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IMPROVING THE QUALITY OF INDONESIA’S HEALTH SPENDING IN THE CONTEXT OF THE HEALTH FINANCING TRANSITION

HEALTH SECTOR PUBLIC EXPENDITURE REVIEW

Hotel Borobudur, Jakarta

December 18, 2017

PRESENTATION OUTLINE

Overview of Indonesia’s Health Financing

Health Expenditure at the Central Level

Health Expenditure at the Sub-National Level

Key Findings and Recommendations

2

0 2 4 6 8 10 12 14

China

Mongolia

Cambodia

Korea, Rep.

Singapore

Indonesia

Vietnam

India

Malaysia

Philippines

Samoa

Thailand

Kiribati

%

Indonesia has struggled to manage the “Health Financing Transition” and build a

sustainable health care financing system for UHC despite strong growth in THE

LOW INCOME

LOWERMIDDLEINCOME

UPPERMIDDLEINCOME HIGH INCOME

Total health spending per capita (left axis)

OOP spending share (right axis)

External spending share (right axis)

01

02

03

04

05

06

0

Sh

are

of to

tal he

alth

exp

en

ditu

re (

%)

52

51

00

500

250

01

00

00

Tota

l h

ea

lth e

xp

en

ditu

re p

er

cap

ita, U

S

250 500 1000 2500 10000 35000 100000GNI per capita, US$

Source: World Development Indicators database

Health financing transition

• In nearly all countries growth in income is accompanied by a growth in Total Health Expenditure (THE) – particularly through pre-paid or pooled mechanisms – and a decrease in out-of-pocket (OOP) spending as a share of THE. At the same time, access to external financing falls as eligibility criteria is frequently tied to income thresholds. These two trends are sometimes referred to as “the health financing transition”.

• But countries often struggle to smoothly manage this transition and build sustainable health care financing systems that provide universal health coverage (UHC).

• In Indonesia, despite strong growth in THE, OOP spending remains high as a source of THE.

Real rate of THE growth 1995-2013

Public, 41,4, (1.5 % GDP)

Social health insurance, 13(0.5 %GDP)

Out-of-pocket, 45,3 (1.6 …

External; 0,8

THE by source in Indonesia 2014

Source: NHA, 2014; Note: Social health insurance only accounts for PBI-JKN (subsidized health premium)

Source: World Bank. World Development Indicators; Note: using constant LCU

4

Sources: NHA, 2014 (The NHA’s definition of public health expenditure is slightly different to that of MoF. It is used here so that it can be compared to other categories of health spending and health spending in other countries.) and World Bank World Development Indicators.

0

100

200

300

400

500

600

700

800

0

5

10

15

20

25

US$

%

as % GDP as % of budget

per capita (US$)

0,6 0,60,8 0,7 0,6

0,81,0 0,9 0,9 0,9 0,9 1,0 1,0 1,1 1,2 1,4

2,9

3,5

4,3

3,93,5

4,2

5,2

4,5

5,35,6

5,2 5,25,4

5,7

6,9

7,8

0

1

2

3

4

5

6

7

8

9

0

20

40

60

80

100

120

140

160

180

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

%

IDR

tri

llio

n

Provinces, LHSDistricts, LHSCentral - PBI, LHSCentral - non-PBI, LHSTotal national health spending as % GDP, RHS

National Public Spending on Health (IDR trillion, nominal)

While national public health spending has increased in recent years, it remains

low relative to comparator countries

Public health expenditure (2014)

• Increases in public health spending were mainly driven by increases in district level spending and the introduction of subsidized health insurance (PBI).

• However, national spending averages hides wide variations in district level health spending.

This underinvestment in health can limit the depth of coverage and

also undermine service delivery

5

• Despite overall improvements in facility readiness to provide essential health services since 2011, gaps remain.

• Notable improvements in service availability and service readiness

Source: Rifaskes 2011; Indonesia QSDS, 2016; Note: Quantitative Service Delivery Survey (QSDS) 2016 - covering more than 900 Puskesmas (National representative sample of 268 Puskesmas in 22 districts), service network (Polindes, Posyandu), and private health providers

Puskesmas General Supply Side Readiness, 2011 and 2016% of Puskesmas with basic elements of service

While overall service readiness has improved demand has not been fully met

6

• Epidemiological changes also affects the demand for basic health services changes

• JKN provides a generous benefit package with no caps or copayments on services received leading to implicit rationing of services

• Improvement in facility readiness in testing and diagnostic inputs for infectious and non-communicable disease alike

• Insufficiency in program guidelines and personnel training hinder the effective coverage and treatment of priority programs

Only 32% of TB cases are detected(an estimated 690,000 missingcases each year) contributing tothe continued high prevalence ofTB (1.6 million cases in 2016) – the2nd largest contributor to the globalTB burden.

