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://urltext.pdf Edit: please provide the link 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 5.1 Inputs from district findings for proposed framework, and key questions for recommendations ...................................................... 40 implementation ..........................................................90 5.2 Proposed interventions ............................................ 40 5.3 District and implementation variations ................ 48 H. List of interviewed facilities ................................. 100 6. Conclusion ..................................................................49 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