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Moving forward to achieve universal health coverage in IndonesiaWasir, Riswandy

DOI:10.33612/diss.124431881

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https://doi.org/10.33612/diss.124431881

https://research.rug.nl/en/publications/moving-forward-to-achieve-universal-health-coverage-in-indonesia(19bf24fa-e4ee-490a-847e-f9e5e5912750).html

https://doi.org/10.33612/diss.124431881

Moving Forward to Achieve Universal Health Coverage in Indonesia | 1

Moving Forward to Achieve Universal Health Coverage in Indonesia

Progress and Challenges

Riswandy Wasir

2 | Moving Forward to Achieve Universal Health Coverage in Indonesia

Moving Forward to Achieve Universal Health Coverage in Indonesia

Progress and Challenges

Author : Riswandy Wasir

Cover design : Kihajar (graphic design) and Riswandy Wasir (concept)

Layout : Kihajar

Printing : Masagena Printing

ISBN (book) : 978-94-034-2694-5

ISBN (electronic version) : 978-94-034-2695-2

The work presented in this thesis was funded by DIKTI Scholarship, the Ministry of

Research, Technology and Higher Education of Republic of Indonesia and the University of

Groningen, the Netherlands. This thesis was conducted within Research Institute for Health

Research (SHARE). Printing of this thesis was financially supported by University Medical

Center Groningen (UMCG), university of Groningen, and the University Library of the


Copyright © Riswandy Wasir, Groningen 2020.

All rights reserved. No part of this thesis may be reproduced or transmitted in any form by

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remains with the publishers or journals


\

…to my beloved family, respectful teachers, and kind friends


Paranymphs

Muh. Akbar Bahar

Sylvi Irawati


Moving Forward to Achieve Universal Health Coverage

in Indonesia

Progress and challenges

PhD thesis

to obtain the degree of PhD at the


on the authority of the

Rector Magnificus Prof. C. Wijmenga

and in accordance with

the decision by the College of Deans.

This thesis will be defended in public on

Wednesday 13 May 2020 at 9.00 hours

by

Riswandy Wasir

born on 12 January 1988

in Makassar, Indonesia


Supervisors

Prof. E. Buskens

Prof. M.J. Postma

Co-supervisor

Dr. W. Goettsch

Assessment Committee

Prof. K. Taxis

Prof. A.K. Mantel

Prof. S.A. Reijneveld


TABLE OF CONTENTS

Chapter 1 General Introduction .................................................................... 9

Chapter 2 Use of medicine pricing and reimbursement policies for universal

health coverage in Indonesia ........................................................ 19

Chapter 3 The implementation of health technology assessment (HTA) in

medicine pricing and reimbursement policies in Indonesia:

insights from multiple stakeholders .............................................. 69

Chapter 4 Trends and projection of health financing for universal health

coverage in Indonesia ................................................................... 111

Chapter 5 Long term risk of incidence of cardiovascular events in Asian

Populations: Systematic review and Meta-Analysis of

Population-Based Cohort Studies ................................................. 131

Chapter 6 Discussion and future perspective ................................................. 167

Addendum Summary ....................................................................................... 183

Samenvatting ................................................................................ 187

Ringkasan ..................................................................................... 193

Acknowledgement ....................................................................... 197

PhD Portofolio .............................................................................. 201

About the Author .......................................................................... 204

Tentang Penulis ............................................................................ 205

Research Institute for Health Research (SHARE) ......................... 206


Chapter 1

GENERAL INTRODUCTION


Concept of universal health coverage

The united nations have committed to achieve universal health coverage (UHC) as

part of the sustainable development goals (SDGs) by 2030[1]. The world health

organizations (WHO) states that UHC has been achieved in a country when all

people and communities can use the promotive, preventive, curative, rehabilitative

and palliative health services they need, of sufficient quality to be effective, while

also ensuring that the use of these services does not expose the user to financial

hardship[2-4]. In order for countries to move towards achieving UHC, a

comprehensive health benefits package needs to be outlined, i.e., a set of healthcare

services that can feasibly be financed and provided by the agency of UHC.

Furthermore, out-of-pocket (OOP) payments, direct payments made by individuals

to health care provider at the time of service use should be reduced or eliminated

[5,6]. The WHO outlines that UHC is achieved by a country when OOP expenditures

fall below 20% of total healthcare expenditures. Furthermore, the WHO urged that

government spending on healthcare should be at least 4% of gross domestic product

(GDP) to achieve UHC[5,7,8].

Indonesia’s health system transformation towards UHC

As a member of the United Nations, Indonesia is also aiming to achieve UHC. The

concept of UHC is in line with the Indonesian constitution or Undang-Undang

Dasar 1945, article 28. Health is a basic right of every individual, and all citizens

are entitled to health services including the poor. In 2004, the government legalized

a national social security system (SJSN) law, which became the basis to regulate the

provision of health insurance for all Indonesian people. Since then, between 2004

and 2013, there were several state-owned insurance companies proffered by the

government of Indonesia. They were Asuransi Kesehatan (Askes, for civil servants),

Asuransi Sosial Angkatan Bersenjata (Asabri, for military personnel), Jaminan

Sosial Tenaga Kerja (Jamsostek, social security program for labourers), Jaminan

Kesehatan Masyarakat (Jamkesmas, for poor and near poor), Jaminan Kesehatan

Daerah (Jamkesda, for poor and near poor in several provinces)[9]. The

implementation of various kinds of social health insurances were among the efforts

1

Chapter One


of the Indonesian government to provide health protection to all Indonesian people.

It was noted, however, that the fragmented health insurance schemes made health

care spending and quality of healthcare services difficult to control. In addition,

between 2002 and 2013, the OOP payments still were the dominant resource,

comprising over 50% of total health expenditures. Thus, back then UHC still

appeared a distant goal for Indonesia[10].

Therefore, at the beginning of 2014, a transformation of the health

insurance system was initiated in Indonesia. All the fragmented health insurances

were integrated into a new national health insurance, which is known as Jaminan

Kesehatan Indonesia-Kartu Indonesia Sehat (JKN-KIS). In this new system, a new

health insurance provider, which is called Badan Penyelenggara Jaminan Sosial-

Kesehatan (BPJS-Kesehatan) was also introduced. Also, the government of

Indonesia officially announced their plan to achieve UHC by 2020 through the JKN-

KIS[11].

In parallel with the introduction of JKN-KIS, several new medicine policies

were implemented as well. First, the national formulary was launched as a medicine

reimbursement policy, and also as health benefits packages for medicines on the

JKN-KIS. The formulary provides a list of medicines covered by the BPJS-

Kesehatan. All the medicines listed in the national formulary should be available in

the healthcare facilities. Second, a so-called e-Catalogue was introduced as a

medicine pricing policy. This provides lists of medicines with specifications, prices,

and suppliers. All healthcare facilities are obliged to purchase medicines, especially

medicines listed in the national formulary, through the e-Catalogue. In addition, a

few months after the launch of the national formulary and the e-Catalogue, the

Ministry of Health established the health technology assessment committee to assess

the potential of medicines that should be included or excluded from the national

formulary and the e-Catalogue. The introduction of several new medicine policies

was expected to support the JKN-KIS program in terms of reducing or eliminating

OOP payments, and subsequently help achieving UHC in Indonesia[10-17].

1

General Introduction


Challenges for the JKN-KIS to achieve UHC by 2020

Indonesia is the fourth most populous and the largest archipelagic country in the

world, with 252 million inhabitants spread over 17.744 islands in 2014[18]. Providing

universal healthcare access to the whole society by 2020 was an ambitious goal of

the Indonesian government. With a large population and relying on one insurance

provider in the JKN-KIS program, Indonesia will run the largest single-payer system

in the world.

Challenges on medicines management

The high proportion of OOPs for medical bills was the main motive for the UHC

declaration at the World Health Assembly meeting in 2005. In addition, the WHO

highly recommends to the low middle-income countries (LMICs) to eliminate

unnecessary spending on medicines for achieving UHC. This is due to the fact that

the proportion of OOPs in healthcare spending for medicines is high, ranging

between 50% and 90% in LMICs. Moreover, medicine expenditure accounted for up

to 67% of total health expenditure[19-21].

As a low middle-income country, reducing OOPs for medicines and

eliminating sources of inefficiency in medicines procurement are major challenges

for Indonesia to achieve UHC. Before the implementation of the JKN-KIS, most

OOP payments in healthcare were for medicines. The price of one type of medicine

also varies in the same area. In addition, the medicines formulary provided by the

previous health insurances, such as Askes, Jamkesmas, Jamkesda, were also lacking

an evidence base [22-24].

Challenges for the health financing system

Health financing is a core function of health systems concerned with the

mobilization, accumulation, and allocation of financial resources to cover the cost of

health needs of the people, individually and collectively [25]. Health financing is

instrumental and intrinsic for countries like Indonesia to move forward towards

UHC. As a single-payer, BPJS-Kesehatan not only collects health budgets for the

sustainability of the JKN-KIS program, but also ensures that budgets are allocated in

line with the UHC target[11].

1

Chapter One


Prior to the implementation of the JK-KIS, Indonesia already was facing

the challenge of increasing health expenditure at the national level. Between 1995

and 2014, instead of relying on government healthcare financing, Indonesia was

dominated by OOP expenditures[26]. In order to accelerate progress towards UHC

and meeting its population coverage target by 2020, the government of Indonesia

have had to manage their health financing system to ensure that the available

resources would meet financial demands in the communities.

Challenges concerning the epidemiological condition

Already before the implementation of the JKN-KIS, efforts made by the Indonesian

government to make Indonesian people healthier indeed have shown significant

progress. This may be concluded from the increasing life expectancy of Indonesian

people by 6 years, i.e., from 63 years in 1990 to 69 years by 2014[27]. Notably, this

raises a new demographic situation in Indonesia, and the JKN-KIS faces a new

challenge. With an ageing population the proportional mortality due to NCDs

increased from 37% in 1990 to 73% in 2014, which have in the meantime become

the main cause of death in Indonesia[28]. The rising burden of chronic non-

communicable diseases in low and middle-income countries (LMICs), like

Indonesia, has major implications for the ability of these countries to achieve UHC.

Over 60 percent of people living with NCDs have experienced catastrophic health

expenditures, which is spending on health care that exceeds a certain proportion of a

household‘s income[26].

Cardiovascular diseases (CVDs) are the leading cause of death and

disability among NCDs. CVDs account for 37% of deaths in Indonesia[27]. As the

biggest disease burden CVD also represents a high financial risk in BPJS-

Kesehatan[26]. It is critical to consider how underlying trends in epidemiology will

impact the scheme‘s expenditures, and its overall financial sustainability. It would

appear that the BPJS-Kesehatan should find sufficient resources to cover the entire

population and indeed achieve UHC by 2020.

1



Gaps of knowledge

In moving forward towards achieving UHC, the JKN-KIS program might

exploit several opportunities that exist for improving the efficiency, effectiveness,

and sustainability of the health system. The role of new medicines policies, the e-

Catalogue and the national formulary, should be fully utilized to support the JKN-

KIS for achieving UHC in Indonesia. The use of the e-Catalogue could homogenize

medicine price in the same region and help to improve effectiveness, efficiency, and

transparency in medicines procurement. The use of national formulary should ensure

the availability of good quality, efficacious, and affordable medicines. These

medicine policies should help Indonesia to reduce OOP payments, especially for

medicines. Furthermore, the use of health technology assessment should also be

implemented in the process of medicines selection on the e-Catalogue and the

national formulary to increase the evidence base and minimize unnecessary

spending. Furthermore, estimating future health spending, and possible sources for

funding is vital for effective health policy. With reliable spending forecasts, decision

makers may adjust long term planning and process. As JKN-KIS continues to

scaleup toward UHC, critical policy decisions are required to increase revenue,

rationalize healthcare expenditure, and anticipate any future deficits to ensure the

scheme is managed sustainably. Looking at the future burden of disease in Indonesia

will help the Indonesia to wisely spending their resources on health.

Unfortunately, there are no studies that report the extent of the progress of

the national formulary, e-Catalogue and the health technology assessment since their

implementation together with the JKN-KIS program in 2014. In addition, detailed

information on the trends of health financing in Indonesia is needed to report the

JKN-KIS‘ financial status. Next characteristics of its design, key arrangements

affecting choices for financial sustainability, key trends in revenues and

expenditures affecting its future financial position, and potential policy actions to

improve its future sustainability are needed. Finally, a detailed study on the future

burden of disease is necessary to make appropriate planning in providing access and

financial protection to all Indonesian people. All these aspects are aimed to be at

least partly covered with this thesis.

1

Chapter One


Thesis objectives

The general aim of this thesis is to evaluate the implementation of UHC in

Indonesia. A number of key issues, and progress of the JKN-KIS program toward

UHC are describing in chapter 2,3, and 4. In chapter 2, we assess the utilization of

the e-Catalogue and the national formulary as medicine pricing and reimbursement

policies for UHC in Indonesia. In chapter 3, we assess the implementation of HTA

in the use of the e-Catalogue and the NF. In chapter 4, we describe the trend and

project the health financing system in Indonesia. Furthermore, in chapter 5, we

estimate the long-term (>10 years) CVD burden, as well as underlying risk factors in

Asian populations. Chapter 6 presents an overview, general discussion, implications

and future perspectives related to the findings of the studies presented in this thesis.

1



References

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et al. Strengthening health systems

for universal health coverage and

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Bayarsaikhan D. Developing a

national health financing strategy:

A reference guide.geneva: World

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financing guidance no 3). . 2017.

3. World Health Organization.

Tracking universal health coverage:

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world health report: Health systems

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health: No magic number. World

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8. World Health Organization. Health

financing strategy for the asia

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9. Pisani E, Olivier Kok M, Nugroho

K. Indonesia's road to universal

health coverage: A political

journey. Health Policy Plan.

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al. Use of medicine pricing and

reimbursement policies for

universal health coverage in

indonesia. PloS one.

2019;14(2):e0212328.

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Chapter One


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al. The implementation of HTA in

medicine pricing and

reimbursement policies in

indonesia: Insights from multiple

stakeholders. PLoS One.

2019;14(11):e0225626.

18. Kemenkes R. Profil kesehatan

indonesia tahun 2014. Jakarta:

Kemenkes RI. 2015.

19. Rickwood S, Kleinrock M, Nunez-

Gaviria M, Sakhrani S, Aitken M.

The global use of medicines:

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Informatics. 2013:5.

20. Bigdeli M, Laing R, Tomson G.

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coverage: Challenges and

opportunities. . 2015.

21. Tangcharoensathien V, Patchara-

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coverage. The Lancet. 2011;377

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Trisnantor, Shita Listyadewi, et al.

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Noncommunicable diseases:

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1

Chapter One


Chapter 2

Use of medicine pricing and reimbursement policies

for universal health coverage in Indonesia

Use of medicine policy for universal health

coverage in Indonesia

Riswandy Wasir

Sylvi Irawati

Amr Makady

Maarten Postma

Wim Goettsch

Erik Buskens

Talitha Feenstra

This chapter is based on the published manuscript:

Wasir R, Irawati S, Makady A, Postma M, Goettsch W, Buskens E, et al. (2019) Use

of medicine pricing and reimbursement policies for universal health coverage in


Abstract

Objectives

This study aimed to define the problems of the current use of the e-Catalogue and

the national formulary (NF)—two elements of medicine pricing and reimbursement

policies in Indonesia for achieving universal health coverage (UHC)—by examining

the knowledge and attitudes of stakeholders. Specifically, to investigate (1) the

perceived challenges involved in the further implementation of the e-Catalogue and

the NF, (2) reasons of prescribing medicines not listed in the NF, and (3) possible

improvements in the acceptance and use of the e-Catalogue and the NF.

Methods

Semi-structured interviews were conducted with stakeholders (policymakers,

healthcare providers, a pharmaceutical industry representative, and experienced

patients) to collect the qualitative data. The data was analysed using directed content

analysis, following the guidelines of the COnsolidated criteria for REporting

Qualitative studies (COREQ) in reporting the findings.

Results

Interestingly, 20 of 45 participants decided to withdraw from the interview due to

their lack of knowledge of the e-Catalogue and the NF. All 25 stakeholders who

fully participated in this research were in favor of the e-Catalogue and the NF.

However, interviewees identified a range of challenges. A major challenge was the

lack of harmonization between the lists of medicines in the e-Catalogue and the NF.

Several system and personal reasons for prescribing medicines not listed in the NF

were identified. Important reasons were a lack of incentives for physicians as well as

a lack of transparent and evidence-based methods of selection for the medicines to

be listed in the NF.

2

Chapter two


Conclusions

The e-Catalogue and the NF have not been fully utilized for achieving UHC in

Indonesia. Some possible improvements suggested were harmonization of medicines

listed in the e-Catalogue and the NF, restructuring incentive programs for

prescribing NF medicines, and increasing the transparency and evidence-based

approach for selection of medicines listed in the e-Catalogue and the NF.

2




Introduction

Many countries strive for universal health coverage (UHC), a concept recommended

by the World Health Organization (WHO) to ensure that all people have access to

health services they need without suffering financial hardship. One of the goals of

UHC is to eliminate out-of-pocket payments (OOPs), a direct payment made by an

individual to healthcare providers at the time of service use[1,2]. OOPs can be a great

catastrophe for the family of a sick individual[3]. In low middle-income countries

(LMICs), the proportion of OOPs in healthcare spending for medicines is high,

ranging from 50% to 90%[4]. Moreover, medicine expenditure accounted for up to

67% of total health expenditure[5]. Appropriate policies are needed to reduce OOPs

on medicines and to control medicine expenditure[6]. Furthermore, in order to move

towards UHC, WHO has recommended to incorporate health technology assessment

(HTA) to establish policies on medicines. The WHO defines HTA as the systematic

evaluation of properties, effects and/or impacts of health technologies and

interventions[7]. HTA is a critical component of evidence-based policy decision

making[8,9].

In line with the global trends, Indonesia also makes a concerted effort to

achieve UHC. Prior to 2014, Indonesians were supported by several social health

insurances. The three biggest social health insurances were Asuransi

Kesehatan (Askes, for civil servants and the military), Jaminan Kesehatan

Masyarakat (Jamkesmas, for poor and near poor), and Jaminan Sosial Tenaga

Kerja (Jamsostek, social security program for labourers). Notably, the fragmented

health insurance schemes made health care spending and service quality difficult to

control. Regarding medicines, previous studies have reported a large number of

different medicine formularies existed with an unclear evidence-base[10]. In addition,

OOPs were still dominant[11,12], e.g. the OOP in total was 49% in 2013[13].

In 2014, the Government of Indonesia introduced a new health insurance

scheme, known as Jaminan Kesehatan Nasional–Kartu Indonesia Sehat (JKN-KIS),

which was managed by Indonesia‘s National Healthcare Security Agency,

namely Badan Penyelenggara Jaminan Sosial–Kesehatan (BPJS-Kesehatan). JKN-

KIS was the result of a merger of pre-existing social health insurance schemes.

2

Chapter two

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0212328#pone.0212328.ref001














Furthermore, the Ministry of Health (MOH) introduced several new medicine

policies for supporting the implementation of the JKN-KIS program.

First, the e-Catalogue is a national medicine pricing policy and exists since

2013. The MOH proposes medicines, usually at the substance level (e.g.

paracetamol), with specifications (dosage and types e.g. tablet, liquid, capsules) to

LKPP (Lembaga Kebijakan Pengadaan Barang Jasa Pemerintah/ National Public

Procurement Agency). Then, LKPP writes a tender for supply at a national scale and

selects the preferred suppliers. As a result, the e-Catalogue provides a list of

medicines with specifications, prices, and suppliers. All healthcare facilities are

obliged to purchase medicines through the e-Catalogue. Nevertheless, healthcare

facilities are allowed to perform their own tender for medicines that they need and

are not listed in the e-Catalogue[14–16].

Second, the national formulary (NF) is a medicine reimbursement policy. It

provides a list of medicines covered by BPJS-Kesehatan. The MOH has established

the NF committee that is in charge of compiling the list of medicines in the NF. All

healthcare facilities and healthcare professionals may propose medicines to be

included in the NF. These medicines are then selected by the NF committee using

several criteria among which efficacy, safety, marketing authorization, and benefit-

risk ratio. In the NF, international non-proprietary names (INN) are used. The first

NF was cmpiled in 2013 referring to formularies used in the previous health

insurances in Indonesia and the last edition of the Indonesian essential medicines

list. The list of medicines in the NF is revised at least every two years. The last

revision was in 2017. All medicines listed in the NF should be available in the

healthcare facilities. The director of the hospital and the hospital‘s medical

committee should approve when healthcare facilities prescribe medicines not listed

in the NF. Notably, the approved medicine is not reimbursed by BPJS-

Kesehatan[15,17,18], which implies either OOPs or payment from the hospital is

needed.

Third, the use of HTA was introduced to assess new medicines which

might have potential to be included in the e-Catalogue and the NF. The assessment

is to be conducted by the HTA committee. This committee was formed by the MOH

2









in April 2014, then renewed in 2016[19,20]. The current HTA committee consists of

eight senior health scientists and one employee of the MOH. They are supported by

a technical staff (thirteen clinicians, two MOH employees, one engineer, and four

secretaries). Currently, the main task of the HTA committee is to develop their

program. The guidelines of the JKN-KIS state that the HTA committee is

responsible for providing recommendations to the MOH regarding the list of

healthcare services, including medicines, which are covered by the BPJS-Kesehatan.

This implies the HTA committee is responsible for advice regarding the NF[15,20,21].

The Indonesian healthcare system since the implementation of the JKN-

KIS shows several positive changes. Healthcare facilities seldom perform their own

tender for procuring medicines[14]. Furthermore, instead of different formularies for

each insurance scheme, there is a single NF. The MOH introduced the e-Catalogue

and the NF, expecting that they would improve effectiveness, efficiency, and

transparency in medicines procurement, as well as ensure the availability of good

quality, efficacious, and affordable medicines[16,22]. Thus, this should help Indonesia

to achieve UHC.

However, problems regarding the practical use of the e-Catalogue and the

NF have been reported. For instance, it was found that many public healthcare

facilites rarely use the e-Catalogue to procure medicines[23]. Moreover, of all

medicines prescribed in 2015, up to 40% were not listed in the NF[24]. This may

explain the increase of OOPs in 2015 to 50%[13]. Out of these, 70% were found to be

OOPs for medicines[25], which obviously contrasts the philosophy of UHC. The

obstacles hindering medicine pricing and reimbursement policies in Indonesia are

far from clear and need to be investigated.

This research aims to shed light on the current use of the e-Catalogue and

the NF by examining the knowledge and attitudes of stakeholders regarding the

JKN-KIS program, especially concerning the e-Catalogue and the NF. Therefore,

this research will investigate (1) the perceived challenges involved in the further

implementation of the e-Catalogue and the NF, (2) the reasons behind the

prescription of medicines not listed in the NF, and (3) possible improvements in the

acceptance and use of the e-Catalogue and the NF.

2

Chapter two














Methods

Semi-structured interviews were conducted to collect information about the

perception of stakeholders regarding the JKN-KIS program, the e-Catalogue, and the

NF. This study followed the reporting guidelines of the COnsolidated criteria for

REporting Qualitative studies (COREQ)[26] to ensure good quality. The COREQ

checklist provides guidance for explicit and comprehensive reporting of qualitative

studies.

Recruitment of participants

A purposive sampling method was used to recruit the stakeholders[27]. The following

stakeholders in the healthcare system were approached to participate: policymakers

(WHO members, NF committee, HTA committee, and JKN-KIS Agency),

pharmaceutical industry, healthcare providers (physicians and pharmacists), and

experienced patients. The stakeholders should have at least 5 years of relevant work

experience. Experienced patients were selected based on the duration of their health

insurance in Indonesia (at least 5 years) and their routine use of medicines (at least 5

years). In order to ensure that these patient criteria were met, participants were

recruited from the BPJS-Kesehatan‘s chronic disease management program

(Program pelayanan penyakit kronis, Prolanis)[28]. The selection criteria of at least 5

years of experience for stakeholders was used to ensure that they could explain the

healthcare system of Indonesia during and before the implementation of the new

medicine policies.

A rough estimation of participants needed for attaining saturation was then

made. A total of at least twenty-two stakeholders were aimed at. This was based on

at least two representatives for each group of policy makers, at least two

pharmaceutical industry representatives, at least four interviewees from each group

of healthcare providers, and at least four patients. The reason for having more

interviewees in the groups of healthcare providers and patients was our interest in

the practical issues of the e-Catalogue and the NF, for instance prescribing

medicines not listed in the NF.

2







Interviews

An overview of the research process is provided in the flowchart (Fig 1). Five

authors (RW, MP, WG, TF, and EB) first developed a conceptual model (S1 Fig),

based on a review of WHO documents on UHC, and Indonesian documents

regarding medicine policy and the use of HTA. As a result, the initial themes and a

list of questions (S1 Table) for each theme were created, covering two research

objectives, namely (1) the use of medicine pricing and reimbursement policy in the

JKN-KIS program and (2) the barriers and facilitators of the application of HTA as

part of this policy.

Figure 1. Research process

The final list of questions was sent to the stakeholders in advance of the

interview, in order to give interviewees some time for preparation. The interviews

were recorded and subsequently transcribed verbatim by RW and SI for further

analysis. The transcripts were sent back to the participants for feedback as a method

to establish the credibility of the results (member checking). New interviews were

conducted until no new issues arose, that is, until data saturation was obtained.

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https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0212328#pone-0212328-g001

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0212328#pone.0212328.s001

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0212328#pone.0212328.s002


Data analysis

Directed content analysis was conducted to systematically organize the qualitative

data into a structured format[29] using MAXQDA version 12.3.2. The two

Indonesian-speaking authors (RW and SI) read each transcript carefully. They then

coded the transcripts independently using the initial themes. The codes were

compared, and the non-fitting items were discussed. Texts that did not fit into one of

the initial themes and were mentioned by several interviewees were coded as new

themes. These new themes were then discussed with the research team (RW, SI,

MP, AM, WG TF, and EB) to ensure consensus. RW and SI then checked saturation

by theme. Saturation was reached when no new information was generated.

For the current study, four initial themes related to medicine policy were

analyzed, namely, (1) the development of medicine policy and national health

insurance, (2) medicine policy for UHC, (3) stakeholders‘ perspective and (4)

prescribing medicines not listed in the NF. The two remaining initial themes were

left aside. The first of these, barriers and promoting factors of HTA, was analyzed in

a separate study focusing on HTA. We skipped the final initial theme from the

interviews, since eliciting the interviewees‘ ideas regarding what conditions had the

largest burden of disease and the amount of expenditure for medications, was

impossible, as explained under interviews above.

Ethical considerations

Written informed consent (S2 File) was obtained from all participants. Before the

interviews, all participants were aware/understood that their participation was

voluntary and that they were free to stop the interview at any time. All participants

consented to review the verbatim transcript of their interview. The research plan and

the interviews to be conducted were reviewed by the University Medical Center

Groningen (UMCG) ethical review board, who deemed the study non-intrusive, and

subsequently provided a formal waiver statement, i.e., the study would not need

regular ethical approval.

2




Results

Participants

Aiming at about 22 final participants, a total of 51 different individuals were

approached during the recruitment process (S2 Table). Out of this number, 45

agreed to participate in this research. However, 9 withdrew after receiving list of

questions; 7 decided to stop their interviews before they were finished, since they

experienced difficulties in answering the questions and were not confident about

their answers; and 4 had no time for an interview, leaving a final number of 25

participants. This means that the remaining interviewed persons were, to a certain

degree, a select group with better knowledge than most stakeholders.

Classification of the twenty-five participants can be seen in Table 1.

Participants included policy makers (WHO members, HTA Committee, NF

Committee, JKN-KIS Agency), a medicine supplier (pharmaceutical industry),

healthcare providers (physician and pharmacist), and users (patients). On average,

the policymakers, the representative from the pharmaceutical industry and

healthcare providers had a work experience of 26 years, with 14 years as the

minimum. Furthermore, all patients interviewed had been enrolled in health

insurance in Indonesia for an average of 11 years at the time of interview.

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Table 1: Classification of participants involved in the study

Participants Gender Age

(years)

Work

experience

(years)

Years using

public health

insurance

Policy makers

WHO Member Male 50 25 -

HTA Committee Female 53 28 -

HTA Committee Male 55 30 -

NF Committee Male 56 31 -

JKN-KIS Agency Female 51 26 -

JKN-KIS Agency Female 46 21 -

Medicine supplier

Pharmaceutical Industry Male 54 29 -

Healthcare Providers

Physician Male 58 33 -





Physician Female 54 29 -

Pharmacist Female 53 28 -

Pharmacist Male 50 25 -





Users

Patients Male 53 - 8


Patients Female 59 - 10


Patients Female 63 - 12


2




Interviews and analysis of transcripts

Semi-structured interviews were conducted with stakeholders between August 2016

and April 2017 by RW. Interviews were conducted face to face (16 participants) or

through video calls (9 participants) in locations comfortable to the participants. One

of the interviewees invited her colleague to answer the questions together. One

interview was conducted in English, while all others were in Bahasa. The average

time spent on each interview was about an hour. All predetermined codes were

covered by the interview results to a sufficient degree.

Several texts from the transcripts could not be coded into one of the five

initial themes (S1 Table), and were mentioned many times by different stakeholders.

Therefore, 18 new themes identified by RW and SI were discussed with AM, WG,

MP, TF, and EB to reach a consensus. Overall, 24 final themes were identified from

the transcripts, of which 17 (S3 Table) were used in this study while the 7 remaining

themes were left for further research and concerned HTA. The 17 themes in the

current research were categorized into 5 topics, which were given overarching

names (Fig 2).

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Chapter two


Figure 2. Clustering the themes

Attitude towards JKN-KIS program

Attitude towards the e-Catalogue

Knowledge of JKN-KIS program

Knowledge of medicine policy before the JKN-KIS program

Knowledge of the JKN-

KIS program, the e-

Catalogue and the NF

Knowledge of medicine policy in the JKN-KIS program

Attitude towards the

JKN-KIS program, the

e-Catalogue and the NF

Attitude towards NF

Challenges for both the e-Catalogue and the NF

Challenges for the e-Catalogue

The challenges of

further implementation

of the e-Catalogue and

the NF

Challenges for the NF

Experience prescribing medicines not in the NF

Attitude towards prescribing medicines not in the NF

Reason for prescribing medicines not in the NF Prescribing medicines

not listed in the NF

Non-NF medicine most often prescribed

NF Medicines most often unavailable

LIST OF THEMES

TOPIC LIST

Recommendation to improve the e-Catalogue and the NF

Recommendation to avoid prescribing medicines not in the NF

Possible solutions for

optimizing the use of

the e-Catalogue and the

NF

Knowledge of the development of the e-Catalogue and the NF

2




Topic 1: Knowledge of the JKN-KIS program, the e-Catalogue and the NF

Among these 25 stakeholders, only patients had limited knowledge of the JKN-KIS

program, the e-Catalogue, and the NF. The other stakeholders could explain the

JKN-KIS program, the e-Catalogue, and the NF. Thus, to obtain accurate

information from the patients for the next theme, the interviewer explained the JKN-

KIS program to the patients, as well as the role and development of the e-Catalogue

and the NF, based on the guidelines of medicines policies in Indonesia[14,16,22].

Topic 2: Attitude towards the JKN-KIS program, the e-Catalogue, and the NF

All stakeholders endorsed the aim of the JKN-KIS program to achieve UHC by

2020 and approved of the existence of the e-Catalogue and the NF. However, they

emphasized that there were still some challenges to optimizing the implementation

of these policies.

“Yes, I agree. Why Universal Health Coverage by 2020, I hope it can be

achieved next year (2017).” [Patient 3]

―I agree with the existence of the e-Catalogue and the NF. However, the

development and the implementation of these policies still need to be optimized.‖ [Physician 3]

Topic 3: The challenges of further implementation of the e-Catalogue and the NF

One challenge for both the e-Catalogue and the NF that almost all stakeholders

mentioned was the lack of harmonization between the list of medicines in the e-

Catalogue and the NF. Some medicines in the NF are not listed in the e-Catalogue

and vice versa. As a result, some NF medicines were in limited supply and difficult

to provide and some were not even available at healthcare facilities. Furthermore,

lack of harmonization between the e-Catalogue and the NF implied that healthcare

facilities did not always use the e-Catalogue to procure medicines. Consequently,

the prices of medicines were higher than needed.

