TB Size (km2) % Rural expenditure (in thousands) Rate per 100k case reporting over cases (‘17) (various years) Population (‘10) (in million IDR) (‘15) Population (‘17) total reported TB case (‘15) per year (‘17)
1,449 4,926 340 176 1% 4.9 5% (5% + 0%)
5% (4,900 hospitals). These characteristics, along with rationale that hospitals who make an investment up front the market environment, the resulting institutional and have ‘skin in the game’ may implement DPPM more relationships, and the progress of the TB program, are effectively or thoroughly. However, more work is needed examined in the following sections. in Makassar as only 3 out of 34 private hospitals were participating in DPPM at the time of this review. Institutional relationship and business landscape While the DHO used to hold trainings led by senior As of mid-2018, there was one GeneXpert machine pulmonologists in Makassar to educate GPs on TB and hosted by a private hospital - RS Ibnu Sina – in addition the TB drug regimen, no trainings have been held in the to the two other GeneXperts in public hospitals. The last few years, indicating a potential downshift in priority hospital was chosen as the private sector host due to for TB education. Specialists interviewed for the review its longstanding reputation in the district and its strong hoped that the DHO would organize a seminar for GPs relationship with the DHO. Similar to other review to build TB capabilities. districts, all costs related to the GeneXpert machine are borne by the PHO and the hospital is given a Role of non-public stakeholders remuneration fee per test of IDR 25,000. Unlike in other districts, there are several associations in Similar to other districts, pharmacies in Makassar cited Makassar that are actively collaborating to advance the TB that the introduction and scale-up of BPJS-K resulted in agenda. The Internist Association (PAPDI), Respirologist decreased sales of prescription drugs. In addition, one Association (PDPI), and Paediatrician Association (IDAI) private PRB pharmacy in Makassar (which received 80% work together to provide members with knowledge- of its revenue from the PRB program) noted that the building activities, including on TB-related topics. These increasing presence of other PRB pharmacies – most activities are self-funded (through membership fees and notably the state-owned company Kimia Farma – has had programs’ registration/enrollment fees). Representatives a major negative impact on sales for pharmacies that rely of both PAPDI and PDPI usually lead trainings and mostly on the PRB program. This pharmacy in particular socializations organized by the DHO. This exchange of experienced a ~15% revenue decline over the past few knowledge-building between the two specialized fields years. enables members of both organizations to understand differing practices or points of view. The close relationship DHO role and implementation of DPPM between PAPDI and PDPI arose because founding members of PADPI were specialized in both internal Clinic DPPM participation in Makassar is still relatively medicine and pulmonology, and helped in the creation of low with only 7 out of ~100 clinics enrolled and having PDPI locally. access to government FDCs. While the Makassar DHO stated that clinics should be proactive in reaching out to Beyond these organizations, however, there is limited the public sector to participate in TB program, clinics may TB-specific activity. For example, the head of the Lab not be aware of the DPPM program or what is required Analysts’ Association (PATELKI) South Sulawesi (province to enroll. For example, one of the reviewed clinics of Makassar) reported that training on TB-related tests cited the requirement for an in-house laboratory as the (sputum microscopy tests) was almost never on the deterrent for joining DPPM, although this is not actually association’s agenda because of limited funding, and a mandatory criterion for DPPM participation. The DHO members likely are uninterested in paying out of pocket also expected hospitals that are not able to join the PHO- for trainings on such tests (unlike phlebotomy, which is a covered DOTS training to pay on their own, with the skill lab analysts don’t mind paying for training for).
71 Unlike in other districts, funding for AISYIYAH in Makassar Smaller clinics without the appropriate facilities for a will continue until 2020 and thus the organization is still sputum corner, on the other hand, typically send patients active in TB case finding, with around 50 active cadres and to Puskesmas directly. around 50 positive TB cases identified per month. Two clinics reviewed that had access to government B.7 Surabaya FDC drugs did not have the ideal facility as requested by DHO to treat TB patients (for example they did not have Surabaya has a relatively high average monthly household a separate waiting room and consultation room). Thus, expenditure of IDR 6.6 million (second highest of the these clinics applied workarounds to ensure they could seven districts reviewed) and no rural population. Unlike continue to treat TB patients without having to invest in other big districts with similar characteristics such as infrastructure, such as scheduling TB patients at a different North Jakarta and Medan, interviews with the DHOs time from other patients in order to control the risk of and clinics suggested that patients in Surabaya had no infection. objection to Puskesmas, especially in the context of TB diagnosis and treatment. This is likely in part because In Surabaya, all of the nine GeneXpert machines are Puskesmas units, similar to those in Tulungagung, provide hosted by public facilities (five in Puskesmas, three in free access to TB services for all Surabaya residents, hospitals, and one in a public lab). The five machines in including clinic-based patients. Despite being a non- the Puskesmas were purchased by the Surabaya DHO Challenge TB district, Surabaya has demonstrated early in order to further build TB capabilities within the public success in DPPM implementation due to the DHO’s sector. This is a key distinction from other districts as ability to fund TB programs and leverage partnerships Surabaya is the only interviewed district that procured with BPJS-K. These characteristics, along with the market GeneXpert machines itself. environment, the resulting institutional relationships, and the progress of the TB program, are examined in the DHO role and implementation of DPPM following sections. DPPM implementation in Kota Surabaya is still in the Institutional relationship and business landscape early stages, but has shown initial positive results. This is demonstrated by the number of hospitals reporting TB While none of the reviewed clinics in Surabaya (or cases, the aforementioned widespread linkages between other review districts) had TB diagnosis capabilities in clinics and Puskesmas, as well as the participation of labs house, clinic-based patients in Surabaya were referred in reporting TB cases. The DHO decree (SK Kepala Dinas to the nearest Puskesmas for free TB diagnosis and Kesehatan) that stated that Puskesmas must accept clinic- treatment without having to transfer capitation. DHO based referrals for diagnosis and treatment is one of the also provided sputum pots to clinics with appropriate primary drivers of the initial progress made. Although the facilities to set up a sputum corner so they can collect DHO decree did not include financial penalties for those patients’ sputum samples. Clinics collect, send, and pay in violation, it has successfully encouraged Puskesmas for the transport of samples to Puskesmas units, which that were initially hesitant to perform this public health is a manageable cost given the relatively light load of function to be more receptive to accepting clinic-based less than ten samples per month. Two of the reviewed patients. Similar to Kabupaten Tangerang, Puskesmas clinics suggested that the sputum sample time window units in Surabaya are receptive to accepting clinic-based in Puskesmas units should be extended for a longer time patients due to the active, continuous monitoring and period, beyond the current window of 8 am to 10 am. evaluation (M&E) by the wasor. In the quarterly M&E
Table 10: Surabaya District Demographic Snapshot
Private sector Avg. HH Population TB Notification (hospitals vs. clinics) Reported TB Size (km2) % Rural expenditure (in thousands) Rate per 100k case reporting over cases (‘17) (various years) Population (‘10) (in million IDR) (‘15) Population (‘17) total reported TB case (‘15) per year (‘17)
20% 2,849 6,601 232 351 0% 6.6 (breakdown not available)
72 meeting, the Surabaya wasor invites both clinics and Fund (although this will be ending soon and thus the Puskesmas to discuss any issues encountered. organization is looking for alternative funding). AISYIYAH is focused on contact investigation where they receive Another likely driver of DPPM implementation in patient data from Puskesmas and perform home visits to Surabaya is the DHO’s ability to secure alternative funding check whether any family members or neighbors of the and resources and continuous engagement with private patients are TB-infected. Through the support of DHO, facilities. For example, the Surabaya DHO partially funded AISYIYAH will also start to investigate contacts of private a training program for clinics using taxes collected from sector patients. cigarettes sales in the district. Forty-one clinics – that were selected by the DHO in collaboration with BPJS-K in order to ensure coverage throughout the city – had C. Inputs from district findings for personnel who were trained on the TB program in proposed recommendations order to build their capabilities in independently treating TB patients with government FDCs. Five out of the 41 This review proposed four recommendations: trained clinics – one in each of the five administrative municipalities in Surabaya – are ready to stock • Intervention A: Conditional fee-for-service for TB government FDC drugs and treat TB patients in-house. diagnosis
The Surabaya DHO has also been proactive in reaching • Intervention B: Inclusion of TB in Program Rujuk out to both DOTS-certified and non-DOTS-certified Balik hospitals. The DHO also ensures that the non-DPPM/ non-DOTS hospitals report their TB patients and remain • Intervention C: Treatment completion incentives up to date with the current DHO TB program by including these facilities in quarterly meetings and in the • Intervention D: DPPM implementation acceleration TB WhatsApp group. Similar meetings are also held for DOTS-hospitals to ensure quality DOTS implementation. There are several key findings from the district interviews conducted that serve as the basis for the In addition, Surabaya was the only reviewed district that recommendations. Table 11 provides detailed linkages received TB case notifications from all private labs on a between the findings and the proposed interventions, quarterly basis. This was enabled by the DHO’s WhatsApp including selected recommendations from the “individual group that reaches all labs throughout Surabaya and private provider/patient review.” enforces the submission of quarterly reports for several selected tests (not just for TB). These reports include details on the number of tests taken, test results, and breakdown D. Analysis of private sector TB drug by gender. The limited effectiveness of WhatsApp groups is sales to estimate private TB caseloads discussed in the main report in section 5.1. D.1 Introduction Role of other non-public stakeholders Currently, based on the incomplete implementation of All professional organizations except for ARSSI and ILKI SITT, WiFi-TB and other notification channels, neither the have a presence in Surabaya. However, this review only Government of Indonesia nor its partners in international found TB-related activities in PDPI. PDPI in Surabaya development have access to a comprehensive, single conducted TB DOTS training for hospitals, with the source of data on private sector TB cases in Indonesia. certifications acknowledged by the DHO. This training Given these data limitations, the review team attempted is sustainable as PDPI charges registration fees to the to create a baseline estimate of private sector TB cases participants; the rationale for why hospitals in Surabaya in North Jakarta and Surabaya (two of the seven target (more so than hospitals in other districts) are willing districts of this review) by analyzing the volume of the to pay these fees to PDPI needs to be further verified, four most common first-line anti-TB drugs – isoniazid (H), but may be because the fee is lower or the training is rifampicin (R), pyrazinamide (Z), and ethambutol (E) – more suited to the private sector. This support from sold through private facilities. PDPI is critical in helping to relieve the DHO’s resource constraints in delivering DOTS training for hospitals. In order to determine the private sector TB caseload, the review team used IQVIA (previously known as Surabaya is one of the two interviewed districts where IMS Health Inc.) data to capture and project TB drug AISYIYAH is still receiving funding from the Global sales at pharmacies, drugstores, independent clinics,
73 Table 11: List of findings and recommendations
Findings from district interviews Recommendations and mapping to interventions
Fee-for-service for TB diagnosis and care Tension over movement of capitation for TB diagnosis impedes Intervention A and B DPPM rollout. {a district decree stating that Puskesmas must accept clinic-based referrals may be a temporary solution, as in Surabaya}
Build on the existing relationships in creating more formalized There are existing relationships between labs and clinics and networks and interventions. between labs and hospitals, such as non-exclusive discounts. Intervention A and B Fee-for-service for both diagnostic tests and for treatment completion. Private clinics face disincentives for TB care (too expensive, Intervention A and C potential loss of capitation to diagnostic sites, etc). Shorter, simpler TB trainings. Individual private provider/patient review
Fee-for-service for GeneXpert under BPJS-K to replace the Global Fund payments and provide a small profit margin. Private hospitals lack access to GeneXpert, and there is not Intervention A and B a compelling business case to install GeneXpert, even if it is available. Existing GeneXpert payments are unsustainable as they Place more public-subsidized GeneXpert machines in private are donor-dependent. hospitals to extend service delivery network. Individual private provider/patient review
Concentrate on PRB pharmacies for interventions such as Smaller pharmacies are struggling for business as BPJS-K drives placement of government FDCs. more clinics to dispense drugs instead. Private TB drug sales Intervention B in general are down and availability at private pharmacies is decreasing. Concentrate on larger and chain pharmacies. Individual private provider/patient review Prioritize large chain labs as appointed diagnostic providers for Smaller labs are also struggling, since patients are more aware of clinic-based patients under the PRB scheme. BPJS-K scheme and seek “free” diagnosis and treatment at clinics. Intervention B Larger and chain labs are doing better, since they usually target more affluent, OOP-paying customers, which is boosted by a Concentrate on larger and chain laboratories for interventions growing middle class with higher disposable income. such as placement of subsidized GeneXpert. Individual private provider/patient review Continue and expand the push for district planning for TB to raise budgets. Enforce the existing guidelines on numbers of facilities per wasor (but now including both public and private facilities in this calculation). Intervention D
Introduce non-monetary TB DPPM performance-based incentives for Puskesmas (e.g. award for most innovative engagement method with clinics) to further motivate Puskesmas DHOs are short on both money and, especially, people/staff to drive the scale-up of TB. to address TB. Consequently, wasors are not empowered to Relieve wasor from non-value-adding activities (e.g. fixing effectively roll out DPPM. SITT, entering data into SITT) that could be assigned to other potentially lower cost resources (e.g., data officer) or technical experts (e.g., IT officer). Intervention D Enhance SITB’s functionality to enable the DHO/PHO monitor facilities’ and districts’ performance and identify high and low performing sites in order to formulate the appropriate action plans. Intervention D
74 Findings from district interviews Recommendations and mapping to interventions
Bring together the data systems of NTP and BPJS-K, so that DOTS-certified hospitals may not necessarily report 100% of TB BPJS-K payment is tied to TB notification. cases in the hospitals to the DHO. Intervention D
Increased orientation of wasors to private sector as a major need for TB activities. Intervention D
District wasors’ attention to private sector (vs. public sector) is Increase the quality of monitoring and evaluation of DPPM variable. implementation: NTP to develop a scorecard that is cascaded down to PHOs and DHOs and used to evaluate the DPPM implementation in private facilities. Intervention D Engage KOPI-TB as an additional resource to scale-up training efforts for health workers in hospitals, clinics, pharmacies, and labs.