Similarly, an additional 3 milliontests a year would need to beconducted to meet the MOH’sscale-up targets as only 13% ofpeople living with HIV were onantiretroviral therapy in 2015

Source: Rifaskes 2011; Indonesia QSDS, 2016; Note: Quantitative Service Delivery Survey (QSDS) 2016 - covering more than 900 Puskesmas (National representative sample of 268 Puskesmas in 22 districts), service network (Polindes, Posyandu), and private health providers

Puskesmas Program Specific Supply Side Readiness, 2011 and 2016% of Puskesmas with basic elements of service

International benchmarking also suggests that Indonesia can improve health

outcomes by improving the quality of its health spending

South AfricaIndia

Russia

BrazilThailand

Cambodia

Vietnam

Lao PDR

Malaysia

Philippines

China

Sri Lanka

Indonesia

05

01

00

15

02

00

HA

LE

Co

un

try

Ra

nke

d

(0=

Lo

we

st 2

00

=H

igh

est

)

0 50 100 150 200THE Percapita Country Ranked

(0=Lowest 200=Highest)

2000

South Africa

India

Russia

BrazilThailand

Cambodia

Vietnam

Malaysia

Philippines

China

Lao PDR

Sri Lanka

Indonesia

05

01

00

15

02

00

HA

LE

Co

un

try

Ra

nke

d

(0=

Lo

we

st 2

00

=H

igh

est

)

0 50 100 150 200THE Percapita Country Ranked

(0=Lowest 200=Highest)

2013

Source: World Development Indicators databasey-axis : HALE-Healthy Life Expectancy at Births (years)x-axis : THE Percapita in 2013 Constant US$Red line= DEA line; Green line=Distance to DEA line

Data envelopment analysis: Total health spending vs life expectancy

A data envelopment analysis reveals that for the same level of health spending, Indonesia underperforms on healthy life expectancy at birth compared to countries such as Sri Lanka and Vietnam.

Source: World Bank World Development Indicators






8

As the responsibility of service delivery is decentralized to the subnational level,

the central government manages only 35% of total public health spending

9

• Sub-national governments (provinces and districts) deliver 65% of public health spending, and thus play a dominant role in achieving national health outcomes.

• Still, within the central government, 93% of health spending is managed by the Ministry of Health (MOH).

Composition of public health spending by level of government (%)

38 3629 35

18 1417

15

45 50 54 50

0

10

20

30

40

50

60

70

80

90

100

2001-04 2005-09 2010-14 2015-16

Central Provinces Districts

Composition of CG health expenditure by line ministries

(percent of total health, average 2015-17 )

BKKBN; 5,0

Ministry of Health;

92,6

BPOM; 2,4

Note: • 2011-16 data are actual, 2017 data is Budget. • The subsidized health premium for the poor for national health security (PBI-JKN) started in 2014, previously it was called JAMKESMAS/PERSAL• Total CG health expenditure refers to total CG spending on health function comprising 3 line ministries/agencies i.e., Ministry of Health (MoH), Drugs & Food Supervision

Agency (BPOM); Population and Family Planning Agency (BKKBN)

MOH Discretionary Spending is limited with increasing PBI-JKN and BLU make

up a larger share of MOH spending

• With the introduction and gradual expansion of JKN, PBI subsidies make up an increasingly larger share of the MOH budget, andthe MOH merely acts as pass-thru releasing money to BPJS to pay providers.

• BLU funding, accounts for 18%, is also earmarked as recurrent spending for 53 centrally managed hospitals and health centers.

• As a result, MOH discretionary spending (non-PBI & non-BLU) accounts for only 38% of total MOH expenditure.

10

MOH expenditure by implementation arrangements, 2011-17 (Bar – nominal IDR trillion; line – real IDR trillion)

Note: • 2011-16 data are actual; 2017 data is Budget. • MoH currently manages 53 BLUs, comprising 40 hospitals and 13 health centers (balai kesehatan).