―If there were NF medicines that should be provided by the healthcare facilities,

but these medicines were not in the e-Catalogue, this confused the medicine

procurement committee, which would then have to spend time obtaining the

standard price of the NF medicine. The price of medicines that has been listed in the e-Catalogue is much cheaper than previous price‖ [Physician 2]

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In fact, the Indonesian government allows the procurement of NF

medicines not listed in the e-Catalogue with the approval of the hospital‘s medical

committee. However, approval often takes a long time.

―To get claims from BPJS-Kesehatan, we ask the approval of the medical

committee to help set the price. We usually wait for unpredictable lengths of time. It takes a long time to get approval.‖ [Pharmacist 6]

A second challenge for both the e-Catalogue and the NF was the presence

of a poor distribution system of medicines in combination with the geographical

conditions of Indonesia. It is not easy to distribute NF medicines in a short period of

time to all locations in Indonesia. This was mentioned in various ways by many

participants.

“Our country is vast. Distributing medicines in Jakarta will be different from

distributing in Papua; the difficulties of distribution in Papua are great. Maybe

the medicine is available, but it gets there too late. If the healthcare provider

does not put the RKO (Plan of Medicine Needs) online, the pharmaceutical

industry cannot anticipate demand. Now the pharmaceutical industry is trying to anticipate but it is too late.‖ [Policymaker 4]

A challenge mentioned primarily by healthcare providers was that of the

low price of medicines in the e-Catalogue. Consequently, some pharmaceutical

industries were unable to provide NF medicines to healthcare facilities. If the

pharmaceutical industry is pressed to provide the medicine at a low price, the quality

of the medicine may also be lower. This is possible since no agency is responsible

for controlling the good manufacturer practices (GMP) of pharmaceutical industry

after they won the tender.

―The price of the medicine set in the e-Catalogue is too low. So, they (the

pharmaceutical industry) reduce their operating expenses. It is feared that

economizing on operational expenses will put the quality of the medicines at

risk.‖ [Pharmacist 4]

“The requirement to take part on a tender of medicines on the e-Catalogue is

very simple. The most important thing is to have a GMP certificate. However,

no one checked the pharmaceutical industry after they won tender.”

[Pharmaceutical Industry]

However, participants also stated that the low price of medicine in the e-

Catalogue is caused by the pharmaceutical industry itself. Pharmaceutical firms bid

2




low prices in order to win tenders and obtain the right to distribute medicines

throughout Indonesia. Moreover, BPJS-Kesehatan was not involved in price-setting

even though it is stated in the National Social Security System (SJSN) Law.

―The price now deemed too low by the pharmaceutical industry is actually a

result of competition among pharmaceutical firms regarding the supply of NF

medicines through the e-Catalogue. So even though the estimated price was

first set quite high – for example, paracetamol per tablet is set at a price of 70

rupiahs – because of the competition, an offer made was far below the price of

70. The goal of these firms is to win the tender.‖ [Pharmaceutical Industry]

―BPJS-Kesehatan is currently losing its power because of the tariff-setting by

the Ministry of Health. In the National Social Security System (SJSN) Law, it is

clear that the BPJS-Kesehatan is mandated to develop health system services

and set prices and tariffs.‖ [Policymaker 5]

Finally, it was observed that the NF was not the only reimbursement policy

considered. For example, several hospitals have developed their own formularies.

Such formularies list additional medicines not on the NF medicine list.

―A hospital formulary is required by every hospital in Indonesia. The hospital

formulary partially refers to the NF. For additional medicines not listed in the

NF, patients do not have to pay, as long as the patients are participants in the

JKN-KIS program and have the approval of the General Director of the

Hospital. Those medicines will be subsidized by the hospitals.‖ [Pharmacist 2]

The various challenges for further implementation of the e-Catalogue and

the NF, mentioned in the interviews, are summarized in Table 2 and are categorized

by policy types.

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Table 2. Implementation challenges of the e-Catalogue and the NF

Policies Challenges

e-Catalogue The price of medicines is set too low.

National Formulary A lack of harmonization with other

prescription guidelines (hospital

formularies and standard treatment

guidelines).

e-Catalogue and National Formulary 1. A lack of harmonization between

the list of medicines in the e-

Catalogue and the NF;

2. A poor distribution system for

medicines and the geographical

conditions of Indonesia.

Topic 4: Prescribing medicines not listed in the NF

All stakeholders were aware of the practice of prescribing medicines not listed in the

NF. All physicians have prescribed medicines not listed in the NF, while all patients

and other stakeholders have obtained prescriptions not listed in the NF.

―Yes. Of course. There were still many prescriptions for medicines not in the NF; even I have prescribed medicines not listed in the NF.” [Physician 5].

Almost all stakeholders were opposed to the prescription of medicines not

listed in the NF. However, despite this reluctance, the stakeholders mentioned

several reasons to explain this practice. Tables 3 and 4 list the main reasons

mentioned as well as the underlying explanations.

2




Table 3. Reasons for prescriptions of medicines not listed in the NF in

relation to the healthcare system

Reasons Causes

Unavailability of NF medicines in the

healthcare facilities.

1. A lack of harmonization between

the list of medicines in the e-

Catalogue and the NF;

2. A poor distribution system;

3. The price of medicines in the e-

Catalogue is too low;

Some important medicines are not listed

in the NF.

1. Failure to negotiate the prices

with the pharmaceutical industry;

2. Some importance medicines

have not yet been registered in

Indonesia;

The existence of other prescription

guidelines.

The regulation of pharmaceutical

service standards in hospitals requires

a hospital formulary and standard

treatment guidelines

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Table 4. Reasons for prescriptions of medicines not listed in the NF in

relation to individual stakeholders

Reasons Causes

Patients ask for non-NF medicines. 1. Patients do not know about the

existence of NF medicines;

2. Patients perceive that NF

medicines are low quality;

3. Patients are able to pay for non-

NF medicines;

4. Patients prefer single

combination medicine rather than

taking separate medicines.

5. A lack of dissemination of NF to

the healthcare facilities

Prescribers perceive no incentive to

prescribe NF medicine.

Physicians have spent a significant

amount of money and time on their

training and expect to profit from

working with the pharmaceutical

industry.

Prescribers lack of confidence in the

development of the NF.

1. The selection of medicines for

inclusion in the e-Catalogue and

the NF is not transparent and is

not based on evidences;

2. Only a limited number of

physicians are involved in the

selection of medicines fo the e-

Catalogue and the NF, thus does

not represent all physicians.

Physicians do not know about the

existence of the NF.

1. A lack of promotion of the NF,

especially for new and resident

physicians;

2. The habit of physicians to

prescribe without references.

No sanction for physicians who

prescribe non-NF medicines.

No system in place to check and fine.

2




The unavailability of NF medicines in healthcare facilities and its causes

has been discussed above. Examples of several NF medicines that often prescribed

but not available in healthcare facilities according to participating healthcare

providers were ceftriaxone, cefotaxime, furosemide, metronidazole, lansoprazole,

omeprazole, and paracetamol.

Medicines missing from the NF are another explanation for non-NF

prescriptions. The list of non-NF medicines often prescribed in healthcare facilities

according to healthcare providers and policymakerswere acetylcholine, amdixal,

flexpen, flunarizine, glyceryl guaicolate, lincomycin, neurodex, novomix,

pantoprazole, and piracetam.

―Glyceryl guaiacolate is an important medicine for a coughing pregnant

woman. This medicine is not in the NF, but its use is important. So, I still prescribe it if there are pregnant women who have a cough.‖ [Physician 5]

Among these many reasons, the most interesting might be those relating to

physicians‘ perspective, since they write the prescriptions. Most of the physicians

interviewed mentioned that their personal reason for prescribing medicines not listed

in the NF was the lack of (financial) incentive.

―Pity the doctor, once they were free to prescribe and get a bonus. Now they are

limited by the NF. Many people insist on going to medical school, because

hopefully, they will earn high salaries in the future. They will have paid

expensive tuition fees, studied diligently, and lived less sociably because there

was no time. But now their income is going to be limited. Pity the doctor, their individual rights were rescinded, for the benefit of society.‖ [Physician 1]

Another reason mentioned by many physicians was lack of confidence in

the development of the e-Catalogue and the NF.

―I think the NF medicines were not selected on the basis of recent scientific

evidences. I still suspect the selection of medicines was based on other

considerations as well. For example, the pharmaceutical industry intervened so

that certain medicines were included in the NF. In my opinion, at this time, the

NF committee has not been able to account for the selection of medicines in the

NF scientifically, because HTA is not yet running.‖ [Physician 5]

―The physicians disagreed with the list of NF medicines. Well, these complaints

are usually from senior physicians who were not involved in drawing up the

NF.‖ [Physician 6]

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In contrast to this, one of the policymakers stated that the list of medicines

in the NF has, only to a certain degree, been selected based on evidences.

―The medicine proposed by physicians for the NF must be supported by

scientific evidence, so that the proposal is accountable, not just a proposal.‖

[Policymaker 4]

Topic 5: Possible solutions for optimizing the use of the e-Catalogue and the NF

Some possible solutions were suggested by stakeholders to overcome the challenges

of the e-Catalogue and the NF. Many participants (14 out of 25) recommended

harmonizing the list of medicines in the e-Catalogue and the NF. Moreover, the

selection of medicines needed to be transparent and evidence-based.

―The government should harmonize all the medicines policies in the JKN-KIS

system such as the NF, e-Catalogue, and also other medicine policies such as

hospital formularies, standard treatment guidelines and Indonesian Case Base

Groups (INA-CBGs)‖ [Pharmacist 5]

“The selection of medicines in the e-Catalogue and the NF should be

transparent and reflect the latest scientific evidence. Therefore, HTA should be

implemented.‖ [Physician 5]

A second possible solution suggested was to apply rewards and

punishments for prescribers in order to avoid prescriptions of medicines not listed in

the NF. Almost all physicians and some policymakers mentioned this.

“A bonus should be given to the physicians if they prescribe NF medicines, and

consequently, the physicians will become more motivated. Furthermore, penalties

can also be issued if the physicians prescribe medicines that are not in the NF.”

[Physician 1]

A third possible solution proposed was to have at least one distributor of

NF medicines in all provinces in Indonesia, or alternatively, to have more than one

industry providing each type of NF medicines. Some pharmacists and policymakers

mentioned this.

―There is a need for an alternative provider to the one who won the tender in

the e-Catalogue, so that the price of more than one potential provider can be

included for the same medicine. Thus, healthcare facilities would have

alternatives when one of the pharmaceutical providers is unable to provide NF

medicines.‖ [Pharmacist 4]

2




A fourth possible solution recommended was to disseminate the list of NF

medicines to patients. Furthermore, the list of NF medicines needed to be extended.

Almost all patients and some policymakers mentioned this.

―Every patient should receive a list of NF medicines, thus consequently being

made aware of whether the medicine being administered to the patient is listed

in the NF or not. The patient can then also ask for an NF medicine if his/her

medicine is not included in the list of free medicines.‖ [Patient 6]

―The list of NF medicines should be expanded, so that all medicines would be free to the patients.‖ [Patient 4]

A fifth possible solution was to ensure the quality of the list of medicines in

the e-Catalogue and the NF. This possible solution was mentioned by the

representative of the pharmaceutical industry.

―Determining the winning bidder for NF medicines should not only be based on

price and production capacity. There must be some kind of pre-qualification.

There should be an audit to ascertain the quality of the medicines, which can be

conducted using the WHO pre-qualification process.‖ [Pharmaceutical

Industry]

Another possible solution from policymakers was to encourage patients to

report to the BPJS-Kesehatan when obtaining a prescription of medicines not listed

in the NF.

―Patients should give feedback on prescribed medicines not listed in the NF. In

every health facility, there was a BPJS-Kesehatan office. So, if there is a

complaint from the patient, we will confirm this with the doctor and pharmacist.‖ [Policymaker 6]

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Chapter two


Discussion

All the stakeholders interviewed were in favour of the e-Catalogue and the NF.

However, many healthcare providers and patients had limited knowledge of the role

and the existence of the e-Catalogue and the NF. Interviewees identified a range of

challenges preventing optimal implementation. The challenges mentioned were

related to the general structure of the healthcare system as well as to individual

behaviour. The stakeholders had the following suggestions for improvement: (1)

The list of medicines in the e-Catalogue and the NF should be harmonized to

accelerate the procurement of NF medicines and to facilitate the availability of NF

medicines in healthcare facilities; (2) The procedure for selecting medicines in the

NF and setting their prices in the e-Catalogue should be made more transparent and

evidence-based in order to convince stakeholders to use them; (3) Physicians could

be rewarded for prescribing NF medicines or sanctioned for writing prescriptions for

medicines not listed in the NF; (4) More dissemination of information concerning

the NF could be targeted to all citizens.

The suggestion to harmonize the e-Catalogue and the NF is related to the

current confusion caused by a lack of harmony. For medicines on the NF, but not

listed in the e-Catalogue, healthcare facilities need to find a reference price.

However, the price must be in accordance with the maximum claims of the BPJS-

Kesehatan. If healthcare facilities procure medicines at higher prices, healthcare

facilities can lose money. Furthermore, the existence of individual hospital

formularies adds to the confusion. Medicines that are not listed in the NF can be

listed in a hospital formulary. A hospital formulary is needed for hospital

accreditation[30,31]. Hence, here we see policies are not in harmony. Similar problems

were noticed in other LMIC countries, e.g. Namibia, with different advices between

different national bodies causing problems[32].

Lack of harmony was indicated by many interviewees. Therefore, the

authors have compared both lists systematically. We found that in 2013[33], there

were 519 substances of medicines with 923 specifications in the NF, and 374 of the

specifications were not listed in the 2018 e-Catalogue. In 2015[34], 562 substances of

medicines with 983 specifications were in the NF, and 359 of specifications were

2




not listed in the e-Catalogue. In 2017[35], 586 substances of medicines with 1031

specifications were in the NF, and 380 were not listed in the e-Catalogue. The e-

Catalogue listed 1076 specifications of medicines[36]. This highlight that the problem

of lack of harmony was stable over time.

The current study identifies reasons for prescribing medicines not listed in

the NF. A full list of the reasons for these non-NF prescriptions can be found in the

results section. A first important reason is that physicians are not convinced by the

listings in the NF, since the selection process was perceived as neither transparent

nor evidence-based. The requirements linked to the successful implementation of a

NF include transparency and an evidence-based selection process of the

medicines[37]. Physicians trust in formularies is a key area[38]. One way to

accomplish this might be the use of HTA, as also suggested by some interviewees.

HTA has been used by many organisations in Economic Co-operation and

Development (OECD) countries to select the medicines to be included in their

NFs[39,40]. Furthermore, HTA can also facilitate the setting of reasonable prices for

medicines[41]. Thailand is one of the Southeast Asian countries which is now

successfully using HTA for selecting medicines in their medicine pricing and

reimbursement list[6,42]. An HTA committee in Indonesia does exist, however, it is

still in its early stages of development. Other Southeast Asian countries, such as the

Philippines, Malaysia and Vietnam are also still in the early stages of HTA

development[43-46].

A second important reason for prescribing non-NF medicines is the lack of

incentives for the healthcare providers, particularly, the physicians who prescribe the

medicines. A previous study suggested that providing incentives to the stakeholders

could reduce the number of medicines not listed in the formularies[47]. Maybe the

Indonesian government could rethink their policy regarding incentives for all

stakeholders. The current regulations of Indonesia vis-à-vis rewards and

punishments for healthcare professionals do not touch on this aspect of the

prescription of medicines listed in the NF. Moreover, such clauses reward and

punish only those physicians working in primary healthcare, not physicians working

in hospitals[48]. In some countries, pay-for-performance schemes for providers have

2

Chapter two


been set up. Such schemes could financially reward physicians for achieving

healthcare system targets[49,50]. The literature discusses various methods to influence

physicians‘ prescribing, including incentives. Other methods consist of educational,

organizational, and regulatory approaches[51,52].

The fourth suggestion to disseminate the NF to all healthcare facilities is

equally important and touches upon the educational approach. Mostly patients had

this suggestion since they were not aware of the existence of the NF. A previous

study also suggested the quality of care to patients may be compromised by the

lacking availability of some essential policy documents in the healthcare

facilities[53]. Medicines listed in the NF are free of charge to patients. If patients are

better aware of the list of medicines, they may avoid to use non-NF medicines.

Therefore, this also can help to reduce OOPs, in particular for medicines.

Though a variety of stakeholders were interviewed in this study, this does

not automatically mean that all stakeholders were represented. This research

contained interviews with a specific group of patients, namely, those from Prolanis.

The main reason for this was that participants from this group were relatively easy to

find and recruit. Furthermore, we knew that at the time of the interviews, they had

been taking medication since before the implementation of the JKN-KNS program

in 2014, and therefore were able to provide informed views. This research

highlighted a variety of barriers, facilitators and solutions which were mentioned by

patients and professionals until saturation was reached. However, although more

participants (25) were interviewed than the number of participants aimed at (22),

this study did not manage to achieve two interviewees for each subgroup of

stakeholders. Notably, only one WHO member, member of NF committee, and

pharmaceutical industry representative were interviewed. Therefore, all policy

makers were combined into one category. Nonetheless, the interviewees attained

were relatively experienced. In particular, the representative of pharmaceutical

industry interviewed was a leader in several pharmaceutical associations in

Indonesia.

2




Conducting semi-structured interviews allowed the researchers to obtain

detailed information about personal feelings, perceptions and opinions from the

participants without any influences from other group members. Moreover, all

ambiguities could be clarified, and incomplete answers were completely followed

up. Several steps were taken to ensure good research practice during the data

compilation and analysis stages. The sampling process used to select participants

and the interview guide were compared with recommendations published in the

COREQ[26]. Transcripts were coded independently by two authors and all

discrepancies were resolved by consensus.

Some suggestions for policy improvement mentioned by the interviewees

could facilitate the improvement of the e-Catalogue and the NF, specifically

avoiding writing prescriptions for medicines not listed in the NF and setting

reasonable prices in the e-Catalogue. These results could prove relevant to other

countries striving to achieve UHC, particularly for the countries which are

experiencing similar problems regarding the implementation of a medicine pricing

and reimbursement policy.

2

Chapter two


Conclusions

In conclusion, the e-Catalogue and the NF as medicine pricing and reimbursement

policies of Indonesia have not been fully utilized to support the JKN-KIS program‘s

aim of achieving UHC. The main challenge identified by the interviewees was the

lack of harmonization between the lists of medicines in the e-Catalogue and the NF.

Important reasons mentioned for prescribing medicines not listed in the NF included

a lack of incentives for physicians as well as a lack of transparent and evidence-

based selection methods for the medicines to be included in the NF. Possible

improvements to the use of e-Catalogue and the NF were discussed. First, the list of

medicines in the e-Catalogue and the NF could be harmonized. Second, the current

incentive program for providers could be altered to provide more rewards for

prescribing NF medicines while more education on the NF would be worthwhile.

Finally, the procedure for selecting medicines in the NF and setting their prices in

the e-Catalogue could be made more transparent and evidence-based in order to

convince stakeholders to use them.

Acknowledgments

The authors would like to thank all stakeholders who participated in this study.

2 2




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2

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2




Supporting Information

S1 Fig. Conceptual framework

Explanation of conceptual framework:

Many countries aim to reform their national health insurance to reach universal

health coverage. Nowadays, 58 countries are using universal health coverage

besides Indonesia. Before 2014, various health insurance schemes covered health

insurance for Indonesian society. As of 2014, all these schemes were integrated

and organized under one agency called BPJS-Kesehatan. The main goal of this

insurance is to achieve universal health coverage by 2019. The problem with

BPJS-Kesehatan was budgetary constraints, with the highest expenditure being

pharmaceuticals. The national formulary was used to organize medicines. HTA

has not yet been applied in the national formulary, while many UHC countries

do.

2

Chapter two


S2 Table. Initial list of themes and of questions

NO THEMES NO QUESTIONS

1 The development

of medicine policy

and national

health insurance

1 Do you know how long the HTA Committee, NF

Committee, and NHI Agency have existed?

2 How many committee members?

3 What are their professions?

4 What are their duties?

5 Why do they exist?

6 What is their function?

7 What is their role in supporting UHC?

8 How is the NHI different from previous health

insurance (Askes, Jamkesmas, etc)?

9 How many people are covered by the NHI Agency

currently?

2 Medicines policy

for UHC

10 What medicines policy or policies should be created

to support UHC?

11 Are you involved in creating the NF and other

medicines policies to support UHC?

3 Users Perspective 12 Do you know how the National Formulary is

compiled?

13 Do you agree with the NF?

14 Do you have policy recommendations to maximize

the use of HTA?

15 Do you have other policy recommendations for

prescribing drugs?

4 Obstruction and

promoting factors

of HTA

16 What is/are the advantage(s) using HTA in

medicines policy?

17 What is/are the disadvantage(s) using HTA in

medicines policy?

18 What is/are the facilitator(s) implementing HTA in

medicines?

19 What is/are the barrier(s) implementing HTA in

medicines?

20 What should other stakeholders do to solve them?

And which ones?

21 What should the government do?

5 The biggest

burden of disease

and medicine

expenditure

22 What is the most widespread disease in Indonesia?

23 How much money is allocated for medicines in the

national health system?

24 What medicines are allocated more money? (Why?)

6 Prescriptions not

in NF

25 Have you ever received prescriptions for drugs not

in the NF (How frequently and why)?

26 Which medicines do you receive most often that are

in the NF?

27 Do you agree when doctors prescribe medicines not

in the NF? Why?

2




S3 File. Final list of questions

List of Questions for participants (excluding patients)

1. What do you know about the JKN-KIS program? Which points can you

explain:

a. Implementing Agency;

b. When executed;

c. Implementation goals;

d. Other personal information according to participants?

2. As far as you know, what public health insurance programs have been

implemented prior to the implementation of the JKN-KIS program?


b. The policy/program that they imposed to control medicines?

3. Do you know why all public health insurance programs are integrated into

JKN-KIS?

4. What are the medicine policies/programs imposing on the JKN-KIS?

a. The role or the functions of the policies

b. What are the policy-making processes?

c. Are you involved in the policy-making process?

d. Who is involved in the policy-making process?

e. Do you agree with the program/policies?

f. Do you think there is/are stakeholder(s) harmed by that policy? For

example, doctors, pharmacists, the pharmaceutical industry, patients, etc.

g. Do you think the policy is based on the latest scientific evidence?

h. In your opinion, are there any other policy proposals that should be

applied?

Key terms:

GOI = Government of Indonesia

HTA = Health Technology Assessment

JKN-KIS = a National Health Insurance scheme of Indonesia UHC = Universal Health Coverage 2

Chapter two


5. What do you know about the HTA?


b. When executed;


6. Do you think the HTA should be applied to the medicine policies on the JKN-

KIS?

7. In your opinion, what are the advantages and disadvantages of using HTA in

medicine policies on JKN-KIS?

8. In your opinion, what are the supporting and inhibiting factors for the use of

HTA on medicine policies in JKN-KIS?

9. In your opinion, what solutions should be found to implement the HTA on

medicine policies in JKN-KIS?

a. What should be done by all stakeholders (policymakers, doctors,

pharmacists, drug companies, patients, etc.)

b. What should be done by the GOI?

10. Have you ever found prescriptions not in the medicine policies on JKN-KIS?

a. Do you know why this occurred?

b. Do you agree with prescriptions not being in the medicines policy?

c. What medicines are most commonly prescribed that are not part of the

policies of JKN-KIS?

d. Do you have any suggestions to overcome this?

11. Do you know how much money is allocated for medicines to support the JKN-

KIS program?

a. Do you know which drugs are allocated the largest budget?

12. Do you know what is the most widespread disease in Indonesia?

a. Do you know how much money is allocated to cope with this disease?

13. Do you have other comments regarding this research?

2




List of Questions for Participants (excluding patients) in

Bahasa

1. Apa yang anda ketahui tentang JKN-KIS. Point yang dapat anda jelaskan

yaitu:

a. Instansi apa yang melaksanakan?

b. Kapan mulai dilaksanakan?

c. Apa tujuan dilaksanakan?

d. Informasi lain yang dianggap perlu disampaikan dari partisipan

2. Sejauh yang anda ketahui, program jaminan kesehatan publik apa saja yang

dilaksanakan sebelum diberlakukannya JKN-KIS?


b. Apakah anda tahu kebijakan/ program apa yang mereka terapkan untuk

mengontrol obat?

3. Apakah anda tahu, mengapa seluruh program jaminan kesehatan publik

berintegrasi ke JKN-KIS?

4. Apa sajakah kebijakan/ program yang sudah diberlakukan oleh pemerintah pada

program JKN-KIS?

a. Apakah anda tahu fungsi kebijakan/ program tersebut?

b. Apakah anda tahu bagaimana proses pembuatan kebijakan tersebut?

c. Apakah anda terlibat dalam proses pembuatan kebijakan tersebut?

d. Siapa-siapa saja yang terlibat dalam proses pembuatan kebijakan tersebut?

e. Apakah anda setuju dengan kebijakan tersebut? Mengapa?

f. Menurut anda, adakah stakeholders (Dokter, Apoteker, Perusahaan obat,

pasien, dll) yang dirugikan dengan kebijakan tersebut?

g. Menurut anda, apakah kebijakan tersebut telah melalui bukti ilmiah

mutakhir?

h. Menurut anda, adakah usulan kebijakan lain yang sebaiknya diterapkan?

Pengertian Istilah:

HTA = Health Technology Assessment/ Penilaian Teknologi Kesehatan;

JKN-KIS = Program Jaminan Kesehatan Nasional di Indonesia;

UHC = Universal Health Coverage/ Cakupan Perlindungan Semesta. 2

Chapter two


5. Apa yang anda ketahui tentang HTA?




6. Menurut anda, apakah HTA sebaiknya diterapkan pada kebijakan obat yang

sudah diterapkan pemerintah untuk mendukung JKN-KIS?

7. Menurut anda, apa keuntungan dan kerugian menggunakan HTA pada

kebijakan obat yang sudah diterapkan pemerintah?

8. Menurut anda, apa faktor pendukung dan faktor penghambat menggunakan

HTA pada kebijakan obat yang sudah diterapkan pemerintah?

9. Menurut anda, soulusi apa yang sebaiknya dilakukan untuk melaksanakan HTA

pada kebijakan obat yang sudah diterapkan pemerintah?

a. Apa yang sebaiknya dilakukan oleh para stakeholders (pembuat kebijakan,

dokter, apoteker, perusahaan obat, pasien, dll)?

b. Apa yang sebaiknya dilakukan oleh pemerintah?

10. Pernahkah anda menemukan peresepan obat di luar kebijakan obat yang sudah

diterapkan pemerintah?

a. Apakah anda setuju dengan peresepan obat diluar kebijakan obat yang

sudah diterapkan pemerintah?

b. Obat apa yang paling sering diresepkan diluar kebijakan obat yang sudah


c. Apakah anda tahu, bagaimana cara mengatasi hal tersebut?

11. Apakah anda tahu berapa banyak anggaran belanja obat yang dialokasikan

untuk mendukung JKN-KIS?

a. Apakah anda tahu obat apa yang mendapatkan anggaran terbesar?

12. Apakah anda tahu penyakit yang terbesar di Indonesia?

a. Apakah anda tahu berapa banyak anggaran untuk obat yang dialokasikan

untuk mengatasi penyakit tersebut?

13. Apakah ada komentar lainyang ingin anda sampaikan terkait penelitian ini?

2




A List of Questions for Patients

1. Do you know about JKN-KIS, which is part of BPJS-Kesehatan? Could you

explain briefly it?

2. Are you a participant in JKN-KIS?

3. When were you be a participant in JKN-KIS?

4. What health insurance did you use before JKN-KIS?

5. For how long were you a participant in that insurance?

6. Are you currently taking any medication?

a. When was the last time you took the drugs?

b. What drugs did you take?

7. Did you also take that medicine when using your previous insurance?

8. Do you feel a difference when taking medication of JKN-KIS compared with

medication of your previous health insurance?

a. Which one is cheaper?

b. Which are more efficacious?

c. Which one do you like, and think is better?

9. Is there a difference, do you feel, in terms of service between JKN-KIS and your

previous health insurance?

a. Are there differences when seeing doctors?

b. Is there a difference when conducting laboratory checks or other checks?

10. Do you know about UHC? Could you explain briefly what you know?

a. Do you agree with the GOI‘s target of reaching UHC in 2019?

b. Do you think it can be achieved?

c. Are there any suggestions from you in order to achieve the UHC?

11. Do you know about NF? Could you explain briefly about that?

a. Do you know how NF is created?

Key terms:



JKN-KIS = a National Health Insurance scheme of Indonesia

UHC = Universal Health Coverage

NF = National Formulary 2

Chapter two


b. Do you agree with NF?

c. What medications do you often receive which are in NF?

d. Have you ever received prescriptions not in the NF? How often? Why?

e. Do you agree with prescriptions not in the NF? Why?

f. Do you have a policy recommendation in prescriptions?

12. Do you know about HTA? Could you explain briefly what you know?

a. Do you think the HTA can be used for medicines policy in Indonesia?

b. In your opinion, what is the advantage of using HTA in determining the

choice of medicines?

c. In your opinion, what are the disadvantages of using HTA in determining

the choice of medicines?

d. In your opinion, what are the promoting factors in implementing an HTA

for drug selection?

e. In your opinion, what are the obstacles in implementing an HTA for drug

selection?

f. In your opinion, what should be done by stakeholders to resolve this?

g. In your opinion, what should the government do?

13. Do you have suggestions for improving medicines policy?

14. Do you have other comments related to this research?

2




A List of Questions for Patients in Bahasa

1. Apakah anda tahu tentang jaminan kesehatan nasional yang dikelola oleh BPJS-

Kesehatan? Bisakah anda Jelaskan sedikit tentang hal itu?

2. Apakah anda anggota BPJS-Kesehatan?

3. Kapan anda mulai menjadi anggota BPJS-Kesehatan?

4. Asuransi apa yang anda gunakan sebelum menjadi anggota BPJS-Kesehatan ?

5. Berapa lama anda menjadi anggota asuransi tersebut?

6. Apakah anda mengkonsumsi obat saat ini?

a. Kapan terakhir kali anda mengkonsumsi obat?

b. Obat apa?

7. Apakah obat tersebut juga anda konsumsi dengan menggunakan asuransi yang

sebelumnya?

8. Apakah ada perbedaan yang anda rasakan ketika menggunakan obat dari BPJS

dengan obat dari asuransi anda sebelumnya?

a. Yang mana yang lebih murah?

b. Yang mana yang lebih berkhasiat?

c. Yang mana yang anda suka dan anggap lebih baik?

9. Apakah ada perbedaan yang anda rasakan dari sisi pelayanan pada Asuransi

BPJS dan Asuransi yang anda gunakan sebelumnya?

a. Apakah ada perbedaan ketika bertemu dengan dokter?

b. Apakah ada perbedaan ketika melakukan cek laboratorium atau

pemeriksaan lainnya?

10. Apakah anda tahu tentang Univeral Health Coverage (UHC)/ Jaminan kesehatan

secara menyeluruh? Bisakah anda Jelaskan sedikit tentang hal itu?

a. Apakah anda sependapat dengan pemerintah Indonesia yang ingin

mencapai UHC di tahun 2019?

b. Apakah anda pikir itu bisa dicapai?

c. Apakah ada saran dari anda untuk mencapai UHC tersebut?

11. Apakah anda tahu tentang Formularium Nasional (Fornas)?

a. Apakah anda tahu bagaimana Fornas dibuat?

b. Apakah anda setuju dengan Formularium Nasional?

2

Chapter two


c. Obat apa yang sering anda terima yang ada di dalam Fornas?

d. Pernakah anda menerima obat di luar Fornas? Seberapa sering? Kenapa?

e. Apakah anda setuju ketika dokter menuliskan obat diluar formularium

nasional? Kenapa?

f. Apakah anda memiliki rekomendasi kebijakan dalam penulisan obat?

12. Apakah anda tahu tentang Health Technology Assessment (HTA) / Penilaian

Teknologi Kesehatan? Bisakah anda Jelaskan sedikit tentang hal itu?

a. Menurut anda, apakah HTA dapat digunakan untuk kebijakan obat di

Indonesia?

b. Menurut anda, apa keuntungan menggunakan HTA dalam menentukan

pilihan obat?

c. Menurut anda, apa kerugian menggunakan HTA dalam menentukan

pemilihan obat?

d. Menurut anda, apa faktor pendukung dalam menjalankan HTA pada

pemilihan obat?

e. Menurut anda, apa faktor penghambat dalam menjalankan HTA pada

pemilihan obat?

f. Apa yang harus dilakukan oleh pemangku kebijakan untuk menyelesaikan

itu?

g. Menurut anda, apa yang harus dilakukan oleh pemerintah?