Associations lack funding and organization to drive significant TB Government of Indonesia (GoI) selects and equips organizations education and provider engagement efforts. to become DPPM implementing entities through a significant funding stream and a clear mandate. GoI to hold the implementing organization accountable against predefined targets for specific activities or outcomes. Intervention D
and hospitals. Since 2005, IQVIA has collected data The primary aim of this analysis was to establish a baseline on the sale of pharmaceuticals in Indonesia, using data estimate of TB cases receiving private sector treatment, from manufacturers, pharmacies, independent clinics, which could then be compared with the reported TB hospitals, and drug stores to provide analytics primarily cases in private sector for North Jakarta and Surabaya to to pharmaceutical companies seeking to understand better understand the magnitude of “missing cases.” The their product sales. In this review, IQVIA was engaged to hope was that this analysis could be repeated over time support data extraction (from existing sales databases) to evaluate whether reporting in the private sector was and data gathering (to improve data coverage in the two improving. districts) for the private sector channels in Indonesia. The methodology outlined below is consistent with previous We also analyzed the private sector TB drug market efforts to measure private TB drug and patient volumes for each district for key characteristics including: total via IQVIA data, in both Indonesia and other high TB sales volume and value by molecule and channel, total burden countries.93 sales volume and value of manufacturers by channel and molecules, and price comparison of TB private FDC This analysis was conducted because, while private sector and loose drugs. The next section is an overview of the TB drug sales are not under the direct control of the methodology, followed by a presentation of the key NTP, sales data can provide useful information on the findings for each district, and then concluding with an likely number of TB cases treated in the private sector and exploration of key limitations and recommendations. inform the NTP’s monitoring of successful improvements in case reporting. Another benefit of this analysis is that it D.2 Methodology is more recent than the Indonesia TB Prevalence Survey and should therefore reflect the impact of JKN expansion. D.2.1 Data collection Drug sales data should also complement the results of the recently completed TB inventory study, which has For the purpose of this review, IQVIA defined the determined the location of un-reported cases in Indonesia targeted four main medical channels95 as: (see section IV.6 below for further recommendations related to the inventory study).94 1). Hospitals: Facilities that had a hospital license, a
75 pharmacist(s), and were either part of a chain of sampling of 30 facilities, or – for the medical channels hospitals or an independent entity with 30 or fewer facilities in a particular district – at least 10% of the total number of facilities per district. 2). Drugstores: Facilities that had a drugstore license, To fulfill the minimum sampling number for district-level did not have a pharmacist, could not sell prescription analysis in North Jakarta, additional sample boosters drugs, and targeted a lower- to middle-class of ten pharmacies, ten drugstores, five hospitals and customer profile twenty independent clinics were needed; for Surabaya, five pharmacies, five drugstores, two hospitals and 3). Pharmacies: Facilities that had a pharmacy license, a twenty independent clinics were required. In addition, pharmacist, could sell prescription drugs, were either as clinics were not part of the existing IQVIA standard part of a chain of pharmacies or an independent national audit data, IQVIA performed an ad-hoc audit on entity, and targeted a middle- to upper-class independent private clinics in both districts. customer profile To ensure high-quality data, IQVIA employed multiple 4). Clinics: Facilities that were either a single-physician layers of quality control procedures. In addition to IQVIA’s or multi-physician private practice with the capability regular quality checks on medical channel data, IQVIA to dispense drugs. Note that this differs from our used manufacturers’ sales data as additional reference definition in the main review report, where clinics points. In addition, the sampling design process was were defined as being only multi-physician practices. standardized with those used in other countries by involving IQVIA’s Asia Pacific and global statistics experts. IQVIA leveraged its 2017 standard national audit data of hospitals, pharmacies, and drugstores, which was designed D.2.2 Analysis to provide insights on channel dynamics to pharmaceutical companies, as the basis of the data for this review. The data provided by IQVIA included annual sales National-level sales figures for pharmacies, drugstores, information by volume (units and dosage units) and price, and hospitals were projected based on a sampling of 500 with product details including pack level, molecule string, pharmacies, 175 drugstores, and 250 hospitals in the top branded vs. generic, and manufacturers. All data collected 20 cities in Indonesia. was for the full 2017 calendar year sales.
The standard national audit was designed to provide To calculate the number of estimated TB cases treated sampling sufficient for a national-level reading. To in the private sector, this review used a volume-based accommodate the need for market data down to the methodology where the total volume of each of the district level, the IQVIA team gathered sample boosters products sold (in milligrams) was divided by the full for each channel in both review districts. Additional regimen per treatment for that product (in milligrams) booster samples were collected to achieve a minimum (see Figure 7 for methodology overview).
Figure 7: Volume based methodology to estimate number of cases that could be treated in the private sector
Method
[Total volume (mg)] Estimated number of TB cases that could [Full regimen per treatment (mg)] be treated in private sector
H R Z E
Intensive Continuous Intensive Continuous Intensive Intensive
# pills per day: 3.5 3.5 3.5 3.5 3.5 3.5 mg/pill: 75mg in 4-FDC 75mg in 2-FDC 150mg in 4-FDC 150mg in 2-FDC 400mg in 4-FDC 275mg in 4-FDC Duration (days): = 2 x 28 days = 4 x 28 days = 2 x 28 days = 4 x 28 days = 2 x 28 days = 2 x 28 days
Total (mg): 44,100 88,200 78,400 53,900
76 The numerator – the total volume in milligrams sold – two forms: solid and liquid. All liquid-form drugs were was calculated by multiplying the total H, R, Z, E mg per converted into mg. To calculate mg equivalents for product by the quantity of products sold, giving the total these products, the review team used the Monthly Index volume of H, R, Z, and E per SKU (in milligrams). This was of Medical Specialities (MIMS) and Indonesian FDA then multiplied by the total SKUs sold in 2017 to derive (BPOM) data to convert volume of products from liquid the total H, R, Z, E volume sold (in milligrams) in 2017. to solid form, to apply the breakdown of combined molecules, and to convert to milligrams. The conversion The denominator for the calculation – the full regimen methodology is provided in an accompanying Excel that is per treatment in mg – was calculated by summing up the available for future implementers or upon request. total milligrams across H, R, Z, and E taken during the six-month period (composed of two months of intensive D.3 Findings for North Jakarta and Surabaya period for H, R, Z, and E, and four months of continuous period for H and R). This calculation used four simplifying The review team and IQVIA identified three potential assumptions: private drug channels for TB in Indonesia:
1). All private TB patients receive and adhere to a 1). NTP buys and distributes drugs to be dispensed for standard regimen of six months of treatment free to TB patients96 (in Puskesmas, public hospitals, private hospitals, and private clinics). 2). For main weight bands: patients take the mg equivalent of either three or four standard FDC pills 2). Private facilities buy drugs and dispense them for per day, arriving at an average mg dosage based on free to BPJS-K TB patients. 3.5 FDC pills taken per day, 3). Private facilities buy drugs and dispense the drugs to 3). One month is equivalent to 28 days non-BPJS-K TB patients in return for out-of-pocket payment by those patients. 4). Private sales volume of potential second-line drugs for MDR-TB are not evaluated The private drug analyses in this section were done using sales through channel (B) plus channel (C). The These assumptions may not reflect true clinical practice providers that are engaged in the NTP program in or true patient adherence, but they establish a consistent channel (A) appear to be the only type of providers who metric to use across multiple geographies and time currently regularly notify TB diagnosis and outcomes to periods. The true number of private sector TB patients NTP. BPJS-K systems are not yet connected to the NTP may differ systematically from the projected numbers (for database, and thus the review team considers channel (B) example, if the true average regimen taken is closer to to capture private sector TB treatment that is generally three months, then the true number of patients will be non-notified and of unknown quality. about twice as high as that projected here). But, unless there are drastic shifts in provider and patient behavior The review team worked closely with the IQVIA team over time, the relative volume trends over time via this through several iterations of the analysis in an attempt to metric should be reliable. improve our estimates.
Thus, the total volume of milligrams prescribed during Step 1: Initial baseline estimates of TB cases for both the the intensive period was calculated by adding the total national and district level seemed low. At the district level, number of milligrams per standard FDC pill for H, R, Z, the variation of estimated TB cases between the four and E (75mg, 150mg, 400mg, and 275mg, respectively) molecules (H, R, Z, and E) were several times greater multiplied by 3.5 pills per day multiplied by 56 days (two than that at national level. The original data underlying this months). analysis is not shown in this report.
The total mg prescribed during the continuation phase is Step 2: IQVIA performed a modification to the projection equivalent to 75mg per pill for H and 150mg per pill for factor97 at both the national and district level. The R multiplied by 3.5 pills by 112 days (four months). The modification increased the consistency across molecules total of the full regimen per treatment is calculated by at the district level (see Figure 21 for a comparison of adding both the intensive and continuous phase. initial and revised district data) but did not result in a noticeable impact at the national level (see Figure 20 for IQVIA provided data on TB drugs sold as either single the original national data; revised national data was not dosage and combined dosage, both of which came in available).
77 Step 3: While comparing national level data across the Estimate of cases that can be treated by private drug years, the review team noticed a significant decline in sales in addition to the reported private sector TB private sector TB drug sales over the past few years, cases compared with the values from earlier studies using IQVIA data.98 The review team discovered that manufacturers’ In both North Jakarta and Surabaya, the estimated sales were declining, but at a slower rate than TB drug number of TB cases based on private drug sales were sales (based on national level data). inconsistent across molecules at both the manufacturer and outlet levels, even in those outlets providing routine Step 4: It was determined that IQVIA defined private electronic extracts. There was a large range between H sector (i.e., not connected to government financing) as and Z, with the spread larger for North Jakarta (~1.7x) only channel (C), because (A) and (B) are government- than for Surabaya (at~1.5x). Given this spread, this review supported, either directly, via government-led drug adopted a conservative approach and used the lowest procurement or indirectly via BPJS-K compensation of the result across molecules to determine the estimated cases. overall package of TB care to the private hospital. This In both districts, Z had the lowest TB drug sales and thus definition was later revised and the final iteration of the the figure for Z was used to estimate total cases. Based analysis defined private sales as those flowing through on this approach, there were an estimated 4,000 TB cases both channels (B) and (C). in North Jakarta and 3,400 cases in Surabaya based on private sector drug sales in 2017 (see figure 8 below). The remainder of Section IV.3 outlines the quantitative findings. Section IV.4 then highlights the limitations of the The review team believes that these private sector drug analysis in further detail. Sections IV.5 summarizes the sales are likely to be in addition to, and not overlap, the implications and recommendations for future analyses total public and private notifications. During qualitative of private sector TB drugs sales. Section IV.6 offers a interviews, the review team observed that most of the reflection of the alternative approach of applying the private providers who were notifying their TB patients previous inventory study methodology in routine district- were treating with government-funded FDCs, although level practices. the exact percentage adhering to this practice is unknown.
