1) Many TB patients in Indonesia initially seek care from private providers like general practitioners or pharmacies but ultimately around 80% receive treatment from private hospitals. This shift from primary to secondary care is driven by factors like patient and provider economic incentives as well as perceptions of service quality. 2) Under the current payment system, general practitioners may refer TB patients to private hospitals rather than public primary care clinics to avoid losing patient capitation fees, while hospitals benefit from additional visits and tests. 3) There is a need to reform payment incentives to encourage initial treatment at the primary care level through measures like result-based payments for case notification, lab referrals, and treatment success.

1. Edhie Santosa Rahmat, MD, MSc
Penasehat untuk Penguatan Sistem Kesehatan
USAID Indonesia – Office of Health
Jl. BudiKemuliaan INo. 1 Jakarta 10110
erahmat@usaid.gov
1
25 Oktober2017
"Does JKN incentivize
public-private mix
in Tuberculosis care?"

2. TB is still a big concern in Indonesia with over 1 million
estimated TB patients despite declining incident rate
Indonesia has over 1M new TB
patients per year, though incidence
rate is declining
Indonesia ranked 2nd globally in terms
of incidentTB patientsin 2015
454510
586
918
1,020
2,840
0
1,000
2,000
3,000
Pakista
n
S.
Africa
Indonesi
a
Indi
a
Chin
a
Nigeri
a
TB patients in 2015 ('000)
Note: Estimated TB patients = TB incident multiplied by population
Source: WHO database, Indonesia Central Statistic Bureau
395399403407
0
100
200
300
400
500
1,000
0
1,500
500
# cases Per 100,000 population
2012
E
2015
E
1,0131,010 1,020
2014
E
1,015
2013
E
Estimated incident cases
Estimated incidence per 100,000 population

3. Many patients seek and receive TB care
from private providers
21
1004
54
21
0
20
40
60
80
100
% of respondents under TB treatment
Private
provider
s
42
Public
provider
s
Other
s
Tota
l
Source: JEMM report, 2017; Indonesia TB prevalence survey, 2013.
1002
24
19
52
0
20
40
60
80
100
Public
provider
s
3
% of respondents seeking TB care
Tota
l
Private
provider
s
Other
s
74
74% of respondents seek initial TB
care from private providers
42% of respondents ultimately
receive TB treatment from private
providers
Hospital
Pharmacies
GP
Increasing
number of
patients both in
GPs and
hospitals

4. Overall case detection rate has held steady at ~32% for
last five years
200
5
200
4
200
3
200
2
200
1
Case detection rate (%)
201
5
201
4
201
3
201
2
201
1
201
0
200
9
200
8
200
7
200
6
Indonesia has the highestnumberof
missingTB patients globally
1. Among TB patients in treatment, 42% are treated by private providers and 58% are treated by public providers. Therefore, private providersshould report 72% as many cases as
public providers (42%/58%). However, they only report 10% as many cases as public providers (9% of cases reported / 91% of cases reported). If private providers were to increase
case reporting such that their notified cases equaled 72% of public notified cases, the incremental number of cases reported by private providers would be 187,759.
Source: WHO TB burden estimates. Challenge TB AnnualReport, 2016.
Upper bound: 50%
Current est.
case detection
rate: 32%
Lower bound: 23%
If private providers were to increase their case notification rate to match the public sector,it would
account for roughly188,000 new reported cases orapproximately 27% of the current
numberof missing cases
?

5. Majority of case notifications come from the public
sector
Source: Indonesia National TB Prevalence Survey, 2013. 2017 JEMM report.
0
20
40
60
80
100
72%
2%
Private
hospitals
Pharmac
y
100%0%
GP
s
% TB case notification
Puskesma
s
8%
Public
hospitals
18%
Tota
l
Public
(90%)
Private
(10%)
Particularly low among GPs &
pharmacies; uptake in private hospitals
driven by NTP engagement
~10% of case notifications