13. Apakah anda memiliki saran untuk meningkatkan kebijakan obat?

14. Apakah anda memiliki saran untuk penelitian ini?

2




S4 File. Informed consent

Lembar penjelasan dan persetujuan kepada partisipan

Peluang dan tantangan kebijakan obat pada program JKN-KIS untuk mencapai

Cakupan Perlindungan Semesta / Universal Health Coverage (UHC)

Saya Riswandy Wasir, Mahasiswa Program Pascasarjana (S3) Departemen

Epidemiologi, Univerity Medical Center Groningen (UMCG), University of

Groningen, Netherlands. Saat ini saya sedang melakukan penelitian yang berjudul

―peluang dan tantangan kebijakan obat pada program JKN-KIS untuk mencapai

cakupan perlindungan semesta‖.

Pemerintah Indonesia telah menerapkan skema asuransi kesehatan nasional

(JKN-KIS) yang terintegrasi dimulai pada tahun 2014. Asuransi kesehatan yang

dikelolah oleh BPJS-Kesehatan dimaksudkan sebagai pengganti seluruh asuransi

kesehatan publik sebelumnya. Peta jaminan kesehatan nasional yang dirilis oleh

pemerintah menyatakan bahwa program JKN-KIS diupayakan mencapai cakupan

perlindungan semseta/ Universal Health Coverage (UHC) pada tahun 2019.

Organisasi Kesehatan Dunia/ World Health Organization (WHO) menyatakan

bahwa bukan hanya kepesertaan yang menjadi indikator tercapainya cakupan

perlindungan semesta, tetapi juga kualitas pelayanan.

Berbagai upaya telah dilakukan oleh pemerintah dan para pemangku

kebijakan untuk meningkatkan mutu pelayanan JKN-KIS. Pada sektor obat,

pemerintah Indonesia telah menerapkan formularium nasional. Manfaat Fornas yaitu

sebagai acuan penetapan penggunaan obat dalam JKN-KIS, serta meningkatkan

penggunaan obat yang rasional, dapat juga mengendalikan mutu dan biaya

pengobatan, serta mengoptimalkan pelayanan kepada pasien Namun, Hasil evaluasi

awal yang dilakukan oleh Direktorat Jenderal Bina Farmasi dan Alat Kesehatan

(Dirjen Binfar dan Alkes) memperlihatkan bahwa kesesuaian obat yang digunakan

di rumah sakit dengan formularium nasional berkisar antara 60 – 86 %. Hal ini

memperlihatkan bahwa masih ditemukan cost-sharing, suatu kondisi dimana peserta

JKN-KIS harus mengeluarkan biaya untuk pembayaran pelayanan kesehatan

2

Chapter two


termasuk obat. Salah satu Indikator tercapainya cakupan perlindungan semesta

(UHC) menurut WHO adalah tidak adanya cost-sharing.

Kami, melakukan penelitian ini untuk mengidentifikasi peluang dan

tantangan kebijakan obat pada program JKN-KIS untuk mencapai cakupan

perlindungan semesta. Penelitian ini akan melibatkan beberapa pemangku

kepentingan yang dianggap memiliki peran dalam membuat kebijakan,

mengimplementasikan serta merasakan dampak dari kebijakan tersebut antara lain

sebagai berikut:

No Partisipan Peran

1 Organisasi Kesehatan Dunia (WHO) Pembuat Kebijakan skala Internasional

2 Komite HTA Pembuat kebijakan skala nasional

3 Komite Formularium Nasional Pembuat kebijakan skala nasional

4 BPJS-Kesehatan Penyelenggara JKN-KIS dan Pembayar

5 Perusahaan Farmasi Pemasok obat

6 Dokter Penyedia pelayanan kesehatan

7 Apoteker Penyedia pelayanan kesehatan

8 Pasien Peserta JKN-KIS/ Pengguna

Penelitian akan dilaksanakan dengan metode wawancara bebas terpimpin

(semi-structured interview). Daftar pertanyaan, surat kesediaan berpartisipasi

(informed consent), dan pedoman wawancara akan diberikan oleh peneliti kepada

partisipan sehari sebelum wawancara atau pada waktu yang telah ditentukan

bersama. Durasi waktu pada saat melaksanakan wawancara mendalam yaitu sekitar

1 (satu) jam.

A. Kesukarelaan untuk ikut penelitian

Bapak/ Ibu/ Saudara bebas memilih keikutsertaan dalam penelitian ini tanpa ada

paksaan. Bila bapak/ ibu/ saudara sudah memutuskan untuk ikut dapat juga

mengundurkan diri setiap saat tanpa dikenai denda ataupun sanksi apapun.

2




B. Prosedur Penelitian

Apabila Bapak/ Ibu/ Saudara bersedia berpartisipasi dalam penelitian ini,

diminta menandatangani lembar persetujuan ini rangkap dua, satu untuk Bapak/

Ibu/ Saudara simpan, dan satu untuk peneliti. Prosedur selanjutnya adalah :

1. Penelitian akan dilaksanakan dengan metode wawancara terpimpin (semi-

structured Interview) sesuai dengan kesepakatan dan kenyamanan bapak/

ibu/ saudara menggunakan alat perekam.

2. Peneliti akan mentranskrip hasil wawancara setelah melaksanakan

interview dengan partisipan.

3. Hasil transkrip akan diperlihatkan kembali kepada partisipan untuk

mengklarifikasi hasil wawancara.

4. Hasil transkrip yang telah disepakati antara peneliti dan partisipan akan

diproses oleh peneliti beserta tim peneliti lainnya untuk kemudian dijadikan

data kualitatif yang akan di publikasi.

C. Kewajiban partisipan

Sebagai partisipan, Bapak/Ibu/Saudara berkewajiban mengikuti aturan atau

petunjuk penelitian seperti yang tertulis di atas. Bila ada yang belum jelas,

Bapak/ Ibu/ Saudara bisa bertanya lebih lanjut kepada peneliti.

D. Risiko

Penelitian ini tidak menyebabkan risiko yang berbahaya, karena peneliti tidak

melakukan intervensi apapun. Risiko ketidaknyamanan atau dampak yang

mungkin akan diterima yaitu merasa bosan dengan banyaknya

pertanyaan- pertanyaan dari peneliti dan kerugian waktu selama

diwawancarai oleh peneliti.

E. Manfaat dan Keuntungan

Manfaat dan keuntungan yang bapak/ ibu/ saudara dapatkan adalah kesempatan

dan kebebasan untuk menjelaskan mengenai apa yang anda rasakan terhadap

kebijakan obat pada program JKN-KIS. Penelitian ini nantinya akan diupayakan

menjadi masukan terhadap pengambil kebijakan dalam meningkatkan sektor

kesehatan nasional.

2

Chapter two


F. Kerahasiaan

Semua informasi yang berkaitan dengan identitas partisipan akan dirahasiakan

dan hanya akan diketahui oleh peneliti. Data hasil penelitian akan disimpan

dan didokumentasikan oleh peneliti serta hanya digunakan untuk

kepentingan ilmiah. Hasil penelitian akan dipublikasikan tanpa identitas

partisipan.

G. Kompensasi

Bapak/ ibu/ saudara akan mendapatkan souvenir sebagai wujud terima kasih

peneliti atas partisipasinya dalam penelitian ini.

H. Informasi Tambahan

Bapak/ ibu/ saudara diberi kesempatan untuk menanyakan semua hal yang

belum jelas sehubungan dengan penelitian ini. Bila sewaktu-waktu terjadi

kekeliruan atau membutuhkan penjelasan lebih lanjut, Bapak/ ibu/ saudara

dapat menghubungi Riswandy Wasir pada no HP: +62-81225835007 atau

bisa juga dengan mengirimkan email: [email protected]

2



mailto:[email protected]


Persetujuan keikutsertaan dalam penelitian

(informed consent)

Saya yang bertandatangan dibawah ini:

Nama :........................................................................

Alamat : .......................................................................

Nomor Hp : .......................................................................

E-mail : .......................................................................

Umur : .......................................................................

Pekerjaan : .......................................................................

Pendidikan Terakhir : .......................................................................

Peran partisipan :

1. Anggota Organisasi Kesehatan Dunia / World Health Organization (WHO)

2. Komite Penilaian Teknologi Kesehatan / Health Technology Assessment

(HTA)

3. Komite Formularium Nasional

4. Instansi Penyelenggara Asuransi Kesehatan Nasional

5. Perusahaan Farmasi

6. Dokter

7. Apoteker

8. Pasien

Menyatakan bahwa, semua penjelasan tersebut telah disampaikan kepada saya

sebagai partisipan dan semua pertanyaan saya telah dijawab oleh peneliti.

Saya mengerti bahwa bila memerlukan penjelasan, saya dapat menanyakan

kepada saudara Riswandy Wasir sebagai peneliti utama.

Dengan menandatangani formulir ini, saya setuju untuk ikut serta dalam penelitian

ini

Tanggal: Tanggal:

Tanda Tangan Partisipan Tanda Tangan Peneliti

Nama Jelas: …………………………….

Nama Jelas: Riswandy Wasir

2

Chapter two


S5 Table. Final list of themes and aim of the themes

No Themes Aims

1 Knowledge of JKN-KIS program To know the extent of participant‘s knowledge

about the JKN-KIS program. Knowledge

measured in this theme is the participant‘s

knowledge about the agency, time execution,

and the goals.

2 Attitude towards JKN-KIS

program

To obtain participant perception and attitude of

JKN-KIS program. Attitude measure in this

theme from other personal information of

participants.

3 Knowledge of medicines policy

before JKN-KIS Program

To know the extent of participant‘s knowledge

on medicines policy before JKN-KIS program.

Such as List of Drug Price Platform (DPHO) in

Askes, List of National Essential medicines

(DOEN), etc.

4 Knowledge of medicines policy

in the JKN-KIS program

To learn the participants‘ knowledge about the

existence of e-Catalogue and the NF and their

role.

5 Knowledge of the development of

e-Catalogue and the NF

To find out the extent of the stakeholders‘

understanding of the process of developing the

e-Catalogue and the NF.

6 Attitude towards e-Catalogue To learn the participants‘ attitude about the

existence of the NF

7 Attitude towards NF To learn the participants‘ attitude about the

existence of the NF

8 The Challenge of e-Catalogue and

the NF

To learn about the challenges of both the e-

Catalogue and the NF.

9 The Challenges of e-Catalogue To learn about the challenges of the e-

Catalogue.

10 The Challenges of the NF To learn about the challenges of the NF.

11 Recommendation to improve e-

Catalogue and the NF

To find out what the possible solutions are to

address the challenges of the e-Catalogue and

the NF.

12 Experience of prescribing not

listed in the NF

To learn how frequently stakeholders, prescribe

or received prescriptions not in medicine

policies in the JKN-KIS program

13 Attitude towards prescribing not

listed in the NF

To learn the participants‘ attitude concerning

and towards prescriptions not in the NF

14 Reason for prescribing not listed

in the NF

To know why prescriptions not in the NF occur.

15 Medicines not listed at the NF

that mostly prescribed

To learn what non-NF medicines are prescribed

the most.

16 Medicines listed at the NF that

mostly unavailable

To learn what medicines are mostly unavailable

in healthcare facilities.

17 Recommendation to avoid

prescribing not listed in the NF

To learn what the stakeholder needs to avoid

prescriptions not in medicine policies.

2




S6

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2

Chapter two


Chapter 3

The implementation of health technology assessment (HTA) in

medicine pricing and reimbursement policies in Indonesia: insights

from multiple stakeholders

The implementation of HTA in Indonesia

Riswandy Wasir

Sylvi Irawati

Amr Makady

Maarten Postma

Wim Goettsch

Talitha Feenstra

Erik Buskens


Wasir R, Irawati S, Makady A, Postma M, Goettsch W, Feenstra T, et al. (2019) The

implementation of HTA in medicine pricing and reimbursement policies in

Indonesia: Insights from multiple stakeholders. PLoS ONE 14(11): e0225626.

https://doi.org/10.1371/journal.pone.0225626


Abstract

Objectives

This study aimed to identify the barriers and facilitators to improve the use of health

technology assessment (HTA) for the selection of medicines listed in the e-

Catalogue and the national formulary in Indonesia.

Methods

Semi-structured interviews were conducted to collect qualitative data. Purposive

sampling was used to recruit the stakeholders consisting of policymakers, a

pharmaceutical industry representative, healthcare providers, and patients. The data

were analyzed using directed content analysis and following the COnsolidated

criteria for REporting Qualitative studies (COREQ).

Results

The twenty-five participants interviewed agreed with the use of HTA for supporting

the e-Catalogue and the national formulary and perceived the advantages of HTA

implementation outweighed the disadvantages. Barriers mentioned were a lack of

capability of local human resources, financial incentives, a clear framework and

insufficient data. Strategies suggested to overcome the barriers were establishing

(inter)national networks to build up capacity, setting up departments of HTA in

several universities in Indonesia, and introducing a clear HTA framework.

Facilitators mentioned were the ambition to achieve universal health coverage, the

presence of legal frameworks to implement HTA in the e-Catalogue and the national

formulary, and the demands for appropriate medicine policies.

Conclusions

Several barriers are currently hampering broad implementation of HTA in medicine

pricing and reimbursement policy in Indonesia. Solutions to these issues appear

feasible and important facilitators exist.

3

Chapter three


Introduction

The 2015 transition from Millennium Development Goals to Sustainable

Development Goals has triggered a shift in global health from service-specific

targets to broader health system goals[1]. Target 3.8 of the Sustainable Development

Goals explicitly states to achieve Universal Health Coverage (UHC)[2]. UHC will be

accomplished when all people receive the healthcare services they need of sufficient

quality and without suffering financial hardship. Therefore, the presence of UHC

ideally will reduce or eliminate the proportion of out-of-pocket payments from

healthcare expenditures[3]. Out-of-pocket payment, a direct payment to the

healthcare providers at the time of service use, can drive an individual or a

household below the poverty line[4]. In low middle-income countries (LMICs), the

proportion of out-of-pocket payments in healthcare expenditures is still high,

particularly for medicines, the number ranges from 50% to 90 %[5].

Appropriate medicine policies combined with an implementation of health

technology assessment (HTA) can facilitate countries to reduce the out-of-pocket

payments for medicines on their way towards UHC. For instance, the United

Kingdom (UK) and Thailand, as one of the oldest and the newest UHC examples

respectively, have shown that the implementation of HTA supports their medicine

policies[6]. Furthermore, the World Health Organization (WHO) highly recommends

the use of HTA to facilitate the creation of a list of medicines in the medicine benefit

package[7]. The WHO defines HTA as the systematic evaluation of properties,

effects and/or impacts of health technologies and interventions[8]. HTA is a critical

component of evidence-based policy decision making[7,9].

In response to target 3.8 of the Sustainable Development Goals, the

Government of Indonesia launched a new national health insurance system, which is

called Jaminan Kesehatan Nasional – Kartu Indonesia Sehat (JKN-KIS) in 2014.

The JKN-KIS aims to achieve UHC by 2020 and is managed by Indonesia‘s

National Healthcare Security Agency, namely Badan Penyelenggara Jaminan Sosial

Kesehatan (BPJS-Kesehatan)[10,11]. Additionally, several new medicine policies were

introduced separately by the Ministry of Health to support the JKN-KIS. First, the e-

Catalogue was introduced as a national medicine pricing policy. The e-Catalgue

3

2

The implementation of health technology assessment (HTA) in Indonesia


provides a list of medicines with specifications, prices, and suppliers. Second, the

national formulary was compiled as a list of medicines covered by the BPJS-

Kesehatan[12]. The e-Catalogue and the national formulary have their own respective

responsible committees, which were both established in 2013, a year before the

implementation of the JKN-KIS. Although the e-Catalogue and the national

formulary were established separately, in practice these policies are interrelated.

Indonesian healthcare facilities can reimburse medicines listed in the national

formulary based on its prices listed in the e-Catalogue[12-14].

According to the national health insurance guidelines of Indonesia, an HTA

approach should be used to select a health technology or intervention, including

medicines, which will be covered by the BPJS-Kesehatan. This implies that HTA

should be used in further developing the e-Catalogue and the national formulary. As

a way forward, both may build on the guideline on the implementation of HTA in

particular for medicines that the Department of Pharmacy and Medical Devices in

the Ministry of Health of Indonesia introduced in 2013[15]. In detail, the national

health insurance recommended that the use of HTA is developed and performed by

an HTA committee installed by the Ministry of Health[12].

Indeed in 2014, several months after the implementation of the JKN-KIS,

the Ministry of Health formed the HTA committee. The committee had eight senior

health scientists and six employees of the Ministry of Health, and was supported by

14 secretaries. The tasks of the committee were establishing a policy concept,

guidelines, and the HTA committee itself to regulate the implementation of HTA[16].

In 2016, the HTA committee was reformed. The current HTA committee is

composed of eight senior health scientists, one employee of the Ministry of Health,

and supported by four secretaries. A technical staff with thirteen clinicians, two

Ministry of Health employees, and one technician is now added to support the HTA

committee tasks. Their current tasks are to define a guideline for HTA

implementation, to establish the HTA committee and their work plan, to build a

relationship with HTA committees in other countries, to assess the technologies or

interventions covered by BPJS-Kesehatan, and to disseminate the results of their

assessments[17].

3

Chapter three


However, although the HTA guideline was published in 2013 and the HTA

committee had been installed in 2014, HTA has not been used in the development of

the e-Catalogue and the national formulary. This might be one of the reasons why

the use of the e-Catalogue and the national formulary could not help to reduce out-

of-pocket payments for medicines in Indonesia[18]. In 2014, the out-of-pocket

payments comprised approximately half of the total health expenditure in Indonesia,

and it has remained at a similar level since[19]. The proportion of out-of-pocket

payments for medicines was 70% in recent years[20]. Furthermore, over the same

period, the Ministry of Health reported that up to 40% of prescribed medicines were

not listed in the NF[21]. Relevant stakeholders were interviewed to provide a better

understanding of how to improve the implementation of HTA in Indonesia, with

particular attention for suggestions on and barriers perceived regarding the use of

HTA in revising the e-Catalogue and the national formulary.

3

2



Materials and Methods

Semi-structured interviews with multiple stakeholders were conducted to collect

qualitative data. The COnsolidated criteria for REporting Qualitative studies

(COREQ) checklist was followed in reporting the results[22].

Study Design and Participants

The process applied in this study can be seen in the flowchart (Fig 1). First, a

conceptual model (S1 Fig) was developed by RW, MP, WG, TF, and EB, based on a

review of WHO documents on UHC, in particular concerning medicine policies and

the use of HTA. Based on the conceptual model, initial list of themes and of

questions (S1 Table) were created to get an overview of the development of

medicine policies and the implementation of HTA in Indonesia. With the aim of

testing the comprehensibility and appropriateness of the interview protocol (S1

File), pilot interviews were conducted with three physicians, three pharmacists, and

three patients. After revision based on the pilot, semi-structured interviews were

then conducted with various stakeholders. Interviews were planned until saturation

was reached.

Figure 1. Research process

3

2

Chapter three


A purposive sampling method was used to recruit stakeholders, which

consisted of policymakers, medicine suppliers, healthcare providers, and patients in

various places of Indonesia. Recruitment criteria were: stakeholders (policy makers,

healthcare provider, industry representative) should have at least 5 years of relevant

work experience. Physicians were not selected based on their specialization, because

HTA would be implemented in the development of the national formulary, which is

used by all healthcare providers regardless of their specialization. Both

pharmaceutical industries approached produced medicines and medical devices and

were responsible for distributing medicine to the healthcare facilities. Patients were

selected based on the duration of their health insurance in Indonesia (at least 5 years)

and their routine use of medicines (at least 5 years). In order to ensure that these

patient criteria were met, participants were recruited from the BPJS-Kesehatan‘s

chronic disease management program (Program pelayanan penyakit kronis,

Prolanis).

A priory estimation of the number of participants required to reach

saturation was made. We estimated that at least twenty-two stakeholders should be

approached based on at least two representatives for each group of policy makers,

i.e., at least two pharmaceutical industry representatives, at least four interviewees

from each group of healthcare providers, and at least four patients. The reason for

having more interviewees in the groups of healthcare providers and patients was our

interest in the practical issues of the implementation of medicine policy and the

difficulties reported for applying HTA for selecting medicine in the medicine

policy. Potential participants were approached by email, phone and visit.

Data analysis

All interviews were audiotaped and then transcribed. The transcripts were

independently coded by two authors (RW, SI) using MAXQDA version 12.3.2.

Directed content analysis [23] was applied to systematically structure the content of

the transcripts. The codes were compared, and in case of disagreements, items were

discussed with AM, WG, MP, TF, and EB to reach a consensus. Twenty four themes

were identified during coding process. The themes were then divided into two

categories. The first concerned medicine pricing and reimbursement policy [18] and

3

2



the second the implementation of HTA. The current manuscript focused on the six

themes (Table 1) related to the implementation of HTA.

Table 1. List of themes

No Themes

1 Attitudes towards HTA implementation

2 Advantages of HTA implementation in the e-Catalogue and the NF

3 Disadvantages of HTA implementation in the e-Catalogue and the NF

4 Barriers to HTA implementation

5 Possible solutions to improve the implementation of HTA

6 Promoting factors of HTA implementation

The transcript interviews from six themes were coded to attain sub-themes.

Saturation at the total level was assessed to identify the sub-themes. Saturation was

considered to be reached when no new information was generated and when at least

three interviewees mentioned the same concern for each sub-theme. These were

checked by RW and SI.

Ethical considerations

The main author is Indonesian; therefore, an official research permit is not requested

as stated in the relevant regulation of Indonesia‖. However, a written informed

consent (S2 File) was obtained from all participants. Before the interviews, all

participants understood that their participation was voluntary and that they were free

to stop the interview at any time. All participants reviewed and consented to the

verbatim transcript of their interview. Additionally, the research plan and the

interviews to be conducted were reviewed by the University Medical Center

Groningen Ethical Review Board, who deemed the study non-intrusive.

Subsequently a formal waiver statement (S3 File) was provided, i.e., the study

would not need a regular ethical approval.

3

2

Chapter three


Results

Participants

Aiming at about 22 final participants, a total of 51 (S2 Table) different individuals

were approached during the recruitment process. Out of this number, 45 agreed to

participate in this research. However, 9 withdrew after receiving the list of

questions; another 7 decided to stop their interviews before they were finished, since

they experienced difficulties in answering the questions, and were not confident

about their answer; Furthermore 4 had no time for an interview, leaving a final

number of 25 participants. Notably, this was more than initially aimed at.

Twenty-five participants participated in this research (Table 2). They were

policy makers (WHO members, HTA Committee, NF Committee and National

Health Insurance Agency), a medicine supplier (a pharmaceutical industry

representative), healthcare providers (physicians and pharmacists), and users

(patients). All participants had the Indonesian nationality, except the WHO

members. The policymakers, the pharmaceutical industry representative and

healthcare providers each have more than 20 years of work experience in the

Indonesian healthcare system. Furthermore, all interviewed patients had been

enrolled in health insurance in Indonesia for an average of 11 years at the time of

interview.

3

2



Table 2. Classification of participants involved

Participants Gender Age

(Years)

Work

experience

(Yes)

Years using

public health

insurance

Professional

location

Policymakers

WHO Members Male 50 25 NA Geneva

HTA Committee Female 53 28 28 Jakarta

HTA Committee Male 55 30 30 Jakarta

NF Committee Male 56 31 31 Yogyakarta

JKN-KIS Agency Female 51 26 26 Jakarta

JKN-KIS Agency Female 46 21 21 Jakarta

Medicine Supplier

Pharmaceutical Industry Male 54 29 29 Jakarta

Healthcare Providers

Physician Male 58 33 33 Lombok

Physician Male 59 34 34 Makassar

Physician Male 66 41 41 Makassar

Physician Male 44 19 19 Surabaya

Physician Male 51 26 26 Jakarta

Physician Female 54 29 29 Yogyakarta

Pharmacist Female 53 28 28 Jakarta

Pharmacist Male 50 25 25 Manado

Pharmacist Male 39 14 14 Kendari

Pharmacist Male 42 17 17 Yogyakarta

Pharmacist Female 51 26 26 Lombok

Pharmacist Female 40 19 19 Makassar

Users

Patient Male 53 NA 8 Makassar


Patient Female 59 NA 10 Makassar


Patient Female 63 NA 12 Makassar


3

2

Chapter three


Interviews and analysis of transcripts

Semi-structured interviews were conducted face to face with 16 participants and

through video calls with 9 participants between August 2016 and April 2017. One

interview was conducted in English, while all others were in Bahasa Indonesia. The

average time spent on each interview was circa one hour.

Transcripts from the themes for HTA were checked to obtain sub-themes

(S3 Table). For all six themes, more than three interviewees mentioned the same

concern on each sub-theme. It means that saturation could be confirmed at the total

level. In table S3 we summarize the answers by respondent group, to make it easier

for readers to understand the main concerns of each stakeholder group. The

complete statement per theme can be found at raw materials (S4 Table).

Findings per theme

Theme 1: Attitudes towards HTA implementation

All stakeholders demonstrated positive attitudes towards applying HTA to the

development of the e-Catalogue and the NF. The main reason expressed for this

attitude was the necessity of having appropriate medicine policies to support the

JKN-KIS program in achieving UHC, in particular, reducing out-of-pocket

payments for medicines. Moreover, participants perceived the advantages would

outweigh the disadvantages.

“If the HTA is applied to the NF or e-Catalogue I am very amenable. This will definitely be very good and provide great benefits” [Physician 5]

Theme 2: Advantages of HTA implementation in the e-Catalogue and the NF

Stakeholders recognized that the main advantage of HTA is to provide scientific

evidence for decision makers to assess the value of a medicine. Additionally, the

participants identified various other benefits when HTA would be implemented in

the e-Catalogue and the NF.

“The money allocated for the health sector is limited, especially for medicines.

So, we can convince the government that more money should be allocated for

medicines” [Policymaker 6]

3

2



The pharmaceutical industry representative mentioned that HTA would

provide a ground for fair pricing in the e-Catalogue. Thus, pharmaceutical industries

would not arbitrarily adapt their prices.

“HTA can provide the rational price for bidding the medicines. Now, the

pharmaceutical industry can bid the medicines as low as possible”

[Pharmaceutical Industry]

The policy makers, healthcare providers, and patients mentioned the use of

HTA would reassure all stakeholders that the medicines listed in the NF were the

best choice of medication. This would convince the government to allocate the

money for providing the medicines listed in the NF, the physicians to prescribe the

medicines listed in the NF, and also the patients to consume the medicines listed in

the NF.

“The advantage is that we may not doubt anymore about taking the medicine listed in the NF” [Patient 1]

Theme 3: Disadvantages of HTA implementation in the e-Catalogue and the NF

Among all interviewees, only a few could mention disadvantages of HTA

implementation in the e-Catalogue and the NF. The most frequently mentioned

disadvantage was the cost of developing the e-Catalogue and the NF probably would

increase, in particular to pay HTA experts. In addition, complicated bureaucracy and

lengthy processes for renewing the medicines listed in the e-Catalogue and the NF

were also mentioned by the policy makers and healthcare providers.

“People could say that this is too heavy or too bureaucratic, you need an excessively lengthy process for this” [Policymaker 1]

Theme 4: Barriers to HTA implementation

The participants identified various barriers that are currently hampering the

implementation of HTA. The first barrier mentioned by all stakeholder categories,

except the patients, was a lack of capability and a lack of capacity of local human

resources. The reasons for this as explained by several interviewees were that HTA

is a new science in Indonesia, and a lack of HTA departments, training and

associations.

3

2

Chapter three


“The science of HTA is still very new in Indonesia. Honestly, there are still

many health workers and maybe including me who do not understand the

application.”[Pharmacist 5]

A second barrier mentioned by all categories of stakeholders, except the

pharmaceutical industry representative, was a lack of incentives. The stakeholders

considered that currently little resources are available for paying the HTA experts,

holding HTA seminars, and performing HTA research.

“There is a significant financial problem for the experts, since the HTA

Committee still depends on the state budget and the standard fees established

by the Ministry of Finance must be adhered to. We cannot give the fee

according to their (HTA experts) expertise because there is a maximum salary that can be awarded when using the state budget”. [Policymaker 3]

A third barrier mentioned by the policy makers pharmaceutical industry

representative and healthcare providers was a lack of a clear framework of how to

implement using HTA results in the medicine policy, in particular in the e-Catalogue

and the NF. These interviewees mentioned that a clear framework is needed since

multiple professions have to cooperate to initiate HTA, perform HTA, assess and

appraise HTA results, and translate findings into policy advise.

“We do not yet have a clear path of how to apply HTA. Moreover, HTA

requires a variety of professions. This will create a conflict of interest. If there

are no clear guidelines, all will be based on the point of view of each profession”. [Pharmaceutical Industry]

A fourth barrier mentioned by the policy makers and healthcare providers

was insufficient data for conducting HTA studies. The HTA committee members

interviewed perceived the insufficient data was caused by difficulties to access data

on the national scale. National data gathering is managed by the JKN-KIS agency.

The JKN-KIS agency representative explained that the insufficient data was caused

by unclarities regarding the data needed for conducting HTA studies. Furthermore,

the health care providers also mentioned that the healthcare registry data, for

instance, individual patient data, have not been integrated in the national scale.

“The number of provinces in Indonesia makes it difficult to integrate all the

data that could be used for HTA studies, so, we still need time to collect the

data needed by the HTA researchers” [Policymaker 6]

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Theme 5: Possible solutions to improve the implementation of HTA

The participants provided a variety of possible solutions to address the barriers

hampering the implementation of HTA. The policy makers indicated a necessity to

establish a good network to build up the capacity. For instance, students and

researchers could be endorsed to conduct HTA studies using Indonesian data.

Currently, the Ministry of Health only depends on the state budget to establish the

HTA committee and to build the capacity. Pharmaceutical industries could be

encouraged to provide additional means.

“The government must obtain alternative funding instead of depending on the

state budget to implement HTA. I think the pharmaceutical industry can

actually be asked to provide additional income in order to finance experts or researchers of HTA studies”. [Policymaker 2]

The pharmaceutical industry representative suggested the creation of a clear

framework for performing HTA implementation. The healthcare providers

recommended that the government would provide more training and seminars to

improve the capability of human resources regarding HTA. The healthcare

professionals similarly suggested opening more HTA departments in universities in

Indonesia. Finally, patients expected the government and all stakeholders to have a

good collaboration in terms of introducing the implementation of HTA in Indonesia.

“The government through the health ministry should establish guidelines to

have a clear path to implement HTA” [Pharmaceutical Industry]

“The government should encourage universities to open HTA departments. So,

we can learn the topics of HTA in a good curriculum”. [Pharmacist 1]

I hope all stakeholders can work together and find a good solution to start the

implementation of HTA in Indonesia”. [Patient 6]

Theme 6: Promoting factors for the implementation of HTA

The participants identified several promoting factors for the implementation of

HTA. First of all, the main factor mentioned by all stakeholder‘s category was that

the JKN-KIS aims to achieve UHC. Several stakeholders perceived that the use of

HTA is suitable for countries that are on their way to implement UHC. A second

promoting factor mentioned was that the use of HTA is already in the regulation for

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implementing JKN-KIS, in particular to select medicines which will be covered by

the BPJS-Kesehatan. Therefore, the use of HTA is mandatory in developing the list

of medicines in the e-Catalogue and the NF. A third promoting factor was the use of

the current e-Catalogue and the NF without HTA implementation have not helped

sufficiently to reduce out-of-pocket payments for medicines.

"The supporting factor is that we are implementing an international scale

program, which is Universal Health Coverage. The HTA program is highly

recommended World Health Organization for countries implementing UHC

program.” [Physician 6]

“The regulation of Indonesia stated that HTA should be conducted for

selecting the healthcare services needed. Indonesia is lucky since it has a legal

aspect, whereas Vietnam does not have this. In some European countries it is

also not present”. [Policymaker 2]

“We need a list of medications which were well selected at the NF. This was to

avoid the doctors prescribed medicines not listed in the NF and also to prevent

patients from spending money because they have to buy medicines that are not covered by BPJS Kesehatan”. [Pharmacist 5]

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Discussion

This study provides insight into the current implementation of HTA in Indonesia in

the development of the e-Catalogue and the National Formulary as medicines

policies, as perceived by multiple stakeholders. To the best of our knowledge, no

previous interview-based studies on this topic were performed in South East Asia.