Figure 8: Estimated TB cases based on private drug sales in North Jakarta (left) and Surabaya (right)
Est. TB cases based on private drug sales Est. TB cases based on private drug sales in North Jakarta in Surabaya # est TB cases (K) # est TB cases (K)
• Drugs sold in private sector can • Drugs sold in private sector can 10.0 10 treat 62% of estimated TB cases 10 treat 34% of estimated TB cases • 2,400 more cases than NTP • 2,100 more cases than NTP reported private sector cases reported private sector cases 8 8 6.8 6.6 6.0 6.5 6 5.6 6 5.3 4.9 4.6 4.8 4.0 3.9 4 4 3.4 5.3 3.3
2 2 2.6 1.6 1.3 0 0 H R Z E NTP total NTP H R Z E NTP total NTP case est.1 reported case est.2 reported
Public Private Breakdown not available
Source: BCG Analysis on IQVIA Market Analysis on Anti TB Drugs in Private Medical Channel in Indonesia 2017 – Research was done by leveraging IQVIA basic Indonesia national data for drug sales and additional sample booster for Surabaya and N. Jakarta to achieve minimum 30 sample or 10% of universe for medical channels with less than 30 facilities, NTP reported TB cases from DHO North Jakarta Notes: All figures are for 2017. 1 N. Jakarta DHO estimated 6.5K total TB cases; assumed 40% treated in private sector per WHO Inventory Study data for North Jakarta 2 No breakdown from DHO for proportion of report from private vs public
78 In addition, the private sector is still using privately H was 19%, Z was 19%, E was 18%, HRZE was 6%, HE procured drugs for other patients, who are unlikely to be was 4%, and HR less than 1%. 89% of the total volume reported through NTP but who are reflected in IQVIA’s sold was composed of loose drugs, with fixed dose data. A recent study on enhancing TB notifications in combinations (FDCs) making up the remaining 11%. The hospitals in Indonesia highlighted similar observation in database also captures the sales channel (data not shown which only TB patients on the NTP regimen (government- in Figures 8). Out of the 1.43 billion mg sold in North funded FDCs that are customized for an intermittent Jakarta, 60% of drug sales were captured by pharmacies, delivery of drugs during the continuation phase) were followed by private hospitals at 20%, independent clinics at reported to the public sector, while TB patients on the 12%, and drugstores capturing the remaining 8%. It should non-NTP daily regimen were not reported99. With these be noted that, notwithstanding this 8% market share, assumptions, the total estimated number of TB patients drugstores are not licensed to sell prescription drugs. under treatment in North Jakarta was ~8,900 (4,000 from private drug sales over 4,900 from public and private In Surabaya, the total volume of TB drugs sold across notifications) and in Surabaya was ~10,000 (3,000 plus molecules was 1.16 billion mg, including R at 33%, Z at 6,600; see Table 12). As a result, our estimate for total 20%, H at 17%, E at 16%, HRZE and HE at 6% each, HRZ TB cases under treatment in North Jakarta is ~2,400 at 1%, and HR at less than 1%. Loose drugs made up cases above the NTP-estimated burden (calculated as 86% of total drug volume purchased, while FDC captured (iv)-(v) in Table 12), and Surabaya’s reported number is the balance. Of the 1.16 billion mg sold in 2017, TB drug approximately the same as the total estimated burden. sales in hospitals and pharmacies were equally large (33% respectively), followed by independent clinics (31%), and Table 12 shows the estimated private TB drug sales, then drugstores (4%); similar to North Jakarta, drugstores NTP’s estimate of total TB cases, and reported TB cases captured the lowest volume of sales. in 2017. Total sales value by molecule and channel Total sales volume by molecule and channel In 2017, the total value of TB drug sales across the four The volume share of each product type – either a common first-line anti-TB drugs in North Jakarta was particular drug (e.g., products containing only H) or IDR 4.9 billion, of which R led as the loose drug with the combination (e.g., all HRZE drugs) – was calculated based most sales value at 60%, followed by H at 11%, HRZE on the total mg of that drug or combination sold. and Z at 9%, E at 7%, HE at 3%, and HRZ at 1%. The majority of sales value occurred in pharmacies (73% In North Jakarta, the total volume of TB drug sales across of total value), with 14% in independent clinics, 8% in all molecules was 1.43 billion mg, of which R was 33%, hospitals, and 5% in drugstores. Across the channels,
Table 12: TB statistics in North Jakarta and Surabaya based on private drug sales
North Jakarta Surabaya
i) 2017 notifications from public sector 3,300 5,300
ii) 2017 notifications from private sector 1,600 1,300
iii) Estimated cases covered by private TB drug sales (non- 4,000 3,400 overlapping with notifications; see text above)
iv) Total TB patients on treatment, from adding notifications and 8,900 10,000 TB drug sales estimate (i+ii+iii) v) Total estimated burden of incident TB (from national 6,500 10,000 estimation process) vi) “Excess” TB patients detected by the calculation that include 2,400 0 private TB drug sales (iv-v)
vii) Total estimated TB patients under private care in 2017 (ii+iii) 5,600 4,700
79 Figure 9: Total volume of TB drug sales based on different molecules in North Jakarta
Total volume sold per annum (109 mg)
1.5 89% of total volume 0.25
0.27 1.0
1.43 0.48
0.5
0.28
0.06 0.00 0.09 0.0 HE HRZ HRZE H R Z E Total
% of 4% 0% 6% 19% 33% 19% 18% volume sold
Figure 10: Total volume of TB drug sales based on different molecules in Surabaya
Total volume sold per annum (109 mg)
1.5 86% of total volume
0.19 1.0 0.23
0.38 1.16 0.5
0.20 0.07 0.07 0.01 0.01
0.0 HE HR HRZ HRZE H R ZE Total
% of 6% 0% 1% 6% 17% 33% 20% 16% volume sold
80 Figure 11: Total value of TB drug sales by molecules and break-down between branded vs generic sales in North Jakarta
Total value of TB drug sales by molecules % of generic and branded drug sales value by molecules in North Jakarta in North Jakarta
Total Sales per annum (bn IDR) % Total Sales per annum 0.04 5 0.14 100 11 12 11 0.32 0.43 4 80 40 0.45
0.55 3 60 Sales 4.89 100 100100 (IDR) 89 88 89 2 40
2.95 60
1 20
0 0 R H HRZE Z E HE HRZ Total R H HRZE Z HEE HRZ
% sales 60% 11% 9% 9% 7% 3% 1% Generic Branded branded drugs dominated the market, capturing over rest of the manufacturers differed based on whether the 55% of total sales. Across molecules, branded100 drug market was analyzed by volume or value. sales made up the full market for FDCs, and more than 50% of loose drug sales. As in North Jakarta, Sanbe was the main market leader in Surabaya for total sales value (34%) and the second For Surabaya, the total value of TB drug sales in 2017 was market leader in terms of total sales volume (17%), just IDR 3 billion, of which almost half of the value was from 1% behind Kimia Farma. In Surabaya, however, Sanbe had the sales of molecule R (45%), followed by HRZE at 13%, less of a lead over its competitors than was observed in Z and H at 9% each, and HRZ, E, HE ,and HR at 7%, 7%, North Jakarta. The market measured by volume was quite 6%, and 4% respectively. As opposed to N. Jakarta, TB closely split across the five main manufacturers; measured drug sales values in Surabaya were spread across multiple on total value, Sanbe was followed by Phapros with channels more evenly, with independent clinics (36%), 27% market share. Regardless of sales volume or value, pharmacies (33%), and hospitals (29%); drugstores only the top five manufacturers were the same between the captured 3% of total sales value. Across molecules, drug sales volume and value methodologies, with Kimia Farma, sales value was predominantly from branded drugs, driving a generic manufacturer and Indofarma making up the the total market for FDC molecules and making up 58% balance. of R, 64% of Z, 90% of H, and 36% of E for the loose drug market. Across channels, branded drugs made up Total sales volume and value of manufacturers by 74% of total sales value for both independent clinics and channel pharmacies, 70% for private hospitals, and 59% for drug stores. In terms of both total sales volume and value across channels in North Jakarta, Sanbe was the clear market Market share of manufacturer based on sales volume leader, particularly in clinical treatment sites (both and value independent clinics and private hospitals), where it captured over 60% of sales. Drugstore and pharmacy channels In North Jakarta, Sanbe had the most market share tended to be more fragmented than clinics or hospitals. based on both total sales volume and total sales value in 2017. Indofarma and Sandoz were among the top five Across channels in Surabaya, no manufacturer had the manufacturers by both sales volume and value, but the lion’s share of sales volume, as the market was generally
81 Figure 12: Total value of TB drug sales by molecules and break-down between branded vs generic sales in Surabaya
Total value of TB drug sales by molecules % of generic and branded drug sales by molecules in Surabaya in Surabaya
Total sales value per annum (bn IDR) % Total sales value per annum
4 100 10
36 0.11 80 42 3 0.19 64 0.21 0.21 60 0.26 100 100 100 100 2 0.27 90 0.39 Sales 40 3.01 (IDR) 64 58 1 20 1.37 36
0 0 R HRZE Z H HRZ E HE HR Total R HRZE Z H HRZ E HE HR
% 45% 13% 9% 9% 7% 7% 6% 4% sales Generic Branded
Figure 13: Market share of manufacturers in North Jakarta
% of total sales volume by manufacturer % of total sales value by manufacturer
% Total Volume sold per annum % Total sales value per annum
100 5 100 4 6 5 9 8 80 80 13 13
60 60 100 100 40 54 40 40
20 20 27 16 0 0 Total Total SANBE SANBE OTHERS OTHERS SANDOZ SANDOZ INDOFARMA INDOFARMA KIMIA FARMA HEXPHARM JAYA ARMOXINDO FARMA ARMOXINDO GALENIUM PHARMASIA
82 Figure 14: Market share of manufacturers in Surabaya
% of total sales volume by manufacturer % of total sales value by manufacturer
% Total volume sold per annum % Total sales per annum
100 11 100 7 9 80 16 80 9
16 27 60 60 17 100 100 40 40 18 33 20 20 22 16 0 0 Total Total SANBE SANBE OTHERS OTHERS PHAPROS PHAPROS INDOFARMA INDOFARMA KIMIA FARMA KIMIA FARMA GENERIC MANUF. GENERIC MANUF.
Figure 15: Total sales volume (above) and value (below) by channel and manufacturer in North Jakarta
Total sales volume by channel and manufacturer per annum (%)
6 3 6 3 4 7 17 8 7 9 10 7 15 15 21 22 26 74 60 43 38
Drug Store Independent Clinic Pharmacy Private Hospital
Total sales value by channel and manufacturer per annum (%)
3 2 1 4 2 5 14 9 2 5 6 10 7 16 16 23 17 86 85
40 46
Drug Store Independent Clinic Pharmacy Private Hospital
GALENIUM PHARMASIA ZENITH YARINDO PHAPROS HEXPHARM JAYA ARMOXINDO FARMA LANDSON ROCELLA KIMIA FARMA MEPROFARM SANDOZ Others BERNOFARM INDOFARMA DEXA MEDICA SANBE GENERIC MANUF.
83 equally fragmented across manufacturers. In addition, the and HRZE – and the only manufacturer with sales of composition of manufacturers varied across channels. HR and HRZ - was Phapros. Sanbe captured the sales However, by value, Sanbe captured more than 50% of value market for R and Z, and was among the top two the drugstore and pharmacy markets and the largest manufacturers in terms of volume. Second, with the share within private hospitals at 39%, indicating a focus on exception of the HE market, the composition of players selling higher priced drugs. Phapros was the clear market in the Surabaya market by molecule was very different leader for clinics. from that of North Jakarta. Third, Third, Sanbe managed to capture significantly more of the R, Z, and E markets Total sales volume and value of manufacturers by by value than by volume, suggesting that it was able to molecule charge significantly higher prices than its competitors.
Based on total sales volume and value by manufacturers Price comparison of TB private FDC and loose drugs across molecules in North Jakarta, Sanbe secured the loose drugs market for R, Z, and E. Kimia Farma led sales The review team conducted price comparison of drugs of H based on volume and Galenium Pharmasia led based based on the average gross price (“average price”), which on value. FDC sales were not captured by one particular excludes discounts and taxes. Based on the average price manufacturer but were divided among Sandoz, Indofarma, of drugs per 100mg by molecules, H, R, Z, and E were Sanbe, and Landson. slightly more expensive in North Jakarta than Surabaya. However, assuming only branded loose drugs were used There are three main observations of difference between in the calculation of total cost of treatment, Surabaya the Surabaya and North Jakarta markets. Firstly. In was approximately IDR 69,000 more expensive than Surabaya, Phapros and Sanbe were the two main general total treatment cost using loose drugs in North Jakarta. market leaders across loose drugs and FDCs. Based on In both districts, the total cost of treatment using FDCs both volume and value, the leading manufacturer for H was approximately 2.6 times as expensive as the total
Figure 16: Total sales volume (above) and value (below) by channel and manufacturer in Surabaya
Total sales volume by channel and manufacturer per annum (%)
6 5 11 9 6 10 12 13 15 14 16 17 21 17 17 20 22 22 20 22
23 29 22 29
Drug Store Independent Clinic Pharmacy Private Hospital
Total sales value by channel and manufacturer per annum (%)
5 5 4 6 7 6 6 8 9 6 9 10 15 8 10 19 17 15 16 20
51 56 55 39
Drug Store Independent Clinic Pharmacy Private Hospital
GALENIUM PHARMASIA ZENITH YARINDO PHAPROS HEXPHARM JAYA ARMOXINDO FARMA LANDSON ROCELLA KIMIA FARMA MEPROFARM SANDOZ Others BERNOFARM INDOFARMA DEXA MEDICA SANBE GENERIC MANUF.
84 Figure 17: Total sales volume (above) and value (below) by manufacturers and molecules in North Jakarta
Total sales volume by molecule and manufacturer per annum (%) 4 1 6 4 3 11 3 10 12 5 18 3 11 30 11 11 6 12 38 17 31 15 100 24 17 71 67 43 49 32 34
H R Z E HE HRX HRZE
Total sales value by molecule and manufacturer per annum (%) 1 1 7 2 1 8 3 3 8 19 11 14 2 9 13 6 30 11 37 15 12 38 13 21 100 75 59 60 35 47 43
H R Z E HE HRX HRZE
GALENIUM PHARMASIA ZENITH YARINDO PHAPROS HEXPHARM JAYA ARMOXINDO FARMA LANDSON ROCELLA KIMIA FARMA MEPROFARM SANDOZ Others BERNOFARM INDOFARMA DEXA MEDICA SANBE GENERIC MANUF.
Figure 18: Total sales volume (above) and value (below) by manufacturers and molecules in Surabaya
Total sales volume by molecule and manufacturer per annum (%) 1 4 3 12 9 7 4 6 29 5 12 14 13 23 29 12 17 20 17 33 19 21 100 100 22 69 57 19 36 38 25 22
H R Z E HE HR HRZ HRZE
Total sales value by molecule and manufacturer per annum (%) 1 5 8 4 4 6 5 9 7 8 26 11 8 12 14 9 20 9 14 13 15 32 35 100 100 79 72 55 44 36 39
H R Z E HE HR HRZ HRZE
GALENIUM PHARMASIA ZENITH YARINDO PHAPROS HEXPHARM JAYA ARMOXINDO FARMA LANDSON ROCELLA KIMIA FARMA MEPROFARM SANDOZ Others BERNOFARM INDOFARMA DEXA MEDICA SANBE GENERIC MANUF.
85 Figure 19: TB treatment using private loose drugs and FDC in North Jakarta (above) and Surabaya (below)
Average price of drugs per 100mg by molecules Total cost of treatment for loose drugs vs FDC
Avg. IDR/100mg Total cost for total treatment2 ('000 IDR) 2,989 2,500 2,304 3,000
2,000
2,000 2.7x 1,500
1,000 1,092 1,000 543 500 390
103 154 101 0 0 RH EZ HRZE HR1 Loose Drugs FDC (Branded) (Branded) Min 20 142 43 11 456 2,196 Max 294 1,450 350 185 624 2,411 Std dev 80 350 104 51 84 152
Source: BCG Analysis on IQVIA Market Analysis on Anti TB Drugs in Private Medical Channel in Indonesia 2017 – Research was done by leveraging IQVIA basic Indonesia national data for drug sales and additional sample booster for Surabaya and N. Jakarta to achieve minimum 30 sample or 10% of universe for medical channels with less than 30 facilities. Notes: All figures are for 2017 and Syrups were excluded from total cost for treatment using loose drugs as cost was significantly higher and caused skew. 1 Based on Surabaya data since no HR product is sold in Jakarta. 2 Total cost if patient is following 6 months regimen of HRZE (2 months) and HR (4 months) – each month consists of 28 days, patients take 3.5 pills in average (1 pill H = 75 R=150 Z=400 E=275) mg.
