Abstract

BackgroundThis 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.MethodsThis 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.ResultsMost 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.ConclusionThere 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.

Highlights

  • This study analyzed current patterns of service use, referral, and expenditure regarding Human Immunodeficiency Virus (HIV) care under the National Health Insurance Scheme (JKN) to identify opportunities to improve HIV treatment coverage

  • 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)

  • In order to achieve the target, the Ministry of Health has produced an action-plan guideline with a set of intermediate outcomes, such as 90% PLHIV (People Living with HIV) recognizing their status, 90% of those PLHIV who are aware of their status are on antiretroviral treatment (ART), and 90% of those on ART are virally suppressed, in alignment with the Joint United Nations Program on HIV/Acquired Immunodeficiency Syndrome (AIDS) targets in 2020

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Summary

Introduction

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. In order to achieve the target, the Ministry of Health has produced an action-plan guideline with a set of intermediate outcomes, such as 90% PLHIV (People Living with HIV) recognizing their status, 90% of those PLHIV who are aware of their status are on ART, and 90% of those on ART are virally suppressed, in alignment with the Joint United Nations Program on HIV/AIDS targets in 2020. This will be expanded to triple 95% coverage when it comes to strategy by 2030. In an effort to bolster sustainable HIV financing through the JKN scheme, a general overview of the current utilization pattern is required as a policy baseline to increase treatment coverage

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