Estimating the budget impact of a Tuberculosis strategic purchasing pilot study in Medan, Indonesia (2018-2019).

BACKGROUND: Indonesia has the world's second-highest tuberculosis (TB) burden, with 969,000 annual TB infections. In 2017, Indonesia faced significant challenges in TB care, with 18% of cases missed, 29% of diagnosed cases unreported, and 55.4% of positive results not notified. The government is exploring a new approach called "strategic purchasing" to improve TB detection and treatment rates and offer cost-effective service delivery. OBJECTIVES: We aimed to analyze the financial impact of implementing a TB purchasing pilot in the city of Medan and assess the project's affordability and value for money. METHODS: We developed a budget impact model to estimate the cost-effectiveness of using strategic purchasing to improve TB reporting and treatment success rates. We used using data from Medan's budget impact model and the Ministry of Health's guidelines to predict the total cost and the cost per patient. RESULTS: The model showed that strategic purchasing would improve TB reporting by 63% and successful treatments by 64%. While this would lead to a rise in total spending on TB care by 60%, the cost per patient would decrease by 3%. This is because more care would be provided in primary healthcare settings, which are more cost-effective than hospitals. CONCLUSIONS: While strategic purchasing may increase overall spending, it could improve TB care in Indonesia by identifying more cases, treating them more effectively, and reducing the cost per patient. This could potentially lead to long-term cost savings and improved health outcomes.

Cervical cancer screening program in Indonesia: is it time for HPV-DNA tests? Results of a qualitative study exploring the stakeholders' perspectives.

OBJECTIVES: Cervical cancer is a significant public health concern in Indonesia, and effective screening methods are necessary to improve the detection and reduce mortality. This study aimed to explore the perspectives of high-level stakeholders involved in cervical cancer screening in Indonesia and whether the use of human papillomavirus-deoxyribonucleic acid (HPV-DNA) methods for cervical cancer screening is acceptable in Indonesian settings. METHODS: A qualitative research approach guided by realist evaluation was applied using focus group discussions (FGDs) between December 2021 and February 2022, conducted with stakeholders involved in cervical cancer screening in Indonesia. They were representatives of practitioners and policymakers involved in the screening, and were recruited through purposive recruitment. The data were analysed using inductive approach of thematic analysis. RESULTS: The analysis of two FGDs with 29 participants identified four main themes: (i) Visual inspection with acetic acid (VIA) method as the most common modality used for cervical cancer screening, (ii) the applied screening programs in the community, (iii) the perceived challenges on the screening program, such as limitations of the National Health Insurance benefits package and a lack of regulations regarding screening procedures, and (iv) the possibilities of HPV-DNA testing as another modality for cervical cancer screening. Incorporating HPV-DNA testing also needs to ensure the capacity of the workers and the readiness of healthcare facilities. CONCLUSION: Although HPV-DNA testing is a promising modality, challenges on the cervical cancer screening in Indonesia remain on the coverage, accessibility of the tools in practice and the women's awareness towards the screening. Ultimately, the findings of this study would help inform policies to improve cervical cancer screening programs in Indonesia.

Analysis of water, sanitation, and hygiene facilities using the WASH-FIT approach and its relation to patient satisfaction and maternal mortality at hospitals in Indonesia.

Introduction: The provision of Water, Sanitation, and Hygiene (WASH) is critical to reducing infection and enhancing the quality of health care services. The study aims to assess WASH facilities in Indonesian hospitals using the Water, Sanitation, and Hygiene Facility Improvement Tool (WASH-FIT) approach and examine their association with customer satisfaction and maternal mortality owing to infection. Methods: We utilized the national scale Health Facilities Research dataset in Indonesian hospitals in 2019. WASH status is determined using WASH-FIT indicators, i.e., water, sanitation, waste management, hand hygiene, environmental cleaning, and management services, and then divided into three levels: poor, adequate, and good categories. Results: The majority of hospitals in Indonesia had a good category, i.e., the range of hospitals with a good category was 79-97% nationally, in 6 aspects: water, sanitation, hand hygiene, environmental cleaning, and management services, except for waste management services (13%). Good WASH service facilities are more frequently found in government hospitals than in private and specialized hospitals, while lower-level hospitals tend to have poor levels of all WASH-FIT indicators. There are significant relationships between adequate sanitation services (ß = 0.724), adequate and good categories of hand hygiene services (ß = 0.712 and 0.866, respectively), environmental cleaning (ß = -0.501 and -0.503, respectively), and management (ß = -0.645 and 0.446, respectively), with the proportion of maternal mortality owing to infection. Furthermore, there was no relationship between WASH-FIT indicators and patient satisfaction, except for good hand hygiene services (ß = 0.453). Discussion: Despite good conditions in almost all WASH-FIT indicators, the improvement of waste management is urgently needed to improve the WASH services in hospitals in Indonesia, as also found in other developing countries.