cost of treatment using branded loose drugs. Total cost of potential double counting may not be valid, with a treatment using generic loose drugs in both districts were projection modification that may not be appropriate approximately ten times cheaper than branded FDCs. Of or exhaustive enough if applied to other districts. note also is the extreme (up to tenfold) variation in the price per 100mg for individual loose drugs. There was far 3). There is a remaining lack of clarity around the less variation for FDC prices. reliability of a possible steep decline in private sector TB drug sales observed from 2015-2017 (based on D.4 Potential limitations of the analyses a comparison of the 2017 IQVIA data in this review to previous IQVIA-based studies of TB drug volume There are three potential areas of limitations in the in Indonesia using 2008-9 and 2015 data. analyses to consider. Each of the following will be explored individually: Inconsistencies across molecules
1). The inconsistency across molecules in the estimated To determine if the inconsistencies across molecules (as number of TB cases (i.e. the large range of estimated used to estimate number of TB cases that can be treated patient volumes when using either H, R, Z, or E) at based on private drug sales) were present at the national- both the district and national level. level, IQVIA ran an analysis and confirmed that the inconsistencies in TB case estimates seen across molecules 2). The approach used by IQVIA to modify the district- in North Jakarta and Surabaya were present at the level figures for bulk volume sales to adjust for national level as well. These differences were at a smaller
86 Figure 20: Estimated TB cases that can be treated based on private sector drug sales using IQVIA national data
Est. # cases (K) Isoniazid (H) is 1 - 1.9x There are also noticeable 300 of other molecules differences between R, Z, E +81%
–28% 200
268 253 100 194 140
0 H R Z E
magnitude at national level (estimated patient volume robustness may be a concern based on factors such as based on H being ~1.4 to 1.9 times more than R and Z at limited market volumes, limited sampling, or unusual national level) compared with the original district analysis distribution dynamics of private TB drugs. (three to five times) but similar after the modification to the projection factor at the district level (less than Projection modification to district-level data twofold; see Figure 21). A similar change in the projection factor at the national level did not result in a significant The initial estimated TB cases based on private sector change, likely due to the differences in data collection drug sales, using the IQVIA data that was based solely and processing between the district level data and the on channel C (hospitals dispensing drugs to non-BPJS-K national audit data. Overall, these results suggested that clients in return for OOP), showed H and E sales were the inconsistencies occurred at the national level originally significantly higher than R and Z in North Jakarta and, in and were likely not (solely) rooted in the methodology Surabaya, H was roughly three to five times higher than used to enable district level reading from national level other molecules. The variability across molecules was not and district level data. an isolated incident that was only observed in the 2017 data. In an analysis conducted in 2011, estimated patient The differences may reflect either data robustness volumes based on H were 63% higher than those based issues or provider behavior (prescription) issues, or on Z.101 a combination of the two. For example, the use of isoniazid for preventive therapy could explain greater To understand what may have caused the situation for sales of this drug, although preventive therapy is not the 2017 analysis, this review pursued two main paths believed to be implemented widely in the private to check the underlying data from IQVIA: 1) Double sector. Other differences might be explained by non- checking of IQVIA’s data gathering and analysis approach standard prescribing practices and regimens, although (e.g., extrapolation process, facilities mix of sampling, off- there is no obvious and consistent pattern in which label usage) and 2) rechecking of the national data to test certain drugs associated with potential regimen variants the overall methodology. show higher volumes (e.g., there was no evidence of systematically higher Z and E, which would be expected In addition, a review of the methodology revealed that from extended or repeated intensive phases, or of bulk SKUs (i.e. SKUs with more than 350 tablets) were systematically higher H and R, which would be expected driving up volume of H in the pharmacy channels and also from extended continuation phases). In-person feedback may have been sold to institutions as opposed to end during this review also showed a consistent knowledge consumers, which could have caused double counting. In of the standard regimen by private providers, although response, IQVIA discounted the projection factor used for prescription data were not analyzed. Meanwhile, data bulk SKUs, a modification which significantly normalized
87 Figure 21: Estimated TB cases that can be treated based on private sector drug sales with initial (left) and revised (right) IQVIA data in North Jakarta and Surabaya
Initial: Revised with modification to projection factor: Est. TB cases based on private sector drug sales Est. TB cases based on private drug sales
Modification method: Discount the bulk SKUs projection that may have been sold to institutions # est TB cases (K) # est TB cases (K) (vs to end consumers) to minimize 30 30 double counting in the analysis 18.4 20.7 District 1: 15 15 5.0 6.8 5.6 6.0 North 3.6 4.0 0 0 Jakarta H R ZE H R Z E
Initial: H and E is ~3-6x of R and Z Revised: H and E is ~1.1-1.5x of R and Z
# est TB cases (K) # est TB cases (K)
30 20.8 30 15 15 District 2: 6.4 6.1 5.0 5.3 4.6 3.4 4.8 Surabaya 0 0 H R Z E H R Z E
Initial: H is ~3-4x of R, Z, and E Revised: H is ~1.1-1.6x of R, Z, and E
the district-level data and minimized the risk of double projected using different methodologies. In the 2008 and counting. However, even though the modification reduced 2015 methodologies, IQVIA market data was primarily the spread across molecules previously observed by generated from manufacturers’ sales transactions with approximately three times, inconsistencies still remained. distributors, but from 2017 IQVIA market data was generated from projection of health care facilities’ sales Significant decline in private sector TB drug sales transactions with patients/customers. Although comparing numbers across these two methodologies is not advised Using the review’s methodology for 2017 data (namely, because the impact of the methodological change is the data including both channels (B) and (C)), IQVIA unknown, the review team decided that these data took the historical data from 2008 and 2015 private points may still be valuable to provide an indication of sector TB drug sales data to understand if there were key potential change and evolution in private sector TB drug differences seen in previous years. An overall downward sales. The data suggest that out-of-pocket treatment for trend was noticed in sales between 2008 and 2017 TB in private sector facilities may be on the decline, but but it was a slow decline of only 4% per year between further analysis will be required to confirm the trend and 2008102 and 2015. However, between 2015 and 2017, magnitude of the change. there was a significant decline in TB drug sales of 14- 38% per year (with this range, also shown in figure 22, IQVIA performed additional checks with manufacturers driven by the variation in the number of estimated TB on whether the downward indication of change noticed cases for 2017, which ranges from 268,000 (calculated from 2008 to 2017 can be validated. However, the using H) to 140,000 (calculated using Z)). In 2008-2009, manufacturers’ data on TB drugs was only available from private TB drug sales were estimated to have been able 2014 onward, and thus was not long or complete enough to treat ~498,000 patients, compared to ~363,000 in to corroborate the 2008-2017 trend on the private 2015 and only ~140,000 (based on lowest molecule medical channel analysis. estimate) in 2017.103 These were calculated using CAGR104 methodology. It is important to note that the With the available 2014-2017 supply side data, the decline IQVIA data estimates from 2008, 2015, and 2017 were of manufacturers’ sales (~4% per year from 2014-2017105)
88 Figure 22: Decline of TB drug sales of -14% to -38% per year between 2015 to 2017 vs. ~4% year between 2008 to 2015
# est cases (K) –4% CAGR 500 –14% to –38% 400
300 268 498 High range estimate 200 363 using H molecule
100 Low range estimate 140 using Z molecule 0 2008 2015 2017 was much lower than the decline of private TB sales from be extremely high, since there remains a reliance on the main sales analysis (14-38% per year from 2015- primary data collection. Based on IQVIA’s experience, the 2017). In addition, the data behind this analysis covers most feasible method was to limit the sampling to 30-40 75-80% of the total prescription drug market, since a) districts, and then extrapolate to other districts based IQVIA covers most of the major players, and b) the sell-in on pattern similarity of the sampled districts, based on numbers (manufacturer’s sales transactions to distributors) demographic profile, socioeconomic profile, health care only include sales through distribution channels (e.g. via facilities availability, number of doctors, etc. There are no distributors, wholesalers, or drugs sold directly to the economies of scale by adding more districts as the cost medical channels) and exclude the products provided for of sampling on a per-district basis does not get cheaper tender/government program. as more districts are sampled. For example, sampling 30 districts would cost hundreds of thousands (US$) for one- By IQVIA’s own measures, its data offering in Indonesia off data because the same exercises, panel recruitments, is considerably less accurate than in India, where TB drug data collection, etc, would need to be repeated in each sales data have been used most often programmatically. district. High recurrent costs therefore remain a significant IQVIA India finds that over 90% of its drug estimations fall challenge. This may only be solved once IQVIA expands within plus or minus 20% of actual sales, and that number its regular sampling to reach statistical significance in has been increasing. Indonesia’s equivalent precision individual districts, thus obviating the need for additional number is only 60% and has been falling.106 sampling just for TB – but there is no indication that this will happen soon. D.5 Recommendations for future use of TB drugs sales data in Indonesia Reliability: The reliability of the method suggested above – extrapolating to non-sampled districts based on limited One of the objectives of this analysis was to assess the and incomplete correlates such as district demographic feasibility of this methodology – using private TB drug indicators – remains unproven. Additional challenges sales data to track un-notified private sector TB cases include: changing methodologies by IQVIA over time, – for ongoing monitoring in multiple or all districts of preventing simple trend analysis and comparability; Indonesia. There are two key considerations for future relatively low levels of facility sampling; and the shifting engagement with IQVIA (or other providers) utilizing procurement channels within Indonesia as BPJS-K similar methodology: cost of the methodology; and data continues to expand, thus shifting definitions of what reliability. “private sector” really means.
Cost: The sampling cost of this methodology for North These challenges in developing robust and reliable health Jakarta and Surabaya was in the range of tens of care data in Indonesia are a reflection of the current state thousands (US$), excluding the costs for analyzing these of the health care market and the willingness of multiple data. However, extending the methodology to cover all stakeholders to collaborate on data analytics, and will approximately 500 districts in Indonesia was not feasible continue to be a challenge for similar exercises in the because the time, cost, and resources required would future. Besides general improvements in this area, a more
89 specific area of future study could include an analysis E. Additional insights of private hospitals enrolled in BPJS-K. Among the 165 private hospitals in IQVIA’s 2017 panel, for example, In addition to the key findings outlined in the main 19% do not show any TB drug transactions even though report, there are additional insights from answers to they are enrolled in BPJS-K. If these private hospitals are specific interview questions not covered in the main also not providing care with NTP-procured drugs, this report. Most of these questions revolve around private would constitute a potential access gap which should be facilities’ incentives and barriers pertaining to TB, and considered in future TB planning. the insights generated complemented the findings and recommendations in the main report. The responses D.6 The inventory study methodology were collected from interviews with the private facilities as a possible inspiration for improved (hospital, clinics, pharmacies, and laboratories) and programmatic approaches structured around the four lenses of the research framework. Table 13 captures the questions and Another input to consider moving forward is the national respective answers from the private facilities. TB inventory study,107 which could suggest certain approaches that could be taken up in regular practice. The study itself was conducted under the leadership F. Interview guides of NTP and the National Institute of Health Research and Development of Indonesia in 2017 to measure the This review was undertaken in three stages: district level of underreporting of diagnosed TB cases to SITT selection; qualitative fieldwork; and socialization of and the NTP. The study employed a random, nationally findings. Fieldwork included one-on-one interviews or representative sample of 23 districts (out of a total of focus group discussions with the key stakeholders: each of 514) from across the country. In each of the sampled the facility types of private hospitals, clinics, pharmacies, districts, all health care providers of TB services were and labs; DHOs; and non-public stakeholders such as mapped, starting from existing but outdated lists of professional associations and CSOs. To facilitate the health care providers, which were then confirmed by interviews, the review team developed and used seven study enumerators. During the study period (first quarter interview guides, one for each interviewed stakeholder of 2017), the deployed resources in the districts were type, to generate insights and answer pre-research stationed in facilities to collect patient records where hypothesis questions. Each interview guide was structured a total of 21,320 unique TB patients were detected, into a few sections with different objectives aligned of which 13,211 were notified and registered in SITT. with the four topics in the research framework. These The incidence was estimated using capture-recapture interview guides are available for download from the modelling of the three TB case lists (SITT, study public, DEC108. and study private).
This mapping and engagement effort could be a part of G. Linkage between objectives, regular NTP activities moving forward, but at the current research framework, and key state of resourcing and capacity, the effort would likely questions for implementation be as resource intensive as the methodology used for the private sector sales data analysis. This is due to the To answer the five study objectives, the review team following reasons: a) the master list of health facilities is followed a research framework of four lenses: institutional not maintained/up-to-date for efficient monitoring; b) typologies; relationships and referrals; overall business NTP would need to once again request permission from landscape, including incentives and barriers to quality care each facility to access their records; and c) a considerable for TB and in general; the DHO role and institutional level of human resources would need to be deployed in attitudes to the implementation of DPPM; and the each district for data collection, as information systems role of other non-public stakeholders. The findings may not be fully established. using this research framework were used to answer six critical questions for implementation which drive the To enable automated TB surveillance, several recommendations of this review. Figure 23 describes in interventions are necessary to address the three problems detail the study objectives, the four lenses, and the six key outlined above: record linkage between the database of questions for implementations. the NTP (in the near future, SITB) and the BPJS-K and hospital systems, and continuous mapping of service providers (potentially through linkage to facility licensing records).
90 Table 13: Additional insights from district interviews
Hypothesis or No Hospitals Clinics Pharmacies Labs question
1 Do you have a strategy • Joining BPJS-K to increase • Opening more clinics to • Ensure complete array • Bigger chain has much for increasing your market share increase capitation of medicine to prevent wider and more market share? What • Rely heavily on • Providing free activities stock-outs and run complete array of is it? marketing, e.g., offering to the public incl. blood frequent discounts. If diagnostic capability. They promotions on certain tests. stock-out occurs, offer to market these advanced tests • Establishing clinics in re-stock the requested tests to class A/B • Work with CSO cadres factories to capture the medicine for specific hospitals; they may also to help find patients capitation from factory patients offer more convenience (not limited to TB) to workers • Free tests/checks (e.g. transportation to get them referred to the (diabetes) for public pick-up / deliver samples) hospital (one hospital in • Rent space out to GPs and faster turnaround Kab Tangerang) time vs. smaller labs • These labs also had the means to offer higher discounts to hospitals or clinics
2 What is the socio- • The SES of customers couldn’t be quantified. However, class B hospitals and large chain pharmacies/labs usually economic status of have a middle-upper and more affluent SES customer profile. your customers? Do • Non-BPJS-K facility usually have a middle-upper and more affluent SES customer profile. they primarily come to • Most facilities did not try to change or influence their customer profile but there were limited examples, e.g., the facility for primary, a non-BPJS-K utama clinic in Medan that considered switching to BPJS-K because of declining number of OOP secondary, or tertiary paying customers and experiencing profit pressure. care? Are you trying to change or influence this? How and why? 3 Who in the facility • Management holds the ultimate decision on which • For labs where owner (i.e. which position/ diagnostic tools to procure, but laboratory person in and management are role) decides which charge (PIC) can make suggestions and present the the same, the owner diagnostic capabilities pros and cons to the management decides which diagnostic to own? capabilities to own. • In bigger lab chains, N/A PIC can propose to management certain test to include. But, HQ most likely already have contract with a specific manufacturer 4 What are the methods • DS-TB: Sputum test, • DS-TB: Interviewed • DS-TB: Sputum test, and tools your facility X-ray, and Mantoux clinics typically do not X-ray test done in house. uses to diagnose test (generally available have x-ray or sputum • MDR-TB: Bigger chain DS-TB? How does in hospitals with test capabilities in house. labs might have IGRA the facility diagnose pediatricians). Limited number of or PCR (not necessarily MDR-TB? Have you • MDR-TB: GeneXpert clinics have sputum test GeneXpert; e.g., Prodia increased/ decreased (4 private hospitals or x-ray in house, but uses Bioneer). Smaller your TB diagnostic in the interview set even these clinics would chain labs that do not tools in the last few were GeneXpert sites). rather refer presumptive have advanced tools years? Which ones MDR-TB suspected TB to Puskesmas or usually refer to hospital specifically? patients are referred hospitals. or bigger chain labs to GeneXpert sites for • MDR-TB: Clinics do not N/A • Labs did not seem to diagnosis from other have MDR-TB diagnostic increase/decrease their facilities. capabilities TB diagnostic tools in • Apart from • No observable change recent years. aforementioned private in diagnostic capabilities hospitals provided as TB makes up less than with GeneXpert by 1% of patients for them public sectors, other and TB diagnostics have interviewed hospitals not changed significantly did not increase their TB enough over the past diagnostic tool capability years for clinics to invest in the past few years. in them.
