Making health financing work for the poor: An evaluation of equity in health systems financing in Indonesia

Concerns about the poor and most vulnerable not getting adequate access to quality health care are widespread in low and middle income countries (LMICs) and have led to an intense advocacy for universal health coverage (UHC) in the last 5 years. Effective implementation of UHC requires equity in health care, defined as payment for health services according to capacity to pay and the receipt of benefits according to need. Indonesia has in recent years embarked on a programme to achieve UHC through a national health insurance scheme (Jaminan Kesehatan Nasional - JKN). However, with coverage currently at 65% and the 2019 goal for full coverage fast approaching, a second wave of JKN reforms are being planned to bolster Indonesia's progress.

The primary aim of this study is to prospectively evaluate the combined effects of a second phase (2017-2019) of JKN-reforms in Indonesia and provide an overall assessment of progress toward the achievement to UHC. The reforms are designed to address factors currently hindering the effective implementation of the national health insurance scheme and in turn the pursuit of UHC by 2019. Over the next 3 years the government will be initiating and strengthening a number of important reforms ranging from re-structuring provider payment schemes through to socialization campaigns to raise awareness of the scheme and its benefits. Strategies for increasing fiscal space for health through increasing tobacco tax and the phasing out of subsidies on fuel are also proposed. Understanding the equity impact of these reforms and how they may (or may not) be facilitating progress towards UHC is of considerable interest to the government of Indonesia.

The study will take a 'whole of system' approach by integrating both the public and the increasingly important private sector of the Indonesian health care system. Using a before and after design, the impact of these UHC reforms will be measured according to three key outcomes: (i) the progressivity of the health care financing system (ii) the pro-poorness of the health care delivery system and (iii) self-reported health outcomes across socioeconomic groups. The quantitative tools of financing and benefit incidence analysis will be used to assess who pays and who benefits from health care spending at baseline (2017) and 2 years into implementation (end 2019). The study will bring together an international research team consisting of those with substantial experience of evaluating UHC-reforms in Africa and the Asia-Pacific and those with an in-depth understanding of the Indonesian health care system. Qualitative studies to document the context pre and post UHC reforms, and the process of implementing UHC reforms will also be undertaken. Stakeholder analysis will be used to support the translation of priority financing reforms identified through the evaluation into viable policy proposals.

The study will advance methods in this field by testing different indicators and indexes of 'need', against which the appropriateness of the distribution of benefits from using health services can be assessed. The study will also advance knowledge through a better understanding of the contribution of the private sector to meeting the needs of the poor and in turn, inform through the stakeholder analysis, ongoing discussions about effective engagement with private sector to strengthen progress towards UHC.

The over-arching goal of this study is to strengthen the healthcare system of Indonesia through more equitable and sustainable health financing policies. As the fourth most highly populated country in the world, with a total population of around 255 million people, the implications of this study's findings for the design of a universal health system will be far-reaching.

Over the next 3 years the government of Indonesia will be initiating and strengthening a number of important reforms to achieve Universal Health Coverage (UHC) by 2019. This study will undertake pre and post comparative assessment of this reform package. Using before and after design, comparisons will be made of: (i) the distribution of the burden of paying for health care across SEGs; (ii) the distribution of health care benefits across socioeconomic groups (SEGs); and (iii) self-reported health outcomes across SEGs. Financing and benefit incidence analysis will be used to measure (i) and (ii) respectively. For the financing incidence analysis (FIA), secondary data derived from the Indonesian National Health Accounts (2014) and the National Socioeconomic Survey (2015) will be used to estimate the healthcare financing mix and household contributions to health financing through direct and indirect taxation and out-of-pocket payments. The benefit incidence analysis (BIA) requires the collection of primary data on health service utilization, the cost of accessing healthcare and socioeconomic status. A cross-sectional household survey will be conducted at baseline (2017) and 2 years into implementation (2019). Self-reported health indicators will also be measured as part of the household survey. These quantitative analyses will be complemented by detailed documentation of the context pre and post-intervention, and the process of implementing the latest UHC reforms. Our qualitative analysis will also provide insight into the relationships between components of the package and outcomes which in turn will facilitate an understanding of the process by which change has occurred. This qualitative information will also help to identify other factors that could have contributed to any observed changes in the study outcomes.

The challenges of providing financial protection and universal health coverage (UHC) for a country of 255 million people and a gross national income per capita of $3600 are huge. This evaluation represents a once-only opportunity to undertake a pre and post comparative assessment of the Indonesian government's planned JKN-reforms to be implemented over the next 3 years. Results will feed into the UHC monitoring activities of the WHO and World Bank, enhance research methods for country-level analysis of health care financing and inform discussions on the role of the private sector in achieving UHC.

a) National government: The Indonesian government is continuing to implement UHC-reforms but presently there are no initiatives underway to rigorously assess whether its objectives to improve equity are being met. This study will be the first of its kind to evaluate UHC-reforms in a developing country that incorporates the dual functions of delivery and financing, covers both public and private sectors and measures impact on health outcomes as well as equity. This study will help strengthen the health financing system of Indonesia and contribute significantly to poverty alleviation strategies. The study findings will indicate population subgroups and disease areas where there are the largest gaps in coverage and government should focus its reform efforts to achieve UHC.
b) Research community: The research project will incorporate further development of methods for measuring equity in health systems financing, most notably by testing different indicators and indexes of 'need', against which the appropriateness of the distribution of benefits from using health services can be assessed. Extending analytical methods in this way will be of use to researchers and policy makers responsible for the allocation of health care funds.
c) International health agencies: In May 2014, the World Health Organization and the World Bank jointly launched a monitoring framework for UHC. Indonesia passed a presidential decree this year to strengthen the framework that was started in January 2014. Monitoring inequities in financial protection is a key focus and many countries are starting to generate credible, comparable data on both health service and financial protection coverage. The approach used in this study is consistent with this monitoring framework and therefore can contribute to global efforts to implement and evaluate UHC strategies worldwide.
d) Private sector providers: Private providers represent a significant force in the Indonesian health care system. For example, only six percent of births in West Java occur in public facilities. Our 'whole of system' assessment of the health financing system will provide a comprehensive picture of the role of the private sector in meeting the health needs of the people especially the poor and inform discussions about effective engagement with private sector to strengthen progress towards UHC. Private provider networks such as the Catholic Hospital Association and the Indonesian Pharmacists Association will join with other stakeholders in this study to help translate this evidence into equitable health financing reforms.

These impacts will be achieved through close ties to government via the direct involvement in this project of the Indonesian Ministry of Health (see letter of support) who will provide analytical support and access to key datasets including National Health Accounts. The University of Indonesia is a well-respected research institution which works closely with the Government in developing evidence-based health policy. The University of Indonesia and UNSW have several ongoing research projects based on a Memorandum of Understanding. UNSW partners also work closely with key financing stakeholders in the region including the World Bank. The Department of Global Health & Development at LSHTM has extensive links with the global health systems community and UHC networks.