All interviewees showed a positive attitude towards the application of HTA to the e-

Catalogue and the NF. The interviewees expected HTA could optimize the use of

the e-Catalogue and the NF to reduce out-of-pocket payments and, subsequently, to

achieve UHC in Indonesia. Furthermore, the stakeholders identified the advantages

of applying HTA to both the e-Catalogue and the NF were greater than the

disadvantages. However, interviewees mentioned that the application of HTA has

the potential to increase costs for the development of the e-Catalogue and the NF.

Specifically, this study clarifies the barriers, possible solutions, and facilitators of

HTA implementation.

Interestingly, some interviewees perceived that the use of HTA would

increase the cost for developing the e-Catalogue and the NF. However, other

participants mentioned that the use of HTA for the e-Catalogue and the NF could

improve efficiency. Our previous study[18] has revealed that the e-Catalogue and the

NF have not been fully utilized in the healthcare facilities and were often ignored by

stakeholders. This implies that unnecessary spendings have been allocated for

producing these two medicine policies. For the e-Catalogue, HTA might support the

setting of minimum prices as one of the problems mentioned was that the final

tendered prices of medicines were too low and might jeopardize quality and

distribution of medicines. Such prices would then reflect reasonable price levels for

each medicine, in terms of costs per quality adjusted life years gained[24]. In

addition, interviewees mentioned that the use of HTA in the NF might help to

provide transparency and evidence for selecting medicines listed in the NF, and that

this could improve its acceptance and use by stakeholders. Several LMICs aiming to

achieve UHC have to consider a way to limit or choose the available healthcare

services and HTA is one of the tools to support reimbursement package decision

making. Many exemplary countries, such as Thailand, China, and Australia show

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Chapter three


how the use of HTA is helpful in selecting the medicines listed in their medicine

reimbursement list. Thus, a more effective way of achieving UHC is achieved[6].

Several barriers to implement HTA were identified and reported in the

results. The two most important barriers mentioned were a lack of local human

resources and a lack of financial incentives. Previous studies[25] based on surveys

stated that these barriers were the major barriers in 19 LMICs, including Vietnam as

Indonesia's neighboring country. In addition, for other neighboring countries, such

as Philipines and Malaysia, capacity building and financial incentives were also

identified as significant barriers for implementing HTA in their medicine policies[26-

28]. In the current study, the interviewees offered several possible solutions to

overcome these obstacles. An interesting solution suggested by the NHI agency was

that the HTA committee could establish a network with other countries that have a

well-established system, and with international HTA organizations. In response to

financial barriers, the authors support a solution suggested by the HTA committee

that the Government of Indonesia could provide an alternative funding instead of

depending on the state budget. The interviewees recognized the need of HTA but

also wondered how it should be funded. We think the implementation as achieved

by the HTA committee of Thailand may serve as an example. The Committee

obtains funding from the Thai Health Promotion Foundation, an institution

established by the Ministry of Health of Thailand to collect health funding through

two percents surcharge levied on the excise tax of alcohol and tobacco. This

institution also obtains its funding from pharmaceutical companies and international

HTA agencies[29].

The main important factor mentioned to support HTA implementation in

the e-Catalogue and the NF was a mandate in the Presidential Decree[30], which

stated that the development of medicine policies must be based on the HTA study.

This implies the HTA must be applied in the e-Catalogue and the NF development.

Based on a previous international study[31], this implication can lead to a continuous

development of the capacity building for local human resources.

Conducting interviews allowed the researcher to obtain detailed

information about personal feelings, perceptions and opinions from the participants

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indepedently from other group members. Moreover, all ambiguities and incomplete

answers could be clarified and followed up. Several steps were taken to ensure a

good research practice during the data compilation and analysis stages. The

sampling processs used to select participants and the interview guide were compared

with recommendations published in the COREQ[22].

Though a variety of stakeholders were interviewed in this study, not all

groups of stakeholders were equally large and it turned out hard to find industry

representatives willing to participate. Notably, only one pharmaceutical industry

representative agreed to participate. Nonetheless, the interviewee was relatively

experienced and was a leader in several pharmaceutical associations in Indonesia.

While saturation was reached at the level of the total group, it could not be

ensured for smaller groups of stakeholders, namely industry and policy makers.

Also, this research contained interviews with a specific group of patients, namely

from the Prolanis. The main reason for this was that participants from this group

were relatively easy to find and recruit. These patients affiliated to the Prolanis

group were considered as being able to provide more information than other patients

since they had already routinely consumed medicines and had actively used public

health insurance in Indonesia for a significant time period. It is relevant to note that

quite a few people did not feel comfortable to participate or withdrew their consent

after having seen the questions for the interview. This may indicate that a substantial

part of stakeholders is not very familiar with the concepts discussed during the

interviews and/or considers the topics as hard to discuss.

Recognizing the current barriers and facilitators identified to apply HTA in

the development of the e-Catalogue and the national formulary could assist decision

makers in developing a blueprint for the further implementation of HTA in

Indonesia. This could also be relevant for international policymakers in other LMICs

with similar characteristics and ambition to achieve UHC.

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Chapter three


Conclusions

Several barriers are currently hampering the implementation of HTA to support

medicine pricing and reimbursement policies in Indonesia. However, solutions for

these issues are under consideration and facilitators do exist. The major barriers to

the implementation of HTA are a lack of capacity of local human resources and a

lack of (financial) incentives. Possible solutions to address these issues would be to

establish a network with other countries that have a well-established system, and

with international HTA organizations. A major opportunity to support the

implementation of HTA in the e-Catalogue and the NF is the existing legal

framework to implement HTA in medicine policies of the JKN-KIS program in

Indonesia.

Acknowledgments

The authors would like to thank all stakeholders who participated in this study.

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development goals to sustainable

development goals. Lancet.

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Fitzgerald J, Habicht J, Harrison G,




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4. Khan JA, Ahmed S, Evans TG.

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expenditure and poverty related to

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healthcare in bangladesh—an

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coverage. Health Policy Plan.

2017;32(8):1102-1110.



coverage: Challenges and

opportunities. . 2015.

6. Yoongthong W, Hu S, Whitty JA,

Wibulpolprasert S, Sukantho K,

Thienthawee W, et al. National

drug policies to local formulary

decisions in thailand, china, and

australia: Drug listing changes and

opportunities. Value Health.

2012;15(1 Suppl):S126-31.

7. Chalkidou K, Marten R, Cutler D,

Culyer T, Smith R,

Teerawattananon Y, et al. Health

technology assessment in universal

health coverage. Lancet.

2013;382(9910):e48-9.


Health technology assessment,

HTA, WHO definition (EB

134/30). . Updated Access on

January 5, 2019.

9. Angelis A, Lange A, Kanavos P.

Using health technology

assessment to assess the value of

new medicines: Results of a

systematic review and expert

consultation across eight european

countries. The European Journal of

Health Economics.

2018;19(1):123-152.

10. Republik Indonesia. Undang-

undang republik indonesia nomor

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24 tahun 2011 tentang badan

penyelenggara jaminan sosial. ;

2011.

11. Mundiharno TH. Peta jalan

menuju jaminan kesehatan

nasional 2012-2019. ; 2012.





pedoman pelaksanaan program

jaminan kesehatan nasional. ;

2014.

13. Kemetrian Kesehatan Republik

Indonesia. Pedoman penerapan

formularium nasional. . 2015.





pengadaan obat berdasarkan

katalog elektronik (E-catalogue). ;

2014.

15. Kementrian Kesehatan R.

Pedoman penerapan kajian

farmakoekonomi. Direktorat

Jendral Bina Kefarmasian dan Alat

Kesehatan, Jakarta. 2013.




nomor 171/ menkes/ SK/ IV/ 2014


kesehatan. . 2014.



kesehatan RI no.

HK.02.02/menkes/422/2016


kesehatan. . 2016.

18. Wasir R, Irawati S, Makady A,

Postma M, Goettsch W, Buskens E,

et al. Use of medicine pricing and




2019;14(2):e0212328.


Global health expenditure database.

. access on October 29, 2018.



Out-of-pocket payments in the

national health insurance of

indonesia. . 2015.

21. Dirjen Binfar dan Alkes

Kemenkes RI. Implementasi

formularium nasional dalam

pelaksanaan jaminan kesehatan

nasional. . 2015.

22. Tong A, Sainsbury P, Craig J.

Consolidated criteria for reporting

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qualitative research (COREQ): A

32-item checklist for interviews

and focus groups. International

journal for quality in health care.

2007;19(6):349-357.

23. Hsieh H, Shannon SE. Three

approaches to qualitative content

analysis. Qual Health Res.

2005;15(9):1277-1288.

24. World Health Organization. WHO

guideline on country

pharmaceutical pricing policies.


25. Babigumira JB, Jenny AM,

Bartlein R, Stergachis A, Garrison

Jr LP. Health technology

assessment in low‐and

middle‐income countries: A

landscape assessment. Journal of

Pharmaceutical Health Services

Research. 2016;7(1):37-42.

26. Jaafar S, Kamaliah Mohd Noh,

Khairiyah Abdul Muttalib, Othman

NH, Healy J, Maskon K, et al.

Malaysia health system review. .

2013.

27. Babar Z. Pharmaceutical policy in

countries with developing

healthcare systems. Springer

International Publishing AG; 2017.

28. Nguyen TA, Vitry A, Roughead

EE. Pharmaceutical policy in

vietnam. In: Pharmaceutical policy

in countries with developing

healthcare systems. Springer;

2017:75-94.

29. Teerawattananon Y, Tantivess S,

Yothasamut J, Kingkaew P,

Chaisiri K. Historical development

of health technology assessment in

thailand. Int J Technol Assess

Health Care. 2009;25(S1):241-252.


Peraturan presiden republik

indonesia nomor 12 tahun 2013

tentang jaminan kesehatan. ; 2013.

31. Kaló Z, Gheorghe A, Huic M,

Csanádi M, Kristensen FB. HTA

implementation roadmap in central

and eastern european countries.

Health Econ. 2016;25(S1):179-

192.

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Supporting Information

S1 Fig. Conceptual framework

Explanation of conceptual framework:

Many countries aim to reform their national health insurance to reach universal

health coverage. Nowadays, 58 countries are using universal health coverage

besides Indonesia. Before 2014, various health insurance schemes covered health

insurance for Indonesian society. As of 2014, all these schemes were integrated

and organized under one agency called BPJS-Kesehatan. The main goal of this

insurance is to achieve universal health coverage by 2019. The problem with

BPJS-Kesehatan was budgetary constraints, with the highest expenditure being

pharmaceuticals. The national formulary was used to organize medicines. HTA

has not yet been applied in the national formulary, while many UHC countries

do.

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S1 Table. Initial list of themes and of questions

NO THEMES NO QUESTIONS

1 The development

of medicine policy

and national

health insurance

1 Do you know how long the HTA Committee, NF

Committee, and NHI Agency have existed?

2 How many committee members?

3 What are their professions?

4 What are their duties?

5 Why do they exist?

6 What is their function?

7 What is their role in supporting UHC?

8 How is the NHI different from previous health

insurance (Askes, Jamkesmas, etc)?

9 How many people are covered by the NHI Agency

currently?

2 Medicines policy

for UHC

10 What medicines policy or policies should be created

to support UHC?

11 Are you involved in creating the NF and other

medicines policies to support UHC?

3 Users Perspective 12 Do you know how the National Formulary is

compiled?

13 Do you agree with the NF?

14 Do you have policy recommendations to maximize

the use of HTA?

15 Do you have other policy recommendations for

prescribing drugs?

4 Obstruction and

promoting factors

of HTA

16 What is/are the advantage(s) using HTA in

medicines policy?

17 What is/are the disadvantage(s) using HTA in

medicines policy?

18 What is/are the facilitator(s) implementing HTA in

medicines?

19 What is/are the barrier(s) implementing HTA in

medicines?

20 What should other stakeholders do to solve them?

And which ones?

21 What should the government do?

5 The biggest

burden of disease

and medicine

expenditure

22 What is the most widespread disease in Indonesia?

23 How much money is allocated for medicines in the

national health system?

24 What medicines are allocated more money? (Why?)

6 Prescriptions not

in NF

25 Have you ever received prescriptions for drugs not

in the NF (How frequently and why)?

26 Which medicines do you receive most often that are

in the NF?

27 Do you agree when doctors prescribe medicines not

in the NF? Why?

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Chapter three


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Chapter three


S4. Table. Raw materials

Raw material can be found in this link below:

https://doi.org/10.1371/journal.pone.0225626.s005

or in this quick response code below

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https://doi.org/10.1371/journal.pone.0225626.s005


S1 File. Interview protocol

List of Questions for participants (excluding patients)

1. What do you know about the JKN-KIS program? Which points can you

explain:


b. When executed;


d. Other personal information according to participants?

2. As far as you know, what public health insurance programs have been

implemented prior to the implementation of the JKN-KIS program?


b. The policy/program that they imposed to control medicines?

3. Do you know why all public health insurance programs are integrated into JKN-

KIS?

4. What are the medicine policies/programs imposing on the JKN-KIS?

a. The role or the functions of the policies

b. What are the policy-making processes?

c. Are you involved in the policy-making process?

d. Who is involved in the policy-making process?

e. Do you agree with the program/policies?

f. Do you think there is/are stakeholder(s) harmed by that policy? For

example, doctors, pharmacists, the pharmaceutical industry, patients, etc.

g. Do you think the policy is based on the latest scientific evidence?

h. In your opinion, are there any other policy proposals that should be

applied?

Key terms:



JKN-KIS = a National Health Insurance scheme of Indonesia UHC = Universal Health Coverage

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Chapter three


5. What do you know about the HTA?


b. When executed;


6. Do you think the HTA should be applied to the medicine policies on the JKN-

KIS?

7. In your opinion, what are the advantages and disadvantages of using HTA in

medicine policies on JKN-KIS?

8. In your opinion, what are the supporting and inhibiting factors for the use of

HTA on medicine policies in JKN-KIS?

9. In your opinion, what solutions should be found to implement the HTA on

medicine policies in JKN-KIS?

a. What should be done by all stakeholders (policymakers, doctors,

pharmacists, drug companies, patients, etc.)

b. What should be done by the GOI?

10. Have you ever found prescriptions not in the medicine policies on JKN-KIS?

a. Do you know why this occurred?

b. Do you agree with prescriptions not being in the medicines policy?

c. What medicines are most commonly prescribed that are not part of the

policies of JKN-KIS?

d. Do you have any suggestions to overcome this?

11. Do you know how much money is allocated for medicines to support the JKN-

KIS program?

a. Do you know which drugs are allocated the largest budget?

12. Do you know what is the most widespread disease in Indonesia?

a. Do you know how much money is allocated to cope with this disease?

13. Do you have other comments regarding this research?

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List of Questions for Participants (excluding patients) in

Bahasa

1. Apa yang anda ketahui tentang JKN-KIS. Point yang dapat anda jelaskan

yaitu:




d. Informasi lain yang dianggap perlu disampaikan dari partisipan

2. Sejauh yang anda ketahui, program jaminan kesehatan publik apa saja yang

dilaksanakan sebelum diberlakukannya JKN-KIS?


b. Apakah anda tahu kebijakan/ program apa yang mereka terapkan untuk

mengontrol obat?

3. Apakah anda tahu, mengapa seluruh program jaminan kesehatan publik

berintegrasi ke JKN-KIS?

4. Apa sajakah kebijakan/ program yang sudah diberlakukan oleh pemerintah pada

program JKN-KIS?

a. Apakah anda tahu fungsi kebijakan/ program tersebut?

b. Apakah anda tahu bagaimana proses pembuatan kebijakan tersebut?

c. Apakah anda terlibat dalam proses pembuatan kebijakan tersebut?

d. Siapa-siapa saja yang terlibat dalam proses pembuatan kebijakan tersebut?

e. Apakah anda setuju dengan kebijakan tersebut? Mengapa?

f. Menurut anda, adakah stakeholders (Dokter, Apoteker, Perusahaan obat,

pasien, dll) yang dirugikan dengan kebijakan tersebut?

g. Menurut anda, apakah kebijakan tersebut telah melalui bukti ilmiah

mutakhir?

h. Menurut anda, adakah usulan kebijakan lain yang sebaiknya diterapkan?

Pengertian Istilah:

HTA = Health Technology Assessment/ Penilaian Teknologi Kesehatan;

JKN-KIS = Program Jaminan Kesehatan Nasional di Indonesia;

UHC = Universal Health Coverage/ Cakupan Perlindungan Semesta.

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Chapter three


5. Apa yang anda ketahui tentang HTA?




6. Menurut anda, apakah HTA sebaiknya diterapkan pada kebijakan obat yang

sudah diterapkan pemerintah untuk mendukung JKN-KIS?

7. Menurut anda, apa keuntungan dan kerugian menggunakan HTA pada

kebijakan obat yang sudah diterapkan pemerintah?

8. Menurut anda, apa faktor pendukung dan faktor penghambat menggunakan

HTA pada kebijakan obat yang sudah diterapkan pemerintah?

9. Menurut anda, soulusi apa yang sebaiknya dilakukan untuk melaksanakan HTA

pada kebijakan obat yang sudah diterapkan pemerintah?

a. Apa yang sebaiknya dilakukan oleh para stakeholders (pembuat kebijakan,

dokter, apoteker, perusahaan obat, pasien, dll)?

b. Apa yang sebaiknya dilakukan oleh pemerintah?

10. Pernahkah anda menemukan peresepan obat di luar kebijakan obat yang sudah


a. Apakah anda setuju dengan peresepan obat diluar kebijakan obat yang

sudah diterapkan pemerintah?

b. Obat apa yang paling sering diresepkan diluar kebijakan obat yang sudah


c. Apakah anda tahu, bagaimana cara mengatasi hal tersebut?

11. Apakah anda tahu berapa banyak anggaran belanja obat yang dialokasikan

untuk mendukung JKN-KIS?

a. Apakah anda tahu obat apa yang mendapatkan anggaran terbesar?

12. Apakah anda tahu penyakit yang terbesar di Indonesia?

a. Apakah anda tahu berapa banyak anggaran untuk obat yang dialokasikan

untuk mengatasi penyakit tersebut?

13. Apakah ada komentar lainyang ingin anda sampaikan terkait penelitian ini?

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A List of Questions for Patients

1. Do you know about JKN-KIS, which is part of BPJS-Kesehatan? Could you

explain briefly it?

2. Are you a participant in JKN-KIS?

3. When were you be a participant in JKN-KIS?

4. What health insurance did you use before JKN-KIS?

5. For how long were you a participant in that insurance?

6. Are you currently taking any medication?

a. When was the last time you took the drugs?

b. What drugs did you take?

7. Did you also take that medicine when using your previous insurance?

8. Do you feel a difference when taking medication of JKN-KIS compared with

medication of your previous health insurance?

a. Which one is cheaper?

b. Which are more efficacious?

c. Which one do you like, and think is better?

9. Is there a difference, do you feel, in terms of service between JKN-KIS and

your previous health insurance?

a. Are there differences when seeing doctors?

b. Is there a difference when conducting laboratory checks or other checks?

10. Do you know about UHC? Could you explain briefly what you know?

a. Do you agree with the GOI‘s target of reaching UHC in 2019?

b. Do you think it can be achieved?

c. Are there any suggestions from you in order to achieve the UHC?

11. Do you know about NF? Could you explain briefly about that?

a. Do you know how NF is created?

Key terms:



JKN-KIS = a National Health Insurance scheme of Indonesia

UHC = Universal Health Coverage

NF = National Formulary

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Chapter three


b. Do you agree with NF?

c. What medications do you often receive which are in NF?

d. Have you ever received prescriptions not in the NF? How often? Why?

e. Do you agree with prescriptions not in the NF? Why?

f. Do you have a policy recommendation in prescriptions?

12. Do you know about HTA? Could you explain briefly what you know?

a. Do you think the HTA can be used for medicines policy in Indonesia?

b. In your opinion, what is the advantage of using HTA in determining the

choice of medicines?

c. In your opinion, what are the disadvantages of using HTA in determining

the choice of medicines?

d. In your opinion, what are the promoting factors in implementing an HTA

for drug selection?

e. In your opinion, what are the obstacles in implementing an HTA for drug

selection?

f. In your opinion, what should be done by stakeholders to resolve this?

g. In your opinion, what should the government do?

13. Do you have suggestions for improving medicines policy?

14. Do you have other comments related to this research?

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A List of Questions for Patients in Bahasa

1. Apakah anda tahu tentang jaminan kesehatan nasional yang dikelola oleh BPJS-

Kesehatan? Bisakah anda Jelaskan sedikit tentang hal itu?

2. Apakah anda anggota BPJS-Kesehatan?

3. Kapan anda mulai menjadi anggota BPJS-Kesehatan?

4. Asuransi apa yang anda gunakan sebelum menjadi anggota BPJS-Kesehatan ?

5. Berapa lama anda menjadi anggota asuransi tersebut?

6. Apakah anda mengkonsumsi obat saat ini?

a. Kapan terakhir kali anda mengkonsumsi obat?

b. Obat apa?

7. Apakah obat tersebut juga anda konsumsi dengan menggunakan asuransi yang

sebelumnya?

8. Apakah ada perbedaan yang anda rasakan ketika menggunakan obat dari BPJS

dengan obat dari asuransi anda sebelumnya?

a. Yang mana yang lebih murah?

b. Yang mana yang lebih berkhasiat?

c. Yang mana yang anda suka dan anggap lebih baik?

9. Apakah ada perbedaan yang anda rasakan dari sisi pelayanan pada Asuransi

BPJS dan Asuransi yang anda gunakan sebelumnya?

a. Apakah ada perbedaan ketika bertemu dengan dokter?

b. Apakah ada perbedaan ketika melakukan cek laboratorium atau

pemeriksaan lainnya?

10. Apakah anda tahu tentang Univeral Health Coverage (UHC)/ Jaminan kesehatan

secara menyeluruh? Bisakah anda Jelaskan sedikit tentang hal itu?

a. Apakah anda sependapat dengan pemerintah Indonesia yang ingin

mencapai UHC di tahun 2019?

b. Apakah anda pikir itu bisa dicapai?

c. Apakah ada saran dari anda untuk mencapai UHC tersebut?

11. Apakah anda tahu tentang Formularium Nasional (Fornas)?

a. Apakah anda tahu bagaimana Fornas dibuat?

b. Apakah anda setuju dengan Formularium Nasional?

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Chapter three


c. Obat apa yang sering anda terima yang ada di dalam Fornas?

d. Pernakah anda menerima obat di luar Fornas? Seberapa sering? Kenapa?

e. Apakah anda setuju ketika dokter menuliskan obat diluar formularium

nasional? Kenapa?

f. Apakah anda memiliki rekomendasi kebijakan dalam penulisan obat?

12. Apakah anda tahu tentang Health Technology Assessment (HTA) / Penilaian

Teknologi Kesehatan? Bisakah anda Jelaskan sedikit tentang hal itu?

a. Menurut anda, apakah HTA dapat digunakan untuk kebijakan obat di

Indonesia?

b. Menurut anda, apa keuntungan menggunakan HTA dalam menentukan

pilihan obat?

c. Menurut anda, apa kerugian menggunakan HTA dalam menentukan

pemilihan obat?

d. Menurut anda, apa faktor pendukung dalam menjalankan HTA pada

pemilihan obat?

e. Menurut anda, apa faktor penghambat dalam menjalankan HTA pada

pemilihan obat?

f. Apa yang harus dilakukan oleh pemangku kebijakan untuk menyelesaikan

itu?

g. Menurut anda, apa yang harus dilakukan oleh pemerintah?

13. Apakah anda memiliki saran untuk meningkatkan kebijakan obat?

14. Apakah anda memiliki saran untuk penelitian ini?


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S2 File. Informed consent

Lembar penjelasan dan persetujuan kepada partisipan

Peluang dan tantangan kebijakan obat pada program JKN-KIS untuk mencapai

Cakupan Perlindungan Semesta / Universal Health Coverage (UHC)

Saya Riswandy Wasir, Mahasiswa Program Pascasarjana (S3) Departemen

Epidemiologi, Univerity Medical Center Groningen (UMCG), University of

Groningen, Netherlands. Saat ini saya sedang melakukan penelitian yang berjudul

―peluang dan tantangan kebijakan obat pada program JKN-KIS untuk mencapai

cakupan perlindungan semesta‖.

Pemerintah Indonesia telah menerapkan skema asuransi kesehatan nasional

(JKN-KIS) yang terintegrasi dimulai pada tahun 2014. Asuransi kesehatan yang

dikelolah oleh BPJS-Kesehatan dimaksudkan sebagai pengganti seluruh asuransi

kesehatan publik sebelumnya. Peta jaminan kesehatan nasional yang dirilis oleh

pemerintah menyatakan bahwa program JKN-KIS diupayakan mencapai cakupan

perlindungan semseta/ Universal Health Coverage (UHC) pada tahun 2019.

Organisasi Kesehatan Dunia/ World Health Organization (WHO) menyatakan

bahwa bukan hanya kepesertaan yang menjadi indikator tercapainya cakupan

perlindungan semesta, tetapi juga kualitas pelayanan.

Berbagai upaya telah dilakukan oleh pemerintah dan para pemangku

kebijakan untuk meningkatkan mutu pelayanan JKN-KIS. Pada sektor obat,

pemerintah Indonesia telah menerapkan formularium nasional. Manfaat Fornas yaitu

sebagai acuan penetapan penggunaan obat dalam JKN-KIS, serta meningkatkan

penggunaan obat yang rasional, dapat juga mengendalikan mutu dan biaya

pengobatan, serta mengoptimalkan pelayanan kepada pasien Namun, Hasil evaluasi

awal yang dilakukan oleh Direktorat Jenderal Bina Farmasi dan Alat Kesehatan

(Dirjen Binfar dan Alkes) memperlihatkan bahwa kesesuaian obat yang digunakan

di rumah sakit dengan formularium nasional berkisar antara 60 – 86 %. Hal ini

memperlihatkan bahwa masih ditemukan cost-sharing, suatu kondisi dimana peserta

JKN-KIS harus mengeluarkan biaya untuk pembayaran pelayanan kesehatan

Chapter three

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termasuk obat. Salah satu Indikator tercapainya cakupan perlindungan semesta

(UHC) menurut WHO adalah tidak adanya cost-sharing.

Kami, melakukan penelitian ini untuk mengidentifikasi peluang dan

tantangan kebijakan obat pada program JKN-KIS untuk mencapai cakupan

perlindungan semesta. Penelitian ini akan melibatkan beberapa pemangku

kepentingan yang dianggap memiliki peran dalam membuat kebijakan,

mengimplementasikan serta merasakan dampak dari kebijakan tersebut antara lain

sebagai berikut:

No Partisipan Peran

1 Organisasi Kesehatan Dunia (WHO) Pembuat Kebijakan skala Internasional

2 Komite HTA Pembuat kebijakan skala nasional

3 Komite Formularium Nasional Pembuat kebijakan skala nasional

4 BPJS-Kesehatan Penyelenggara JKN-KIS dan Pembayar

5 Perusahaan Farmasi Pemasok obat

6 Dokter Penyedia pelayanan kesehatan

7 Apoteker Penyedia pelayanan kesehatan

8 Pasien Peserta JKN-KIS/ Pengguna

Penelitian akan dilaksanakan dengan metode wawancara bebas terpimpin

(semi-structured interview). Daftar pertanyaan, surat kesediaan berpartisipasi

(informed consent), dan pedoman wawancara akan diberikan oleh peneliti kepada

partisipan sehari sebelum wawancara atau pada waktu yang telah ditentukan

bersama. Durasi waktu pada saat melaksanakan wawancara mendalam yaitu sekitar

1 (satu) jam.

I. Kesukarelaan untuk ikut penelitian

Bapak/ Ibu/ Saudara bebas memilih keikutsertaan dalam penelitian ini tanpa ada

paksaan. Bila bapak/ ibu/ saudara sudah memutuskan untuk ikut dapat juga

mengundurkan diri setiap saat tanpa dikenai denda ataupun sanksi apapun.

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J. Prosedur Penelitian

Apabila Bapak/ Ibu/ Saudara bersedia berpartisipasi dalam penelitian ini,

diminta menandatangani lembar persetujuan ini rangkap dua, satu untuk Bapak/

Ibu/ Saudara simpan, dan satu untuk peneliti. Prosedur selanjutnya adalah :

5. Penelitian akan dilaksanakan dengan metode wawancara terpimpin (semi-

structured Interview) sesuai dengan kesepakatan dan kenyamanan bapak/

ibu/ saudara menggunakan alat perekam.

6. Peneliti akan mentranskrip hasil wawancara setelah melaksanakan

interview dengan partisipan.

7. Hasil transkrip akan diperlihatkan kembali kepada partisipan untuk

mengklarifikasi hasil wawancara.

8. Hasil transkrip yang telah disepakati antara peneliti dan partisipan akan

diproses oleh peneliti beserta tim peneliti lainnya untuk kemudian dijadikan

data kualitatif yang akan di publikasi.

K. Kewajiban partisipan

Sebagai partisipan, Bapak/Ibu/Saudara berkewajiban mengikuti aturan atau

petunjuk penelitian seperti yang tertulis di atas. Bila ada yang belum jelas,

Bapak/ Ibu/ Saudara bisa bertanya lebih lanjut kepada peneliti.

L. Risiko

Penelitian ini tidak menyebabkan risiko yang berbahaya, karena peneliti tidak

melakukan intervensi apapun. Risiko ketidaknyamanan atau dampak yang

mungkin akan diterima yaitu merasa bosan dengan banyaknya

pertanyaan- pertanyaan dari peneliti dan kerugian waktu selama

diwawancarai oleh peneliti.

M. Manfaat dan Keuntungan

Manfaat dan keuntungan yang bapak/ ibu/ saudara dapatkan adalah kesempatan

dan kebebasan untuk menjelaskan mengenai apa yang anda rasakan terhadap

kebijakan obat pada program JKN-KIS. Penelitian ini nantinya akan diupayakan

menjadi masukan terhadap pengambil kebijakan dalam meningkatkan sektor

kesehatan nasional.

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Chapter three


N. Kerahasiaan

Semua informasi yang berkaitan dengan identitas partisipan akan dirahasiakan

dan hanya akan diketahui oleh peneliti. Data hasil penelitian akan disimpan

dan didokumentasikan oleh peneliti serta hanya digunakan untuk

kepentingan ilmiah. Hasil penelitian akan dipublikasikan tanpa identitas

partisipan.

O. Kompensasi

Bapak/ ibu/ saudara akan mendapatkan souvenir sebagai wujud terima kasih

peneliti atas partisipasinya dalam penelitian ini.

P. Informasi Tambahan

Bapak/ ibu/ saudara diberi kesempatan untuk menanyakan semua hal yang

belum jelas sehubungan dengan penelitian ini. Bila sewaktu-waktu terjadi

kekeliruan atau membutuhkan penjelasan lebih lanjut, Bapak/ ibu/ saudara

dapat menghubungi Riswandy Wasir pada no HP: +62-81225835007 atau

bisa juga dengan mengirimkan email: [email protected]

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Persetujuan keikutsertaan dalam penelitian

(informed consent)

Saya yang bertandatangan dibawah ini:

Nama :........................................................................

Alamat : .......................................................................

Nomor Hp : .......................................................................

E-mail : .......................................................................

Umur : .......................................................................

Pekerjaan : .......................................................................

Pendidikan Terakhir : .......................................................................

Peran partisipan :

9. Anggota Organisasi Kesehatan Dunia / World Health Organization (WHO)

10. Komite Penilaian Teknologi Kesehatan / Health Technology Assessment

(HTA)

11. Komite Formularium Nasional

12. Instansi Penyelenggara Asuransi Kesehatan Nasional

13. Perusahaan Farmasi

14. Dokter

15. Apoteker

16. Pasien

Menyatakan bahwa, semua penjelasan tersebut telah disampaikan kepada saya

sebagai partisipan dan semua pertanyaan saya telah dijawab oleh peneliti.

Saya mengerti bahwa bila memerlukan penjelasan, saya dapat menanyakan

kepada saudara Riswandy Wasir sebagai peneliti utama.

Dengan menandatangani formulir ini, saya setuju untuk ikut serta dalam penelitian

ini

Tanggal: Tanggal:

Tanda Tangan Partisipan Tanda Tangan Peneliti

Nama Jelas: …………………………….