91 Table 13: Additional insights from district interviews (Continued)
Hypothesis or No Hospitals Clinics Pharmacies Labs question
5 For GeneXpert, do you • GeneXpert sites acquire • None have GeneXpert capabilities. procure the cartridges machine and cartridges • Prodia has a GeneXpert machine in their Prodia National Referral Laboratory, from private or public from the government. but the machine is reportedly used to run non-TB tests, such as for chlamydia and sources? gonorrhea.
6 What would incentivize • Private facilities are • Not incentivized to • Private labs are you to provide more incentivized to provide provide more advanced incentivized to provide advanced diagnostic more advanced diagnostic tools as more advanced tools? Which one is diagnostic tools if the there are no volume diagnostic tools if the most attractive? Why? costs of the machine plus guarantees from referrals. costs relating to the • More suitable or cartridge/reagent plus machine plus cartridge/ competitive pricing maintenance are covered reagent plus maintenance model (e.g., Cost by the government plus are covered by the per Reportable FFS (with a reasonable government plus FFS Result vs. procuring margin) regardless of the (with a reasonable the diagnostic method/tools margin) - regardless of equipment, • Private hospitals also the method/tools discounted price cited the improved N/A from group purchase, reputation from hosting etc) the advanced tools • Volume guarantee (especially if its exclusive from referral and subsidized) as an network added incentive. • Fee-for-service (BPJS-K) for diagnostic method/ tools- which one and why?
7 If your facility has an • Usually, hospital • Based on the prescribing • Based on prescribing in-house pharmacy management has a behavior of physicians behavior of physicians or is a pharmacy, who formulary (drug list) in the clinics, which around the outlets which in the facility decides that can be altered if should be reflected should be reflected which drugs (FDC the medical committee on the sales/demand on the sales/ demand N/A vs. loose, first-line vs. agrees to change based trend observed by the trend observed by the second-line) to stock on doctors’ request. in-house pharmacists for pharmacists. or procure? prescription drugs.
8 (For facilities stocking • Hospitals that are willing • Mixed response. at least some private to stock public TB drugs • An increase in Gov’t TB TB drugs), would you are incentivized because drugs is beneficial for be willing to stock they no longer need clinics as they do not public TB drugs (or to purchase the drugs need to pay to purchase increase current supply themselves, but the ones TB drugs for patients of public drugs)? Why/ who are not willing to anymore. why not? stock public TB drugs • However, increased cited the administrative reporting may deter N/A N/A burden (including clinics from wanting to completing long public stock public TB drugs, sector TB forms) as especially if there aren’t disincentives. enough staff to help with the increased workload from reporting.
92 Hypothesis or No Hospitals Clinics Pharmacies Labs question 9 What would incentivize • Ability to treat DS-TB • Reduces clinic’s • N/A. However, based you to stock and patients who refuse capitation burden as on an interview, one prescribe government- referral to primary health it is free and does not pharmacy admitted that funded TB drugs based care without paying need to come out of it is willing to provide on TB care guidelines in OOP for TB drugs at capitation of patient. access for government- your facilities? cheaper cost. • Consistent across funded FDC if it can get • Reduce requirement • Consistent across all types of facilities: a reasonable margin from and financial all types of facilities: reduced requirements providing the drugs. burden to access reduced requirements and financial burden government-funded and financial burden to access government- FDCs? How and to access government- funded FDCs incentivize by how much if funded FDCs incentivize facility to provide the N/A financial? facility to provide the FDCs. • Direct or indirect FDCs. financial incentives for correct prescription? How much and how to claim? • Any others?
10 Do TB care doctors/ • ~50% of DOTS • If government-funded physicians have hospitals reviewed FDCs are available, a preference for have a preference for preference would be prescribing loose TB prescribing government- FDCs. drugs over FDCs? funded FDCs over loose • However, if government- If yes, what % of drugs (for complicated funded FDC is not them and what are TB patients, physicians available, patients can potential reasons prescribe loose drugs choose to purchase (e.g. habit, belief almost exclusively). private loose drugs vs of higher efficacy)? • Reasons for preference FDCs. Typically, non- Does the facility of FDCs: Reduce the BPJS-K clinics require have any authority to risk of patients mixing patients to pay OOP influence the doctors’ up their medication and for drugs, while BPJS-K preference? forgetting or taking the clinics, more often than wrong ones. not, will pay on behalf • Reasons for prescribing of the patients (unless loose drugs include: patients don’t know their stigma that comes rights). with free gov’t drugs N/A N/A perceived as lower quality, patients are allergic to a component of FDCs, those with higher purchasing power prefer to purchase branded loose drugs and loose drugs are given to non-BPJS-K patients. • Most hospitals admitted that they can suggest/ influence doctor’s preference, but in the end it’s doctors’ right to choose which drugs to prescribe.
93 Table 13: Additional insights from district interviews (Continued)
Hypothesis or No Hospitals Clinics Pharmacies Labs question 11 Does the institution • None interviewed mentioned having an incentive for monitoring and follow-up care. have an incentive for monitoring and promoting the continuity of long-term and follow-up care in N/A general (not just for TB)? Is that a monetary or reputational incentive?
12 Is there any system • For hospitals with DOTS • No monitoring or • There are no systems to promote this corner, the facilities’ follow-up system in in place for pharmacists monitoring of follow-up appointed person in place. However, in some to follow up on patients care? Is this used for TB charge (PIC)/medical clinics nurses will follow- when their prescriptions (e.g, patient adherence personnel, usually a up with patients who are due to be filled. to six- month nurse in charge of data miss treatment/control • Currently there are no treatment regimen, recording, will follow up appointments. consequence for facility check-ups, follow-up with patients if patients • Currently there are no or PIC if they do not for missed prescription do not come for the consequence for facility follow up with patient refills or check-ups)? scheduled appointment. or PIC if they do not and ensure treatment What are some key If patients still do not follow up with patient completion. challenges? show up after 2-3 days, and ensure treatment • How do you PIC will notify DHO and completion. ensure physicians’ DHO will reach out to compliance Puskesmas closest to the in monitoring patient to do loss-to- patient treatment follow-up tracing. completion (if they • Currently there are no N/A are responsible for consequence for facility doing so)? or PIC if they do not • If not, who is in follow up with patient charge and who do and ensure treatment you think is better completion. positioned for the • In the hospital, a nurse role and why? is typically in charge • Are there any for monitoring. They consequences if are considered better facility/PIC does positioned for the role not follow up as they usually follow with patients and up with the patient ensure treatment scheduling, and this is not completion? specific to TB.
13 Are TB diagnosis and • TB diagnosis and • Treatment for TB in treatment functions treatment functions clinics is not centralized; limited to certain are not limited to in general, any GP individuals in your certain individuals, e.g., a can diagnose/treat hospital/clinic, or pediatrician without TB TB patients. However, spread widely across certification may treat for DOTS-certified all physicians in presumptive TB patients. clinics (i.e., MoU the hospital/clinic? Physicians in hospitals with Puskesmas), the N/A N/A What are the main generally have knowledge physicians are typically TB considerations in hiring of TB diagnosis and trained via training from such people? Are they treatment, but are not the DHO. TB certified? necessarily TB certified.
94 Hypothesis or No Hospitals Clinics Pharmacies Labs question 14 What proportion of • On average, in the 41 • Majority of clinics the physicians in your hospitals reviewed, 75% interviewed were facility are specialists of the physicians are pratama clinics; they do (including internists and specialists and 25% GPs. not have specialists, only hospitalists) vs. what Reportedly there is no GPs and/or dentists. proportion are GPs difference in the quality without internist or of care provided by GPs hospital qualifications? vs. those of specialists • Are there differences N/A N/A in the quality of care they provide/ compliance to facility’s policies? What are they?
15 If indicated there are • There does not seem to be any incentive/ TB certified / specialist encouragement for doctors to obtain a separate TB staff, what support (e.g. certification. paid leave, non-financial rewards, etc.) does the facility provide to N/A N/A encourage doctors to obtain the certification?
16 Are doctors / • Both salary and • Mixed model, but physicians paid a salary commission. Doctors/ generally both salary or commission or both? physicians are typically and commission. Are they paid additional paid a salary and Commissions can be amounts based on commission, where the based on the number of either BPJS-K or other commission is based on patients treated (BPJS-K income? BPJS-K or number of and non-BPJS-K) or N/A N/A patients. based on number of work shifts per month (regardless of the number of patients).
17 If previously indicated • Mix of other private/ • Mix of other private/ presence of dual public hospitals/clinics/ public hospitals/clinics/ practice doctors, where private practice/ private practice/ else do they practice? Puskesmas. Puskesmas. N/A N/A What types of other facilities?
18 What proportion of • Unable to determine • Income proportion their incomes come proportion of incomes unknown. As physicians from respective based on sources from are generally paid higher sources? Is it more interviews. However, in private hospitals than economically desirable physicians are generally in private clinics, it would for physicians to paid higher in private be more economically practice partly in hospitals than in primary desirable for physicians N/A N/A a hospital vs. in a care. Thus, it would be in clinics to practice in a standalone PHC clinic? more economically hospital as well. Or to practice in desirable to practice in multiple hospitals? multiple hospitals
95 Table 13: Additional insights from district interviews (Continued)
Hypothesis or No Hospitals Clinics Pharmacies Labs question
19 How many doctors/ • Exact % not known, • Exact % not known, physicians working usually mix of facilities. usually mix of facilities. at your hospital are Doctors/physicians Doctors/physicians also working at (or do not typically refer do not typically refer operating) private patients to the other patients to the other clinics and vice versa? facilities they work in. facilities they work • Do they refer in. One exception: patients from the Puskesmas staff facility to the clinics who work in private or from clinics to the clinics typically refer hospital? presumptive TB in the • Do you see this as clinics to Puskesmas. an issue impacting health outcomes of patients? If yes, what actions have you N/A N/A taken to monitor and manage this?
20 As administrator / • Enforcer is usually the DHO/PKM. Internally, there • All pharmacies submit manager/owner: do usually isn’t any requirements or penalties for non- a report monthly you enforce reporting compliance. on psychotropic and requirements for any • Chain business model may not necessarily enable chain narcotics but nothing conditions? For TB? If facilities to enforce better DPPM implementation. on TB. yes, how often? If no, TB. Although larger facilities tend to participate in why not, and what are government programs, they do not necessarily have your ideas about how better enforcement of DOTS implementation, unless to do so and whether there’s a mandate top-down from the management. it might work (lack of clear consequences for non-compliance, lack of clear/ guaranteed benefits, not comfortable, high cost burden, high N/A administrative burden, etc.)? • For chain facilities, do you believe that having a chain business model enables you to enforce better – why or why not?
96 Hypothesis or No Hospitals Clinics Pharmacies Labs question 21 Do you see any • Most hospitals claimed • The capitation system challenges with the that INA-CBG payment for clinics often dis- existing INA CBG/ scheme is insufficient for incentivizes clinics from capitation system in TB treatment, resulting in treating patients at the enabling you to manage patients being requested PHC level since it is the economics of to visit hospitals multiple a relatively rare, and delivering quality TB times so hospitals can expensive disease to care? claim multiple visits, treat. Hence, clinics • Would you prefer a and/or up-coding TB prefer sending patients fee-for-service and patients to be able to to PKM/hospitals for unbundling scheme claim a higher INA- diagnosis/treatment for TB services? CBGs reimbursement while still receiving the Would it incentivize to recoup losses capitation payment. the hospital to from the insufficient • No reviewed clinic that increase its service reimbursement. screened for cough sent quantity as well as • Only one reviewed patient for TB testing. quality? How? hospital screened for N/A N/A • Which service/ cough in the outpatient product would department, and it then you prefer to be then provided surgical unbundled and why? mask to reduce airborne • Do you currently disease spread, this is not screen for cough limited to TB. in the outpatient department, then send the coughers for TB testing? If not, what would it take to incentivize such an action?
22 When was the last • DHO usually contacts • Generally, PKM do • For pharmacies, almost time somebody from the facility only if not call the facility if all pharmacies reviewed DHO or PKM visited reporting is late/ reporting is on time. If reported they never or called the facility not done correctly. If reporting is not done received visits from for TB monitoring or reporting is correct/ correctly or is late, DHO or PKM relating reporting? on time, DHO usually PKM will contact clinics to TB monitoring or do not call or visit for updates. Reporting reporting. facility on TB monitoring is done every three or reporting issues. months. Reporting is done every • In Surabaya, DHO three months, and the TB will invite clinics and forms are submitted to Puskesmas to meet and the DHO. In Kabupaten discuss any issues. Tangerang, DHO will N/A visit every hospital that participates in PPM.