6. National Prevalence Survey indicates lower patient-
reported treatment success rate of 60% across public &
private sector
0
500
1,000
1,500
2,000
2,500
# of TB patient interviewed
Declared
cured by a
health
profession
al
No
money
Feelin
g
better
Unavailablit
y of TB
medicine
Other
s
Tota
l
No
transportatio
n / nobody
to collect
medicine
Afraid of
side
effectes
Feeling no
improveme
nt
46
(2%)
53
(3%)
2,045
(100%)45
(2%)
1,222
(60%)
9
(0%)107
(5%)525
(26%)
38
(2%)
Private clinicsPublic health centresPublic hospitals OthersPrivate hospitals
Largest proportion
of lapsers are from
public hospitals
While affordability leads
to only 13% of treatment
lapse, 58% of those
patients are in the private
sector
Source: Indonesia National TB Prevalence Survey, 2013
Difference between
treatment success
rate reported in NPS
vs from MoH might be
driven by non-
reported casesthat
is not recordedby
MoHbut identified in
NPS, indicating that
non-reported cases
might have higher
rate of uncompleted
treatment. Could
also be due to patient
reporting error.
?

7. However, NTP now envisions new form of "district-based
PPM", being piloted in Jakarta and Medan
Dinas
Kesehatan
Patient referral
flow
Reporting flow
Source: NTP presentation during meeting w ith Global Fund, 20 July 2017.
PPM priorities & programs
Dinkes to be in
charge for
hospitals
Private Public
Hospital
Secondarycare facility
Puskesmas
GP Clinic
Pharmac
y
Lab
Primary carefacility
Puskesmas to
oversee TB reporting
and care at
independent GPs
and clinics

8. Primary data collection: provider interviews
Key questions
• What are the typical pathways for patients presenting with
TB symptoms?
• What is the profile of private sectorproviders? How many
TB cases do they see and how many do they notify?
• What are the prevalent diagnosis and treatment practices
in the private sector? How do they compare to NTP /
WHO guidelines and other local regulations?
• What is the overall treatment costfor TB? How are these
costs handled, via JKN or out of pocket?
• What role do differentagencies or organizations play in
TB diagnosis,reporting & treatment in the private sector?
• How can current patient pathways & experience be
optimized to improve patient and public health outcomes?
Sample breakdown
10 private sector health care
providers
• 6 physicians, with a mix
betweengeneral practitioners
and pulmonologists
• 2 pharmacy managers
• 1 laboratory manager
1

9. Primary data collection: Focus on four districts
North Sumatra
Medan (largest city outside
Java; rapidly developing with
27 private hospitals)
Jakarta
Focus on 2 districts:
a) North Jakarta (industrial)
b) East Jakarta (low income/
high population density)
East Java
Jember: Smaller
city/urban setting, can
extrapolate to West Java
Backup

10. Number of TB patients treated and success rate for
four districts in this review
30
20
10
0
100
90
80
70
60
50
40
110
East
Jakarta
77
Meda
n
88
Jembe
r
93
103
% TB treatment success rate in select districts1, 2014
North
Jakarta
1. From people w ho started treatment and reported
Source: Jakarta health profile report 2014; North Sumatera health profile report 2014; East Java health profile report 2014
Indonesia
average
= 84%
Success rate ranging from 77% to
103%
Number of BTA+ patient treated is
highest in North Jakarta
1,996
2,518
3,128
6,535
0
2,000
4,000
6,000
8,000
No of BTA+ patient treated
Jembe
r
East
Jakarta
Meda
n
North
Jakarta
Current state of TB in Indonesia
> 100% because providers in North Jakarta may
treat patient from other parts of Jakarta (e.g. South
Jakarta (TSR=~34%) and East Jakarta
(TSR=~77%)) but patients transferring in to North
Jakarta are not reflected in the denominator of
notified cases

11. Sampling strategy for survey
2
Sample Universe Sample Universe Sample Universe Sample Universe Sample
East
Jakarta
50 568 30 41 20 981 30 62 30
North
Jakarta
50 356 30 26 15 561 30 48 20
Medan 50 566 30 76 30 955 30 76 30
Jember 50 158 30 13 5 185 30 10 5
Pharmacies Laboratories GP Specialists
Source: http://bppsdmk.kemkes.go.id/info_sdmk/info/; http://apif.binfar.depkes.go.id/index.php?req=view_services&p=pemetaanApotek;
http://www.depkes.go.id/resources/download/pusdatin/profil-kesehatan-indonesia/profil-kesehatan-Indonesia-2015.pdf;
Patients
Total sample of 395 will be representative of provider
universe, but not a fully random sample