14 17 20 15 19 21 21

5 6

6 8

9 10 10

6 7

8

23

20

25 26

0

10

20

30

40

50

60

2011 2012 2013 2014 2015 2016 2017*

MoH-Non BLUs BLU PBI-JKN Total (real 2010=100)

As a large share of MOH spending is earmarked for PBI/BLU, the composition of

spending is geared towards curative care rather than promotion and prevention

• PBI-JKN and the BLU component of Health Service programs predominantly fund curative interventions in hospital settings.

• As a result, there is less scope for the MOH to fund key public health promotion and prevention activities.

11

Composition of MOH spending by program, 2015-17

Promotive/preventive

Curative

Note: 2011-16 data are actual; 2017 data are Budget.

0 5 10 15 20 25 30

Strengthening Implementation ofNational Health Insurance

Health Services Development-BLUs

Health Services Development-Non BLUs

Disease Prevention and Control

Pharmaceutical and Medical Devices

Community Health Development

Health Research and Development

Increased Oversight and Accountabilityof MoH Apparatus

Management and ImplementationSupport for MoH Other Technical Task

Development and Empowerment ofHuman Resources**

Trillions

201520162017*

Management and support

Composition of MoH spending by health care interventions (indicative)

(% of total MoH exp, average 2015-17 )

Curative Interventions

-BLUs; 18

Curative Interventions

-PBI; 44

Promotive/Preventive Interventions; 26

Management & Supporting

Programs; 13






12

65% of public health spending happens at the district level with facilities

receiving revenue from several sources of financing

District(APBD)

Local revenue

BPJS

PAD

MOF (APBN)

PHO

DAU

DBH

DAK

Grants

Other

DEKON

Sector specific resources

(MOH)

DHO

Hospitals

TP

Puskesmas

Pa

ym

en

t

Demand Side Financing Supply Side Financing

PB

I

Pre

miu

m

2% sa

lary

co

ntrib

utio

ns

PB

I-JK

N

tra

nsf

ers

Fiscal transfers

Households

Province(APBD)

User Fees/OOP

Private Employer

Pre

miu

m

DEKON

• Revenue at the district level is strongly dependent on MOF transfers

• But they are mostly unconditional and not-earmarked for health (with the exception of health DAK)

• As a result allocation to health is at the discretion of local governments

• The share of MOH sector specific financing (e.g. Dekon) that gets sent to district health offices is small

Even though district health spending has increased between 2001-2013 to reach 10% of total district spending, national averages hide wide variations in spending

District expenditure by function, % total

14

7 8 10 10 11 11 11

33 36 28 26 25 25 25

34 28 35 34 34 34 34

13 17 15 17 17 17 17

-

20

40

60

80

100

Other Sector Infrastructure

Education Government General Administration

Health

0

5

10

15

20

25

30

0

200

400

600

800

1000

Kab

. Tap

anu

li Se

lata

n

Ko

ta L

ho

kseu

maw

e

Ko

ta S

un

gai P

enu

h

Ko

ta B

anja

rmas

in

Kab

. Pes

isir

Sel

atan

Ko

ta B

ima

Ko

ta T

om

oh

on

Ko

ta P

adan

g

Kab

. Sem

aran

g

Kab

. Ace

h J

aya

Kab

. Mer

auke

Kab

. In

dra

giri

Hili

r

Kab

. Cila

cap

Ko

ta C

ilego

n

Kab

. Ban

jar

Ko

ta B

anja

r B

aru

Kab

. Sim

eulu

e

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ta T

ange

ran

g

Ko

ta P

asu

ruan

Ko

ta T

egal As

shar

e o

f go

vern

men

t ex

pe

nd

itu

re (

%)

Per

cap

ita

(th

ou

san

d ID

R)

Districts

Per Capita health expenditure As share of Government Expenditure

Health spending by district (per capita and as share of government expenditure), 2016

Sources: World Bank COFIS database using MOF data and QSDS (2016); Note: data is based on a nationally representative sample of 22 districts

• 8/20 districts sampled spend <10% of their government budget on health despite the legal mandate. And health spending as share of district spending varied between 3-27%.

Integration of Financing – Central and Sub National

15

• Although vary across sampled districts, in general there is an increasing trend in sub national financing for programs;

• The increase of sub national government funding may be driven by increased of interfiscal transfers or local commitment

• In some of the sampled sites, a significant amount of local funds were spent on program drugs which were the responsibility of the Central government

• Information on central funds often missed local planning cycle, and lack of details on activities financed

Source : CHEPS-UI & WB, PET 2017

TB Program Financing by Source – District level 2013 - 2016

Shifts in health financing at the sub national level

16

Sources of district revenue as percentage of total revenue, 2013 – 2015

• Revenue from BPJS has become the largest source of revenue for district health offices, mostly from puskesmas in the form of capitation payments.