97 Table 13: Additional insights from district interviews (Continued)
Hypothesis or No Hospitals Clinics Pharmacies Labs question 23 Do you think the • Mixed answers about • Mixed responses. • No specific inputs • Generally labs do not relationship between improvement of Some clinics think the from most reviewed interact much with the the private and public relationship between relationship is healthy, pharmacies. public sector. sector needs to be public and private sector. especially in districts • One pharmacy in Kab. improved? If yes, what • What’s going well: The where Puskesmas units Tang mentioned that do you think can DHOs across districts are were willing to accept DHO is not quick be improved in the active in inviting hospitals clinic-based patients for enough to socialize new relationship between for seminars (may not be tests or treatment. The regulations and they the private and public related to TB). reverse is true for clinics usually hear it first from sector? What specific • What can be improved: in districts where tension their own associations. initiatives/ actions increased guidance on with Puskesmas existed. • PRB pharmacies think would be required to DPPM implementation the public sector should do so? (one hospital in Kota do a much better job Tangerang in the process in preventing stock- of DOTS introduction outs in e-catalogue; mentioned that it was they also think BPJS-K not sure of the next should reimburse PRB steps after drafting the pharmacies on time. MoU), increased feedback from DHO regarding TB loss-to-follow-up patients (a hospital in Surabaya mentioned that DHO does not inform the hospital if the loss-to-follow up patient has been located and treated/contacted after the hospital gives the information to the DHO). 24 What is the best way • The fee-for-service • A pay-for-performance • Pharmacies could • Fee-for-service for TB for the government to payment mechanism for payment scheme to possibly be distribution diagnosis is the best continuously engage the TB diagnostic tests for incentivize clinics for points for government mechanism to engage private sector? hospitals on the condition treatment completion FDCs where they are private labs. that uncomplicated TB reimbursed for drug patients are down- handling fees. referred to primary care and results are reported to DHO. Alternatively, a pay-for-performance payment scheme where they are rewarded based on treatment completion.
25 Do you also work • For hospitals/clinics that work with external labs, • Some pharmacies can • All labs have commercial with other commercial samples are usually picked up and delivered by the send drugs to patients arrangements with providers, such external labs (eliminating the need for hospitals/clinics in the area (but not medical equipment as commercial to have their own transport network). dedicated for transport, providers and reagent arrangements for and can only send within distribution companies. sample transportation, small radius). Larger drug procurement, drug pharmacies usually have or reagent delivery/ an external courier distribution co., medical service. equipment providers (Abbot, Roche, etc.)?
Legend for the four lenses of research framework:
Institutional relationships and referrals Business landscapes (incentives and barriers) DHO role and implementation of PPM Role of non-public stakeholders
98 Figure 23: Linkage between study objectives, research framework, and key questions for implementation
Six critical questions to Five study objectives stated Research framework to drive design recommendations in Terms of Reference inquiries & discussion for implementation
1. Understand the business case for 1. Institutional and referral 1. Where should patients get providing TB-related services and relationships among private diagnosed? drugs in the private sector, facilities and public sector 2. How do we make sure hospitals including commercial and 2. Overall business landscape, down-refer uncomplicated TB non-commercial incentives and incentives, and barriers to increase patients? disincentives uptake and improve the quality of 3. How do we incentivize institutions 2. Understand attitudes among TB care to report? private sector providers toward 3. DHO role and implementation of participation in JKN and potential 4. How do we incentivize institutions district-based public-private mix interventions that could be to ensure treatment completion? (DPPM) implemented through JKN 5. Where should patients access 4. Role of other non-public 3. Develop an estimate of government-funded FDCs? stakeholders or civil society unreported TB cases treated in organizations, including 6. How do we further enable or the private sector that can be professional associations and incentivize DHO/Puskesmas to used as a baseline to assess the community organizations perform more of their public effect of interventions to improve health function (e.g. increase PPM case notification participation, follow-up TB patients 4. Develop a landscape of key in private sector)? district-level actors that have the potential to contribute to improving the provision or uptake of TB services in the private sector 5. Socialize findings with Dinas Kesehatan and other stakeholders to inform the national dialogue on PPM for TB in Indonesia
99 H. List of reviewed facilities
Facility District Name and description
RS Islam Orpeha Class C, BPJS-K, DOTS unit (reporting to public sector) RS Muhammadiyah Bandung Class D, BPJS-K, DOTS unit (reporting to public sector) RS Era Medika Tulungagung Class C, BPJS-K, DOTS unit (reporting to public sector) (6) RS Prima Medika Class D, BPJS-K, non-DOTS unit RS Madinah Class D, BPJS-K, DOTS unit (reporting to public sector) RS Putra Waspada Class D, BPJS-K, DOTS unit (reporting to public sector)
RS Hermina Bitung Class C, BPJS-K, in the process of setting up DOTS unit (reporting to public sector) RS Mulia Insani Kabupaten Class C, BPJS-K, in the process of setting up DOTS unit (reporting to public sector) RS Selaras Tangerang Class D, BPJS-K, DOTS unit (reporting to public sector) (5) Siloam Hospital Lippo Village Class B, BPJS-K, DOTS unit (reporting to public sector) RS Suci Paramita Class D, BPJS-K, non-DOTS unit Hospitals (41) RS Islam Jakarta Sukapura Class C, BPJS-K, DOTS unit (reporting to public sector) RS Paru Firdaus Class C, BPJS-K, DOTS unit (reporting to public sector) RS Pluit Jakarta Utara Class B, non BPJS-K, DOTS unit (reporting to public sector) (6) RS Pantai Indah Kapuk Class B, non BPJS-K, non-DOTS unit RS Atma Jaya Penjaringan Class B, BPJS-K, DOTS unit (reporting to public sector) RS Mitra Keluarga Kelapa Gading Class B, non BPJS-K, DOTS unit (reporting to public sector)
RS Murni Teguh Class B, BPJS-K, DOTS unit (reporting to public sector) RSU Delima Class C, BPJS-K, DOTS unit (reporting to public sector) RS Advent Medan Class C, BPJS-K, DOTS unit (reporting to public sector) (6) RS Mitra Sejati Class B, BPJS-K, DOTS unit (reporting to public sector) RS Martha Friska Class B, BPJS-K, DOTS unit (reporting to public sector) RS Columbia Asia Class B, non-BPJS-K, DOTS unit (reporting to public sector)
100 Facility District Name and description
RS Ibnu Sina Class B, BPJS-K, DOTS unit (reporting to public sector) RS Akademis Jaury Class B, BPJS-K, non-DOTS unit RS Grestelina Makassar Class B, BPJS-K, non-DOTS unit (6) RS Awal Bros Class B, BPJS-K, DOTS unit (reporting to public sector) RS Siloam Class B, BPJS-K, non-DOTS unit RS Stella Maris Class B, BPJS-K, DOTS unit (reporting to public sector)
RSU Bakti Asih Class C, BPJS-K, DOTS unit (reporting to public sector) RS Mulya Class C, BPJS-K, in the process of setting up DOTS unit (reporting to public sector) Kota Tangerang RS EMC Tangerang Hospitals (6) Class B, BPJS-K, in the process of setting up DOTS unit (reporting to public sector) (41) RS Awal Bros Kota Tangerang Class B, BPJS-K, DOTS unit (reporting to public sector) RS An-Nisa Class C, BPJS-K, in the process of setting up DOTS unit (reporting to public sector) RS Medika Lestari Class C, BPJS-K, non-DOTS unit
RS Wijaya Wiyung Class D, BPJS-K, non-DOTS unit RS Onkologi Class C, non BPJS-K, non-DOTS unit Surabaya RS Adi Husada Kapasari (6) Class C, BPJS-K, DOTS unit (reporting to public sector) RS Gotong Royong Surabaya Class D, non BPJS-K, DOTS unit (reporting to public sector) RS Islam Jemursari Surabaya Class B, BPJS-K, DOTS unit (reporting to public sector) RS Siloam Class B, BPJS-K, DOTS unit (reporting to public sector)
101 Facility District Name and description
Klinik Khasanah Medika Pratama, BPJS-K, stocks gov’t FDCs Klinik Cordova Tulungagung Pratama, BPJS-K, does not stock gov’t FDCs (4) Klinik Madinah Pratama, BPJS-K, does not stock gov’t FDCs Klinik Dr. Emi Pratama, BPJS-K, does not stock gov’t FDCs
Apotek + Klinik Milenia Sejahtera Pratama, BPJS-K, stocks gov’t FDCs Klinik Omega Cikupa Pratama, BPJS-K, stocks gov’t FDCs Kabupaten Klinik Usada Nugraha Tangerang Pratama, BPJS-K, does not stock gov’t FDCs Klinik & Lab IMI (6) Pratama, BPJS-K, does not stock gov’t FDCs Klinik Omega Rajeg Pratama, BPJS-K, does not stock gov’t FDCs Klinik Citra Sehat Utama, non BPJS-K, does not stock gov’t FDCs
Klinik Pratama Santo Yosef Pratama, BPJS-K, stocks gov’t FDCs Klinik Wahana Sejahtera Pratama, BPJS-K, does not stock gov’t FDCs Clinics Jakarta Utara Klinik Armada Medika 2 Penjaringan (36) (5) Pratama, BPJS-K, does not stock gov’t FDCs Klinik Semper Sisma Medika Pratama, BPJS-K, does not stock gov’t FDCs Klinik Pratama Melania Pademangan Pratama, BPJS-K, does not stock gov’t FDCs
Klinik Aviati Pratama, BPJS-K, stocks gov’t FDCs Klinik MMC Pratama, BPJS-K, does not stock gov’t FDCs Medan Klinik Harapan Bunda 2 (5) Pratama, BPJS-K, does not stock gov’t FDCs Klinik Citra Medika Pratama, BPJS-K, does not stock gov’t FDCs Klinik Citra Bakti Pratama, BPJS-K, stocks gov’t FDCs
Klinik Azka Nadhifa Pratama, BPJS-K, stocks gov’t FDCs Ratulangi Medical Center (RMC) Utama, non BPJS-K, stocks gov’t FDCs Makassar Klinik Lacasino (5) Pratama, BPJS-K, does not stock gov’t FDCs Klinik HK Medical Center Pratama, BPJS-K, does not stock gov’t FDCs Klinik Monginsidi Pratama, BPJS-K, does not stock gov’t FDCs
102 Facility District Name and description
Klinik Bhakti Asih Pratama, BPJS-K, does not stock gov’t FDCs Klinik Mekar Sari Medika Kota Tangerang Pratama, non BPJS-K, does not stock gov’t FDCs Klinik Siloam (5) Pratama, BPJS-K, does not stock gov’t FDCs Klinik Sudimara Barat Pratama, BPJS-K, does not stock gov’t FDCs Klinik Rizky Medika Pratama, non BPJS-K, does not stock gov’t FDCs
Clinics (36)
Klinik MedPoint Pratama, BPJS-K, does not stock gov’t FDCs Klinik Rajawali Pratama, BPJS-K, does not stock gov’t FDCs Surabaya Klinik Amanina Medika (6) Pratama, BPJS-K, does not stock gov’t FDCs Klinik Dinayla Utama 84 Pratama, BPJS-K, stocks gov’t FDCs Klinik Putri Rahayu Surabaya Pratama, BPJS-K, stocks gov’t FDCs Klinik Indosehat 2003 Pratama, BPJS-K, stocks gov’t FDCs
Apotek Seras Sehat Besuki BPJS-K, non-chain, does not stock TB drugs Apotek Ngunut Farma Non BPJS-K, non-chain, stocks TB drugs Apotek Demuk Farma Non BPJS-K, non-chain, does not stock TB drugs Tulungagung Apotek Wisnu Farma Pharmacies (8) Non BPJS-K, chain, stocks TB drugs (55) Apotek Sido Waras BPJS-K, non-chain, stocks TB drugs Apotek Putra Waspada Non BPJS-K, non-chain, stocks TB drugs Apotek Namira Farma Non BPJS-K, non-chain, stocks TB drugs Apotek Bhakti Santoso No data on BPJS-K empanelment, non-chain, stocks TB drugs
103 Facility District Name and description
Apotek Curug Sehat Non BPJS-K, non-chain, stocks TB drugs Apotek Sehati Non BPJS-K, non-chain, stocks TB drugs Apotek + Klinik Milenia Sejahtera Non BPJS-K, chain, stocks TB drugs Kabupaten Apotek K-24 Vienna Tangerang Non BPJS-K, chain, stocks TB drugs (8) Apotek Keluarga Sehat Medika Non BPJS-K, non-chain, stocks TB drugs Apotek Citra Mulia 1 Non BPJS-K, chain, stocks TB drugs Apotek Citra Mulia 2 Non BPJS-K, chain, stocks TB drugs Apotek Binong Permai Non BPJS-K, non-chain, stocks TB drugs
Apotek Mitra Sana Non BPJS-K, chain, does not stock TB drugs Apotek Putri Damai BPJS-K, non-chain, stocks TB drugs Apotek Tugu Indah BPJS-K, non-chain, stocks TB drugs Apotek Syifa Medika Pharmacies Jakarta Utara Non BPJS-K, non-chain, stocks TB drugs (55) (8) Apotek Roxy Penjaringan Non BPJS-K, chain, stocks TB drugs Apotek Sisma Pharma Medika Non BPJS-K, chain, stocks TB drugs Apotek K-24 Kelapa Gading BPJS-K, chain, stocks TB drugs Apotek Juanda Non BPJS-K, non-chain, stocks TB drugs
Apotek Dety Non BPJS-K, non-chain, stocks TB drugs Apotek Anugerah Non BPJS-K, non-chain, stocks TB drugs Apotek Hary Na Jaya Non BPJS-K, non-chain, stocks TB drugs Medan Apotek Timoti (7) Non BPJS-K, chain, stocks TB drugs Apotek Marita Non BPJS-K, non-chain, stocks TB drugs Apotek Varia BPJS-K, chain, does not stocks TB drugs Apotek Kurnia Farma No data on BPJS-K empanelment, non-chain, stocks TB drugs
104 Facility District Name and description
Apotek Sehat Non BPJS-K, non-chain, stocks TB drugs Apotek Sana Farma BPJS-K, chain, does not stock TB drugs Apotek Sejati Farma Non BPJS-K, non-chain, stocks TB drugs Apotek Pelita Makassar Non BPJS-K, non-chain, stocks TB drugs (8) Apotek Jaya Abadi Non BPJS-K, non-chain, stocks TB drugs Apotek Berkat Farma Non BPJS-K, non-chain, stocks TB drugs Apotek Alfa Medica Non BPJS-K, non-chain, stocks TB drugs Apotek Anugerah Non BPJS-K, chain, stocks TB drugs
Apotek Sanafarma Cibodas BPJS-K, chain, stocks TB drugs Apotek Roxy Ciledug Non BPJS-K, chain, stocks TB drugs Apotek/Klinik Mitra Medicare BPJS-K, chain, stocks TB drugs Apotek Cipondoh Pharmacies Kota Tangerang Non BPJS-K, non-chain, stocks TB drugs (55) (8) Apotek Banjar Baru Non BPJS-K, chain, stocks TB drugs Apotek Pintu Air Non BPJS-K, non-chain, stocks TB drugs Apotek Sumber Berkat Non BPJS-K, chain, stocks TB drugs Apotek Pro Hemat Non BPJS-K, non-chain, stocks TB drugs