12. % of all provider
changes
Findings: Patients are moving away from Puskesmas
and towards private hospitals
Source: Patient interview s, n=204. 50 respondents per district except North Jakarta w ith 54 respondents. 2nd visit n=194. 3rd visit n=170. 4th visit n=130. 5th visit n=81. 6th visit
n=53.
Private
Hospital
Pharmacy/
other store
Puskesmas
Private
GP/clinic
Lab
Public
Hospital
Two trends observed: Patients moving from public sector
to private sector and from primary to secondary care
1-5%
5-10%
>10%
Other
Secondary provider
Primary
provider
32% start here
79% end here
21% start
here
6% end here
44% start here
12% end here
3% start
here
3% end here
Lab likely associated
with or located in
private hospital
Patients seek
care directly
with a
physician, or
after first
visiting a
private
pharmacy or
lab

13. >65% of patients use 1 of 5 common pathways
30 unique patient pathways reported, with remaining pathways each having <5% of patients
Source: Patient interview s, n=204. 50 respondents per district except North Jakarta w ith 54 respondents. 2nd visit n=194. 3rd visit n=170. 4th visit n=130. 5th visit n=81. 6th visit
n=53.
23%
22%
9%
8%
Puskesmas
Private GP/clinic Puskesmas
Private Hospital
Private Hospital
% of patients
taking pathway
Other
Secondary provider
Primary
provider
Puskesmas Private Hospital
Pharmacy /
other store
5% Private Hospital
Pharmacy /
other store
Assumes lab
visits between
two private
hospital visits are
to the lab within
the hospital
Interviews indicate that when patients start at
Puskesmas and then move to private hospitals,
diagnosis typically occurs at the hospital. TB
suspects may have been asked to return to the
Puskesmas for observation (and choose to go
instead to a hospital), misdiagnosed, or the
facility does not have the necessary test
capabilities.
?
Interviews indicate that when patients are
referred from a private GP or clinic to a
Puskesmas, diagnosis typically occurs at the
Puskesmas. TB suspects are often referred
because the Puskesmas can conduct
diagnostic tests.
?

14. Incentives are driving TB patients toward private
secondary care
Private
Hospital
Public
Hospital
Puskesmas
Private
GP/clinic
Public Private
PrimarySecondary
Initially:44
%
Ultimately:
12%
Initially:3
%
Ultimately:
3%
Initially:32
%
Ultimately:
79%
Initially:21
%
Ultimately: 6%
32% of patients
47%ofpatients
Five key factors driving the shift from primary
care to secondarycare and from public to
private providers
• Low patientawareness ofTB symptoms,
delaying treatment and resulting in more
severe cases of TB likely to result in hospital
care
• Patientpreferences (e.g.,convenience of
"one-stop shop",shorterwait times, perceived
service quality & cleanliness)
• Patienteconomics(e.g., additional costs
covered via BPJS at in-house hospital labs and
pharmacies)
• Provider economics(e.g., GPs afraid to lose
capitation if referring to Puskesmas,but not
secondarycare; later visits are higher-margin
for hospitals)
?
"My sister recommended a private facility that's
easy to get appointments and takes BPJS so it’s
free"
– Patient, Jember
"I refer to specialist when the symptoms is at later
stage, e.g. coughing blood."
– GP, North Jakarta
Source: Patient interview s. N=204. Figures given as net % of total patients, accounting for patient flow in the other direction.

15. Discussion
• JKN Capitation ends up to referral
• Referral to Primary care with advanced
diagnostic capacity may loose JKN members
• Referral to hospital for diagnostic without
penalty/economic lost to Primary care
• Hospitals benefit for not refer back (incentives
for frequent OPD visits)
Hospital based TB Care
25 Oktober2017
15

16. Implication & Suggestion
Hospital based TB care:
- High cost for insurer (BPJS-K)
- Low treatment adherence (<60% vs. 80% at primary care)
- Additional cost for patients/families, but they get one stop
services
Need to change payment system:
- Potential Efficiency for non-complicated case at hospital
- Pilot result based incentive for primary care (Case
Notification, Lab referral, treatment success)
- Rooms for private sector (separate payment for lab,
GenXpert etc.)
25 Oktober2017
16