Nama Jelas: Riswandy Wasir

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Chapter three


S3 File. A formal waiver statements

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Chapter three


Chapter 4

Trends and projection of health financing for

universal health coverage in Indonesia

Riswandy Wasir,

Maarten Postma

Jurjen Van der Schans

Ali Gufron Mukti

Erik Buskens

Submitted


Abstract

Objectives

Universal Health Coverage (UHC) is part of the sustainable development goals

(SDGs) that should be achieved by 2030. The World Health Organization (WHO)

proposed several health financing goals for countries aiming for UHC: out-of-

pocket (OOP) payments should be less than 20% of total health expenditures (THE),

voluntary healthcare payment schemes should not surpass a maximum of 10 % of

THE, and, finally, governmental healthcare schemes should represent at least 4% of

the gross domestic product (GDP). In 2014, Indonesia introduced, Jaminan

Kesehatan Nasional-Kartu Indonesia Sehat (JKN-KIS), a national health insurance,

aiming for UHC by 2020. This study assesses the progress of Indonesia‘s health

financing towards UHC.

Methods:

Data from the period of 2000–2016 on population, GDP and health financing of

Indonesia were extracted from the Indonesian central bureau of statistics, ministry of

health of Indonesia, national health accounts of Indonesia and WHO global health

expenditure database. Developments of Indonesia‘s health financing by schemes and

revenue schemes were assessed. Then trends in health financing by schemes were

extrapolated. Linear extrapolation was applied to estimate population size, GDP, and

health expenditures through 2030. Comparisons with the foreseen UHC targets were

displayed.

Results:

Between 2000 and 2016 OOP payments still dominated health financing of

Indonesia. From 2014 to 2016, government schemes increased and OOP schemes

decreased. Based on extrapolation of trends we predict government spending to

increase, and the household OOP scheme to decrease until 2030. Notably, the target

for achieving OOP below 20% will not be achieved by 2020. This most likely will

take five more years. Meanwhile, we also estimate the government expenditure

schemes to remain less than 2% of GDP for considerably longer.

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Chapter four


Conclusions:

JKN-KIS may a cornerstone for Indonesia to achieve UHC according to the WHO

targets. By 2030, the targets of reducing household OOP payments below 20% and

reducing voluntary healthcare payment to 10% appear feasible to achieve given de

funds required will be made available. However, the target of government schemes

as high a 4% of GDP may be a challenging target.

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Health financing system for universal health coverage in Indonesia


Introduction

In 2015 the commitment to achieve universal health coverage (UHC) as part of the

sustainable development goals by 2030 was agreed by all member states of the

United Nations[1]. UHC is defined by all people in a society being able to obtain the

high-quality health services that they need, without the possibility that the cost of

paying for these services at the time of use will push them into severe financial

hardship[2]. Appropriate health financing systems are required for achieving UHC in

a country. The system should provide prepaid pooled resources to make sure that the

households do not experience financial difficulties while or after obtaining health

services[3]. Many countries committed to achieving UHC are reviewing, analyzing,

and modifying their health financing arrangements[4,5].

In 2017, the Organization for Economic Co-operation and Development

(OECD), Eurostat and the World Health Organization (WHO) produced a system of

health accounts (SHA) 2011 to provide a framework of health financing schemes. In

moving forward to achieving UHC, SHA 2011 could facilitate countries for

understanding and assessing their health expenditure. According to WHO, targets of

health expenditure for achieving UHC are that (1) the household out-of-pocket

(OOP) schemes should be below 20% of the total health expenditure (THE); (2) the

voluntary healthcare payment schemes should not surpass a maximum of 10 % of

THE; and (3) the government schemes and compulsory contributory healthcare

financing schemes should at least reach 4% of GDP[6-8].

Indonesia is one of the countries of the United Nations which is currently

striving to achieve UHC. Indonesia‘s constitution or Undang-Undang Dasar 1945,

article 28 states that health is a basic right of every individual, and that all citizens

are entitled to health services including the least affluent. Between 2000 and 2014,

there were several social health insurances offered by the government of Indonesia.

These were Asuransi Kesehatan (Askes, for civil servants and the military), Jaminan

Sosial Tenaga Kerja (Jamsostek, social security program for laborers, Jaminan

Kesehatan Masyarakat (Jamkesmas, for poor and near-poor), and Jaminan

Kesehatan Daerah (Jamkesda, for poor and near poor in several provinces)[9,10].

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Chapter four


Because the different schemes were difficult to manage and lead to unequal

access, on the first of January 2014 all the social health insurances were merged into

one single national health insurance, which is known as Jaminan Kesehatan

Nasional-Kartu Indonesia Sehat (JKN-KIS). Through the JKN-KIS program, the

Indonesian government has officially stated its commitment to achieve UHC by

2020. The Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS-Kesehatan) is a

new public health insurance provider created by the Indonesian government to

implement the JKN-KIS program. As a single payer, BPJS Kesehatan plays a role in

collecting a prepaid pool from the government, private firms, and households into a

single national pool[11,12].

Understanding current and future trajectories of health financing is vital for

Indonesia to assess their progress towards UHC. Notably, it remains unclear whether

Indonesia has organized its health financing system in line with the UHC targets.

Overall, this study aims to assess the progress of the health financing system in

Indonesia. Trends of health financing schemes prior to and after the implementation

of JKN-KIS are described. Furthermore, projection of health financing schemes is

also made through 2030, i.e., in line with the target of achieving UHC set in SDGs

agenda.

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Methods

Data sources

The historical data of Indonesia between 2000 and 2016 were extracted from multiple

sources. Data on Indonesian health financing systems, gross domestic product (GDP),

and number of the population, were obtained from the Indonesian central bureau of

statistics, ministry of health of Indonesia, national health account of Indonesia, and the

global health expenditure database. The data on health financing and GDP were reported

in current US dollars. Exchange rates are adjusted per year.

In this study, components of health financing data were collected by

following the SHA 2011 revised edition framework[13]. In this framework,

components of health financing are categorized by schemes and by revenues. Health

financing by schemes are structural components of health care financing systems.

Health financing schemes comprise four components: (1) government schemes and

compulsory contributory healthcare financing schemes, which has two sub

components: government and social health insurance schemes; (2) voluntary

healthcare payment schemes, which has three sub components: voluntary health

insurance, non-profit organization, and enterprise financing schemes; (3) household

OOP schemes; (4) rest of the world (non-resident) schemes.

Health financing by revenues are the sources of revenues of health

financing by schemes. Health financing by revenues comprises of six components:

(1) transfer from government domestic revenue, which has three components:

internal transfer and grants, transfer by government on behalf of specific groups,

other transfers from government domestic revenues; (2) transfer distributed by

government from foreign origin; (3) social insurance contribution; (4) voluntary

prepayment; (5) Other domestic revenues from four sources, namely, household,

corporations, non-profit organization, and unspecified sources; (6) direct foreign

transfer.

The sources of health financing by schemes and by revenues is presented in

table 1. The funds for health financing by schemes may come from one or more

health financing source[13].

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Chapter four


Table 1. Relations of health financing by schemes and by revenues

Health financing by schemes Health financing by revenues

Government schemes Internal transfer and grants

Transfer distributed by government from

foreign origin

Other transfer from government domestic

revenue

Unspecific other domestic revenue

Social health insurance schemes Internal transfer and grants

Transfer by government on behalf of

specific groups

Social insurance contribution

Voluntary health insurance

schemes

Voluntary prepayment from households and

employers

Non-profit organization

financing schemes

Other transfer from government domestic

revenue

Other revenues from households

Other revenues from corporations

Other revenues from non-profit

organization

Direct foreign transfer

Enterprise financing schemes Other revenues from corporations

Household OOP schemes Other revenues from households

Rest of the world Transfer distributed by government from

foreign origin

Direct foreign transfer

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Describing trend of Indonesia’s health financing

A time trend analysis using MS. Excel was used to describe trend of health

financing by schemes and by revenue in Indonesia prior to and after the

implementation of the JKN-KIS program. The expenditures of each component of

health financing by schemes and by revenues are calculated in each year from 2000

to 2016.

Projection of Indonesia’s health financing

The projection of Indonesia‘s health financing was obtained using time trends of

health financing by schemes only. This is because health financing by schemes is the

key and these make up the structural components of the health financing system.

There have been no political interventions that directly affect health financing by

schemes, although health financing by revenues depends on political decisions.

The time trend of four components of health financing by schemes were

extended using linear extrapolation through 2030, i.e., the year set by the SDGs‘

agenda. Considering the year of JKN-KIS implementation in 2014 and the data

available until 2017, the observed years for the extrapolation were 2014 through

2016. Notably, the observed years for the proportion of GDP of Indonesia are

extrapolated from 2000 through 2016 since there have not been relevant policy

changes for defining Indonesia's GDP during this period.

Assessment of Indonesia’s health financing towards UHC

For the initial assessment the proportions of the three components of health

financing by schemes, (1) household OOP schemes; (2) voluntary healthcare

payments schemes; and (3) the government schemes and compulsory contributory

healthcare financing schemes, were calculated for each year. These proportions were

obtained by dividing their yearly amount by total expenditures of health financing

schemes in the pertaining year. Total yearly expenditures of health financing

through the various schemes is obtained by accumulating all expenditures of health

financing. Finally, the initial targets of UHC by WHO SDGs were used to assess

Indonesia‘s progress towards sustainable health financing.

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Chapter four


Results

Trend of Indonesia’s health financing

Indonesia‘s health financing by schemes

Figure 1 shows trend of health financing by schemes between 2000 and 2016 in

Indonesia. Overall, it can be clearly seen that expenditures of all components on

health financing by schemes increased every year. Household OOP schemes

dominated the health financing by schemes during seventeen years. This scheme

reached a peak, with $15.021 billion, in 2011, which was the period before the

implementation of the JKN-KIS. Expenditure on social health insurance schemes

doubled, amounting to $3.955 billion in 2014, in the first year of JKN-KIS

implementation. Then this figure continued to increase and reached a peak in 2016,

with $5.378 billion. Expenditure of enterprise financing schemes was higher than

two other voluntary healthcare payment schemes. Expenditures within of the ‗rest of

the world‘ financing schemes or non-residents was the smallest and only found

between 2000 and 2006. These expenditures were not on record afterward.

Figure 1. Trend of Indonesia’s health financing by schemes between 2000 and

2016

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Indonesia‘s health financing by revenue

Figure 2 shows the trend of health financing by revenues between 2000 and 2016 in

Indonesia. Overall, it can be clearly seen that domestic revenues from household

dominated the health financing of Indonesia during the seventeen years. Internal

transfer and grants were the second highest revenue of health financing in all

periods. After the implementation of the JKN-KIS, this revenue increased

consistently and reached a peak, with $8.1 billion in 2016. In contrast, revenues

from corporations and NPISH consistently decreased during the JKN-KIS

implementation. Interestingly, revenues from social insurance increased

significantly in the beginning of the JKN-KIS implementation from $2.2 billion in

2013 to $3.7 billion in 2014, however, in the next two years this revenue decreased.

There were three revenues of health financing contributing only in 2015 and 2016.

They were revenues from (1) government transfer on behalf of specific group; (2)

government transfer from other domestic; and (3) unspecific domestic revenue.

Figure 2. Trend of Indonesia’s health financing by revenues between 2000 and

2016

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Chapter four


Projection of Indonesia’s health financing

Figure 3 illustrates the projection of Indonesia‘s health financing schemes up to

2030. Overall, expenditure of health financing schemes in Indonesia will increase

from US $3.5 billion in 2000 to US $43.4 billion in 2030. Between 2000 and 2014

the health financing schemes have been dominated by the household OOP scheme,

which will change drastically. In 2015, household OOP schemes contributed equally

to government and compulsory contributory healthcare financing schemes. In the

following years until 2030, expenditure of government and compulsory contributory

healthcare financing schemes are predicted to take over the dominance of health

financing schemes in Indonesia.

Figure 3. Projection of health financing by schemes in Indonesia up to 2030

Assessment of Indonesia’s health financing toward UHC

The final purpose of this study was to evaluate the progress of health financing of

Indonesia towards achieving UHC. Figure 4 shows the proportion of health

financing by schemes in Indonesia between 2000 and 2030. It can be clearly seen

that the proportion of household OOP schemes has been decreasing after the

implementation of the JKN-KIS. This proportion is predicted to fall below 20% by

2024 and will be 9% in 2030. Proportion of voluntary healthcare payment schemes

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also decreased after the implementation of the JKN-KIS and the proportion will drop

to 10 % by 2020. The proportion of government schemes and compulsory

contributory healthcare financing schemes showed a positive trend after the

implementation of the JKN-KIS. The proportion is projected to continuously

increase and will reach 81% by 2030. Nevertheless, although this has a positive

trend, as seen in figure 5, this proportion will not reach and still remains far below

4% of GDP by 2030.

Figure 4. Proportion of health financing by schemes in Indonesia between 2000

and 2030

Figure 5. Proportion of health financing with the Indonesian GDP between

2000 and 2030

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Chapter four


Discussion

We set out this study with the aim of assessing Indonesia‘s health financing

progress. Interestingly, in the results we found that the targets for achieving UHC by

2020 will not be attained. The target for reducing household OOP schemes below 20

% will probably be reached by 2024. The target for reducing voluntary healthcare

payment at 10% may be achieved by 2021. Importantly, these first two targets may

still be achieved well before the SDGs in 2030. However, the government schemes

and compulsory contributory health financing schemes will most likely fall

considerably below 4% of GDP by 2020. This last target will remain a challenge for

Indonesia to achieve by 2030.

Prior to the implementation of the JKN-KIS (between 2000 and 2013), we

found that OOP schemes and revenues from household dominated Indonesia‘s

health financing. A previous study, 14 observing health financing of Indonesia in the

perspective of revenues found similar results. These results are consistent with the

WHO report 15 which found OOP to dominate health expenditure in low-middle-

income countries. It would appear that financial protection for health in Indonesia

was low before the implementation of the JKN-KIS. One of the problems that is

ensuing from this issue, is that OOP for healthcare can cause individuals and

communities to go bankrupt and pushing them into poverty[16,17].

An interesting finding in this study is that after the implementation of the

JKN-KIS in 2014 expenditure of social health insurance schemes increased quite

significantly from $2.0 billion (8,52% of THE) in 2013 to US $4.0 billion (14,25%

of THE) by 2014. In the same period, the trend of OOP schemes by household

decreased to US$ 1.5 billion (7% of THE). Both trends mark important changes in

health financing in Indonesia. These results indicate that the JKN-KIS has the

intended impact of health financing in Indonesia since the JKN-KIS reduced

household OOP schemes at the expense of increased social health insurance

schemes. Other high and middle income countries that have achieved UHC, such as

the Netherlands, the United Kingdom, and Thailand, have shown that the OOP by

household decrease at the expensed of increased social health insurances[3].

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Surprisingly, we noted that the expenditures of social health insurance

schemes are not equal with their revenues since the implementation of the JKN-KIS.

This is different from the situation before the implementation of the JKN-KIS, i.e.,

there used to be a balancing between expenditure and sources of social health

insurances. This is corroborated by the evidence from several newspapers[18-20]

broadcasting that BPJS-Kesehatan was experiencing deficits since the first year of

implementation up to now. Based on the BPJS-Kesehatan report, the accumulation

of deficit of the JKN-KIS up to December 2018 was US $2.5 billion[21]. Our review

found that there are four main possible causes. Firstly, the use of social health

insurance benefits doubled compare to the era before the JKN-KIS[22-24]. Secondly,

the premium paid by members of the JKN-KIS is low, probably caused by not

setting the premium amount according to the actuarial analysis, a method used to

calculate the social health insurance contributions[25-27]. Thirdly, premium

collectability is not optimal among the self-enrolled members (17% of JKN-KIS

participants). Of all self-enrolled members, only 57% routinely pay their

contribution. Moreover, 23% of self-enrolled members register when becoming ill

and stop paying the contribution after treatment has been obtained [28,29]. Fourthly,

JKN-KIS expenditures are dominated by disorders requiring long-term and even

lifetime use of medications[14,21,30-32].

It is important to note that the expenditure of government and compulsory

contributory health financing schemes are predicted to increase by 2.5 times in 2030

compared to 2014. Hence, the deficit of the JKN-KIS should be addressed soon to

stabilize revenue and ensure financial sustainability of the JKN-KIS. This will be a

new challenge for the Indonesian government, but, if managed to do so, the goal for

achieving UHC could be maintained. Several countries heading towards UHC, such

as Korea and Taiwan, experienced similar deficits in the initial period of

implementing UHC. Government subsidies for health and raising premium rates

periodically are the policies used to address these deficits[33-39]. The Indonesian

government might also consider applying these policies since under the Indonesian

Social Security Law[40] the government was mandated to finance any deficit and

4

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Chapter four


revise the premium tariff every two years. Moreover, premium of BPJS-Kesehtan

has not been revised since 2016[27,41].

Strengths of this study are that the SHA 2011 revised edition framework

allowed for this study to investigate health financing in Indonesia in a more

comprehensive way by looking from the perspective of financing schemes and

revenues. Investigating health financing using frameworks described by SHA 2011

revised edition is the new approach not only useful for Indonesia. Many countries

also, particularly southeast Asian and low middle-income countries have also

reported their health financing not to be in line with SHA 2011 revised edition

framework. Health financing by schemes could help for the assessment of universal

health coverage assessment. Whereas, revenues of health financing schemes could

provide better understanding to facilitate the policy makers to arrange the allocation

of health funding. Therefore, this research will provide information to the

government to develop or revise appropriate policies to improve the health financing

system in Indonesia and to achieve UHC.

However, the results of this study should be considered in the context of

possible limitations. In this study, the projections of Indonesia‘s health financing is

extrapolated up to 2030. There will clearly be opportunities for new and revised

policies within a 10-year period towards the target SDGs. Revised policies could

obviously have an impact on the projected results. The current results assume that

policy and intentions to fund will not change in the next decade. In addition, we

assumed linear extrapolation to be predictive of the future trend of healthcare

financing. Furthermore, the observed years used for extrapolation was only three

years (2014, 2015, and 2016) since up to now data on health financing in Indonesia

after implementation of the JKN-KIS was only available on these years.

Additionally, our projection did not consider ageing population which might cause

changes in expenditure patterns. All these limitations could cause our predictions on

healthcare financing to diverge from the actual expenditure. However, it is likely

that the trend will remain positive, and the predictions are a first indication for

policy makers in Indonesia.

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Conclusions

JKN-KIS is contributing to achieve UHC in Indonesia according to the WHO

targets. Firstly, the target for reducing household OOP payments below 20% will not

be achieved by 2020. It might be achieved by 2024. Secondly, the target for

reducing voluntary healthcare payment at 10% will probably be achieved by 2021.

These two targets are still well before 2030 SDGs. Notably, the government

schemes expenditure as 4% share of GDP remains a challenging target for achieving

until 2030 SDGs.

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Chapter four


References





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2019;14(2):e0212328.

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15. World Health Organization. Public

spending on health: A closer look

at global trends. . 2018.

16. Nundoochan A, Thorabally Y,

Monohur S, Hsu J. Impact of out of

pocket payments on financial risk

protection indicators in a setting

with no user fees: The case of

mauritius. International journal for

equity in health. 2019;18(1):63.

17. Hailemichael Y, Hanlon C,

Tirfessa K, et al. Catastrophic

health expenditure and

impoverishment in households of

persons with depression: A cross-

sectional, comparative study in

rural ethiopia. BMC Public Health.

2019;19(1):930.

18. The Jakarta Post. Higher healthcare

premiums 'urgent', BPJS kesehatan

pleads as finances bleed. . 2019.

19. IDN Financials. BPJS kesehatan

deficit hits rp 7 trilion as of june

2019, 2019.

20. Nikkei Asian Review. Indonesia

struggles to pay for huge universal

health care program. . 2019.

21. BPJS Kesehatan. Laporan

pengelolaan program dan laporan

keuangan jaminan sosial kesehatan

tahun 2018. . 2019.

22. Erlangga D, Ali S, Bloor K. The

impact of public health insurance

on healthcare utilisation in

indonesia: Evidence from panel

data. International journal of

public health. 2019;64(4):603-613.

23. Rolindrawan D. The impact of

BPJS health implementation for the

poor and near poor on the use of

health facility. Procedia-Social and

Behavioral Sciences.

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24. Maharani C, Afief DF, Weber D,

Marx M, Loukanova S. Primary

care physicians‘ satisfaction after

health care reform: A cross-

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central java, indonesia. BMC health

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25. Susanty A, Puspitasari NB,

Wicaksono PA, Pungky PPA.

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26. Hidayat B, Mundiharno NJ,


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national health insurance in

indonesia: A first year review.

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Indonesian-German Social

Protection Programme. 2015.

27. Prabhakaran et al. Financial

sustainability of indonesia’s

jaminan kesehatan nasional:

Performance, prospects, and policy

options. Washington, DC:

Palladium, Health Policy Plus, and

Jakarta, Indonesia: Tim Nasional

Percepatan Penanggulangan

Kemiskinan (TNP2K); 2019.

28. Agustina R, Dartanto T, Sitompul

R, et al. Universal health coverage

in indonesia: Concept, progress,

and challenges. The Lancet.

2019;393(10166):75-102.

29. Dartanto T, Halimatussadiah A,

Rezki JF, et al. Why do informal

sector workers not pay the

premium regularly? evidence from

the national health insurance

system in indonesia. Applied health

economics and health policy.

2019:1-16.



keuangan 2015. . 2016.




tahun 2016. . 2017.

32. Tandon A, Pambudi ES, Harimurti

P, et al. Indonesia health financing

system assessment: Spend more,

spend right, spend better. World

Bank; 2016.

33. Lee JC. Health care reform in south

korea: Success or failure? Am J

Public Health. 2003;93(1):48-51.

34. Kang MS, Jang HS, Lee M, Park E.

Sustainability of korean national

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health insurance. J Korean Med

Sci. 2012;27(Suppl):S21-S24.

35. Kwon S. Thirty years of national

health insurance in south korea:

Lessons for achieving universal

health care coverage. Health Policy

Plan. 2008;24(1):63-71.

36. Lu JR, Hsiao WC. Does universal

health insurance make health care

unaffordable? lessons from taiwan.

Health Aff. 2003;22(3):77-88.

37. Huang SK, Tsai SL, Hsu MT.

Ensuring the sustainability of the

taiwan national health insurance. J

Formos Med Assoc. 2014;113(1):1-

2.

38. Davis K, Huang AT. Learning from

taiwan: Experience with universal

health insurance. Ann Intern Med.

2008;148(4):313-314.

39. Cheng T. Reflections on the 20th

anniversary of taiwan‘s single-

payer national health insurance

system. Health Aff.

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40. Republik Indonesia. Undang-

undang republik indonesia nomor

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Putra Mandiri; 2004.

41. Deloitte. Ensuring the

sustainability of JKN-KIS for the

indonesian people. . 2019.

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Chapter four


Chapter 5

Long term risk of incidence of cardiovascular events in

Asian Populations: Systematic review and Meta-Analysis of

Population-Based Cohort Studies

Riswandy Wasir

Sylvi Irawati

Amand Floriaan Schmidt

Atiqul Islam

Talitha Feenstra

Erik Buskens

Bob Wilffert

Eelko Hak


Sylvi Irawati, Riswandy Wasir, Amand Floriaan Schmidt, Atiqul Islam, Talitha

Feenstra, Erik Buskens, Bob Wilffert & Eelko Hak (2019) Long-term incidence and

risk factors of cardiovascular events in Asian populations: systematic review and

meta-analysis of population-based cohort studies, Current Medical Research and

Opinion, 35:2, 291-299, DOI: 10.1080/03007995.2018.1491149


Abstract

Background:

Scientific studies on cardiovascular disease (CVD) burden and risk factors are

predominantly based on short-term risk in Westerner populations, and such

information may not be applicable to Asian populations, especially over the longer

term. This review aims to estimate the long-term (>10 years) CVD burden, including

coronary heart disease (CHD) and stroke, as well as associated risk factors in Asian

populations.

Methods:

PubMed, Embase and Web of Science were systematically searched, and hits

screened on: Asian adults, free of CVD at baseline; cohort study design (follow-up

>10 years). Primary outcomes were fatal and non-fatal CVD events. Pooled

estimates and between-study heterogeneity were calculated using random effects

models, Q and I 2 statistics.

Results:

Overall, 32 studies were eligible for inclusion (follow-up: 11–29 years). The average

long-term rate of fatal CVD is 3.68 per 1000 person-years (95% CI 2.84–4.53), the

long-term cumulative risk 6.35% (95% CI 4.69%–8.01%, mean 20.13 years) and the

cumulative fatal stroke/CHD risk ratio 1.5:1. Important risk factors for long-term

fatal CVD (RR, 95% CI) were male gender (1.49, 1.36–1.64), age over 60/65 years

(7.55, 5.59–10.19) and current smoking (1.68, 1.26–2.24). High non-HDL-c, and b-

and c-tocopherol serum were associated only with CHD (HR 2.46 [95% CI 1.29–

4.71] and 2.47 [1.10–5.61] respectively), while stage 1 and 2 hypertensions were

associated only with fatal stroke (2.02 [1.19–3.44] and 2.89 [1.68–4.96]

respectively).

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Chapter five


Conclusions:

Over a 10 year þ follow-up period Asian subjects had a higher risk of stroke than

CHD. Contrary to CVD prevention in Western countries, strategies should also

consider stroke instead of CHD only

5

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Long term risk of incidence of cardiovascular events in Asian Populations


Introduction

Despite declining trends in fatal cardiovascular disease (CVD), coronary heart

disease (CHD) and stroke remain a significant cause of death and morbidity

worldwide[1,2]. Owing to the fact that most CVD events are not fatal anymore, the

prevalence and burden of CVD is increasing further. To prevent or postpone CVD

occurrence, high-risk subjects need to be identified earlier, allowing for early

targeting of modifiable risk factors and treatments with (personalized) preventive

medications[3–6]. This is especially true for Asian countries where more than half of

the world‘s population resides, and where CVD death is on the rise[7,8]. Most studies

on Asian populations have traditionally focused on the occurrence and risk factors of

CVD within a short-term period (10 years)[9,10]. This may underestimate a long-term

CVD risk (>10 year follow-up), especially when detrimental behavioral and

environmental factors may occur earlier in life and continue to go unmanaged[11–14].

Furthermore, the majority of this research also stems from ―developed‖ Western

countries[15–17], where the risk of CHD is approximately four times higher than of

stroke[18,19]. This focus on CHD may not appropriately translate to CVD prevention

in Asians. The current review aims to estimate the long-term CVD burden and risk

factors.

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Chapter five


Methods

Study design

The protocol for this review was registered with PROSPERO (Reference

CRD42016042939). This report was written based on a MOOSE checklist[20].

Search strategy

A search strategy was developed by S.I., E.H., B.W. and librarians (K.S., S.W.)

(supplemental online material). S.I. conducted the search through PubMed, Embase

and Web of Science on 12 July 2016. A web-based reference manager, RefWorks,

was used to identify and eliminate duplicate studies. Predetermined inclusion criteria

were applied in title/abstract and full-text screenings by S.I. and R.W.

independently. Authors of the original studies were contacted to obtain any required

information. In both screenings, the interrater agreement for study inclusion was

assessed using Cohen‘s kappa (Œ). Any disagreements between review authors were

resolved by discussion. A third review author (E.H. or B.W.) was consulted when no

agreement was reached after discussion.

Study selection

To obtain long-term incidence rates in the general population, only cohort studies

were included. All types of review, meta-analyses, randomized controlled trials,

cross-sectional studies, case series, case reports, editorials, letters and commentaries

were excluded. We focused on Asian healthy adults (aged 18 years) from the general

population. Subjects were free from CVD, i.e. had no history of myocardial

infarction (MI) or stroke, at the start of the study. Only studies with a follow-up

period of more than 10 years were included. Studies investigating only males or

females, participants with a specific condition or disease, or occupational based

cohort were excluded.

The primary outcomes of interest were fatal and non-fatal CVD events.

Secondary outcomes included any CHD and stroke incidences, fatal CHD, fatal

stroke, and all-cause mortality. Only studies which defined their outcomes similarly

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or using the International Statistical Classification of Diseases (ICD) from the World

Health Organization (WHO) were included.

Data extraction, risk of bias assessment and statistical analysis

To describe absolute risks, both rates and proportion with a 95% confidence interval

(CI) were calculated for each outcome. The measure of association between risk

factors and each outcome was presented as a pooled relative risk (RR), also with

95% CI. Forest plots were created using Microsoft Office Excel 2010[21] and Review

Manager (RevMan) version 5.3 (2014). Publications using the same existing data set

were consolidated into a single record, with data preferentially extracted based on

the longest period of follow-up. S.I. extracted data while R.W. and A.I. checked the

correctness of the process. The risk of bias of the included studies was assessed by

S.I. and R.W. independently using the Risk of Bias Assessment tool for Non-

randomized Studies (RoBANS) (supplemental online material)[22]. Disagreements

were resolved by discussion. A third review author (E.H.) was consulted when no

agreement was reached after discussion.

In both descriptive and analytic meta-analyses, we used a random-effects

model to calculate the pooled estimates[23]. Heterogeneity across studies was

evaluated using the Q-test (p value .10 used as a cut-off point) and the I 2 statistic

with 95% CI[24–26]. When I2 was >50%, studies were subdivided based on the study

duration.

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Chapter five


Results

Study identification, study characteristics and risk of bias

assessment

Of 1705 initial titles and abstracts, 1546 were excluded. After reviewing 159 full

texts, 32 studies were included in the meta-analysis[27–58] (Figure 1, Supplemental

Online Material Table SI). The strength of interrater agreement after both

title/abstract and full-text screenings was satisfactory (agreement 92%, Cohen‘s

kappa 0.43; 79%, 0.55, respectively). Most studies were from Japan (21 studies),

followed by Taiwan (5), China (3), Israel (2) and Singapore (1). The duration of

followup ranged from 11 to 29 years. Of 32 studies, 27 studies had started following

their participants since the 1980s or 1990s, four since the 1960s or 1970s and only

one since 2000. The participants‘ age ranged from 18 to 92 years. Of these studies,

the risk of bias in one or more domains in 10 and 18 studies were considered high

and unclear, respectively (Supplemental Online Material Table SII).

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Figure 1. Study selection flow

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Chapter five


Primary outcomes: fatal and non-fatal cardiovascular disease

events

The ―average‖ (pooled-estimate) long-term rate of fatal CVD in the Asian

populations was 3.68 per 1000 person-years (95% CI 2.84–4.53) (Figure 2). Studies

from Singapore, Japan and Taiwan, all of which started their follow-up in the 1980s

or 1990s, contributed to this number. Only the fatal CVD rate in Singapore (4.67

[4.52–4.81]) was above the average and the highest estimate. The average

cumulative fatal CVD over mean 20.13 years was 6.35% (95% CI 4.69%–8.01%)

(Supplemental Online Material Figure FI). The highest cumulative fatal CVD was

found in Taiwan, at 7.18% (95% CI 6.58%–7.77%) over mean 22.5 years, which

was also the longest period of follow-up.

Figure 2. Long-term (>10 years) rate of fatal cardiovascular disease in the

Asian populations. Figure created using a tool from Someka.net.

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Secondary outcomes: any coronary heart disease and stroke

incidences, fatal coronary heart disease, fatal stroke, and all-cause

mortality

The average long-term incidence rate of any stroke was higher than fatal and non-

fatal coronary events (3.14 per 1000 person-years [95% CI 2.12–4.16] vs. 1.51

[0.84–2.18]) (Table 1). The estimates for fatal and non-fatal coronary events were

drawn from studies in the East-Asian populations (Japan and China) while those for

any stroke events were only from Japan. Compared to the average estimates and to

the Chinese, the Japanese had a higher incidence rate of fatal and non-fatal coronary

events. However, in Japan itself, both the incidence rate and cumulative incidence of

any stroke were higher than fatal and non-fatal coronary events, even after excluding

a study started in the 1960s[57] when the incidence of any stroke was still very high

(3.14 per 1000 person-years [95% CI 2.12–4.16] vs. 1.72 [0.00–3.64]; 3.92% [3.35–

4.48] vs. 2.23% [0.00–4.69]).

Table 1. Long-term risk of fatal and non-fatal coronary and any stroke events

in the Asian populations.

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Chapter five


The long-term fatal rate of subcomponents of CVD was derived from three

countries: Singapore, Taiwan and Japan (Table 2). Overall, the average long-term

rate of fatal stroke was higher than fatal CHD (1.46 per 1000 person-years [95% CI

1.18–1.75] vs. 1.03 [0.26–1.81]). Singapore had above-average rates for fatal CHD

(2.56 per 1000 person-years [2.45–2.66]) while Taiwan had them for fatal stroke

(1.8 per 1000 person-years [1.57–2.02]). This was also reflected in between-country

comparisons. Singapore had the highest rate for fatal CHD and Taiwan had the

lowest. In contrast, when the rate of fatal stroke was considered, the rank was the

exact opposite. Specifically, the rate and cumulative estimate of fatal stroke in Japan

and Taiwan were higher than those of CHD. The risks were opposite in Singapore.