Apotek Telemedika Farma 4 BPJS-K, chain, stocks TB drugs Apotek K24 Non BPJS-K, non-chain, stocks TB drugs Apotek Optima BPJS-K, chain, does not stock TB drugs Apotek Maleo Surabaya BPJS-K, chain, does not stock TB drugs (8 Apotek Medical Center ITS Surabaya BPJS-K, non-chain, does not stock TB drugs Apotek Banyu Urip Surabaya BPJS-K, non-chain, stocks TB drugs Apotek Karunia Farma BPJS-K, non-chain, stocks TB drugs Apotek Setiabudi Non BPJS-K, non-chain, stocks TB drugs
105 Facility District Name and description
Lab Sam Husada Non-chain, not BPJS-K appointed for chronic diseases Lab Prodia Tulungagung Chain, BPJS-K appointed for chronic diseases (4) Lab Ultra Medika Chain, not BPJS-K appointed for chronic diseases Lab Kalidawir Non-chain, not BPJS-K appointed for chronic diseases
Lab Samara Medika Sepatan Chain, not BPJS-K appointed for chronic diseases Klinik + Lab IMI Kabupaten Non-chain, not BPJS-K appointed for chronic diseases Lab Sandy Asih Kota Bumi Tangerang Chain, not BPJS-K appointed for chronic diseases (5) Lab BioMed Cikupa Chain, not BPJS-K appointed for chronic diseases Lab Pramista Chain, not BPJS-K appointed for chronic diseases
Lab Prodia Kelapa Gading Chain, BPJS-K appointed for chronic diseases Lab Bio Medika Kelapa Gading Chain, not BPJS-K appointed for chronic diseases Jakarta Utara Lab Prodia Pluit (5) Chain, BPJS-K appointed for chronic diseases Lab Bio Medika Sunter Laboratories Chain, not BPJS-K appointed for chronic diseases (30) Lab Biotest Kelapa Gading Chain, not BPJS-K appointed for chronic diseases
Lab Pramita Chain, BPJS-K appointed for chronic diseases Lab Gatot Subroto Medan Chain, not BPJS-K appointed for chronic diseases (4 Lab SM Raja Chain, not BPJS-K appointed for chronic diseases Lab Thamrin Chain, not BPJS-K appointed for chronic diseases
Lab Cahayasaga Non-chain, not BPJS-K appointed for chronic diseases Lab Parahita Chain, not BPJS-K appointed for chronic diseases Makassar Lab Prodia (5) Chain, BPJS-K appointed for chronic diseases Lab Tirta Medical Center Chain, not BPJS-K appointed for chronic diseases Lab Pramita Chain, not BPJS-K appointed for chronic diseases
Lab Biomedika Chain, not BPJS-K appointed for chronic diseases Kota Tangerang Lab Biomed (3) Chain, not BPJS-K appointed for chronic diseases Lab Usada Insani Non chain, not BPJS-K appointed for chronic diseases
106 Facility District Name and description
Lab Prodia Surabaya Chain, BPJS-K appointed for chronic diseases Lab Parahita Dharmawangsa Surabaya Laboratories Surabaya Chain, BPJS-K appointed for chronic diseases (30) (4) Lab Granostic Non-chain, not BPJS-K appointed for chronic diseases Lab Pramita Chain, BPJS-K appointed for chronic diseases
PDPI (Pulmonologists Association) Tulungagung IDI (Doctors Association) IAI (5) (Pharmacists Association) PKFI (Clinics and Primary Healthcare Association) ARSSI (Private Hospitals Association)
ASKLIN (Clinics Association) PATELKI (Lab Technicians Association) Kabupaten IAI (Pharmacists Association) Tangerang IDI (Doctors Association) (7) IDAI (Pediatricians Association) PAPDI (Internists Association) PDPI (Pulmonologists Association)
PAPDI (Internists Association) IAI (Pharmacists Association) Jakarta Utara IDAI (Pediatricians Association) (6) IDI (Doctors Association) PKFI (Clinics and Primary Healthcare Association) Non-public ILKI (Laboratories Association) stakeholders:
Professional IDI (Doctors Association) Associations Medan IAI (Pharmacists Association) PKFI (37) (5) (Clinics and Primary Healthcare Association) ARSSI (Private Hospitals Association) PAPDI (Internists Association)
IAI (Pharmacists Association) ASKLIN (Clinics Association) Makassar IDI (Doctors Association) IDAI (7) (Pediatricians Association) PAPDI (Internists Association) PDPI (Pulmonologists Association) PATELKI (Lab Technicians Association)
Kota Tangerang IAI (Pharmacists Association) ASKLIN (3) (Clinics Association) PDPI (Pulmonologists Association)
PAPDI (Internists Association) Surabaya PDPI (Pulmonologists Association) (4) IDAI (Pediatricians Association) PKFI (Clinics and Primary Healthcare Association)
107 Facility District Name and description
LKNU A CSO focused on TB case finding with the help of paid cadres Tulungagung AISYIYAH (3) Women Islamic organization involved in case detection and treatment monitoring, funded by GF PPTI Association of TB eradication Indonesia
Kabupaten AISYIYAH Tangerang Women Islamic org. involved in case detection and treatment monitoring, funded by GF (1)
Jakarta Utara PETA (1) Organization focusing on MDR-TB patients through funding from GF and does home Non-public and hospital visits and education to patients and family of patients stakeholders:
CSOs PESAT (10) Organization of ex MDR-TB patients focused on helping MDR-TB patients Medan AISYIYAH Women Islamic org. involved in case detection and treatment monitoring, funded by GF (3) JKM Organization aimed at enhancing the ability of the community to take precautions, and detection and treatment of TB, MDR-TB, and TB-HIV among susceptible groups
Makassar AISYIYAH (1) Women Islamic org. involved in case detection and treatment monitoring, funded by GF
Kota Tangerang No CSO interviewed (0)
Surabaya AISYIYAH (1) Women Islamic org. involved in case detection and treatment monitoring, funded by GF
108 Endnotes
1. World Health Organization, Global Tuberculosis Report from https://dec.usaid.gov/dec/content/Detail. 2018. Geneva: WHO; 2018 (http://apps.who.int/iris/bitstream/ aspx?vID=47&ctID=ODVhZjk4NWQtM2YyMi00Yj handle/10665/274453/9789241565646-eng.pdf accessed 24 RmLTkxNjktZTcxMjM2NDBmY2Uy&rID=NTEzNzYx. September 2018). 16. Health Policy Plus, The Financial Sustainability of Indonesia’s 2. World Health Organization, 2018. Engaging health care National Health Insurance Scheme: 2017–2021, May 2018. providers in TB care and prevention: A landscape analysis. 17. JKN regulation No. 59 tahun 2014. 3. The Boston Consulting Group, Indonesia National TB Program, USAID. Engaging Private Providers to Improve TB Outcomes in 18. Public health care constitutes of Puskesmas, sub-district based Indonesia; 2018. https://pdf.usaid.gov/pdf_docs/PA00SWQD.pdf. community health centers overseen by the MoH. Private primary health care constitutes of GPs and private clinics, classified into 2 4. CAGR is the rate of increase in the value of a quantity, types: pratama and utama. A pratama clinic is defined as a clinic compounded over several years. Unlike average annual led by a GP or dentist with a minimum of 2 medical personnel growth rate (AAGR) that does not account for the effects of made up of GPs and/or dentists; an utama clinic is defined as compounding, the CAGR smoothes out or diminishes the effect a clinic led by a specialist or dentist with competency in what of volatility. the clinic specializes in, and medical personnel made up of at least 1 specialist from each type of specialized services provided 5. PPJK are tasked with carrying out the preparation of technical (there are no specific/defined type of specialties required to be policies, implementation and monitoring, evaluation, and reporting designated as an utama clinic) in the field of health insurance in accordance with the provisions of the legislation. 19. Partial referral or “rujukan parsial” is a mechanism in BPJS-K in which patients are sent to another health facility only for part of 6. R4D is the implementing organization that helps structure the the treatment, e.g. diagnosis only or drugs pick up only. discussions between Indonesian institutions such as NTP, PPJK, and BPJS-K on strategic purchasing options. 20. Co-funded between Global Fund and APBN (national budget). APBN allocate US$1mn, while GF allocate US$172k to procure 7. Indonesia Tuberculosis Prevalence Survey 2013-2014. MoH cartridges. APBN only covers maintenance cost of GoI-procured Indonesia, June 2015. Of 2,170 who had ever had TB treatment, GeneXpert, while GF covers maintenance of the GeneXpert 35% received that treatment in private facilities (379 were machines procured using the grant. treated in private hospitals and 386 in private practitioners’ clinics). Finally, of the 125 who were on TB treatment at the time 21. GFATM is responsible for financing incentives for all of the survey, 42% were receiving that treatment from the private GeneXpert sites, which now reportedly receive lower incentives sector (26 from private hospitals, 7 from private clinics, and 19 at IDR10K/test. APBN does not cover this incentive. from private practitioners). 22. PMK no 52 tahun 2016. 8. Indonesia TB Patient Pathway Analysis (PPA), Jan 16th 2017. 23. As opposed to the kelurahan (sub-sub-district) Puskemas 9. Wells WA, Ge CF, Patel N, Oh T, Gardiner E, Kimerling ME. Size units, which only exist in Jakarta and do not take on this function. and usage patterns of private TB drug markets in the high burden countries. PLoS One. 2011 May 4;6(5):e18964. doi: 10.1371/ 24. These data and other quantitative data in this report were journal.pone.0018964. collected as part of the mapping exercise during the district-level interviews. Data came from either DHOs (for district-wide data) 10. World Health Organization, 2018. Engaging health care or individual private facilities (in these latter cases, the number of providers in TB care and prevention: A landscape analysis. facilities sampled is indicated).
11. Health Policy Plus, The Financial Sustainability of Indonesia’s 25. BPJS-K presentation during first “Technical Working Group” National Health Insurance Scheme: 2017–2021, May 2018. session of R4D in August 2018.
12. The Boston Consulting Group, Indonesia National TB Program, 26. Mahendradhata et al. 2015. “How do private general USAID. Engaging Private Providers to Improve TB Outcomes in practitioners manage tuberculosis cases? A survey in eight cities Indonesia; 2018. https://pdf.usaid.gov/pdf_docs/PA00SWQD.pdf. in Indonesia” BMC Research Notes2015 8:564, https://doi. org/10.1186/s13104-015-1560-7. 13. To download Methodology for District Selection for Market Research, please visit https://pdf.usaid.gov/pdf_docs/PA00SVC4. 27. BPJS-K website (https://faskes.bpjs-kesehatan.go.id); data pdf. extracted in July 2018
14. The USAID Country Development Cooperation Strategy 28. Several DOTS criteria are included in accreditation (CDCS) serves as an outline for USAID engagement with requirement. They are not mandatory, but the accreditation points Indonesia. USAID CDCS districts are those districts where from establishing and running a DOTS corner can help hospitals USAID focuses its programmatic efforts. For more information, reach the highest “Paripurna” status, which increases institutional please visit https://www.usaid.gov/indonesia/cdcs. prestige.
15. Detail of the interview guides can be found in 29. Permenkes No. 73 Year 2016; clinics without inpatient care are section VI of the annex and can be downloaded not obligated to provide pharmaceutical services
109 30. Permenkes No. 58 Year 2014; pharmacies in hospitals need at 43. Estimated cost approximately IDR 210K, assuming ~IDR50k least one licensed pharmacist in inpatient department, outpatient for doctor’s fee, IDR78k for sputum smear test and IDR85k department, emergency room, and Intensive Care Unit / Intensive for chest x-ray vs. BPJS-K reimbursement of ~IDR170K for an Cardiac Care Unit/Neonatus Intensive Care Unit/Pediatric outpatient in a typical type C hospital. Intensive Care Unit 44. The Boston Consulting Group, Indonesia National TB Program, 31. Permenkes No. 9 Year 2014 (http://pelayanan.jakarta.go.id/ USAID. Engaging Private Providers to Improve TB Outcomes in download/regulasi/permen-kesehatan-nomor-9-tahun-2014- Indonesia 2018. tentang-klinik.pdf) 45. In smaller districts such as Tulungagung, where public 32. Permenkes No. 74 Year 2016; for puskesmas units, licensed awareness of BPJS-K entitlement seemed to be lower, some pharmacists are required at recommended ratio of 1 pharmacist clinics refer patients to pay OOP at private labs. for every 50 daily patients 46. See, for example, Montagu D, Goodman C. Prohibit, constrain, 33. Permenkes No. 31 Year 2016; encourage, or purchase: how should we engage with the private health-care sector? Lancet. 2016, 388: 613-621. 34. BPJS-K purchasing system. 47. The Boston Consulting Group, Indonesia National TB Program, 35. DEPKES, Number of Pharmacies in Indonesia, 2018. http:// USAID. Engaging Private Providers to Improve TB Outcomes in apif.binfar.depkes.go.id/grafik-apotek.php; number of standalone Indonesia; 2018. pharmacies is not available. 48. Kemeterian Kesehatan Republik Indonesia. 2017. “The Joint 36. Kimia Farma is 90% state owned but offers pharmacy External TB Monitoring Mission (JEMM TB) Indonesia 2017. franchise licenses. The franchisee provides the facility infrastructure and operates the outlet under the Kimia Farma 49. DOTS hospital refer to hospitals that have already been brand as a business – receiving benefit from a profit-sharing DOTS accredited by KARS and have an MoU with the DHO. agreement (the franchisee receives 3-5% of turnover) and an asset utilization sharing agreement (e.g., renting out space for an 50. Balakrishnan, Shibu; Technical Assistance to National ATM). Thus, although Kimia is 90% state owned, the individual Tuberculosis Programme, Indonesia, to understand barriers franchised outlets are expected to operate more like for-profits to TB notification from major public hospitals and Interface in terms of motivation and business models. Source: http:// Organization model for Public-Private Mix and to identify corporate.kimiafarmaapotek.co.id/page/kerjasama-operasional-kso appropriate interventions; August 2018.
