USAID Health Financing Activity, Central Jakarta, Indonesia.
Ministry of Health, South Jakarta, Indonesia.
BMC Health Serv Res. 2022 Jan 22;22(1):97. doi: 10.1186/s12913-021-07434-9.
This study analyzed current patterns of service use, referral, and expenditure regarding HIV care under the National Health Insurance Scheme (JKN) to identify opportunities to improve HIV treatment coverage. As of September 2020, an estimated 543,100 people in Indonesia were living with HIV, but only 352,670 (65%) were aware of their status, and only 139,585 (26%) were on treatment. Furthermore, only 27,917 (4.5%) viral load (VL) tests were performed. Indonesia seeks to broaden its HIV response. In doing so, it intends to replace declining donor-funding through better coverage of HIV/AIDS services by its JKN. Thus, this study aims to assess the current situation about HIV service coverage and expenditure under a domestic health-insurance funded scheme in Indonesia.
This study employs a quantitative method by way of a cross-sectional approach. The 2018 JKN claims data, drawn from a 1% sample that JKN annually produces, were analyzed. Nine hundred forty-five HIV patients out of 1,971,744 members were identified in the data sample and their claims record data at primary care and hospital levels were analyzed. Using ICD (International Statistical Classification of Diseases and Related Health Problems), 10 codes (i.e., B20, B21, B22, B23, and B24) that fall within the categories of HIV-related disease. For each level, patterns of service utilization by patient-health status, discharge status, severity level, and total cost per claim were analyzed.
Most HIV patients (81%) who first seek care at the primary-care level are referred to hospitals. 72.5% of the HIV patients receive antiretroviral treatment (ART) through JKN; 22% at the primary care level; and 78% at hospitals. The referral rate from public primary-care facilities was almost double (45%) that of private providers (24%). The most common referral destination was higher-level hospitals: Class B 48%, and Class C 25%, followed by the lowest Class A at 3%. Because JKN pays hospitals for each inpatient admission, it was possible to estimate the cost of hospital care. Extrapolating the sample of hospital cases to the national level using the available weight score, it was estimated that JKN paid IDR 444 billion a year for HIV hospital services and a portion of capitation payment.
There was an underrepresentation of PLHIV (People Living with HIV) who had been covered by JKN as 25% of the total PLHIV on ART were able to attain access through other schemes. This study finding is principally aligned with other local research findings regarding a portion of PLHIV access and the preferred delivery channel. Moreover, the issue behind the underutilization of National Health Insurance services in Indonesia among PLHIV is similar to what was experienced in Vietnam in 2015. The 2015 Vietnam study showed that negative perception, the experience of using social health insurance as well as inaccurate information, may lead to the underutilization problem (Vietnam-Administration-HIV/AIDSControl, Social health insurance and people living with HIV in Vietnam: an assessment of enrollment in and use of social health insurance for the care and treatment of people living with HIV, 2015). Furthermore, the current research finding shows that 99% of the total estimated HIV expenditure occurred at the hospital. This indicates a potential inefficiency in the service delivery scheme that needs to be decentralized to a primary-care facility.
本研究分析了在国家健康保险计划（JKN）下艾滋病毒护理服务的使用、转介和支出模式，以确定提高艾滋病毒治疗覆盖率的机会。截至 2020 年 9 月，印度尼西亚估计有 54.31 万人感染艾滋病毒，但只有 35.267 万人（65%）知晓自己的状况，只有 139585 人（26%）接受治疗。此外，仅进行了 27917 次（4.5%）病毒载量（VL）检测。印度尼西亚寻求扩大其艾滋病毒应对措施。为此，它打算通过更好地覆盖其 JKN 的艾滋病毒/艾滋病服务来取代不断减少的捐助资金。因此，本研究旨在评估印度尼西亚国内医疗保险资助计划下艾滋病毒服务覆盖和支出的现状。
本研究采用定量方法，通过横断面方法进行。分析了来自 JKN 每年生产的 1%样本的 2018 年 JKN 索赔数据。在数据样本中确定了 1971744 名成员中的 945 名艾滋病毒患者，分析了他们在初级保健和医院一级的索赔记录数据。使用 ICD（国际疾病和相关健康问题统计分类），10 个代码（即 B20、B21、B22、B23 和 B24）属于艾滋病毒相关疾病类别。对于每个级别，按患者健康状况、出院状况、严重程度和每笔索赔的总费用分析服务利用模式。
首次在初级保健一级寻求护理的大多数艾滋病毒患者（81%）被转介到医院。72.5%的艾滋病毒患者通过 JKN 接受抗逆转录病毒治疗（ART）；22%在初级保健一级；78%在医院。来自公立初级保健机构的转诊率几乎是私立提供者（24%）的两倍（45%）。最常见的转诊目的地是级别较高的医院：B 级 48%，C 级 25%，其次是最低的 A 级 3%。由于 JKN 按每次住院向医院付费，因此可以估计医院护理的费用。利用可用的权重得分，将医院病例的样本外推到全国水平，估计 JKN 每年为艾滋病毒医院服务支付 4440 亿印尼盾，并支付部分人头费。
接受 JKN 覆盖的 HIV 患者人数不足，只有 25%的接受 ART 的 HIV 患者能够通过其他方案获得服务。这一研究结果与其他关于部分 HIV 患者获得服务和首选服务渠道的当地研究结果基本一致。此外，印度尼西亚艾滋病毒患者对国家健康保险服务利用率低的问题与越南 2015 年的情况类似。2015 年越南的研究表明，负面看法、使用社会健康保险的经验以及不准确的信息，可能导致利用率低的问题（越南行政艾滋病控制，越南的社会健康保险和艾滋病毒感染者：对艾滋病毒感染者参加和利用社会健康保险进行护理和治疗的评估，2015 年）。此外，目前的研究结果表明，艾滋病毒总支出的 99%发生在医院。这表明服务提供计划存在潜在的低效率，需要分散到初级保健机构。