Health financing policies during the COVID-19 pandemic and implications for universal health care: a case study of 15 countries.

BACKGROUND: The COVID-19 pandemic was a health emergency requiring rapid fiscal resource mobilisation to support national responses. The use of effective health financing mechanisms and policies, or lack thereof, affected the impact of the pandemic on the population, particularly vulnerable groups and individuals. We provide an overview and illustrative examples of health financing policies adopted in 15 countries during the pandemic, develop a framework for resilient health financing, and use this pandemic to argue a case to move towards universal health coverage (UHC). METHODS: In this case study, we examined the national health financing policy responses of 15 countries, which were purposefully selected countries to represent all WHO regions and have a range of income levels, UHC index scores, and health system typologies. We did a systematic literature review of peer-reviewed articles, policy documents, technical reports, and publicly available data on policy measures undertaken in response to the pandemic and complemented the data obtained with 61 in-depth interviews with health systems and health financing experts. We did a thematic analysis of our data and organised key themes into a conceptual framework for resilient health financing. FINDINGS: Resilient health financing for health emergencies is characterised by two main phases: (1) absorb and recover, where health systems are required to absorb the initial and subsequent shocks brought about by the pandemic and restabilise from them; and (2) sustain, where health systems need to expand and maintain fiscal space for health to move towards UHC while building on resilient health financing structures that can better prepare health systems for future health emergencies. We observed that five key financing policies were implemented across the countries-namely, use of extra-budgetary funds for a swift initial response, repurposing of existing funds, efficient fund disbursement mechanisms to ensure rapid channelisation to the intended personnel and general population, mobilisation of the private sector to mitigate the gaps in public settings, and expansion of service coverage to enhance the protection of vulnerable groups. Accountability and monitoring are needed at every stage to ensure efficient and accountable movement and use of funds, which can be achieved through strong governance and coordination, information technology, and community engagement. INTERPRETATION: Our findings suggest that health systems need to leverage the COVID-19 pandemic as a window of opportunity to make health financing policies robust and need to politically commit to public financing mechanisms that work to prepare for future emergencies and as a lever for UHC. FUNDING: Bill & Melinda Gates Foundation.

Mitigating the impacts of the COVID-19 pandemic on vulnerable populations: Lessons for improving health and social equity.

The COVID-19 pandemic had an inequitable and disproportionate impact on vulnerable populations, reversing decades of progress toward healthy populations and poverty alleviation. This study examines various programmatic tools and policy measures used by governments to support vulnerable populations during the pandemic. A comparative case study of 15 countries representing all World Health Organization's regions offers a comprehensive picture of countries with varying income statuses, health system arrangements and COVID-19 public health measures. Through a systematic desk review and key informant interviews, we report a spectrum of mitigation strategies deployed in these countries to address five major types of vulnerabilities (health, economic, social, institutional and communicative). We found a multitude of strategies that supported vulnerable populations such as migrant workers, sex workers, prisoners, older persons and school-going children. Prioritising vulnerable populations during the early phase of COVID-19 vaccination campaigns, direct financial subsidies and food assistance programmes were the most common measures reported. Additionally, framing public health information and implementing culturally sensitive health promotion interventions helped bridge the communication barriers in certain instances. However, these measures remain insufficient to protect vulnerable populations comprehensively. Our findings point to the need to expand fiscal space for health, enlarge healthcare coverage, incorporate equity principles in all policies, leverage technology, multi-stakeholder co-production of policies and tailored community engagement mechanisms.

Knowledge, attitudes, and practices related to COVID-19 in Indonesia: A post delta variant wave cross-sectional study.