37. Prolanis (a chronic disease management program) is a 51. CTB_DRAFT Detail Task of PPM Network Tupoksi Wasor dan program that aims to provide more effective and cost-efficient Puskesmas medical care for patients with chronic diseases (e.g., type 2 diabetes and hypertension) by working together with BPJS-K 52. Balakrishnan, Shibu; Technical Assistance to National and the health care facilities, and by including interventions such Tuberculosis Programme, Indonesia, to understand barriers as home visits, counseling, lab tests, and group activities. Related to TB notification from major public hospitals and Interface but distinct from Prolanis is PRB, which is a referral program for Organization model for Public-Private Mix and to identify chronic disease patients in stable condition that allows them to appropriate interventions; August 2018. access their medications at pharmacies as opposed to having to 53. The 13 professional organizations involved are IDI (Physicians go back to hospitals. Patients are reevaluated in secondary care association), PDPI (Respirologist association), PAPDI (Internist facilities every three months and may continue with the PRB association), IDAI (Pediatrician association), PDUI (General program if their condition is stable. Physician association), PERDOKI (Occupational medicine 38. These figures come from district-level data from the DHO association), PDS PATKLIN (Clinical pathologist association), interviews in 2018 (reflecting 2017 data), while national data for PATELKI (Lab analyst association), PDKI (Family doctor the denominators was from 2018 GTB Landscape Analysis. Total association), PAMKI (Clinical microbiologist association), PPNI notifications (public plus private) for 2017 are from the WHO (Nurses association), PDSRI (Radiologist association), and IAI report. (Pharmacist association).
39. 120 GPs out of ~200 total in Tulungagung have been 54. TB Care I was implemented globally from 2010-2015; TB Care participated in WiFi-TB training and can access the WiFi-TB I Final Report. retrieved September 2018 from https://www. application. challengetb.org/reportfiles/TB_CARE_I_Final_Full_Report.pdf.
40. This includes Puskesmas in both Kecamatan (sub-district) and 55. The detailed number of clinics with access to FDCs in Kelurahan (village). Figures are provided by the DHOs during interviewed districts can be found in section 4.3 “State of play by district interviews in the second quarter of 2018. district”.
41. The 90 clinics noted are only the pratama clinics; the utama 56. The unnecessary BPJS-K cost of up-referrals is calculated by clinic number is unknown. multiplying (1) estimated number of visits per patient over 6 months, and (2) reimbursement per visit. Assume 5 visits for each 42. DEPKES, 2016 data and company annual reports. The top 15 outpatient over 6 months and BPJS-K reimbursement per visit of private hospitals are typically chains, which include: Siloam, Mitra IDR 170K based on a typical Class C hospital using Q-code for Keluarga, Hermina, Pertamedika, Awal Bros, Sari Asih, Ramsay, consultation. Omni, Ciputra, EKA Group, Columbia Asia, Mayapada, Bunda Medika, EMTEK, and Pluit. 57. Patient Adherence to Tuberculosis Treatment: A Systematic
110 Review of Qualitative Research, https://www.ncbi.nlm.nih.gov/ 72. The number of pharmacies in all districts except Medan pmc/articles/PMC1925126/. For Indonesia-specific evidence of include Kimia Farma. Data source for North Jakarta and Surabaya: lower treatment success in hospital-based care, see Irawati SR, data based on interview with DHO. The remaining districts’ data Basri C, Arias MS, Prihatini S, Rintiswati N, Voskens J, Kimerling ME. were extracted from: http://apif.binfar.depkes.go.id/ . Hospital DOTS linkage in Indonesia: a model for DOTS expansion into government and private hospitals. Int J Tuberc Lung Dis. 2007 73. Data source for Medan, Tulungagung, and Kota Tangerang: Jan;11(1):33-9. Human Resources Development and Empowerment Agency for Health, MoH website, and Makassar: Makassar Center for Health 58. Currently online reporting in SITT only happens once every Laboratory website. three months, which means the hospital would need to wait three months to provide proof of reporting. With integration 74. Puskesmas Kecamatan (sub-district Puskesmas) are typically of with BPJS-K system, reporting can be done together with two facility types: Puskesmas Rujukan Mikroskopis; or Puskesmas payment reimbursement. Pelaksana Mandiri (see definitions in footnotes below). Puskesmas Kelurahan (village Puskesmas) are typically of Puskesmas Satelit; 59. Performance-Based Incentives for Health: A Way to Improve among interviewed districts, only DKI Jakarta has both Puskesmas Tuberculosis Detection and Treatment Completion. https://www. Kecamatan and Puskesmas Kelurahan, whereas the remaining cgdev.org/files/13544_file_TB_Incentives.pdf. districts have no such classification.
60. Cheng Yi, et.al. Using Financial Incentives to Improve the Care 75. Puskesmas Rujukan Mikroskopis is a Puskesmas that is capable of Tuberculosis Patients. The American Journal of Managed Care. of creating sputum slides, doing microscopic examination of 2015;21(1):e35-e42. sputum, receiving referrals, and conducting technical guidance to Puskesmas Satelit. 61. WHO. Handbook for the use of digital technologies to support Tuberculosis medication adherence. 76. Puskesmas Pelaksana Mandiri is a Puskesmas that has a TB microscopic laboratory that functions to perform microscopic TB 62. PMO: Pengawas Minum Obat (ensures TB patients take services, without cooperating with or supervising Puskesmas Satelit. medicines to avoid relapse). 77. Puskesmas Satelit is a Puskemas that does not have laboratory 63. RASCI is a responsibility matrix used to display responsibilities facilities for TB diagnosis, but is able to make sputum slides to be of individuals based on their role on a certain process/task. The sent to Puskesmas Rujukan Mikroskopis for diagnosis. roles are: Responsible, Accountable, Support, Consulted, Informed. 78. For example, sputum corner, inpatient and outpatient room 64. For potential indicators, see Annex 2 of Guy Stallworthy, that satisfy the MoH TB guidelines. William Wells, Monica Dias. 2018. Engaging private health care providers in TB care and prevention: A landscape analysis. http:// 79. In addition to GPs. Pulmonology unit or internist unit is more www.who.int/tb/publications/2018/PPMLandscapeAnalysis.pdf commonly found in clinics utama.
65. Guy Stallworthy, William Wells, Monica Dias. 2018. Engaging 80. Including either FDCs, loose drugs, or both. private health care providers in TB care and prevention: A landscape analysis. http://www.who.int/tb/publications/2018/ 81. Low DPPM implementation: Relatively low percentage of PPMLandscapeAnalysis.pdf clinics/hospitals participating in PPM (i.e. less than 10%), relatively low percentage of DOTS-certified hospitals (i.e. less than 50%), 66. World Health Organization. 2017. Handbook for high tension between Puskesmas and clinics over capitation. the use of digital technologies to support Tuberculosis medication adherence. http://apps.who.int/iris/bitstream/hand High DPPM implementation: Relatively high percentage of clinics/ le/10665/259832/9789241513456-eng.pdf hospitals participating in PPM (i.e. more than 10%), relatively high percentage of DOTS-certified hospitals (more than 50%), no/ 67. To download Methodology for District Selection for Market limited tension between Puskesmas and clinics over capitation. Research, please visit https://pdf.usaid.gov/pdf_docs/PA00SVC4.pdf. 82. North Jakarta: The DHO and 8 of 11 of the interviewed 68. USAID Country Development Cooperation Strategy clinics and hospitals noted patients reject referrals to PKM and (CDCS) serves as an outline for USAID engagement with would rather stay/be referred directly to secondary care. Indonesia. USAID CDCS districts refers to districts where USAID implements its program. For more information, please visit https:// 83. Medan: The DHO and 7 of 11 of the interviewed clinics and www.usaid.gov/indonesia/cdcs. hospitals noted patients reject referrals to PKM and would rather stay/be referred directly to secondary care. 69. Data sources for each indicator are listed in an accompanying Excel that is available upon request. 84. Makassar: The DHO and 7 of 11 of the interviewed clinics and hospitals noted patients reject referrals to PKM and would 70. Data ranges from 2013-2016. Jakarta Utara: 2013 data, Medan rather stay/be referred directly to secondary care. and Makassar: 2015 data, and Tulungagung, Kab. Tangerang, Kota Tangerang, and Surabaya: 2016 data. Inconsistency was due to the 85. Kota Tangerang: 10 out of 12 interviewed facilities mentioned availability of information from the Statistics Indonesia (termed that patients follow suggested referral paths (either from clinics “BPS”) website. to Puskesmas or from secondary care down to primary care).
71. Data source for Kota Tangerang, Makassar and Surabaya: 2015 86. Surabaya: The DHO and all facilities except for 1 interviewed DHO report. North Jakarta, Medan, Tulungagung, and Kabupaten hospital follow suggested referral paths (either from clinics to Tangerang: 2017 data based on interview with DHO. Puskesmas or from secondary care down to primary care).
111 87. Kab. Tangerang: The DHO and 10 of 11 facilities noted no burden countries. PLoS One. 2011 May 4;6(5):e18964. This study resistance from patients when referred to the PKM for treatment. captured TB Alliance studied TB drug sales data of H, R, Z and E molecules between 2004 and 2009. 88. Tulungagung: All 4 interviewed clinics and 4 of 6 interviewed hospitals mentioned that uncomplicated TB patients preferred 102. The published estimate in the 2011 study for 2008-2009 seeking treatment in Puskesmas because Puskesmas were year was 498K patient regimens in Indonesia; Wells WA, Ge CF, perceived to have better capabilities and support to care for TB Patel N, Oh T, Gardiner E, Kimerling ME. Size and usage patterns patients. of private TB drug markets in the high burden countries. PLoS One. 2011 May 4; 6(5):e18964. 89. Prodia prospectus. Frost and Sullivan Analysis in 2015. The next 5 key players were Pramita, Parahita, Cito, Biomedika, and 103. 2008 data: Wells WA, Ge CF, Patel N, Oh T, Gardiner Kimia Farma; please note Kimia Farma is considered public, but E, Kimerling ME. Size and usage patterns of private TB drug included in the figures since breakdown was not available. markets in the high burden countries. PLoS One. 2011 May 4; 6(5):e18964, 2015 data: TB Alliance (unpublished), and 2017 data: 90. At the time this review was written, there were 120 GPs that IQVIA data from this review. had access to WiFi-TB out of 209 GPs in Tulungagung. 104. CAGR is the rate of increase in the value of a quantity, 91. DOTS was introduced as one of the nationwide requirements compounded over several years. Unlike average annual for KARS hospital accreditation in 2012. growth rate (AAGR) that does not account for the effects of compounding, the CAGR smoothes out or diminishes the effect 92. Accreditation status from lowest to highest are: lulus perdana, of volatility. dasar, madya, utama, and paripurna. 105. Manufacturers data provided by IQVIA did not go as far 93. See: Wells WA et al. Size and usage patterns of private TB back as 2008. drug markets in the high burden countries. PLoS One. 2011 May 4;6(5):e18964; Islam T et al. Market size and sales pattern 106. See https://www.iqvia.com/-/media/iqvia/pdfs/library/ of tuberculosis drugs in the Philippines. Public Health Action. publications/acts-2017-31st-edition.pdf?_=1536169536018. 2013. 3: 337–341; Arinaminpathy N et al. The number of privately IQVIA notes that this annual publication pertains to IQVIA’s treated tuberculosis cases in India: an estimation from drug sales manufacturer sales data in each country, but these measures do data. Lancet Infect Dis. 2016. 16: 1255-1260; and Malhotra et al, in not reflect the accuracy of the unique dataset created for this preparation. review or other data offerings.
94. See page 87 of the WHO TB report 2018 at: http://apps.who. 107. World Health Organization, Global Tuberculosis Report int/iris/bitstream/handle/10665/274453/9789241565646-eng. 2018. Geneva: WHO; 2018 (http://apps.who.int/iris/bitstream/han pdf , and the preliminary results posted at http://www.who.int/ dle/10665/274453/9789241565646-eng.pdf). tb/advisory_bodies/impact_measurement_taskforce/meetings/ tf7_p04_Indonesia_inventory_study_results.pdf. 108. https://dec.usaid.gov/dec/content/Detail. aspx?vID=47&ctID=ODVhZjk4NWQtM2YyMi00Yj 95. IQVIA. March 2018. Market Analysis on Anti TB Drugs in RmLTkxNjktZTcxMjM2NDBmY2Uy&rID=NTEzNzYx. Private Medical Channels in Indonesia.
96. NTP drugs are eligible to private facilities that meet certain requirements (e.g. establish DOTS corner in the facilities, report TB cases to public sector)
97. Modification method: Discount the bulk SKUs (products containing >350 items in one stock keeping unit (SKU)) projection that may have been sold to institutions as opposed to end consumers to minimize double counting in the analysis
98. Wells WA, Ge CF, Patel N, Oh T, Gardiner E, Kimerling ME. Size and usage patterns of private TB drug markets in the high burden countries. PLoS One. 2011 May 4;6(5):e18964. doi: 10.1371/ journal.pone.0018964, and Malhotra et al, in preparation.
99. Balakrishnan, S. August 2018. Mission Report: Technical Assistance to National Tuberculosis Programme, Indonesia, to understand barriers to TB notification from major public hospitals and Interface Organization model for Public-Private Mix and to identify appropriate interventions.
100. Branded was defined as products that have their own brand/ registered name, and did not use the molecule/active ingredients as their brand. Generic/unbranded was defined as products that use the molecule/active ingredients as their brand name.
101. Wells WA, Ge CF, Patel N, Oh T, Gardiner E, Kimerling ME. Size and usage patterns of private TB drug markets in the high
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