Table 2. Long-term risk of fatal coronary heart disease and fatal stroke in the

Asian population

The average long-term rate of all-cause mortality was 11.31 per 1000

person-years (95% CI 7.49–15.12) from Japan (five studies) and Taiwan (one

study). Compared to the average, the risk in Japanese (10.87 [6.69–15.04]) was

below while in Taiwanese (13.52 [12.91–14.13]) was above. The same pattern was

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found in long-term cumulative all-cause mortality (Supplemental Online Material

Table SIII).

Risk factors for long-term fatal and non-fatal cardiovascular

disease events

Of the individual studies included in this review (Supplemental Online Material

Table SI), risk factors of fatal CVD were still dominated by traditional variables

such as: smoking[29,52], hypertension[30,50,51], overweight and obesity[31]. There was a

synergistic effect between current smokers and each of these factors: hypertension,

obesity and metabolic syndrome, which modified their effects on fatal CVD[29,52].

Risk factors associated with long-term risks of fatal CHD and stroke were different,

except for the use of incense (aromatic sticks release fragrant smoke when burned)

in Singapore (HR 1.13 [95% CI 1.01–1.26] and 1.24 [1.06–1.45] for fatal CHD and

fatal stroke, respectively)[47]. Risk factors associated only with fatal CHD were non-

fasting non-HDL-c 189 mg/dL (vs. 150 mg/dL)[32], and b- and c-tocopherol serum

(HR 2.46 [95% CI 1.29–4.71] and 2.47 [1.10–5.61], respectively)[34]. On the

contrary, compared to normal blood pressure, stage 1 and 2 hypertension were

significantly associated only with fatal stroke (HR 2.02 [95% CI 1.19–3.44] and

2.89 [1.68–4.96], respectively)[51]. Several protective factors also appeared to have

contradictory effects on fatal CHD and fatal stroke. Non-fasting HDL-c 60–79

mg/dL (vs. 40–59 mg/dL) and high intake of fruit and vegetables were protective

only against fatal CHD (HR 0.38 [95% CI 0.19–0.75] and 0.57 [0.37–0.87],

respectively)[28,46] while b-carotene serum, high intake of fruit, and per 10 mg/m3

increase in particulate matter levels were only protective against fatal stroke (HR

0.60 [95% CI 0.37–0.98], 0.72 [0.54–0.95], 0.69 [0.59–0.82], respectively)[34,44,46].

Male gender, older age and current smokers were risk factors for fatal CVD

(RR 1.49 [95% CI 1.36–1.64], 7.55 [5.59–10.19], 1.68 [1.26–2.24], respectively)

(Figure 3). The risk of males compared to females in developing fatal CHD was

higher than that in fatal stroke (RR 1.77 [95% CI 1.60–1.96] vs. 1.46 [1.28–1.68]).

Additionally, the risk of suffering a fatal stroke among elderly compared to middle-

aged people was higher than that of fatal CHD (RR 7.36 [95% CI 5.72–9.47] vs.

5.96 [4.17–8.52]).

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Chapter five


Figure 3. Meta-analysis of long-term risk factors for fatal and non-fatal

cardiovascular disease, fatal coronary heart disease, fatal stroke, and

all-cause mortality in the Asian populations.

Sensitivity and subgroup analysis

We conducted sensitivity analysis and subdivided studies based on duration of

follow-up which resulted in non-significant heterogeneities (Supplemental Online

Material Figure FII and FIII). Over a >20 year follow-up, the cumulative fatal stroke

was higher than fatal CHD (4.18% [95% CI 3.48%–4. 89%] vs. 1.57% [1.01–2.14]).

The risks of suffering fatal CHD and fatal stroke were twice as high among males

compared to females in a 15/20 year follow-up. However, in the longer term, the

risk of fatal stroke was slightly lower than of fatal CHD among males compared to

females (RR 1.34 [95% CI 1.23–1.46] vs. 1.52 [1.04–2.22]).

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Discussion

This study explored the risk of (non)-fatal CVD in Asian populations without prior

CVD with follow-up of more than 10 years. Previously, the Asia-Pacific Cohort

Study Collaboration (APCSC) and the Evidence for Cardiovascular Prevention from

Observational Cohorts in Japan Study (EPOCH-JAPAN) metaanalyses focused on

CVD after a shorter follow-up period (10 years)[10,59,60]. The APCSC included cohort

studies mainly from China and Japan and single cohorts from Thailand, South Korea

and Hong Kong while EPOCH-JAPAN only included Japanese cohorts[9,59].

Our study extends findings from these earlier studies to a 10 year þ follow-

up, where the average long-term cumulative incidence of fatal CVD, both in the

Asian population as a whole (6.35% [95% CI 4.69%–8.01%], mean follow-up 20.00

years) and in Japanese alone (5.93% [3.68–8.23], mean follow-up 19.60 years) was

around two times larger than the short-term risk found in APCSC (3.52% [3.47%–

3.58%], median follow-up 6.1 years)10 and in EPOCH-JAPAN (2.89% [2.76–3.02],

mean follow-up 10.2 years)[60].

Our analysis appears to support the assumption that the cumulative risk of

long-term fatal CVD increases non-exponentially over time. A former study

suggested that the 20 year risk of hard CHD should be at least twice the 10 year risk

using a Framingham score approximation[61]. However, in the latter study, this

―naïve‖ approach was proven to underestimate the true risk because it overlooked

aging as an important factor of CVD. The most close estimation of longterm risk

was a model which took competing risk of nonCVD death into account[62]. From two

individual studies included in our review, the 20 year and lifetime risks of CHD and

stroke (competing-risk adjusted) did not always increase linearly or exponentially in

the Japanese. The most rapid increase of the 20 year and lifetime risks for both

events compared to the 10 year risks occurred in the youngest index age group (45

years) and the leaps of increase were getting smaller as index ages were getting

older[55,56]. The long-term risk of CVD also varied depending on gender and the

burden of CVD risk factor(s)[55,56,58].

The average long-term cumulative incidence of subcomponents of CVD in

the Asian populations was higher than the short-term risk, six times for fatal CHD

5

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Chapter five


(1.61% [95% CI 0.42%–2.81%] vs. 0.27% [0.25–0.28]) and four times for fatal

stroke (2.42% [1.83–3.02] vs. 0.57% [0.55–0.59])[10]. However, in Japan, the risk

was only almost two times higher than the short-term risk for both events (fatal

CHD: 1.14% [0.65–1.64] vs. 0.58% [0.52–0.63], fatal stroke: 2.22% [1.16–3.29] vs.

1.36% [1.27–1.45])[60]. Consistent with the short-term risk, the longterm risk of fatal

stroke in the Asian population was also larger than that of fatal CHD. In our study,

the long-term fatal stroke/CHD ratio was lower than the short-term ratio in Asians

(1.5:1 vs. 2:1) similar to the Japanese (2:1)[10,60]. Western subjects had an opposite

fatal stroke/CHD ratio after both short-term (1:3)[10] and long-term periods (e.g.

around 1:4 in men and 1:2 in women, index age of 45 years with 2 major CVD risk

factors)[18]. The relative importance of fatal stroke over fatal CHD on the long-term

risk of fatal CVD in different populations was previously reported by Ancel Keys

and coinvestigators from the Seven Countries Study. Started 60 years ago in 1958,

the study involved 16 cohorts of 12,763 men aged 40–59 years in seven countries.

Of the 16 cohorts, one originated from the US, two were from Finland (eastern and

western), one from the Netherlands (Zutphen), three from Italy (Crevalcore,

Montegiorgio and Rome), two from Croatia (Dalmatia and Slavonia), three from

Serbia (Velika Krsna, Zrenjanin and Belgrade), two from Greece (Crete and Corfu)

and two from Japan (Tanushimaru and Ushibuka)[63–65]. The 25 year age-adjusted

stroke death rates in the US (36 per 1000) and most of Europe (Finland, Greece,

Italy, Netherlands, Belgrade; range: 38–77 per 1000) were lower than Japan (83 and

107 per 1000), Serbia (94 and 119 per 1000) and Croatia (83 and 113 per 1000)[63].

In contrast, the 25 year age-adjusted CHD death rates in the US and Europe (range:

118–202 per 1000), except in Dalmatia, were higher than Japan (45 and 63 per

1000) and Greece (46 and 95 per 1000).

This 25 year data from Japan was largely in agreement with our data,

although there was a population difference and a large time difference between our

included studies and this Seven Countries Study. Although the variety of

investigated populations, especially with regard to Asians, was limited to Japan, the

study still highlights different contributors to fatal CVD in different populations.

The different pattern of CVD burden between Asian and Western populations might

5

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be translated into different risk factors which potentially require a different approach

to the CVD prevention.

We only found a few short-term and no long-term followup studies

investigating any possible differences between the two populations. In a short-term

study (mean 4 years), among other factors (SBP, total cholesterol [TC], body mass

index [BMI], diabetes and current smoking), only triglyceride (TG) was

significantly different between the two populations (p < .05), with a stronger

association with fatal CHD in Westerners (HR 1.66 [95% CI 1.33–2.07]) than in

Asians (1.26 [1.12–1.41]). Interestingly, for subtypes of stroke, SBP was the only

factor differing significantly between the two populations with a stronger association

in Asians than in Westerners (fatal cerebral infarction: HR 1.44 [95% CI 1.35–1.54]

vs. 1.36 [1.17–1.57]; fatal cerebral hemorrhage: 1.72 [1.63–1.82] vs. 1.49 [1.31–

1.70])[66].

Based on individual studies included in our review, these same factors have

different effects on developing CHD and stroke over a long-term period, e.g. non-

fasting non-HDL-c 189 mg/dL and HDL-c 60–79 mg/dL were associated only with

long-term fatal CHD (HR 2.46 [95% CI 1.29–4.71] and 0.38 [0.19–0.75],

respectively) while stage 1 and 2 hypertensions were associated only with long-term

fatal stroke (HR 2.02 [1.19–3.44] and 2.89 [1.68–4.96], respectively). In shortterm

studies in Asian Pacific subjects, a lower level of one standard deviation (15.6

mg/dL) of HDL-c was associated only with fatal or non-fatal CHD (HR not clearly

reported)[67]. However, hypertension was significantly associated with short-term

risk of both fatal and non-fatal CHD, cerebral infarction, and cerebral hemorrhage

(HR 2.47 [95% CI 2.16–2.82], 3.99 [3.32–4.80] and 9.26 [7.25–11.82])[68].

To summarize, three points are worth mentioning: 1) the risk of stroke is

higher than CHD over a long-term period in Asians, 2) the limited evidence

available showed a significant contribution of hypertension to the risk of developing

CHD and stroke over a short-term period but only to the risk of stroke over a long-

term period in Asians, and 3) the risk factors of developing CHD and stroke over a

short-term period are different between Asians and Westerners while no evidence is

available on the comparison of risk factors over a long-term period between the two

5

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Chapter five


populations. These points suggest that a different approach to CVD prevention may

be needed. It is also worth noticing that most of the studies included and discussed

here, both short-term and long-term studies, were conducted mainly in East Asian

regions and in an era when the use of cardiovascular preventive medications was not

highly promoted. Thus, this finding also reflects the lack of epidemiologic studies on

CVD in other Asian regions, especially in lower-middle income countries, where

CVD deaths take place the most.

The strengths of this review lie in its use of a comprehensive search

strategy to include studies from all Asian countries and selection of only studies

with more than 10 years of follow-up and with participants free of CVD at baseline,

which enabled long-term absolute risk estimation. Prior studies relied on country

death registries without specifying whether participants had already suffered from

CVD at baseline[69,70].

Given the moderate to substantial degree of study heterogeneity (I 2 ¼

50%–90%), we had to stratify our analyses. Another limitation is the difference in

the start and end dates of the observation periods of the included studies. Those

limitations were addressed by exploring regional and temporal variations, presenting

the pooled estimate from studies started at the same period, and subgrouping studies

based on duration of follow-up. Unavailable data for events in specific age groups

also limits the standardization of (non)-fatal CVD rates which may overestimate or

underestimate the burden depending on the structure of the study populations. The

focus on English publications is another limitation; however, it is unclear whether

language restriction may result in bias[71,72], for example some Asian countries

explicitly publish research in English only[73]. Due to the limited number of studies,

it was not possible to formally address publication bias. We could only pool risk

estimates for limited CVD risk factors because of the small number of studies

investigating the same risk factors and the unavailability of individual participant

data.

5

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Conclusion

The long-term fatal CVD risk was almost double that of the reported short-term risk.

Unlike Western populations, in the long term stroke risk remained larger than CHD

risk. Male gender, older age and current smoking were important risk factors for

long-term fatal CVD. Factors like non-HDL-c and HDL-c had different effects on

long-term CHD and stroke, with hypertension being a more important predictor of

longterm stroke risk than of short-term risk. Since most studies, even short-term

studies, were from East Asian countries, there is limited information on both short-

term and longterm burden, and risk factors of CVD, in other Asian countries. The

different pattern of CVD risk and risk factors in Asian populations compared to

Westerners asks for a different approach towards prevention.

5

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Chapter five


Transparency

Declaration of funding

This work was supported by LPDP and DIKTI scholarships from the Ministry of

Finance and the Ministry of Research, Technology and Higher Education of the

Republic of Indonesia, respectively. The LPDP and DIKTI had no direct role in

research design, data collection, analysis and interpretation, or manuscript writing

and publication. Author contributions: All authors were involved in study design,

interpretation, review and final approval of the manuscript. Additionally, S.I.

conducted search and study selection, data extraction, risk of bias assessment, data

analysis, and prepared the first draft of the manuscript. R.W. conducted study

selection, confirmed the correctness of data extraction and risk of bias assessment.

A.F.S. provided advice in the data interpretation and important intellectual content

in the draft of the manuscript. A.I. confirmed the correctness of data extraction and

provided statistical advice. T.F. provided advice in the data analysis and important

intellectual content in the draft of the manuscript. E.B. provided important

intellectual content in the draft of the manuscript. B.W. resolved disagreements in

study selection and provided important intellectual content in the draft of the

manuscript. E.H. resolved disagreements in study selection and risk of bias

assessment, and provided important intellectual content in the data analysis and the

draft of the manuscript.

Declaration of financial/other relationships

S.I., R.W., A.F.S., A.I., T.F., E.B., B.W. and E.H. have disclosed that they have no

significant relationships with or financial interests in any commercial companies

related to this study or article. CMRO peer reviewers on this manuscript have no

relevant financial or other relationships to disclose.

5

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Acknowledgements

We would like to thank Karin Sijtsma for her contribution to developing the search

strategy and Sjoukje van der Werf for her contribution to checking the

appropriateness of the search strategy. We also would like to thank several authors

of the included studies (Pao-Hwa Lin, WoonPuay Koh and Ying Wang) for their

contribution to providing complementary data for the meta-analysis.

Data availability statement

The data that support the findings of this study are available from the corresponding

author, Sylvi Irawati, upon reasonable request.

5

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Chapter five


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Supplemental online material

Search strategy

PubMed®

#1 "Asia"[Mesh] OR Asia*[tiab] OR Arab[tiab] OR Arabs[tiab] OR

Arabia*[tiab] OR Saudi*[tiab] OR Persian*[tiab] OR Palestinian*[tiab] OR

Bangladesh[tiab] OR Bengali*[tiab] OR Bahrain*[tiab] OR Bahrani*[tiab]

OR Bhutan*[tiab] OR Brunei*[tiab] OR Cambodia*[tiab] OR Khmer*[tiab]

OR China[tiab] OR Chinese[tiab] OR Beijing[tiab] OR Hong Kong[tiab] OR

Macau[tiab] OR Mongol*[tiab] OR Tibet*[tiab] OR India*[tiab] OR

Dravidian*[tiab] OR Maldiv*[tiab] OR Indonesia*[tiab] OR Iran*[tiab] OR

Iraq*[tiab] OR Israel*[tiab] OR Bukhar*[tiab] OR Jew*[tiab] OR

Japan*[tiab] OR Jordan*[tiab] OR Korea*[tiab] OR Kuwait*[tiab] OR

Lao*[tiab] OR Leban*[tiab] OR Malay*[tiab] OR Myanmar[tiab] OR

Burm*[tiab] OR Nepal*[tiab] OR Oman*[tiab] OR Pakistan*[tiab] OR

Philippine*[tiab] OR Filipin*[tiab] OR Qatar*[tiab] OR Russia*[tiab] OR

Dungan[tiab] OR Hui[tiab] OR Kazakh*[tiab] OR Kyrg*[tiab] OR

Kirghiz[tiab] OR Siberia*[tiab] OR Uzbek*[tiab] OR Turk*[tiab] OR

Uyghur*[tiab] OR Singapore*[tiab] OR Sri Lanka*[tiab] OR Sinhalese[tiab]

OR Syria*[tiab] OR Taiwan*[tiab] OR Tajik*[tiab] OR Thai*[tiab] OR

Timor-Leste[tiab] OR Vietnam*[tiab] OR Yemen*[tiab] OR Kurd*[tiab] OR

Tatar*[tiab] OR Karakalpak*[tiab] OR Bashkir*[tiab] OR Altay[tiab] OR

Altai*[tiab] OR Pashtun*[tiab] OR Pathan*[tiab] OR Afghan*[tiab] OR

Hazara*[tiab] OR Aima*[tiab] OR Nuristan*[tiab] OR Mord*[tiab]

#2 "Risk "[Mesh] OR risk*[tiab] OR associat*[ti] OR relat*[ti] OR factor*[ti]

OR predict*[ti]

#3 "Cohort Studies"[Mesh:noexp] OR cohort*[tiab]

#4 "Cardiovascular Diseases"[Mesh] OR cardiovasc*[ti] OR heart[ti] OR

cardiac[ti] OR myocard*[ti] OR "Cerebrovascular Disorders"[Mesh] OR

cerebrovasc*[ti] OR stroke*[ti]

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Chapter five


#5 longterm[tiab] OR long-term[tiab] OR longerterm[tiab] OR longer-term[tiab]

OR lifetime[tiab] OR life-time[tiab] OR long-time[tiab] OR longtime[tiab]

OR followed-up[ti] OR follow-up[ti]

#6 #1 AND #2 AND #3 AND #4 AND #5

#7 #6 Filters: English

Embase®

#1 'asia'/exp OR arab:ab,ti OR arabs:ab,ti OR arabia*:ab,ti OR saudi*:ab,ti OR

persian*:ab,ti OR palestinian*:ab,ti OR bangladesh:ab,ti OR bengali*:ab,ti

OR bahrain*:ab,ti OR bahrani*:ab,ti OR bhutan*:ab,ti OR brunei*:ab,ti OR

cambodia*:ab,ti OR khmer*:ab,ti OR china:ab,ti OR chinese:ab,ti OR

beijing:ab,ti OR 'hong kong':ab,ti OR macau:ab,ti OR mongol*:ab,ti OR

tibet*:ab,ti OR india*:ab,ti OR dravidian*:ab,ti OR maldiv*:ab,ti OR

indonesia*:ab,ti OR iran*:ab,ti OR iraq*:ab,ti OR israel*:ab,ti OR

bukhar*:ab,ti OR jew*:ab,ti OR japan*:ab,ti OR jordan*:ab,ti OR

korea*:ab,ti OR kuwait*:ab,ti OR lao*:ab,ti OR leban*:ab,ti OR malay*:ab,ti

OR myanmar:ab,ti OR burm*:ab,ti OR nepal*:ab,ti OR oman*:ab,ti OR

pakistan*:ab,ti OR philippine*:ab,ti OR filipin*:ab,ti OR qatar*:ab,ti OR

russia*:ab,ti OR dungan:ab,ti OR hui:ab,ti OR kazakh*:ab,ti OR kyrg*:ab,ti

OR kirghiz:ab,ti OR siberia*:ab,ti OR uzbek*:ab,ti OR turk*:ab,ti OR

uyghur*:ab,ti OR singapore*:ab,ti OR 'sri lanka':ab,ti OR 'sri lankan':ab,ti

OR 'sri lankans':ab,ti OR sinhalese:ab,ti OR syria*:ab,ti OR taiwan*:ab,ti OR

tajik*:ab,ti OR thai*:ab,ti OR 'timor leste':ab,ti OR vietnam*:ab,ti OR

yemen*:ab,ti OR kurd*:ab,ti OR tatar*:ab,ti OR karakalpak*:ab,ti OR

bashkir*:ab,ti OR altay:ab,ti OR altai*:ab,ti OR pashtun*:ab,ti OR

pathan*:ab,ti OR afghan*:ab,ti OR hazara*:ab,ti OR aima*:ab,ti OR

nuristan*:ab,ti OR mord*:ab,ti

#2 'risk'/exp OR risk*:ab,ti OR associat*:ti OR relat*:ti OR factor*:ti OR

predict*:ti

#3 'cohort analysis'/exp OR cohort*:ab,ti

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#4 'cardiovascular disease'/exp OR cardiovasc*:ti OR heart:ti OR cardiac:ti OR

myocard*:ti OR 'cerebrovascular disease'/exp OR cerebrovasc*:ti OR

stroke*:ti

#5 longterm:ab,ti OR 'long term':ab,ti OR longerterm:ab,ti OR 'long-term':ab,ti

OR lifetime:ab,ti OR 'life time':ab,ti OR 'long time':ab,ti OR longtime:ab,ti

OR 'followed up':ti OR 'follow up':ti

#6 #1 AND #2 AND #3 AND #4 AND #5

#7 #6 AND [english]/lim

#8 #7 AND ([article]/lim OR [article in press]/lim OR [review]/lim)

Web of ScienceTM

#1 TS=(Asia* OR Arab OR Arabs OR Arabia* OR Saudi* OR Persian* OR

Palestinian* OR Bangladesh OR Bengali* OR Bahrain* OR Bahrani* OR

Bhutan* OR Brunei* OR Cambodia* OR Khmer* OR China OR Chinese

OR Beijing OR "Hong Kong" OR Macau OR Mongol* OR Tibet* OR India*

OR Dravidian* OR Maldiv* OR Indonesia* OR Iran* OR Iraq* OR Israel*

OR Bukhar* OR Jew* OR Japan* OR Jordan* OR Korea* OR Kuwait* OR

Lao* OR Leban* OR Malay* OR Myanmar OR Burm* OR Nepal* OR

Oman* OR Pakistan* OR Philippine* OR Filipin* OR Qatar* OR Russia*

OR Dungan OR Hui OR Kazakh* OR Kyrg* OR Kirghiz OR Siberia* OR

Uzbek* OR Turk* OR Uyghur* OR Singapore* OR "Sri Lanka" OR "Sri

Lankan" OR "Sri Lankans" OR Sinhalese OR Syria* OR Taiwan* OR Tajik*

OR Thai* OR Timor-Leste OR Vietnam* OR Yemen* OR Kurd* OR Tatar*

OR Karakalpak* OR Bashkir* OR Altay OR Altai* OR Pashtun* OR

Pathan* OR Afghan* OR Hazara* OR Aima* OR Nuristan* OR Mord*)

#2 TOPIC: (Risk*) OR TITLE: (associat* OR relat* OR factor* OR predict*)

#3 TOPIC: (Cohort*) OR TITLE: (associat* OR relat* OR factor* OR predict*)

#4 TS=(cardiovasc* OR cerebrovasc*) OR TI=(heart OR cardiac OR myocard*

OR stroke*)

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Chapter five


#5 TS=("longterm" OR "long-term" OR "longerterm" OR "longer-term" OR

"lifetime" OR "life-time" OR "longtime" OR "long-time") OR

TI=("followed-up") OR TI=("follow-up")

#6 #1 AND #2 AND #3 AND #4 AND #5

#7 #6 Refined by: DOCUMENT TYPES: (ARTICLE OR REVIEW) AND

LANGUAGES: (ENGLISH)

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The Risk of Bias Assessment tool for Non-randomized Studies

(RoBANS)

1. Domain selection participant

Were the exposure and comparison groups selected from the same

populations (i.e. the exposure group did not differ from the control group

with respect to study period or study centre, or historical control group was

used)? Was the absence of outcomes among the study participants confirmed

at the start of the study?

‗Low risk‘ of bias: exposure and control groups are the same population

group (identical institution and period), and the absence of outcomes among

the study participants was confirmed at the start of the study.

‗High risk‘ of bias:

- The exposure and control groups were selected from different

population groups (e.g. the intervention group differs from the control

group with respect to study period or study centre, or historical control

groups were used).

- The presence of outcomes among the study participants was not

confirmed at the start of the study.

‗Unclear risk‘ of bias: it is uncertain whether the selection of participants

resulted in a ‗high risk‘ or a ‗low risk‘ of bias.

2. Domain confounding variables

Were the major confounding variable factors adequately confirmed and

considered during the design phase (e.g. through matching, participation

restriction or other methods) OR analysis phase (e.g. through stratification,

propensity score approaches, statistical adjustments or other methods)?

‗Low risk‘ of bias:

- The major confounding variables were adequately confirmed and

considered during the design phase (e.g. through matching, participation

restriction or other methods).

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Chapter five


- The major confounding variables were adequately confirmed and

accounted for during the analysis phase (e.g. through stratification,

propensity score approaches, statistical adjustments or other methods).

‗High risk‘ of bias:

- The major confounding variables were not considered.

- Although the existence of major confounding variables was confirmed,

these variables were not adequately considered during the design and

analysis phases.

‗Unclear risk‘ of bias: it is uncertain whether the confounding variables


3. Domain measurement of exposure

Was the data obtained from trustworthy sources (e.g. medical records) OR

structured interviews?

‗Low risk‘ of bias: exposure data were described using at least one of the

methods listed below:

- Data were obtained from trustworthy sources, such as medical records.

- Data were obtained from structured interviews.

‗High risk‘ of bias: any one of the following conditions:

- Data were obtained through self-reported methods.

- A clear case of interviewer bias: a situation in which the characteristics

of the investigators causes the study data to be standardized in a manner

that affects the study results. This phenomenon can be reduced through

the training of investigators.

- A clear case of recall bias: a situation in which the respondents‘ degree

of recall can affect the study results.

‗Unclear risk‘ of bias: it is uncertain whether the exposure measurement


4. Domain blinding of outcome assessments

Were outcome assessments blinded OR if blinding was not present, can its

absence be judged to have had no effect on the outcome measurements?

‗Low risk‘ of bias: any one of the following conditions:

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- The outcome assessments were blinded.

- Although blinding was not present, its absence was judged to have no

effect on the outcome measurements.

‗High risk‘ of bias: blinding was not performed or incomplete, and this lack

of appropriate blinding appears likely to have affected the outcome

measurements.

‗Unclear risk‘ of bias: it is uncertain whether the blinding of the outcome

assessments resulted in a ‗high risk‘ or a ‗low risk‘ of bias.

5. Domain incomplete outcome data

Was there no missing data? If there was missing data, were the causes of any

missing data considered to be relevant to the study outcomes? If there was

missing data, was the quantity of the missing data a product of similar

developments in the exposure and control groups and were the causes of

these developments similar?


- There are no missing data.

- The causes of any missing data are considered to be relevant to the study

outcomes (i.e. censoring does not create a bias in the survival data).

- The quantity of missing data was a product of similar developments in

both the intervention (exposure) and the control groups, and the causes of

these developments are similar.


- The missing data could affect the study outcome. These effects may be

attributed to the differences in the missing data between the intervention

(exposure) group and the control group, or the effects may be caused by

the absence of important measurements.

‗Unclear risk‘ of bias: it is uncertain whether the incomplete outcome data


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Chapter five


6. Domain selective outcome reporting

Was the experimental protocol available and were the predefined

primary/secondary outcomes described as planned? In the absence of the

experimental protocol, were all the expected outcomes included in the study

descriptions?


- The experimental protocol was available and the predefined

primary/secondary outcomes were described as planned.

- All the expected outcomes were included in the study descriptions (even

in the absence of the experimental protocols).


- The predefined primary outcomes were not fully reported.

- The outcomes were not reported in accordance with the previously

defined standards.

- There were primary outcomes that were not pre-specified in the study (in

addition to outcomes with clear explanations, such as unexpected adverse

effects).

- The existence of incomplete reporting regarding the primary outcome of

interest.

- The absence of reports on important outcomes that would be expected to

be reported for studies in related fields.

‗Unclear risk‘ of bias: it is uncertain whether the selective outcome reporting

resulted in a ‗high risk‘ or a ‗low risk‘ of bias. Most of the studies examined

were classified in this category.

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Supplemental materials

Other suplemental online materials can be found in this link below:

https://www.tandfonline.com/doi/suppl/10.1080/03007995.2018.1491149?scroll=to

p

or in this quick response code below

5

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Chapter five

https://www.tandfonline.com/doi/suppl/10.1080/03007995.2018.1491149?scroll=top

https://www.tandfonline.com/doi/suppl/10.1080/03007995.2018.1491149?scroll=top


Chapter 6

GENERAL DISCUSSION


Overview

With the studies described in this thesis we aim to evaluate the progress of the

Jaminan Kesehatan Nasional-Kartu Indonesia Sehat (JKN-KIS) towards universal

health coverage (UHC) since the it‘s implementation in 2014. In this chapter, we

will provide an update on the three key challenges JKN-KIS has encountered, i.e.,

medicines management, health financing system, and the epidemiological situation.

Furthermore, we will provide future a perspective, and present the implications of

our findings.

Medicines management during the implementation of the JKN-KIS

The e-catalogue and the national formulary (NF) are two policy instruments

regulating medicine pricing and reimbursement in support of JKN-KIS to achieve

UHC. Ideally, the e-Catalogue would help improve effectiveness, efficiency, and

transparency. Additionally, the NF would help ensure the availability of good

quality, efficacious, and affordable medicines, which subsequently should reduce

out-of pocket payment (OOP) for medicines. However, a year after the

implementation of the JKN KIS, many public healthcare facilities still rarely used

the e-Catalogue, and 40% of all medicines prescribed were not listed in the NF.

Importantly, 70% of OOP expenditures in Indonesia were for medicines in 2015[1-3].

To understand the slow implementation of both instruments we first undertook a

qualitative study.

In chapter 2, we performed a semi-structured interview with stakeholders to

identify the problems with the e-Catalogue and the NF. We found that the lack of

harmonization between medicines listed in the e-Catalogue and the NF was a major

issue. This triggered us to systematically compare the NF medicines published in

2013, 2015, and 2017 with the e-Catalogue 2018 version[4-6]. We found that indeed

41% in 2013, 37% in 2015, and 37% in 2017 of NF medicines were not listed in the

2018 e-Catalogue version. This indicates a continuing lack of harmonization

between the e-Catalogue and the NF. Furthermore, we also identified several

reasons for prescribing medicines that are not listed in the NF. The most important

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Chapter six


reason was that physicians perceived the selection process of the NF as neither

transparent nor evidence-based[7].

In addition, in 2014, several months after the implementation of the JKN-

KIS the health technology assessment (HTA) committee was installed by the

Indonesia‘s Ministry of Health[8,9]. Ideally, this committee would have provided the

transparency and evidence base for the e-Catalogue and the NF in line with the

guidelines of the JKN-KIS implementation[10]. However, HTA has as yet not been

part of the development of the e-Catalogue and the NF. Barriers of HTA

implementation for the e-Catalogue and the NF that we found in chapter 3

concerned a lack of human resources, a lack of financial incentives, a lack of a clear

framework and insufficient data. The first two barriers represent the most important

obstacles. Reasons for the lack of human resources were that HTA is a new science

in Indonesia, and only few HTA departments exist, formal training is not nationally

provided, and an official association is missing in Indonesia. Clearly, financial

resources would be needed to pay the HTA experts, to organize HTA seminars, and

conduct HTA research[11]. Subsequently, we looked into the health insurance

coverage and data regarding healthcare expenditures.

Health financing system during the implementation of the JKN-KIS

The Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS-Kesehatan) is a new

public health insurance provider implementing the JKN-KIS program. As a single

payer, the BPJS-Kesehatan plays a role in collecting a prepaid pool from the

government, private firms, and households into a single national reserve[12].

Furthermore, the most important role of the BPJS-Kesehatan is to ensure that budget

is allocated in line with the UHC targets[13-15]. In chapter 4, we assess health

financing in Indonesia towards UHC. We found that the target for achieving UHC

by 2020 will likely not be attained. The target of reducing household OOP schemes

to below 20 % may be reached by 2024. The target for reducing voluntary healthcare

payment to less than 10% may already be achieved by 2021. The government

schemes and compulsory contributory health financing schemes, however, will still

remain far away from 4% of GDP by 2020.