Introduction: Public information and regulations related to the coronavirus disease 2019 (COVID-19) have been widely published and continuously changed. The Indonesian government has responded to the emerging evidence by regularly updating its unprecedented and preventive measures against the transmission of COVID-19 to the public. It is important to understand how the public responded to these updates. This study aimed to investigate the knowledge, attitudes, and practices of Indonesians toward COVID-19 after the emergence of the delta variant wave. Methods: A cross-sectional study was conducted among the adult population of non-healthcare workers in Indonesia through an online questionnaire using the SurveyMonkey platform. A total of 1,859 respondents completed this survey from September to October 2021. The knowledge, attitudes, and practices data were analyzed descriptively to find their frequency and percentage. A multivariate analysis was conducted to confirm the factors affecting the respondents' knowledge, attitudes, and practices with a p-value of <0.05 set as significant. Results: Being female, having a higher education level, and having a higher frequency of access to COVID-19 news showed significant impacts on knowledge, attitudes, and practices (p<0.001). Older age stratification influenced the knowledge level (p<0.05) but had no significant effect on people's attitudes and practices toward COVID-19. Respondents' perceived probability of being exposed to COVID-19 (p < 0.05) and their COVID-19 infection frequency (p < 0.001) significantly influenced their knowledge. Household income and respondents' knowledge significantly affected their attitudes toward COVID-19. Furthermore, only their attitudes had a significant impact on the respondents' practices. Perceived severity, perceived susceptibility, and vaccination status did not significantly influence their knowledge, attitudes, and practices (p > 0.05). Conclusion: After more than a year of the COVID-19 pandemic, Indonesians maintain their high level of knowledge, attitudes, and practices. COVID-19 disinformation must be combatted by strengthening authorized media, empowering communities, and improving governance among institutions during and post-pandemic.

The effect of COVID-19 on women's experiences of pregnancy, birth and postpartum in Indonesia: a rapid online survey.

BACKGROUND: The interrelationship of psychological and social factors in the current COVID-19 pandemic has been highlighted in research mainly focused on the global north. The impact of lockdowns can exacerbate psychological distress and affect access to services. Less is known about the psychosocial impact on women in the context of lower-middle income countries (LMICs); the aim of this study was to capture the impact of COVID-19 on women's experiences of pregnancy, birth and postpartum in Indonesia. METHODS: We conducted a rapid cross-sectional online survey of women across all 34 provinces in Indonesia to capture participants' experiences. Data were collected between 10th July to 9th August 2020 including demographics, effects on general and mental health and impact on service use. Descriptive statistics and thematic analysis were used to analyse responses, including those women who self-identified with a pre-existing mental health problem. RESULTS: Responses were obtained from 1137 women, this included pregnant women (n = 842) and postpartum women (n = 295). The majority of women (97%) had accessed antenatal care during their pregnancy, but 84% of women reporting feeling fearful and anxious about attending visits, resulting in some women not attending or changing provider. A small number (13%) were denied the presence of a birth companion, with 28% of women reporting that their babies had been removed at birth due to protocols or baby's health. Feeling anxious was a common experience among women (62%) during their pregnancy, birth or postnatal period, with a small number (9%) feeling depressed. Lockdown measures led to tensions within personal and family relationships. CONCLUSIONS: Women in Indonesia reported that the pandemic added an increased burden in pregnancy, birth and post-partum period: physically, psychologically, spiritually and financially. Maternity services were disrupted and health insurance cover lacked responsiveness, which either directly or indirectly impacted on women's choices, and equal access to care. Given the longevity of the current pandemic there is a need to develop tailored supportive interventions for women and their families and develop bespoke training for midwives and other relevant health professionals.

Out-of-pocket expenditure and catastrophic costs due to COVID-19 in Indonesia: A rapid online survey.

Background: The Corona Virus Disease 2019 (COVID-19) pandemic has created a substantial socioeconomic impact, particularly in developing countries such as Indonesia. Purposes/objectives: This study aimed to describe the COVID-19-related out-of-pocket spending of Indonesian citizens and the proportion of whom experienced catastrophic health spending during the COVID-19 pandemic using the patient's perspective. Methodology: We conducted a rapid cross-sectional online survey across provinces in Indonesia to capture participants' experiences due to COVID-19. Data were collected between September 23rd to October 7th of 2021 including demographics, income, and expenditures. Descriptive statistics were used to analyze the respondents' characteristics. Patients's perspective of total cost was estimated from out-of-pocket of COVID-19 direct costs and compared them to total expenditure. If the proportion of COVID-19 total costs exceeded 40% of the total expenditure, the respondents were deemed to have faced catastrophic costs. Results: A total of 1,859 respondents answered the questionnaire. The average monthly income and expenditure of respondents were 800 USD, and 667 USD respectively. The monthly expenditure was categorized into food expenditure (367 USD) and non-food expenditure (320 USD). The average of COVID-19-related monthly expenditure was 226 USD, including diagnostic expenditure (36 USD), preventive expenditure (58 USD), medical expenditure (37 USD for COVID-19 treatment; and 57 USD for post-COVID-19 medical expenses), and non-medical expenditure (30 USD). Analysis showed that 18.6% of all respondents experienced catastrophic costs while 38.6% of the respondents who had COVID-19 treatment experienced catastrophic costs. Conclusion: The high proportion of catastrophic costs among respondents suggests the need for COVID-19 social protection, especially for COVID-19 diagnostic and prevention costs. The survey findings have led the government to increase the benefit coverage other than medical costs at the hospitals.