• Up to 40% of capitation revenue is designated for operational expenditures with the remainder going towards bonuses and financial incentives for health workers.

• However, capitation payments are regulated by 11 regulations and there is confusion between local governments, providers, and BPJS on what operational expenditures are covered under JKN capitation (individual health care) and what is covered under the government budget (public health functions) especially where individual treatment also serves a public health function (e.g. screening and outreach for TB).

• In 2015, 54% of puskesmas’ spending was on staff incentives and only 13% on medicines, consumables, and equipment.

• Over 85% of the puskesmas were unable to utilise all the funds received through capitation.

Weak accountability and a lack of checks and balances in the way JKN is implemented

undermines services delivery where supply side readiness is ill equipped to meet demand and

threatens the financial sustainability of JKN

17

• Earmarked transfers for health (DAK, PBI) make up the largest share of district revenue, but neither are linked to performance.

• On the supply side, DAK transfers (in green) – used to purchase infrastructure, medical equipment, and drugs – does not appear to be correlated with the level of supply side readiness (in orange) which measures whether health facilities are able to provide basic health services. This may mean result in lower capacity puskesmas’ referring patients to the hospital sector for services that would be more cost-effective to treat at the primary health care level.

• On the demand side, in a weakly monitored environment, puskesmas’ close-ended operating budget may also incentivize them to underprovide services and refer patients to hospitals.

• As a result, BPJS ends up double-paying for some services, first through the capitation payment and second through the referral. Here too, limited monitoring of hospital claims may incentivize hospitals to ‘up-code’ to INA-CBG tariffs that have higher payment rates and discharge patients early for later readmission as hospital reimbursements are essentially open-ended – with no caps on their spending.

50

60

70

80

90

10

0

Perc

enta

ge (

%)

010

20

30

40

50

DA

K a

s s

ha

re o

f G

HE

(%

)

Kota Lh

okse

umaw

e

Kab

. Tap

anuli S

elatan

Kota Ban

jarm

asin

Kab

. Merau

ke

Kab

. Pes

isir Selatan

Kota Pas

urua

n

Kab

. Ind

ragiri Hilir

Kota Sun

gai P

enuh

Kota Teg

al

Kab

. Ban

jar

Kota Mataram

Kab

. Sim

eulue

Kota Ban

jar Baru

Kab

. Yalim

o

Districts

Source: Indonesia QSDS, 2016DAK=average share 2013-2015

DAK vs General Supply Side Readiness Index






18

Key findings and recommendations (1/3)

19

Key Findings Key Recommendations

1a. Overall allocation and adequacy of health spending

Indonesia’s public spending for

health is among the lowest in

the world (1.4% GDP in 2016).

Increase total public health spending (at the central and sub-national level) to 2.3% of GDP by 2020;

Increase fiscal space with earmarked revenues (e.g tobacco taxes), improved efficiency, and

reprioritization to fund:

• Supply-side readiness, especially: Primary health care; MOH’s Healthy Indonesia through the Family

Approach program; Maternal health; Vaccinations; Disease control; Community-based interventions in

nutrition

• JKN-PBI: Obtain 100% coverage of bottom 40% and increase in CMPM

1b. Intra-health-sector Central (35%) & SNG Government expenditure (65% of the total health budget)

CG delivers only 1/3 of public

health spending

Ensure coordination and consistency in planning, budgeting, and implementation with sub-national

governments to achieve overall health outcomes

Spending by BLUs (central

hospitals and health centers)

accounts for 18 percent of CG

spending.

Improve the efficiency and effectiveness of BLUs spending as part of sector spending reform.