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General Discussion


Notably, we did find that the JKN-KIS has contributed to moving the health

financing in Indonesia towards the UHC targets. Before the JKN-KIS

implementation, between 2000 and 2013, OOP schemes and revenues from

household dominated Indonesia‘s health financing. Then, after the JKN-KIS had

been implemented, we found that the expenditure of social health insurance schemes

increased quite significantly from US $2.0 billion (8.52% of total health

expenditure) in 2013 to US $4.0 billion (14.25% of total health expenditure) by

2014. In the same period, the trend of OOP schemes by household decreased by US$

1.5 billion (7% of total health expenditure).

However, we also found that the expenditures of social health insurances

schemes were higher than its revenues since the implementation of the JKN-KIS. This is

different from the situation before the implementation of the JKN-KIS, i.e., there used to

be a balance between expenditures and resources from social health insurances. Our

findings corroborate the signals from several newspapers[16-18] that broadcasted that

BPJS-Kesehatan was experiencing deficits from the first year of implementation onward.

The BPJS-Kesehatan reported that the accumulation of the JKN-KIS‘ deficit up to

December 2018 was US $2.5 billion[19]. Based on our review, we found four main

possible causes of deficits. Firstly, the utilization of social health insurance benefits

doubled compare to the era prior to the JKN-KIS[20-22]. Secondly, the premium paid by

members of the JKN-KIS is low, probably caused by not setting the premium amount

according to the actuarial analysis, which is the most common method used to calculate

the social health insurance contributions[23-25]. Thirdly, premium collectability has not

been optimal among the self-enrolled members (17% of JKN-KIS participants). Of all

self-enrolled members, only 57% routinely pay their contribution. Moreover, 23% of

self-enrolled members only register when becoming ill, and stop paying the contribution

after treatment has been obtained[26,27]. Fourthly, expenditures of the JKN-KIS are

dominated by chronic disorders that might otherwise bankrupt individuals, such as

cardiovascular, diabetic, and cancer. These required prolonged hospitalization and high

cost treatment[19,28-31].

The latter was part of further studies on the demographic and epidemiological

perspectives of Indonesia.

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Chapter six


Epidemiological conditions during the implementation of the JKN-KIS

While striving to achieve UHC by 2020, BPJS-Kesehatan is facing demographic and

epidemiological changes in Indonesia. After the implementation of the JKN-KIS,

life expectancy of Indonesian people increased from 69 years in 2014 to 71 years in

2017[32]. Notably, an ageing population implies that the prevalence of non-

communicable diseases increases. Especially cardiovascular diseases (CVDs)

increased from 2013 to 2018. For instance, stroke rose from 7% to 10.9%, and

hypertension from 25.8% to 34.1% [33,34]. Moreover, the most frequently used JKN-

KIS benefits packages since the first year of implementation has been for CVDs.

From January to August 2018, the BPJS-Kesehatan spent US $1.1 billion for CVDs

treatment. The latter represents two thirds of the eight chronic diseases with high

cost[35].

With the high prevalence of CVDs and the largest proportional financial

burden to the BPJS-Kesehatan, the government of Indonesia urgently needs to

develop a new approach to curb the emergence of CVDs. Prevention and addressing

the risk factors of CVDs could avoid or delay the incidence and prevalence of

CVDs[36,37]. In chapter 5, we estimated the long-term CVDs burden and risk factors

in Asian populations through a systematic review. The most important results were

that male sex, older age, and current smoking are the most prominent risk factors for

long-term CVDs in the Asian populations[38]. It is clear that only smoking can be

influenced through various interventions. Unfortunately, in our systematic review,

we did not find studies from Indonesia. Despite the unavailability of information

regarding long term risk of CVDs in Indonesia, this result might be used as a

reference. Clearly, Indonesia needs to recognize and identify people with additional

risk factors for CVDs that may potentially be influenced through the government

policies.

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General Discussion


Future perspective

As noted above the progress of JKN-KIS is such that UHC will not be achieved by

2020. Partly, this seems to have been caused by inefficient use of resources. Hence,

several policy options for promoting efficiency and eliminating waste during the

implementation of the JKN-KIS are necessary. In this part we encourage policy

options that government of Indonesia could implement to improve efficiency.

Furthermore, we propose further research to support and improve the progress of

UHC in Indonesia.

Policy options for improving UHC in Indonesia

It has been identified that the e-Catalogue and the NF have not been fully utilized to

support the aim of the JKN-KIS to achieve UHC. Hence, in order to avoid

unnecessary spending on medicines during the implementation of the JKN-KIS we

suggest the government of Indonesia to improve the harmonization between the e-

Catalogue and the NF. Several studies have explained that the asynchroneous

policies on medicine pricing and reimbursement lead to unnecessary spending on

medicines [39-41]. Furthermore, we also suggest to provide transparency and an

evidence-base in developing the e-Catalogue and the NF. Thus, a reasonable price in

the e-Catalogue may be negotiated while avoiding prescription of medicines not

listed in the NF.

As we explained in chapter 2, and 3, as supported by several studies, that

the use of HTA might facilitate transparency in the e-Catalogue and the NF [42,43,44].

Although several barriers currently hampering the implementation of HTA in the

development of the e-Catalogue and the NF, the existence of an Indonesian

Presidential Decree[45] may force the Indonesian government to utilize HTA in the

development of the e-Catalogue and the NF. Also, it would be beneficial for

Indonesia to establish a network with other neigbouring countries that have a well-

established system, and with international HTA organizations to learn how to

establish a national HTA process[11].

With respect to the deficit of the BPJS-Kesehatan that we found in chapter

4, the government of Indonesia should prioritize further use of HTA to ensure the

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Chapter six


financial sustainability of the JKN-KIS program. Also, several adjacent policies

must be put in place to resolve most common and relevant causes of deficit.

Notably, here we will offer possible solutions of the possible causes of deficits that

we identified above.

Firstly, regarding the increasing utilization of JKN-KIS benefit packages,

we propose to extensively review the claim system and subsidized group data. In the

claim system, several frauds, such as unnecessary treatment, phantom and repeated

billing were found at the primary and secondary health providers[46-48]. For example,

in the subsidized groups data, there seem to be some people who do have ability to

pay included in the data, and entries of some poor people were not included in the

data. This is also caused by the subsidized group data that have not been updated

since 2008[25]. Secondly, regarding the low JKN-KIS premium income we suggest to

set the premium to be in line to the actuarial analysis. The national social security

council and several institutions have provided actuarial calculations for setting the

JKN-KIS premium, but so far it has never been used when revising the BPJS-

Kesehatan premium[23-25]. Thirdly, regarding a lack of contribution from the self-

enrolled members, we proposed to improve public awareness and BPJS-Kesehatan

system. For the public awareness, all individuals should be obliged to register for

JKN-KIS memberships. In 2018, 24 % of Indonesian population had not been

enrolled to the BPJS-Kesehatan. Furthermore, the self-enrolled members of BPJS-

Kesehatan should become full and regular contributors They should contribute

regularly either healthy or sick. In case they are unable to pay their contributions due

to financial hardship, they could join to the subsidized groups of the JKN-KIS[26,27].

Importantly, several reasons for self-enrolled members not paying the contribution

were attributable to failing of the BPJS-Kesehatan system itself. These were as a

lack of information on membership payment method, a lack of comprehensive

knowledge of JKN-KIS‘s benefit package, and dissatisfaction with the workforce of

healthcare services[27]. Therefore, we propose to improve BPJS-Kesehatan

infrastructure, particularly the payment method, to massively increase insurance

literacy to the societies, and finally to improve health professional capacity.

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General Discussion


Fourthly, considering the dominance of chronic disorders that might

bankrupt individuals as well as the BPJS-Kesehatan as such, we propose to improve

preventive programs instead of spending all resources on curative care. In particular

for CVDs we confirmed that smoking is the key risk factor that may be modified in

Asia[38]. Especially since Indonesia has the highest prevalence of smoking in the

world, with 34% overall prevalence in adults, and 65% in adult men this appears an

essential first risk factor to address. The high prevalence of smoking particularly

among people living in poverty, increases their vulnerability[33,49]. Hence, we

recommend to increase the cost of cigarette and tobacco taxes to ultimately reduce

the prevalence of CVDs, and the financial burden on the JKN-KIS. Several countries

have shown that raising the price of cigarettes and tobacco reduces smoking, and

subsequently the prevalence and incidence of CVDs[50].

Further research for improving UHC

In this thesis, we have identifiede the main challenges currently faced by Indonesia in its

efforts to achieve UHC, along with strategies to face these challenges. Notably, there is

still a lot of research needed to deal with medicines management, healthcare financing,

and curbing chronic disease in Indonesia. Further research for improving UHC in

Indonesia is obviously needed. First of all, it is important to assess the demographics of

the JKN-KIS claim data. This information will trigger further research that can improve

efficiency in the JKN-KIS program. For instance, we could compare the claims data of

the JKN-KIS with the data on the disease burden of Indonesia. The results may indicate

whether treatment and expenditure are appropriately used. Furthermore, from the claim

data we might try and estimate the balance between costs and effects of medicines or

treatments in one disease. The most cost-effective medicines or treatment should be

prioritized in the e-Catalogue and the NF. However, currently the claims data of the

JKN-KIS are not available. Availability of these BPJS-Kesehatan data should be

enhanced to trigger research and help the BPJS-Kesehatan to improve efficiency, and

maintain the goal of achieving UHC. Several UHC countries, such as the Netherlands,

the UK, South Korea, Taiwan, Japan, and Thailand, have shown that providing claims

data to the academia and researchers helps these countries for maintaining and

optimizing their UHC [51-54].

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Chapter six


Implications

This thesis comes at a crucial time for recognizing the progress of the JKN-KIS in

moving forward towards UHC. Strategies presented in this thesis, i.e., harmonizing

the e-Catalogue and the NF, and utilizing HTA in the e-Catalogue and the NF could

facilitate the Indonesian government to improve efficiency and avoid unnecessary

expenditure on medicines. Furthermore, recognizing deficit and also its causes

would help to ensure financial sustainability of the JKN-KIS and maintain the goal

for UHC. In addition, identifying and addressing the modifiable risk factors of

CVDs would in the future relieve the government of catastrophic diseases, which is

currently the highest financial burden within the JKN-KIS. Such studies might also

provide comprehensive information and guidance to other countries aiming to

achieve and maintain UHC. Especially, low middle-income countries have similar

issues with high medicine expenditures, dominant OOP payments, and increasing

NCDs [55,56].

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General Discussion


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Chapter six


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Addendum


SUMMARY

All countries in the United Nations (UN) has committed to achieving

universal health coverage (UHC) as part of the sustainable development goals by

2030. The World Health Organization (WHO) states that UHC has been achieved by

a country when all people and communities can use the promotive, preventive,

curative, rehabilitative and palliative health services they need, of sufficient quality

to be effective, while also ensuring that the use of these services does not expose the

user to financial hardship. The WHO outlines that UHC is achieved by a country

when out-of-pocket (OOP) expenditure falls below 20% of total healthcare

expenditures. Furthermore, the WHO urged that government spending on healthcare

should be at least 4% of a country‘s gross domestic product (GDP) to achieve UHC.

As a member of the UN, Indonesia is aiming to achieve UHC. This goal is

increasingly supported with the Indonesian constitution or Undang-Undang Dasar

1945, article 28. Health is a basic right of every individual, and all citizens are

entitled to health services including those living in poverty. At the beginning of

2014, the government of Indonesia officially announced its plan to achieve UHC by

2020 through a new national health insurance, which is known as Jaminan

Kesehatan Nasional-Kartu Indonesia Sehat (JKN-KIS). This program is managed

by a new health insurance program, which is called Badan Penyelenggara Jaminan

Sosial-Kesehatan (BPJS-Kesehatan). The JKN-KIS was the result of a merger of

pre-existing social health insurance schemes. The fragmented health insurance

schemes made health care spending and quality of healthcare services difficult to

control.

Prior to the JKN-KIS implementation, there were several unresolved issues

concerning medicine management, health financing system, and the epidemiological

situation in Indonesia. In medicine management, the proportion of OOPs for

medicines was high, accounting for over 50% of total health expenditures.

Furthermore, medicine expenditure accounted for 67% of total health expenditure.

With respect to health financing, the government of Indonesia experienced

difficulties in increasing health expenditure at the national level. Instead of relying


on government healthcare financing, Indonesia was dominated by OOP

expenditures. Regarding the epidemiological situation, the ageing population lead

the proportional mortality due to non-communicable diseases almost doubled from

37% in 1990 to 73% in 2014. Of all non-communicable diseases, cardiovascular

diseases (CVDs) are the leading cause of deaths and disability.

The main objective of this thesis was to evaluate the progress of the JKN-

KIS in moving forward to achieve UHC in Indonesia. In particular, it set out to

provide comprehensive findings on how the JKN-KIS has encountered three key

challenges on medicine management, health financing, and epidemiological

situation. In Chapter 1, we will briefly explain the concept of UHC according to the

WHO. This is followed by an explanation of the Indonesia‘s health system

transformation towards UHC, and the potential challenges for achieving UHC by

2020. Furthermore, the gaps in knowledge and the thesis objectives are presented.

In Chapter 2, we performed semi structured interviews to identify the

problems of the e-Catalogue and the National Formulary (NF). These are the two

new policy instruments that were introduced to regulate medicine pricing and

reimbursement during the implementation of the JKN-KIS. Ideally, the e-Catalogue

would help improve effectiveness, efficiency, and transparency on procuring

medicine on healthcare facilities. While the NF would help ensure the availability of

good quality, efficacious and affordable medicines. Therefore, these policies should

help the JKN-KIS to control the medicine expenditure and reduce OOPs for

medicines, which subsequently to achieve UHC. However, a year after the

implementation, many public healthcare facilities only rarely used the e-catalogue

for medicine procurement, and 40% of all medicines prescribed were not listed in

the NF. We found that the major issue was the lack of harmonization between

medicine listed in the e-Catalogue and the NF. Then, the most important reasons for

prescribing medicines outside the NF was a lack of transparency and evidence base

in the development of the NF.

In Chapter 3, we identified the barriers and facilitators of implementing

health technology assessment (HTA) in the development of the e-Catalogue and the

NF. The HTA committee was installed by the Indonesia‘s Ministry of Health several


months after the implementation of the JKN-KIS. Ideally, the committee would have

provided the transparency and evidence base of the e-Catalogue and the NF in line

with the guidelines of the JKN-KIS implementation. However, HTA has not been

part of the development of the e-Catalogue and the NF. Several barriers of HTA

implementation in the e-Catalogue and the NF were a lack of capacity, a lack of

financial incentives, a lack of a clear framework and insufficient data. The first two

barriers represent the most important obstacles. Reasons for the lack of capacity

were that HTA is a new science in Indonesia, and only few HTA departments exist,

formal training is not nationally provided, and an official association is missing in

Indonesia. Furthermore, financial resources would be needed to pay the HTA

experts, to organize HTA seminars, and conduct HTA research.

In Chapter 4, we assess health financing in Indonesia towards UHC. This is

to understand whether Indonesia has organized its health financing system in line

with the UHC targets. Trends of health financing prior to and after the

implementation of the JKN-KIS are described. Furthermore, the projection of health

financing schemes is also extended through 2030, as the year of sustainable

development goals agenda. We found that the target for achieving UHC by 2020

will not be attained. The target for reducing household OOP schemes below 20 %

may be reached by 2024. The target for reducing voluntary healthcare payment to

less than 10% may be achieved by 2021. Importantly, the government schemes and

compulsory contributory health financing schemes will remain far away from 4% of

the GDP by 2020. Furthermore, we also found that in the first year of the JKN-KIS

implementation, the expenditure of the BPJS-Kesehatan increased significantly from

$2.0 billion (8.52% of THE) to US $4.0 billion (14.25% of THE). This resulted in

the OOP schemes by household decreasing to US$ 1.5 billion (7% of THE).

Increasing social health insurance expenditures and reducing OOP is the right

progress for achieving UHC. However, we found that the revenues of the BPJS-

Kesehatan was insufficient for fulfilling their expenditure. This led the BPJS-

Kesehatan to continuously develop a deficit since the first-year of implementation.

In Chapter 5, we estimate the long-term CVD burden and risk factors in

Asian populations through a systematic review. The most important results for the


objective of the thesis was that the male sex, old age, and smooking status are the

most prominent risk factors for long-term fatal CVD in the Asian population. In our

systematic review we did not find studies from Indonesia in line with the inclusion

criteria of our studies (cohort studies, Asian healthy above 18 years, free from

CVDs, 10-year follow-up period). Notably, our inclusion criteria could obtain long-

term incidence rate in the general population. Given the unavailability of

information regarding long term risk factors of long-term fatal CVD in Indonesia,

this result could be used as a reference to recognize that smoking is the modifying

risk factor of CVDs. Therefore, this can be influenced through various interventions

to reduce the mortality of CVDs in Indonesia and to reduce the financial burden of

the BPJS-Kesehatan.

In Chapter 6, we present the general discussion of this thesis. We start with

an overview of how the JKN-KIS has encountered the three key main challenges.

Then, the future perspective will offer policy options to address the challenges and

suggestions for further research needed for improving UHC. We will then explain

how this thesis gives possible guidance to Indonesia and other countries. Finally, the

conclusion of this thesis is that JKN-KIS is the cornerstone for Indonesia to achieve

UHC in line with WHO targets. However, improving efficiency and raising financial

resources for health are crucial for the JKN-KIS to address several challenges that

are currently hampering the efforts being made to achieve UHC.


SAMENVATTING

De Verenigde Naties hebben toegezegd om in 2030 universele

gezondheidsdekking (UHC) te bereiken als onderdeel van de doelstellingen voor

duurzame ontwikkeling. De Wereldgezondheidsorganisatie (WHO) stelt dat UHC is

bereikt in een land waar alle mensen en gemeenschappen gebruik kunnen maken van

preventieve, genezende, revaliderende en palliatieve gezondheidsdiensten die zij

nodig hebben, van voldoende kwaliteit zijn om doeltreffend te zijn, en er

tegelijkertijd voor te zorgen dat het gebruik van deze diensten de gebruiker niet

blootstelt aan financiële moeilijkheden. De WHO schetst dat UHC wordt bereikt

door een land wanneer de eigen uitgaven (OOP) onder 20% van de totale uitgaven

voor gezondheidszorg dalen. Bovendien drong de WHO erop aan dat de

overheidsuitgaven voor gezondheidszorg ten minste 4% van het bruto binnenlands

product bedragen om UHC te bereiken.

Als lid van de Verenigde Naties streeft Indonesië naar UHC. Dit doel wordt

in toenemende mate ondersteund door de Indonesische grondwet of Undang-Undang

Dasar 1945, artikel 28. Gezondheid is een basisrecht van elk individu en alle burgers

hebben recht op gezondheidsdiensten, inclusief de armen. Begin 2014 kondigde de

Indonesische regering officieel haar plan aan om UHC tegen 2020 te bereiken via

een nieuwe nationale ziektekostenverzekering, die bekend staat als Jaminan

Kesehatan Nasional-Kartu Indonesia Sehat (JKN-KIS). Dit programma wordt

beheerd door een nieuw zorgverzekeringsprogramma, genaamd Badan

Penyelenggara Jaminan Sosial-Kesehatan (BPJS-Kesehatan). De JKN-KIS was het

resultaat van een fusie van reeds bestaande sociale ziektekostenverzekeringen. Door

de gefragmenteerde ziektekostenverzekeringen waren de uitgaven voor de

gezondheidszorg en de kwaliteit van de gezondheidszorg moeilijk te controleren.

Voorafgaand aan de implementatie van JKN-KIS zijn er verschillende

onopgeloste kwesties op het gebied van medicijnbeheer, gezondheidsfinanciering en

epidemiologische situatie in Indonesië. Bij medicijnbeheer is het aandeel van OOP's

voor geneesmiddelen hoog, tot meer dan 50% van de totale gezondheidsuitgaven.

Bovendien waren de geneesmiddelenuitgaven goed voor 67% van de totale


gezondheidsuitgaven. Met betrekking tot gezondheidsfinanciering ondervond de

regering van Indonesië moeilijkheden bij het verhogen van de gezondheidsuitgaven

op nationaal niveau. In plaats van te vertrouwen op overheidsfinanciering voor de

gezondheidszorg, werd Indonesië gedomineerd door OOP-uitgaven. Wat de

epidemiologische situatie betreft, leidt een vergrijzende bevolking ertoe dat de

proportionele sterfte als gevolg van niet-overdraagbare ziekten bijna is verdubbeld

van 37% in 1990 tot 73% in 2014. Van alle niet-overdraagbare ziekten zijn hart- en

vaatziekten de belangrijkste doodsoorzaak en oorzaak van invaliditeit.

Het hoofddoel van dit proefschrift is het evalueren van de voortgang van de

JKN-KIS om UHC in Indonesië te bereiken. Met name om een uitgebreide

beschrijving te geven over hoe de JKN KIS drie belangrijke uitdagingen op het

gebied van medicijnbeheer, gezondheidsfinanciering en epidemiologische situatie is

tegengekomen. In hoofdstuk 1 zullen we het concept van UHC kort uitleggen

volgens de WHO. Gevolgd door uitleg over de transformatie van het Indonesische

gezondheidssysteem naar UHC en de potentiële uitdagingen om UHC tegen 2020 te

bereiken. Verder worden daar de kenniskloof en de doelstellingen van de diverse

studies gepresenteerd.

In hoofdstuk 2 hebben we een semi-gestructureerd interview uitgevoerd

om de problemen van de e-Catalogus en het Nationaal Formularium (NF) te

identificeren. Dit zijn de twee nieuwe beleidsinstrumenten die de prijsstelling en

vergoeding van geneesmiddelen regelen tijdens de implementatie van de JKN-KIS.

In het ideale geval zou de e-catalogus de doeltreffendheid, efficiëntie en

transparantie van de aankoop van medicijnen in zorginstellingen helpen verbeteren.

OOk het NF zou bijdragen tot de beschikbaarheid van goede, effectieve en

betaalbare geneesmiddelen. Daarom zou dit beleid de JKN-KIS moeten helpen om

de uitgaven voor geneesmiddelen te beheersen en de OOP voor geneesmiddelen te

verminderen, om uiteindelik UHC te bereiken. Een jaar na de implementatie

gebruikten veel openbare zorginstellingen de e-catalogus echter slechts zelden voor

het verkrijgen van medicijnen en 40% van alle voorgeschreven medicijnen was niet

opgenomen in de NF. We ontdekten dat het belangrijkste probleem het gebrek aan

harmonisatie was tussen de medicijnen die in de e-Catalogus en het NF staan

Addendum


vermeld. De belangrijkste redenen voor het voorschrijven van geneesmiddelen

buiten het NF waren dan ook een gebrek aan transparantie en evidence-base bij de

ontwikkeling van het NF.

In Hoofdstuk 3 identificeerden we de belemmeringen en facilitator van het

implementeren van health technology assessment (HTA) bij de ontwikkeling van de

e-Catalog en het NF. De HTA-commissie werd enkele maanden na de implementatie

van de JKN-KIS geïnstalleerd door het Indonesische ministerie van

Volksgezondheid. Idealiter zou de commissie de transparantie en bewijsbasis van de

e-Catalog en de NF hebben geleverd in overeenstemming met de richtlijnen van de

implementatie van JKN-KIS. HTA heeft echter geen deel uitgemaakt van de

ontwikkeling van de e-catalogus en de NF. Verschillende belemmeringen voor de

implementatie van HTA in de e-catalogus en de NF waren een gebrek aan capaciteit,

een gebrek aan financiële prikkels, een gebrek aan een duidelijk kader en

onvoldoende gegevens. De eerste twee belemmeringen vormen de belangrijkste

obstakels. Redenen voor het gebrek aan capaciteit waren dat HTA een nieuwe

wetenschap is in Indonesië en dat er maar weinig HTA-afdelingen zijn, dat er geen

nationale opleiding wordt gegeven en dat er in Indonesië een officiële vereniging

ontbreekt. Bovendien zouden financiële middelen nodig zijn om de HTA-experts te

betalen, HTA-seminars te organiseren en HTA-onderzoek uit te voeren.

In hoofdstuk 4 beoordelen we gezondheidsfinanciering in Indonesië

richting UHC. Dit is om te begrijpen of Indonesië zijn systeem voor

gezondheidsfinanciering heeft georganiseerd in overeenstemming met de UHC-

doelstellingen. Trends van gezondheidsfinanciering voor en na de implementatie van

de JKN-KIS worden beschreven. Bovendien wordt de prognose van

financieringsregelingen voor de gezondheidszorg ook verlengd tot 2030, als agenda

voor het jaar van doelstellingen voor duurzame ontwikkeling. We stelden vast dat de

doelstelling om UHC tegen 2020 te halen niet gehaald zal worden. De doelstelling

om de OOP-regelingen voor huishoudens onder de 20% te verminderen, kan tegen

2024 worden bereikt. De doelstelling om de vrijwillige betaling voor

gezondheidszorg tot minder dan 10% te verminderen, kan tegen 2021 worden

bereikt. Belangrijk is dat de overheidsregelingen en verplichte bijdragende

Samenvatting


regelingen voor gezondheidsfinanciering nog steeds ver weg blijven van 4% van het

BBP tegen 2020. Verder ontdekten we ook dat in het eerste jaar van de

implementatie van JKN-KIS de uitgaven van de BPJS-Kesehatan stegen van $ 2,0

miljard (8,52% van totale uitgaven gezondheidszorg) tot $ 4,0 miljard (14,25%). Dit

leidde ertoe dat de OOP-regelingen per huishouden afnamen tot US $ 1,5 miljard

(7%). Het verhogen van de uitgaven voor sociale verzekeringen en het verminderen

van OOP is de juiste koers voor het bereiken van UHC. We ontdekten echter dat de

inkomsten van de BPJS-Kesehatan niet voldoende waren om hun uitgaven te

dekken. Dit leidde ertoe dat de BPJS-Kesehatan sinds de implementatie in het eerste

jaar voortdurend een tekort ontwikkelde.

In hoofdstuk 5 schatten we de CVD-belasting op lange termijn en

risicofactoren in Aziatische populaties door middel van een systematische review.

De belangrijkste resultaten waren dat mannelijk geslacht, oudere leeftijd en het

huidige roken de meest prominente risicofactoren zijn voor fatale HVZ op lange

termijn bij de Aziatische bevolking. In onze systematische review vonden we studies

uit Indonesië niet in overeenstemming met de inclusiecriteria van onze studies

(cohortstudies, Aziatisch gezond boven 18 jaar, vrij van HVZ, 10 jaar follow-up

periode). Onze bevindingen ewaren dat op langer termijn een stijgende incidentie te

verwachten is. Aangezien er geen informatie beschikbaar is over de risicofactoren

op lange termijn van fatale HVZ in Indonesië, kan dit resultaat worden gebruikt als

een referentie om te erkennen dat roken de wijzigende risicofactor van CVD's is. Dit

kan worden beïnvloed door verschillende interventies om de mortaliteit van hart- en

vaatziekten in Indonesië te verminderen en de financiële last van de BPJS-

Kesehatan te verminderen.

In hoofdstuk 6 presenteren we de algemene discussie van dit proefschrift.

We beginnen met het overzicht om te beschrijven hoe JKN-KIS de drie belangrijkste

uitdagingen is tegengekomen. Vervolgens biedt het toekomstperspectief

beleidsopties om de uitdagingen aan te gaan; en verder onderzoek nodig om UHC te

verbeteren. Vervolgens leggen we uit hoe dit proefschrift mogelijk richting geeft aan

Indonesië en andere landen. Ten slotte is de conclusie van dit proefschrift dat JKN-

KIS de hoeksteen is voor Indonesië om UHC te bereiken in overeenstemming met

Addendum


de WHO-doelen. Het verbeteren van de efficiëntie en het verhogen van financiële

middelen voor de gezondheid zijn echter noodzakelijk voor de JKN-KIS om

verschillende uitdagingen aan te pakken die momenteel de verwezenlijking van

UHC belemmeren.

Samenvatting


RINGKASAN

Negara yang tergabung dalam Perserikatan Bangsa-Bangsa (PBB) telah

berkomitmen untuk mencapai cakupan kesehatan universal (UHC) sebagai bagian

dari tujuan pembangunan berkelanjutan 2030. Organisasi kesehatan dunia (WHO)

menyatakan bahwa UHC tercapai di suatu negara ketika semua masyarakatnya dapat

mendapatkan pelayanan kesehatan berupa promotif, preventif, kuratif, rehabilitatif

dan paliatif, dengan kualitas yang tinggi, tanpa membuat masyarakat terpapar

kesulitan membayar ketika menerima pelayanan tersebut. WHO menjelaskan

indikator UHC tercapai oleh suatu negara ketika pembiayaan kesehatan dari kantong

masyarakat (OOP) turun di bawah 20% dari total pembiayaan kesehatan suatu

negara. WHO juga mendesak setiap negara yang ingin mencapai UHC agar

pembiayaan kesehatan dari pemerintah harus mencapai setidaknya 4% dari produk

domestik bruto.

Sebagai anggota dari PBB, Indonesia bertujuan untuk mencapai UHC.

Pencapaian target UHC semakin didukung oleh Undang-Undang Dasar 1945, pasal

28, yaitu kesehatan adalah hak dasar setiap individu, dan semua warga negara

berhak atas layanan kesehatan termasuk orang miskin. Pada awal 2014, pemerintah

Indonesia secara resmi mengumumkan rencana mereka untuk mencapai UHC

sebelum tahun 2020 melalui asuransi kesehatan nasional baru, yang dikenal sebagai

Jaminan Kesehatan Nasional-Kartu Indonesia Sehat (JKN-KIS). Program ini

dikelola oleh program asuransi kesehatan baru, yang disebut Badan Penyelenggara

Jaminan Sosial-Kesehatan (BPJS-Kesehatan). JKN-KIS adalah hasil dari

penggabungan skema asuransi kesehatan sosial yang sudah ada sebelumnya. Skema

asuransi kesehatan yang terfragmentasi membuat pengeluaran perawatan kesehatan

dan kualitas layanan kesehatan sulit dikendalikan.

Sebelum pelaksanaan JKN-KIS, ada beberapa masalah kesehatan yang

belum terselesaikan, yaitu pada manajemen obat-obatan, pembiayaan kesehatan, dan

situasi epidemiologis di Indonesia. Dalam manajemen obat-obatan, proporsi OOP

untuk obat-obatan tinggi, berkisar lebih dari 50% dari total pengeluaran kesehatan.

Selanjutnya, pengeluaran obat-obatan mencapai 67% dari total pengeluaran


kesehatan. Mengenai pembiayaan kesehatan, pemerintah Indonesia mengalami

kesulitan untuk meningkatkan pengeluaran kesehatan di tingkat nasional. Alih-alih

mengandalkan pembiayaan kesehatan dari pemerintah, Indonesia didominasi oleh

pembiayaan kesehatan dari masyarakat. Dalam hal situasi epidemiologis, angka

harapan hidup yang meningkat menyebabkan proporsi orang meninggal karena

penyakit tidak menular mencapai hampir dua kali lipat, yaitu dari 37% pada tahun

1990 menjadi 73% pada tahun 2014. Dari semua penyakit tidak menular, penyakit

kardiovaskular adalah penyebab utama kematian dan kecacatan.

Tujuan tesis ini adalah untuk mengevaluasi perkembangan JKN-KIS dalam

melangkah menuju pencapaian UHC di Indonesia. Terutama, untuk memberikan

temuan komprehensif tentang bagaimana JKN KIS telah menghadapi tiga tantangan

utama pada manajemen obat-obatan, pembiayaan kesehatan, dan situasi

epidemiologis. Dalam bab 1, kami menjelaskan secara singkat mengenai konsep

UHC menurut WHO. Kemudian, penjelasan tentang transformasi sistem kesehatan

Indonesia menuju UHC, dan tantangan potensial mereka untuk mencapai UHC

sebelum tahun 2020. Selanjutnya, gap terhadap pengetahuan dan tujuan tesis

disajikan pada bab 1.

Dalam bab 2, kami melakukan wawancara semi terstruktur untuk

mengidentifikasi masalah e-katalog dan formularium nasional (fornas). Ini adalah

dua instrumen kebijakan baru yang mengatur penentuan harga dan penggantian

biaya obat selama implementasi JKN-KIS. Idealnya, e-katalog membantu

meningkatkan efektivitas, efisiensi, dan transparansi dalam pengadaan obat-obatan

pada fasilitas kesehatan. Sementara fornas membantu memastikan ketersediaan obat-

obatan yang berkualitas baik, manjur dan terjangkau. Oleh karena itu, kebijakan ini

seharusnya membantu JKN-KIS untuk mengontrol pengeluaran obat-obatan dan

mengurangi OOP untuk obat-obatan, sehingga dapat mencapai UHC. Namun,

setahun setelah implementasi, banyak fasilitas kesehatan umum jarang

menggunakan e-katalog untuk pengadaan obat-obatan, dan 40% dari semua obat

yang diresepkan tidak terdaftar dalam fornas. Kami menemukan bahwa masalah

utama adalah kurangnya harmonisasi antara obat-obatan yang tercantum dalam e-

katalog dan fornas. Kemudian, alasan utama dokter ketika meresepkan obat-obatan

Addendum


di luar fornas adalah kurangnya transparansi dan basis bukti dalam pengembangan

fornas.

