Each year, as many as 64,000 people die from tuberculosis (TB) in Indonesia. Although the Ministry of Health’s (MOH) National TB Program (NTP) has made great progress over the last few years, the country is still one of twenty-two high TB-burden countries in the world. Indonesia is also one of the twenty-seven countries considered to have a high burden of multi-drug resistant TB (MDR-TB). In 2011, the nation reported 6,100 cases of MDR-TB.
Donor funding has been a major factor in the success of Indonesia’s TB program over the last few years, especially The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) grants. Indonesia has, however, progressed economically and is now a relatively low priority for Global Fund grants, which are expected to end or reduce significantly by 2015.
Despite Indonesia’s economic growth, the sustainability of the TB program will be a major challenge without support from this critical donor, especially during the funding transition period.
TB program costs in Indonesia were around $100 million in 2011 and are expected to increase to at least $130 million in 2015, due to the scaling up of TB activities, especially treatment for MDR-TB patients. In 2012, domestic funding will cover approximately 30 percent of the TB program costs. The government has committed to covering most of the remaining 70 percent of costs by 2015.
The MOH’s financial sustainability strategy includes implementing universal health coverage in 2014. Universal health coverage (UHC) is expected to generate additional resources for TB activities, as TB diagnosis and treatment will be part of the benefits package for the whole population, instead of the few who presently have this coverage. Other funding sources will include increased national, provincial, and local government budgets and corporate social responsibility donations.
The MOH will also work to ensure that services are provided and managed in cost-effective and efficient ways.
One challenge to successfully implementing the strategy is that Indonesia’s health care system is decentralized, with funding and service delivery spread across 33 provincial and 530 local governments. These governments do not always follow central government policies or prioritize TB budgets. The TB program will be competing with HIV & AIDS and malaria programs for funding, as their Global Fund grants are also ending.
Under USAID’s TB CARE I project, led by KNCV Tuberculosis Foundation (KNCV), Management Sciences for Health (MSH) is helping the NTP to develop its financial sustainability strategy. The NTP is leading this process and is presenting the strategy to the Global Fund for approval and to the Ministries of Finance, Planning, and Local Governments to advocate for their support.
MSH has also helped the NTP to analyze TB program costs for use in setting insurance reimbursement rates and to develop estimates of the economic burden of TB for advocacy with local governments. Furthermore, MSH is working with the MOH to improve the generation of insurance revenues for TB and to measure the improvements in financial sustainability.
Results from this work will be presented at the Second Global Symposium on Health Systems Research in Beijing and the 43rd Union World Conference on Lung Health in Kuala Lumpur.
In 2013, through TB CARE I, MSH will continue to provide support in costing, insurance, and budgeting to further strengthen the MOH’s financial sustainability strategy. The project will also produce and publish financing sustainability guidelines, which will be distributed to other countries.
David Collins, MA, FCA, is MSH’s director of finance and accounting; he also provides technical assistance to developing country governments in health finance, including costing, insurance and performance-based financing.