Supporting priority-setting as a means to achieving Universal Health Coverage
iDSI has been providing practical support to the recently established National Health Insurance scheme (JKN) and Indonesian Ministry of Health as it reforms its health service. The Indonesia government aspires to provide universal health coverage to all 255 million Indonesians by 2019. Indonesian authorities approached iDSI for assistance, and following a scoping visit by the Health Intervention and Technology Assessment Program of Thailand (HITAP), Indonesia was selected for a practical support project in 2013.
An objective of iDSI engagement was to strengthen national institutions and processes, such as the National Health Technology Assessment (HTA) committee established by Ministry of Health decree in 2014, in order to improve critical policy decision making and thereby population health. HITAP and NICE International, working through iDSI, began working with Indonesian policymakers and researchers to build on existing capacity for evidence-informed priority setting, including joint development of HTA evaluations ranging public health to secondary care interventions, and advising on the establishment and implementation of an HTA policy roadmap in support of universal health coverage. In 2014, WHO added their support including an evaluation of the WHO Package of Essential Non-Communicable Disease Interventions (PEN) programme as implemented in Indonesia, and working with other international partners to support HTA development. Aside from WHO, other partners include donors such as USAID and the Department of Foreign Affairs and Trade, Australia, and technical partners such as PATH, South Korea’s National Evidence-based Health Care Collaborating Agency, and Mahidol University, Thailand. Together with Indonesian health officers and key stakeholders, iDSI explored the need, demand and capacity for HTA research in the country, and cultivated partnerships between stakeholders to enable effective translation of HTA research into evidence-informed policy.
A key attribute of iDSI engagement is that it is not purely technical assistance but also emphasises institutional partnerships. Aside from hands-on support for the HTA evaluations, iDSI conducted several workshops, visits, and study tours to share technical and process expertise. Capacity building activities targeted technical aspects of conducting HTA, as well as supporting policymakers absorb HTA outputs to inform decisions. It was important to build on the existing skill base in Indonesia to ensure the sustainability of any evidence-informed processes for priority-setting. Policymakers identified the need to support the national HTA committee, government-related research units such as LITBANG (the National Institute of Health Research and Development), as well as academic institutions and researchers, as part of a broader high level commitment to develop the nascent HTA programme in Indonesia. Through the work of iDSI and our partners on the ground, the Indonesian government has demonstrated high-level commitment to the HTA programme through a willingness to bring together key national stakeholders such as the Ministry of Health and critically the social health insurer Badan Penyelenggara Jaminan Sosial (BPJS), in developing a future roadmap for HTA. This roadmap will include processes and methods for HTA topic selection, assessment, appraisal, and dissemination.
A good example of the applicability of HTA to support universal health coverage is the WHO PEN programme which details a screening strategy for two non-communicable diseases: diabetes and hypertension. In 2011, a PEN programme was widely implemented at a primary care level in Indonesia. A subsequent economic evaluation of PEN, with iDSI support, including an evaluation of two proposed alternative screening strategies, clearly demonstrated that screening is highly cost-effective and leads to greater health gains at population-level versus no screening. The current programme was estimated to reduce healthcare costs by 14.22 million IDR (£675; $1031) per DALY averted, and yield 7.10 more DALYs averted than no screening; and while considered to be the best policy choice overall, cost-effectiveness could be further improved by targeting screening at high-risk groups of population aged 40 and above (Rattanavipapong et al., in press). Throughout the process, local research teams, clinicians and officials took the lead with support from iDSI, highlighting our emphasis on building local capacity.
Two further cost-utility analyses for primary and secondary care interventions are planned, focusing on sildenafil as a treatment for pulmonary arterial hypertension, and interventions for end stage renal dialysis. These could contribute towards improved, evidence-informed clinical guidelines and allow for more efficient and equitable healthcare decisions, as well as form the start of national HTA development and implementation for the next 5-10 years. Nonetheless, challenges remain notably in relation to Indonesia’s lack of epidemiological and costing data, suggesting the need for further support that takes a system-wide approach to the factors conducive to the development and use of HTA. Increased engagement with regional networks such as HTAsiaLink, ASEAN, and other regional counterparts, combined with continued iDSI assistance will be beneficial.