Essential Medicines in Universal Health Coverage: A Scoping Review of Public Health Law Interventions and How They Are Measured in Five Middle-Income Countries.

Very few studies exist of legal interventions (national laws) for essential medicines as part of universal health coverage in middle-income countries, or how the effect of these laws is measured. This study aims to critically assess whether laws related to universal health coverage use five objectives of public health law to promote medicines affordability and financing, and to understand how access to medicines achieved through these laws is measured. This comparative case study of five middle-income countries (Ecuador, Ghana, Philippines, South Africa, Ukraine) uses a public health law framework to guide the content analysis of national laws and the scoping review of empirical evidence for measuring access to medicines. Sixty laws were included. All countries write into national law: (a) health equity objectives, (b) remedies for users/patients and sanctions for some stakeholders, (c) economic policies and regulatory objectives for financing (except South Africa), pricing, and benefits selection (except South Africa), (d) information dissemination objectives (ex. for medicines prices (except Ghana)), and (e) public health infrastructure. The 17 studies included in the scoping review evaluate laws with economic policy and regulatory objectives (n = 14 articles), health equity (n = 10), information dissemination (n = 3), infrastructure (n = 2), and sanctions (n = 1) (not mutually exclusive). Cross-sectional descriptive designs (n = 8 articles) and time series analyses (n = 5) were the most frequent designs. Change in patients' spending on medicines was the most frequent outcome measure (n = 5). Although legal interventions for pharmaceuticals in middle-income countries commonly use all objectives of public health law, the intended and unintended effects of economic policies and regulation are most frequently investigated.

Efficiency Measurement in Health Facilities: A Systematic Review in Low- and Middle-Income Countries.

BACKGROUND: Limited healthcare resources in low- and middle-income countries (LMICs) have led policy-makers to improve healthcare efficiency. Therefore, it is essential to understand how efficiency has been measured in the LMIC setting. OBJECTIVE: This paper reviews methodologies used for efficiency studies in health facilities in LMICs. METHODS: We searched MEDLINE, Embase, Global Health, EconLit and ProQuest Dissertations and Theses databases to Week 6 in 2018. We included all types of quantitative analysis studies relating to the measurement of the efficiency of services at health facilities in LMICs. We extracted data from eligible studies, and assessed the validity for each study. Because of the substantial heterogeneity of the studies, results were presented narratively. RESULTS: A total of 137 papers were eligible for inclusion. These articles covered a wide range of health facility types, with more than half of the studies relating to hospitals. Our systematic review showed that there is an increasing trend in efficiency measurements in LMICs using various methods. Most studies employed data envelopment analysis as an efficiency measurement method. The studies typically included physical inputs and health services as outputs. Sixty-one percent of the studies analysed the contextual variables of the health facility efficiency. CONCLUSION: This review highlights the potential for methodological improvement and policy impacts in efficiency measurements.

Assessing health facility performance in Indonesia using the Pabón-Lasso model and unit cost analysis of health services.

Total health care costs have dramatically increased in Indonesia, and health facilities consume the largest share of health resources. This study aims to provide a better understanding of the characteristics of the best-performing health facilities. We use 4 national Indonesian datasets for 2011 and analysed 200 hospitals and 95 health centres. We first apply the Pabón-Lasso model to assess the relative performance of health facilities in terms of bed occupancy rate and the number of admissions per bed; the model gathers together health facilities into 4 sectors representing different levels of productivity. We then use a step-down costing method to estimate the cost per outpatient visit, inpatient, and bed days in hospitals and health centres. We combined both ratio analysis and applied bivariate and multivariate analyses to identify the predictors of the best-performing health facility; 37% of hospitals and 33% of health centres were located in the high-performing sector of the Pabón-Lasso model. The wide variation in unit costs across health facilities presented a basis for benchmarking and identifying relatively efficient units. Combining the unit cost analysis and Pabón-Lasso model, we find that health facility performance is affected by both internal (size and capacity, financing, type of patients, ownership, accreditation status, and staff availability) and external factors (economic status, population education level, location, and population density). Our study demonstrates that it is feasible to identify the best-performing health facilities and provides information about how to improve efficiency using simplistic methods.