• Identify sources of inefficiencies in BLU spending (personnel and material are the largest spending

categories)

• Assess the implementation of the Key Performance Indicators (on financial and medical management)

and the linkage with the remuneration policy (see notes for more detail)

• Strengthen linkages between BPJS payment and APBN transfers with BLU Key Performance Indicators

measurements (Strategic Purchasing)


20


1b. Intra-health-sector Central (35%) & SNG Government expenditure (65% of the total health budget)

• Spending continues to focus on

curative rather than promotive &

preventive

Strengthen readiness and quality of primary health care – linking DAK with performance indicators related to improved

primary care facilities such as accreditation, fulfillment of basic inputs to national priority programs

Incentivize and enforce Local Governments (LG) in achieving Health Minimum Service Standards (Standar

Pelayanan Minimal) using existing financial transfer mechanisms. The SPM indicators are emphasizing on preventive and

promotive, and they are also in line with the MOH strategy ‘Healthy Indonesia through family approach

Strengthen links of JKN payment to primary care facilities with performance related to improved public health;

The indicators used for payment for performance are linked priority health programs for instance TB case management

(case finding, treatment, and success of treatment);

Encourage engagement with CSOs in delivering some of the services (outreach, patient follow up, IEC) that are proven

to be cost effective by clarifying the existing fund channeling mechanisms (BanTah, Swakelola) esp at SNG;

Improve tracking of health expenditure – assess and develop better PFM mechanism that enables tracing public

spending from various sources and links with results;

• Fragmentation of financing especially

at SNG and (public) health facilities

• Duplication leads to wasteful

spending

Improve coordination of government supply side financing that are transferred to the sub national and service

delivery points: (i) ensure the timeliness of information about fiscal as well as in-kind transfers so it fits with local planning

and budgeting cycle; the information should include ‘size/amount’ and also ‘activities’;

Improve coordination of supply side and demand side financing: A comprehensive view to look at health financing;

BPJS payment as well as other financial liability (e.g compensation for remote areas) should be coordinated with transfer

schemes for DTPK (remote, borders, islands)

Assess further the policy to give greater (financial) autonomy for public primary health facility (Puskesmas BLU):

their current performance, the challenges to trace funding, PEA (political economy analysis); and The policy question: is it

the future direction for Puskesmas?


21


2a. Service delivery at the facility level: Health facility service availability (1/2)

• There is a disconnect between

health expenditure and the level

of supply side readiness at

public health facilities

• The availability and readiness

of health services is

improving, but gaps remain

and regional disparity persists

• Lack of supply-side readiness

means that the share of out of

pocket expenditure has

remained high

• Strengthen the health facility accreditation process. Accreditation certifies that a health facility

meets the Government’s regulatory requirements and standards to ensure quality of services.

• Improve the implementation of the existing accreditation programs for FKTP (primary health

care) and FKTL (hospitals/referral services).

• Use existing financial mechanism as levers to improve supply side readiness : DAK transfers

and JKN payment to incentivize health facilities to achieve accreditation and implement Continuous

Quality Improvement (CQI). Accreditation status may offer a tool to better coordinate supply side

planning and resources allocation (e.g. DAK) by making transfers more performance-oriented. Upon

accreditation districts/facilities would receive:

• a one-time performance bonus, paid as part of DAK (paid to the district and then shared with the

health facility)

• higher payments through JKN (differential between public and private sector).

• Strengthen Governance and

Accountability

• Develop Performance Dashboard including a health facility performance report card and

supporting tools; introduce the health facility performance report card to provincial and district health

offices

• Improve Health Management Information System that can produce timely and useful information

for budget and planning, provider performance monitoring, and overall benchmarking will be an

essential building block; Streamlining existing HMIS will improve efficiency as well.

• Build local government capacity for planning, budgeting, budget execution, financial

management and reporting, especially for districts with low performance.

TERIMA KASIH

22

Annex

• STRATEGIC HEALTH PURCHASING FOR UHC BASED ON

INTERNATIONAL EXPERIENCE

23

Many countries face similar challenges as they strive towards UHC and global evidence suggests

that strategic purchasing offers a holistic framework to addressing the underinvestment in health,

JKN sustainability, and UHC

24

• Many countries face similar challenges as they strive towards UHC often having to choose between increasing revenues, limiting coverage (either through limited benefit packages or cost-sharing arrangements), and/or improving efficiency in the use of funds.

• But global evidence has shown increasing revenue is limited by the fiscal capacity of the government – a relevant constraint in Indonesia.

• And in countries where the benefit levels remain relatively shallow (e.g. Cambodia, Laos, Myanmar) or where breadth of coverage is prioritized over depth of services (as in Indonesia, Vietnam, Philippines), access and financial protection has beenlimited.

• This highlights the importance of improving the quality of health care spending, often prompting a transition from passive towards more strategic purchasing.

• Strategic purchasing involves making decisions on which services to provide, who is best placed to provide them (public vs private sector) and at what level of care (primary vs secondary or tertiary care), and how should they be purchased to ensurethe right quantity and quality of services.