Dalam Bab 3, kami mengidentifikasi faktor penghambat dan pendukung

penerapan penilaian teknologi kesehatan (HTA) dalam mengembangkan e-katalog

dan fornas. Komite HTA ditunjuk oleh Menteri Kesehatan Indonesia beberapa bulan

setelah implementasi JKN-KIS. Idealnya, komite HTA dapat menyediakan bukti

ilmiah dan transparansi pengembangan e-katalog dan fornas sesuai dengan pedoman

pelaksanaan JKN-KIS. Namun, HTA belum menjadi bagian dari pengembangan e-

katalog dan fornas. Beberapa hambatan implementasi HTA dalam e-katalog dan

fornas adalah kurangnya kapasitas, kurangnya insentif keuangan, kurangnya

kerangka kerja yang jelas dan data yang tidak mencukupi. Dua hambatan pertama

merupakan hambatan yang paling utama. Alasan kurangnya kapasitas karena HTA

adalah ilmu baru di Indonesia, dan hanya sedikit departemen HTA yang tersedia,

pelatihan formal tidak disediakan secara nasional, dan asosiasi resmi tidak ada di

Indonesia. Selanjutnya, sumber daya keuangan akan diperlukan untuk membayar

para ahli HTA, untuk mengatur seminar HTA, dan melakukan penelitian HTA.

Dalam bab 4, kami melakukan penilaian terhadap pembiayaan kesehatan

UHC di Indonesia. Ini untuk memahami apakah Indonesia telah mengatur sistem

pembiayaan kesehatannya sesuai dengan target UHC. Tren pembiayaan kesehatan

sebelum dan sesudah implementasi JKN-KIS dijelaskan pada bab ini. Selain itu,

proyeksi skema pembiayaan kesehatan juga dibuat hingga 2030, target tahun

pencapaian tujuan pembangunan berkelanjutan. Kami menemukan bahwa target

untuk mencapai UHC sebelum tahun 2020 tidak akan tercapai. Target untuk

mengurangi skema OOP < 20% dapat dicapai pada tahun 2024. Target untuk

mengurangi pembiayaan kesehatan privat < 10% dapat dicapai pada tahun 2021.

Yang paling utama adalah skema pembiyaan kesehatan pemerintah masih akan jauh

dari 4% PDB sebelum tahun 2020. Selanjutnya, kami juga menemukan bahwa pada

tahun pertama implementasi JKN-KIS, pengeluaran BPJS-Kesehatan meningkat

secara signifikan dari US $ 2,0 miliar (8,52% dari THE) menjadi US $ 4,0 miliar

(14,25% dari THE). Hal ini menyebabkan skema OOP oleh rumah tangga menurun

menjadi US $ 1,5 miliar (7% dari THE). Meningkatkan pengeluaran asuransi

Ringkasan


kesehatan sosial dan mengurangi OOP adalah kemajuan yang tepat untuk mencapai

UHC. Namun, kami menemukan bahwa pendapatan BPJS-Kesehatan tidak cukup

memadai untuk memenuhi pengeluaran mereka. Hal ini membuat BPJS-Kesehatan

terus mengembangkan defisit sejak implementasi tahun pertama.

Dalam Bab 5, kami memperkirakan beban penyakit kardiovaskular (CVD)

jangka panjang dan faktor risiko pada populasi Asia melalui tinjauan sistematis.

Hasil yang paling penting adalah bahwa jenis kelamin laki-laki, usia yang lebih tua,

dan perokok adalah faktor risiko yang paling menonjol untuk CVD jangka panjang

pada populasi Asia. Dalam tinjauan sistematis ini, kami tidak menemukan studi dari

Indonesia sesuai dengan kriteria inklusi studi kami (studi kohort, orang Asia yang

sehat di atas 18 tahun, bebas dari CVD, 10 tahun masa tindak lanjut). Khususnya,

kriteria inklusi kami dapat memperoleh tingkat insiden jangka panjang pada

populasi umum. Mengingat tidak tersedianya informasi mengenai faktor risiko

jangka panjang dari CVD fatal jangka panjang di Indonesia, hasil ini dapat

digunakan sebagai referensi untuk mengetahui bahwa perokok adalah faktor risiko

CVD yang dapat dirubah. Oleh karena itu, ini dapat dipengaruhi melalui berbagai

intervensi untuk mengurangi angka kematian akibat CVD di Indonesia dan untuk

mengurangi beban keuangan BPJS-Kesehatan.

Dalam bab 6, kami menyajikan diskusi umum dari tesis ini. Kami mulai

dengan ikhtisar untuk menggambarkan bagaimana JKN-KIS telah menghadapi tiga

tantangan utama utama. Kemudian, pada perspektif masa depan, kami akan

menawarkan opsi kebijakan untuk mengatasi tantangan, dan penelitian lebih lanjut

diperlukan untuk meningkatkan UHC. Kemudian kami akan menjelaskan bagaimana

tesis ini memberikan panduan yang memungkinkan untuk Indonesia dan negara-

negara lain. Akhirnya, kesimpulan dari tesis ini adalah bahwa JKN-KIS adalah

landasan bagi Indonesia untuk mencapai UHC yang sejalan dengan target WHO.

Namun, meningkatkan efisiensi dan meningkatkan sumber daya keuangan untuk

kesehatan adalah keharusan bagi JKN-KIS untuk mengatasi beberapa tantangan

yang saat ini menghambat pencapaian UHC di Indonesia.

Addendum


Acknowledgement

“Feed two birds with one seed”, this proverb might describe me during the period I

was pursuing my PhD, marrying my love, and raising my kids in the last four years.

Therefore, I would like to send my greatest gratitude to Allah, the Almighty, who

mercifully bestows upon me health, strength, determination, and patience to

encounter these monumental occasions in the same period. I really enjoyed

experiencing these remarkable moments simultaneously because of precious support

from many parties. Hence, I would like to sincerely express my gratitude in these

pages to all people and institutions for their contributions during my tremendous journey.

To start, I would like to pay my special regards to my supervisors, and co-

supervisors. Mostly, I would like to thank you for your flexibility and for allowing

me to develop my research ideas. I realize my research, especially in data collection,

was costly, time consuming, and ambitious. But, your financial assistance, followed by your comprehensive supervision, made my goals achievable.

Prof. Erik Buskens, you are the one who contributed in all stages of my PhD

trajectory. I am really grateful because you always provided me the opportunity to

confide both my academic and personal matters. Your intelligent advice, and

especially wise encouragements you delivered to me during our weekly meetings

always increased my confidence. Most importantly, I was always glad to receive

your feedback on manuscripts, cover letters for the journals, and so on. Sentences

will change like written by a highly professional writer. One unforgettable moment

was when preparing my oral presentation for attending ISPOR 2018 conference. I

am indebted since you helped me to create a professional slide set and speech.

Lastly, I sincerely appreciate the availability of your time for me, even though you recently were in mourning for your father's death.

Prof. Maarten Postma, you are the first person that I encountered in Groningen. I

remember when nominated as a DIKTI scholarship awardee. Then, I was required to

to submit a letter of acceptance as soon as possible. In three days, you helped me to

obtain it. Furthermore, my fortune was that you gave me another desk in PTEE

instead of just the one in Epidemiology. This allowed me to meet with other

forgoing Indonesians, expecting they could help me to avoid becoming homesick

and familiarize me with the Dutch culture. Most importantly, I am glad to your

creative solutions in dealing with my academic and personal matters. So, thank you

very much for giving me a chance as your PhD student, helping me to get started on

PhD, and always providing me meaningful ways to accomplish my PhD journey.

Dr. Wim Goettsch, I remember the first time we met at the Dutch National Health

Care Institute in Diemen. You provided me an important reference to develop a

framework for my first and second research project. You also connected me to Amr

Makady, to help me analyze the qualitative data and run the qualitative study tool.

So, thank you for collaborating on my two studies and for accepting to be my co-

promoter in your busy time. Collaborating with the special advisor HTA at the


Dutch National Health care Institute will be certainly worthwhile, and great for my future networking.

Dr. Talitha Feenstra, the first two years of my PhD journey were the most difficult

period. Lucky me to have you as my daily supervisor in these days. You

passionately explained me several basic research skills, such as searching references

in PubMed, writing reports to the supervisors, and scheduling my research project.

Your strict and intensive supervision helped me to be a disciplined and independent

researcher for the next two years of my PhD period. So, thank you very much for the valuable technical skills that you provided to me.

I would like to express my profound gratitude to my research collaborators: Prof.

Ali Ghufron Mukti, Silvy Irawati, Jurjen Van der Schans, and Amr Makady, for their analytical assistances, and meaningful feedback on my manuscripts.

I would also thank the assessment committee: Prof. Menno Reijneveld, Prof.

Katja Taxis, and Prof. Aukje Mantel for providing me their valuable time, particularly during the COVID 19 pandemic to read and appraise my thesis.

I am also truly thankful to the staff of the Epidemiology Department: Erwin, Aukje,

Lizette, and Gerben, and the staff of PTEE unit in the Pharmacy Department: Jannie, Bert, and, Hugo, for their practical and technical support.

I also thank my friends and colleagues in the PTEE unit: Prof. Bob Wilffert, Prof.

Eelko Hak, Abraham, Mas Adjie, Mbak Afifah, Kak Akbar, Christian, Mas

Didik, Eva, Kak Ira, Mas Ivan, Jurjen, Mas Khairul, Linda, Mbak Lusi, Mbak

Neily, Nynke, Pepijn, Pieter, Qi, Simon, Mbak Sofa, Mbak Sylvi, Taichi, Tanja,

Mbak Tia, Kak Ury, Yuan; in the Patient-Centered HTA Unit: Paul, Thea, Henk,

Maarten, Karin, Sander, Koen, Ariuntuya, Ahmed, Kaying; and in the

Epidemiology Department: Omar, Pato, Reinder, Katri; you all brightened my

PhD journey through scientific talks in our group meetings, and spontaneous conversation on any occasion.

I would like to express my deepest thanks to Kak Ury for provoking me to pursue

my PhD at the University of Groningen, teaching me life skills, portraying me the Dutch academic atmosphere, and sharing your badminton techniques to me.

I would like to send my sincere thanks to Kak Akbar for being a big brother to me

in Groningen and allowing me to have chitchat every time. Most importantly, your

wife Andis, and son Abdullah, have become close friends for my wife and children.

I and my family are now counting down the days for a lot of wonderful moments we

will create in Makassar.

My deepest gratitude also goes to Pak Asmoro and family as well as Kak Habibie

and family for accompanying my wife while delivering my second kids in the

UMCG Hospital. At that time I was also expected to deliver my presentation in the study group meeting and then pick my family up at the airport thereafter.

Addendum


Being a thousand miles from home to pursue my PhD and build my new sweet

household feels easier with all friendship from the Indonesian student association in

Groningen and the Groningen Indonesian Moslem community. Therefore, I would

like to sincerely thanks them all who made Groningen become my second home.

Budhe Nunung-Pakde Zaid, Oom Herman-Budhe Arie, Oom Weno-Uwak Asiyah,

Oom Archie-Tante Mary. Mas Didik Setiawan and family, Mas Amak and family,

Mas Zaki Almuzakki and Family, Mas Surya and Family, Mas Ali Syariati and

Family, Mas Mega and Family, Mas Joko and family, Mas Azkario, Mbak May,

Mbak Dina, Mas Adhyatmika and family, Mas Kuswanto and Family, Bli Kadek

and Family, Mas Zainal and Family, Mas Azis and family, Mbak Nur Qomariah,

Mas Fajar and family, Mas Khairul and family, Mas Ivan and family, Mas Yudi

and Family, Mbak Nuriel, Mas Ristiono and family, Mas Didin and family, Mas

Latief and family, Mas Krisna and family, Mas Hegar and family, Mas Azkamuji

and family, Mas Luthfi, Mas Guntur, Mas Yoga, Mas Ade and family, Mas Agung

and family, Mas Fika and family, Mas Chalis and family, Mas Afif, Mas Bhimo,

Mbak Inda and Family, Mas Umar Djalins, Mas Ajie Mahar, Mas Fean, Mas

Lana and family, Mas Ali Abdurrahman and family, Adzkia, Ibu Neno Purba,

Fathki, Stephanie, Yessaya, Kinanti, Inez, Sarah, Afra, Laras, Mas Rifki, Kang

Angga, Mas Romy and family, Kang Deny and all my Indonesian friends who could not be listed in this acknowledgement.

I also credit my house landlord, Mr. Sulaiman Surie for providing me a house for

living with my family which is close to the UMCG. This helps me to be flexible to do my work and check my little family during lunchtime.

I would also like to express my deepest gratitude to those who have provided me

motivation and their sincere prayers for my PhD life: Bapak Anies Rasyid

Baswedan (Governor of DKI Jakarta), Bapak Prof. Nurdin Abdullah (Governor of

South Sulawesi), Bapak Syahrul Yasin Limpo (Indonesia‘s Minister of

Agriculture), Bapak Agus Arifin Nu'mang (ex-vice governor of South Sulawesi),

Bapak Aksa Mahmud, Bapak AGH Sanusi Baco, and all people attending at my salvation event to start my PhD trajectory.

Finally, I wish to express my deepest gratitude to my beloved family for giving me

extraordinary motivation. The unforgettable moments when you all repeatedly drove

me to the airport accompanied by your heartfelt tears. These moments continuously

crossed to my mind in all my activities in Groningen. Hence, I dedicate this thesis to all of you and hopefully, this answers all your prayers and wishes.

To my parents (Bapak and Mama): Prof. Wasir Thalib and Ummu Kalsum, as

well as my parent in law (Papa and Ibu): Prof. Sidin Ali and Hafsah Usman, I

consider myself nothing without you. Thank you so much for your endless love,

sincere unceasing prayer, moral and financial support to me. Most importantly, I pay

my deepest gratitude for helping me to take care of my wife, son, and daughter in

the last year of my PhD. So that I only pay attention to my PhD journey without any obstacle in the way.

Acknowledgement


To my siblings: Kak Rika Fatimah Wasir, Kak Rizqurrachman Wasir, Rina

Wahyuni Wasir; my brother and sister in law: Kak Ikrar Sakti Yusuf, Kak

Wahida Masrah, Andi Agung Yasser, My nephews, and nieces: Iffat, Dzakiyah,

Adzkia, Fakhri, Farzan, Rafassya, Radeva. My wife‘s siblings (also in law): Kak

Risna Sari, Kak Irwan Rais, Kak Tri hastiti Fiskawarni, Kak Zulhajji Hamid;

and my wife‘s nephews, and nieces: Sadam, Zaky, Fildzah, Fairah, I am very

pleased for your time to take care of Bapak and Mama, as well as Papa and Ibu when I was not in Indonesia.

To my beloved wife, Fadilah Aulia Rahma, accepting me as your husband in the

first year of my PhD, and, subsequently, living with me in Groningen was a

remarkable moment in my life. As a youngest and carefree child of Papa and Ibu,

with a strong determination to be a doctor, I never thought you would actualy leave

your comfort zone and your ideals. Most importantly, you were willing to give birth

to our kids in Groningen, without being accompanied by extended family, as is

common in Indonesia. Amazingly, in addition to fulltime caring for our two kids,

you provided me delicious foods and tidied my clothes up every day to ensure my

nutrition and appearance during my research work. So, thank you very much for

devoting your quality time, and your career to allow me to pursue my PhD, and

raising our kids. I owe you everything. Therefore, I dedicate this thesis and of course the rest of my life to you.

To my kids, Muhammad Mikail Davian Riswandy and Mikhayla Maritza

Riswandy, your smiles and funny reactions always relieve my stress and booster my

spirit to write my manuscripts. Importantly, you both foster my self-awareness to

make the best use of time during Pursuing my PhD. So, thank you for providing

quality time for me during my PhD Journey and for expressing to me that I should

obtain value in every single activity. I apologize for leaving you both for a while in Indonesia. Surely, we will have our quality time again.

Ministry of research and higher education, thank you for providing me a DIKTI

scholarship. Without your funding I would not have been able to develop my scientific competence and discoveries in four years.

Last but not least, I am grateful to all people who contributed to my PhD projects

that cannot be listed one by one in this acknowledgment. Thank you very much!

Groningen, April 2020

Riswandy Wasir

Addendum


PHD PORTOFOLIO

Personalia

Name : Riswandy Wasir

Gender : Male

Place and Date of Birth : Makassar, 12 January 1988

Nationality : Indonesian

E-mail : [email protected]

Department of PhD : Epidemiology, University Medical Center Groningen

PhD Period : December 2015-Mei 2020 (4 years, 6 months)

Promotors : Prof. Dr. Erik Buskens

Prof. Dr. Maarten Postma

Co-Promotors : Dr. Wim Goettsch

List of Publications

Wasir R, Irawati S, Makady A, Postma MJ, Goettsch W, Feenstra T, Buskens E

(2018). Use of medicine policies for universal health coverage in Indonesia. Value

in Health, 21(3), S1, October, 2018. DOI: https://doi.org/10.1016/j.jval.2018.09.004


(2018). Barriers to and facilitators of the application of health technology

assessment in medicine pricing and reimbursement policies in Indonesia. Value in

Health, Volume 21, S184, October, 2018. DOI:

https://doi.org/10.1016/j.jval.2018.09.1099

S Irawati S, R Wasir R, Schimdt AF, Islam A, Feenstra T, Buskens E, Wilfert B, E

Hak (2019). Long term risk of incidence of cardiovascular events in Asian

Populations. Systematic review and Meta-Analysis of Population-Based Cohort

Studies. Current Medical research and opinion, 35(2), 291-299. DOI:

https://doi.org/10.1080/03007995.2018.1491149

Wasir R, Irawati S, Makady A, Postma MJ, Goettsch W, Buskens E, Feenstra T

(2019). Use of medicine pricining and reimbursement policies for universal health

coverage in Indonesia. PloS ONE, 14(2), [e0212328]. February, 2019 DOI:



(2019). The implementation of HTA in medicine pricing and reimbursement policies

in Indonesia: Insight from multiple stakeholders. PloS ONE, 14(11), [e022565626].

November, 2019 DOI: https://doi.org/10.1371/journal.pone.0225626







Wasir R, Postma MJ, van der Schans J, Mukti AG, Buskens E (2019).

Implementation of universal health coverage in Indonesia. Value in Health, 22(3),

S782, November, 2019. DOI: https://doi.org/10.1016/j.jval.2019.09.2024

Wasir R, Postma MJ, van der Schans J, Mukti AG, Buskens E. Trends and projection of

health financing for universal health coverage in Indonesia. (Submitted)

Irawati S, Wasir R, Bahar MA, Hak E, Wilffert, B, Taxis K, Postma MJ, Buskens

E, The burden of cardiovascular disease and trend of claim reimbursement for statin

prescription in Indonesia after the implementation of the National Health Insurance

(Jaminan Kesehatan Nasional, JKN) 2014-2016 (In preparation)

Wasir R, Postma MJ, van der Schans J, Buskens E. Health and economic

implications of national treatment coverage for cardiovascular disease in Indonesia:

an estimation of the return on investment on statin (In preparation)

Scientific Conferenes

Wasir R, Feenstra T, Postma MJ, Goettsch W, Buskens E. The role of a health

technology assessment in medicine policy to enable universal health coverage in low

middle-income countries: Indonesia as a reference case. The 3rd InaHEA conference,

July 28-30th, 2016, Yogyakarta, Indonesia. (Poster presentation).


(2018). Use of medicine pricing and reimbursement policies for universal health

coverage in Indonesia. International Society for Pharmacoeconomics and Outcomes

Research (ISPOR) Europe 2018, New Perspective for improving 21st Century health

system. 10-14 November 2018, Barcelona, Spain. (Oral Presentation)


(2018). Use of medicine pricing and reimbursement policies for universal health

coverage in Indonesia. International Society for Pharmacoeconomics and Outcomes

Research (ISPOR) Europe 2018, Student research spotlight. 10-14 November 2018,

Barcelona, Spain. New Perspective for improving 21st Century health system. 10-14

November 2018, Barcelona, Spain. (Poster Presentation)


(2018). Barriers to and facilitators of the application of health technology

assessment in medicine pricing and reimbursement policies in Indonesia.

International Society for Pharmacoeconomics and Outcomes Research (ISPOR)

Europe 2018, New Perspective for improving 21st Century health system. 10-14

November 2018, Barcelona, Spain. (Poster Presentation)

Wasir R. Experience on the first event of ISPOR student research spotlight.

Webinar Presidents Teleconference. November 2018. (Panelists)

Wasir R, Postma MJ, van der Schans J, Mukti AG, Buskens E. Trend and

Projection on financial protection for universal health coverage in Indonesia. The

Addendum



13th Post Graduate Forum on Health System and Health Policy. Medical specialist

within the Health System in Asia: A perspective on production and utilization. 19-20

July 2019, Yogyakarta, Indonesia. (Poster Presentation)

Wasir R, Postma MJ, van der Schans J, Mukti AG, Buskens E. Implementation of

universal health coverage in Indonesia. International Society for Pharmacoeconomics

and Outcomes Research (ISPOR) Europe 2019. Digital transformation of Healthcare. 2-

6 November 2019, Copenhagen, Denmark. (Poster Presentation)

Awards Nominations

Top outcomes research at International Society for Pharmacoeconomics and

Outcomes Research (ISPOR) Europe 2018, New Perspective for improving 21st

Century health system. 10-14 November 2018, Barcelona, Spain

Top-3 Poster Prize at the 13th Post Graduate Forum on Health System and Health

Policy. Medical specialist within the Health System in Asia: A perspective on

production and utilization. 19-20 July 2019, Yogyakarta, Indonesia

PhD level courses taken

Courses Year Workload

Academic Writing 2016 2 ECTS

PhD Introductory Event 2016 1 ECTS

Pharmacoeconomics 2016 5 ECTS

Qualitative Data Collection and Analysis 2016 5 ECTS

Ethics of Research and Scientific Integrity for Researchers 2017 2,5 ECTS

Managing your PhD 2017 2 ECTS

Presentation Skills 2018 2 ECTS

Publishing in English 2018 2 ECTS

Budget Impact Analysis I: A 6-Step Approach at ISPOR

Europe, Barcelona, Spain

2018 5 hours

Budget Impact Analysis II: Application and Design Issues at

ISPOR Europe, Barcelona, Spain

2018 5 hours

Introduction to Modelling at ISPOR Europe, Copenhagen,

Denmark

2019 5 hours

Statistical Methods for Health Economics and Outcomes

Research at ISPOR Europe, Copenhagen, Denmark

2019 5 hours

Bayesian Analysis: Overview and Applications at ISPOR

Europe, Copenhagen, Denmark

2019 10 hours

PhD Portofolio


About the Author

Riswandy Wasir was born on January 12th, 1988 in

Makassar, South Sulawesi, Indonesia. He is the third

son of four children from Ayahanda Prof. Dr. H. M.

Wasir Thalib, MS and Ibunda Dra. Hj. Ummu Kalsum

Ali Tadjo. His primary, secondary and tertiary school

was obtained in Makassar, which are respectively in

SD Negeri Kompleks IKIP, SMP Negeri 6 and SMA

Negeri 3. He obtained a Bachelor of Pharmacy at

Universitas Muslim Indonesia (UMI), a Pharmacist

certificate at Universitas Islam Indonesia (UII) and a Master of Public Health at the

University of Gadjah Mada (UGM). In December 2015, He started his PhD

trajectory at the unit of Patient-Centered Health Technology Assessment (HTA),

Epidemiology Department, University Medical Center of Groningen (UMCG),

University of Groningen, Groningen, the Netherlands under the supervision of Prof.

Dr. Erik Buskens, Prof. Dr. Maarten Postma and Dr. Wim Goettsch. His PhD project

focused on the health policy strategies to enable countries (in particular Indonesia)

to achieve universal health coverage as part of the sustainable development goals.

His study is funded by the Ministry of Research, Technology and Higher Education

of the Republic of Indonesia under the scheme of DIKTI scholarship. During his

PhD trajectory, he has published his studies in international peer-reviewed journals

and also actively presented his studies at international conferences. One of his

studies was nominated for top outcomes research at the International Society for

Pharmacoeconomics and Outcomes Research (ISPOR) Europe 2018, in Barcelona,

Spain. He was also awarded a top-3 poster prize at the 13th Post Graduate Forum on

Health System and Health Policy, in Yogyakarta, Indonesia. Currently, he continues

his career as a lecturer and researcher at the Sekolah Tinggi Ilmu Farmasi (STIFA)

Makassar, Makassar, South Sulawesi, Indonesia. His research interests are in the

areas of universal health coverage and health policy, particularly in policies in

medicine management. He married his beloved wife Fadilah Aulia Rahma, a

youngest and carefree child of Prof. Dr. H. M. Sidn Ali, M.Pd and Dra. Hj. Hafsah

Usman, M.Pd. The marriage of Riswandy and Fadilah has been blessed with two

beloved children, Muhammad Mikail Davian Riswandy and Mikhayla Maritza

Riswandy. Their kids were both born in Groningen in the period of pursuing a PhD

of Riswandy Wasir.

Addendum


Tentang Penulis

Riswandy Wasir lahir pada 12 Januari 1988 di

Makassar, Sulawesi Selatan, Indonesia. Dia adalah

putra ketiga dari empat bersaudara dari pasangan

Ayahanda Prof. Dr. H. M. Wasir Thalib, MS dan

Ibunda Dra. Hj. Ummu Kalsum Ali Tadjo. Sekolah

dasar, menengah pertama dan menengah atas diperoleh

di Makassar, yang masing-masing di SD Negeri

Kompleks IKIP, SMP Negeri 6 dan SMA Negeri 3. Ia

memperoleh gelar Sarjana Farmasi di Universitas

Muslim Indonesia (UMI), sertifikat Apoteker di

Universitas Islam Indonesia (UII) dan Magister

Kesehatan Masyarakat di Universitas Gadjah Mada (UGM). Pada Desember 2015,

dia memulai perjalanan PhD-nya di Unit Patient-Centered Health Technology

Assessment (HTA), Epidemiology Department, University Medical Center of

Groningen (UMCG), University of Groningen, Groningen, Belanda di bawah

pengawasan Prof. Dr. Erik Buskens, Prof. Dr. Maarten Postma dan Dr. Wim

Goettsch. Proyek PhD-nya berfokus pada strategi kebijakan kesehatan untuk

memungkinkan negara, khususnya Indonesia, untuk mencapai cakupan kesehatan

universal (Universal Health Coverage, UHC), yang merupakan bagian dari tujuan

pembangunan berkelanjutan. Studinya didanai oleh Kementerian Riset, Teknologi,

dan Pendidikan Tinggi, Republik Indonesia di bawah skema beasiswa DIKTI.

Selama perjalanan PhD, dia telah menerbitkan beberapa artikel di jurnal

internasional bereputasi tinggi dan juga aktif mempresentasikan penelitiannya di

konferensi internasional. Salah satu penelitianya dinobatkan sebagai penelitian

dengan luaran terbaik pada International Society for Pharmacoeconomics and

Outcomes Research (ISPOR) Europe 2018, di Barcelona, Spanyol. Dia juga

dianugerahi sebagai presenter poster terbaik ke 3 di Post Graduate Forum on Health

System and Health Policy ke 13, di Yogyakarta, Indonesia. Saat ini, dia melanjutkan

karirnya sebagai dosen dan peneliti di Sekolah Tinggi Ilmu Farmasi (STIFA)

Makassar, Makassar, Sulawesi Selatan, Indonesia. Minat penelitiannya adalah di

bidang universal health coverage dan kebijakan kesehatan, terutama dalam

kebijakan manajemen obat-obatan. Dia menikahi gadis pujaan hatinya Fadilah Aulia

Rahma, putri bungsu yang riang dari Prof. Dr. H. M. Sidn Ali, M.Pd dan Dra. Hj.

Hafsah Usman, M.Pd. Pernikahan Riswandy dan Fadilah telah dikaruniai dua anak

kesayangan, Muhammad Mikail Davian Riswandy dan Mikhayla Maritza Riswandy.

Anak-anak mereka berdua lahir di Groningen ketika Riswandy Wasir sedang

mengejar gelar PhDnya.

PhD Portofolio


Research Institute SHARE

This thesis is published within the Research Institute SHARE (Science in

Healthy Ageing and healthcaRE) of the University Medical Center Groningen /

University of Groningen.

Further information regarding the institute and its research can be obtained from our internet

site: http://www.share.umcg.nl/

More recent theses can be found in the list below. (supervisors are between brackets)

2020

Renting N

Clinical workplace learning today; how competency frameworks inform

clinical workplace learning (and how they do not)

(prof ROB Gans, prof ADC Jaarsma, prof JCC Borlefs)

Kramer T

How to develop a Grand Slam winner…; physical and psychological skills in

Dutch junior tennis players

(dr MT Elferink-Gemser, prof C Visscher, dr BCH Huijgen)

Raven D

Where‘s the need? The use of specialist mental health services in adolescence

and young adulthood

(prof AJ Oldehinkel, prof RA Schoevers, dr F Jörg)

Stoter IK

Staying on track; the road to elite performance in 1500 m speed skating

(dr MT Elferink-Gemser, prof C Visscher, prof FJ Hettinga)

Silva Lagos LA

Gestational diabetes mellitus and fetoplacental vasculature alterations;

exploring the role of adenosine kinase in endothelial (dys)function

(dr MM Faas, prof T Plösch, prof P de Vos, prof L Sobrevia)

Reints R

On the design and evaluation of adjustable footwear for the prevention of

diabetic foot ulcers

(prof ir GJ Verkerke, porf K Postema, dr JM Hijmans)

Bekhuis E

A body-mind map; epidemiological and clinical aspects of the relation between

somatic, depressive and anxiety symptomatology

(prof JGM Rosmalen, prof RA Schroevers, dr L Boschloo)

Havinga PJ

Breaking the cycle? Intergenerational transmission of depression/anxiety and

opportunaties for intervention

(prof RA Schoevers, prof CA Hartman, dr L Boschloo)

Geer SJ van der

Trismus in head and neck cancer patients

(prof PU Dijkstra, prof JLN Rodenburg, dr H Reintsema)

http://www.share.umcg.nl/


Salavati N

Preconception environmental factors and placental morphometry in relation to

pregnancy outcome

(prof JJHM Erwich, prof RM van der Beek, dr MK Bakker, dr SJ Gordijn)

Fels IMJ van der

Movement, cognition and underlying brain functioning in children

(dr E Hartman, prof C Visscher, prof RJ Bosker, dr J Smith)

Braaksma P

Moving matters for children with developmental coordination

(prof R Dekker, prof CK van der Sluis, dr MM Schoemaker, dr I Stuive)

Akkerman M

Functioning beyong pediatric burns

(prof LHV van der Woude, dr LJ Mouton, dr MK Nieuwenhuis)

Buurke TJW

Adaptive control of dynamic balance in human walking

(dr CJC Lamoth, prof LHV van der Woude, dr AR den Otter)

Bos GJFJ

Physical activity and physical fitness in children with chronic conditions

(prof PU Dijkstra, prof JHB Geertzen)

Heugten P van

Talent in international business defined: implications and applications for

honours education

(prof ADC Jaarsma, dr MVC Wolfensberger, dr M Heijne-Pennninga)

Kranenburg HA

Adverse effects following cervical manual physical therapy techniques

(prof CP van der Schans, dr MA Schmidt, dr GJR Luijckx)

Lameijer CM

Perspectives on outcome following hand and wrist injury in non-osteoporotic

patients

(prof CK van der Sluis, prof HJ ten Duis, dr M El Moumni)

2019

Nijholt W

Gaining insight in factors associated with successful ageing: body composition, nutrition, and

cognition

(prof CP van der Schans, dr JSM Hobbelen, dr H Jager-Wittenaar)

Schaap FD

Dementia Care Mapping in the care for elderly people with an intellectual disability and

dementia

(prof SA Reijneveld, dr EJ Finnema, dr GJ Dijkstra)

For earlier theses visit our website

Complete_thesis.pdf - the University of Groningen research ...

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