What do health workers in Timor-Leste want, know and do? Findings from a national health labour market survey.

BACKGROUND: The objectives of this study were to understand the labour market dynamics among health workers, including their preferences and concerns, and to assess the skills, competence and performance (i.e. the 'know-do gap') of doctors working in Timor-Leste. METHODS: This cross-sectional survey was implemented in all 13 districts of Timor-Leste in 2014. We surveyed 443 health workers, including 175 doctors, 150 nurses and 118 midwives (about 20% of the health workers in the country). We also observed 632 clinical consultations with doctors, including 442 direct clinical observations, and tested 190 vignettes. RESULTS: The study highlights some positive findings, including the gender balance of health workers overall, the concentration of doctors in rural areas, the high overall reported satisfaction of staff with their work and high motivation, the positive intention to stay in the public sector, the feeling of being well prepared by training for work, the relatively frequent and satisfactory supervisions, and the good attitudes towards patients as identified in observations and vignettes. However, some areas require more investigations and investments. The overall clinical performance of the doctors was very good in terms of attitude and moderate in regard to history taking, health education and treatment. However, the average physical examination performance score was low. Doctors performed better with simulated cases than the real cases in general, which means they have better knowledge and skills than they actually demonstrated. The factors that were significantly associated with the clinical performance of doctors were location of the health facility (urban doctors were better) and consultation time (cases with more consultation time were better). Regression analysis suggests that lack of knowledge was significantly associated with lack of performance, while lack of motivation and equipment were not significant. CONCLUSIONS: The survey provides essential information for workforce planning and for developing training policies and terms and conditions that will attract and retain health workers in rural service. Improving the work environment and performance of doctors working in rural health facilities and ensuring compliance with clinical protocols are two priority areas needed to improve the performance of doctors in Timor-Leste.

The socioeconomic impact of multidrug resistant tuberculosis on patients: results from Ethiopia, Indonesia and Kazakhstan.

BACKGROUND: One of the main goals of the post-2015 global tuberculosis (TB) strategy is that no families affected by TB face catastrophic costs. We revised an existing TB patient cost measurement tool to specifically also measure multi-drug resistant (MDR) TB patients' costs and applied it in Ethiopia, Indonesia and Kazakhstan. METHODS: Through structured interviews with TB and MDR-TB patients in different stages of treatment, we collected data on the direct (out of pocket) and indirect (loss of income) costs of patients and their families related to the diagnosis and treatment of TB and MDR-TB. Direct costs included costs for hospitalization, follow-up tests, transport costs for health care visits, and food supplements. Calculation of indirect costs was based on time needed for diagnosis and treatment. Costs were extrapolated over the patient's total treatment phase. RESULTS: In total 406 MDR-TB patients and 197 other TB patients were included in the survey: 169 MDR-TB patients and 25 other TB patients in Ethiopia; 143 MDR-TB patients and 118 TB patients in Indonesia; and 94 MDR-TB patients and 54 other TB patients in Kazakhstan. Total costs for diagnosis and current treatment episode for TB patients were estimated to be USD 260 in Ethiopia, USD 169 in Indonesia, and USD 929 in Kazakhstan, compared to USD 1838, USD 2342, and USD 3125 for MDR-TB patients, respectively. These costs represented 0.82-4.6 months of pre-treatment household income for TB patients and 9.3-24.9 months for MDR-TB patients. Importantly, 38-92 % reported income loss and 26-76 % of TB patients lost their jobs due to (MDR) TB illness, further aggravating the financial burden. CONCLUSIONS: The financial burden of MDR-TB is alarming, although all TB patients experienced substantial socioeconomic impact of the disease. If the patient is the breadwinner of the family, the combination of lost income and extra costs is generally catastrophic. Therefore, it should be a priority of the government to relieve the financial burden based on the cost mitigation options identified.