• Defining an explicit benefit package, essential drugs list, and target population that is commensurate

with all available resources – on both the demand and supply side – through a systematic and

transparent process for prioritizing interventions.

• Commonly used criteria for prioritizing activities and interventions under a benefit package include

burden of disease, equity, cost-effectiveness (based on an economic evaluation or health technology

assessment), budget impact, and the public health nature of interventions that have either positive or

negative externalities (e.g. immunizations, infectious disease control).

• This will require improvements in health management and information systems (HMIS) that are currently

fragmented and of low compliance to be able to provide useful data to inform policy formulation.

• There are often trade offs that must be weighed between high impact cost-effective services and those

that impose the greatest financial burden on patients. And population targeting may be one way to

ensure that limited resources are matched to populations that would benefit the most.

• Globally, health promotion and prevention, immunization and vaccinations, infectious disease control,

and essential primary health care services are usually provided freely by the government.

In the context of Indonesia, strategic purchasing will entail…

What services to

buy

• Selecting providers from who to buy will typically involve some form of contracting between purchasers

of health care (e.g. local governments, BPJS) and providers (e.g. public and empaneled private facilities)

to clarify each party’s obligations.

• Private providers play a significant role in service delivery in Indonesia and increased private sector

engagement should be contingent on stronger mechanisms to ensure a minimum standards.

• In 2015, the MOH adopted the accreditation of public and private facilities as a regulatory mechanism

for improving facility performance and ensuring continuous quality improvement.

• Once up and running, the GOI could share information on accreditation status and facility performance

through the use of performance score cards to enable patients to make more informed decisions on

where to seek quality care. The use of score cards has also been shown to help reinforce providers’

intrinsic motivation to quality care.

• In addition, accreditation status may offer a tool to better coordinate supply side planning and resources

allocation (e.g. DAK) by making transfers more performance-oriented.

• At the same time, it would be important to strengthen government capacity to identify the incentives

that encourage engagement with non-state providers, especially as local governments are often unware

of available mechanisms that would allow contracting with non-state providers.


From whom to

buy

• How services should be purchased typically will require setting the terms of the contract, selecting

provider payment methods, setting provider payment rates, and monitoring provider performance to

find the right mix of incentives that influence the quantity and quality of services.

• On the demand side, the current allocation of purchasing functions under JKN will necessitate greater

collaboration between MOH and BPJS as currently BPJS has the responsibility to manage the JKN deficit

but limited levers to influence service delivery patterns that drive expenditure growth.

• Although the original 2004 social security law allocated most of the key purchasing functions (provider

payment methods, tariff-setting, and quality monitoring) to BPJS, a series of regulations brought these

functions back largely under the control of the Ministry of Health.

• The main lever BPJS currently has to reduce unnecessary hospital costs is to strengthen the power of

capitation to shift utilization from hospitals back to puskesmas. There are several ways BPJS can

strengthen the power of capitation, but dialogue and collaboration will be needed with MOH, MOF, and

local governments

– Improve the KBK scheme by selecting performance-oriented indicators that focus on puskesmas performance and avoidable hospital

admissions making them more effective gatekeepers to higher level care

– Ensure puskesmas have the capacity to provide all basic PHC services so that BPJS does not ‘double-pay’ for services through capitation and

again when referred

– Reduce the regulatory constraints on how puskesmas can utilize capitation to improve absorption of capitation funds

• Here too, HMIS that can produce timely and useful information for budget and planning, provider

performance monitoring, and overall benchmarking will be an essential building block. Claims data

through Pcare and Eklaim offer promising sources of data however initial steps may be needed to

improve coding practices, reporting requirements, data quality, and validation.

• Looking at health financing of primary health care more holistically (both demand and supply side

sources of financing to puskesmas), globally, facilities that can pool all resources and have greater

autonomy in the use of funds have better outcomes and it would be important to assess the

performance of BLUD vs non-BLUD facilities.


How to buy

Foundational elements to strengthen strategic purchasing

Who does what?

Clarity on roles and responsibilities

• Benefit package selection

• Supply side planning

• Purchasing

• Provider payment rate-setting

• Service delivery and quality standards

• Monitoring provider performance

How is it done?

• Public budget system that can link inputs to outcomes

• Provider payment system that rewards performance

• Health management and information system

• Monitoring and evaluation system

What skills are needed?

• Revenue projections

• Budget and planning

• Resource management

• Contracting ability

Institutional structure

Operational system

Capacity building

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