Indonesia’s pursuit of universal health coverage: challenges in selecting high-value healthcare and preventing waste

This was an invited guest blog written by colleagues in Thailand’s Health Intervention and Technology Assessment Program.

Health care technologies, including medicines, vaccines, and devices, contribute towards improved health outcomes but are also drivers of the rising costs of healthcare. Therefore, in the interest of sustainability it is essential to assess the value of these technologies on a regular basis. Indonesia, the fourth most populous country in the world, has a prime example of an evolving health system that is facing rising health care costs. This challenge, along with Indonesia’s transition from official development assistance for health and a budget deficit facing the country’s social insurance administration organization (called BPJS), which administers the national health insurance program, have made health technology assessment (HTA) a critically important tool. HTA can help policy makers to set priorities and ensure effective resource allocation, which in turn can help support the longevity of universal health coverage (UHC). This blog briefly describes Indonesia’s HTA initiative, which is in a nascent stage—like a toddler learning to walk on its own.

Since 2014, the International Decision Support Initiative (iDSI), led by Thailand’s Health Intervention Technology Assessment Program (HITAP) and Imperial College London’s Global Health and Development Group, has been liaising with the Health Technology Assessment Committee (HTAC)  in Indonesia’s Ministry of Health. Over the last five years, with iDSI’s technical support, the HTAC has commissioned seven studies that local stakeholders identified as being important; each of these studies have had a significant impact on health policy in Indonesia.

In 2017 and 2018, four studies were conducted on drugs that are “budget burners” for BPJS. The first explored the irrational use of nilotinib (a leukemia drug); it found that USD 0.5 million could be saved if imatinib prescription practices follow the national guidelines. The second study was a systematic review comparing the effectiveness of analogue insulin with human insulin. The review pointed out that despite the guidelines recommending the use of human insulin as first-line treatment, analogue insulin is widely used (accounting for 99% of total insulin prescription) in Indonesia, and the average price of human insulin is two to four times more expensive than peer countries. The reason for this high price is the monopoly of a single provider over the insulin market in Indonesia. If the price of insulin analogue were to be negotiated successfully and/or the prescription pattern changed to be more favorable to human insulin, there is the potential for savings of USD 9 million annually.

The last two studies investigated the cost effectiveness of bevacizumab and cetuximab, respectively, along with chemotherapy for cancer treatment. These cancer drugs are not reimbursed by developed economies such as the United Kingdom but can be obtained under the benefits package in the UHC scheme in Indonesia. The study of bevacizumab found that if this drug is removed from the benefits package, a total of USD 14 million could be saved by the UHC provider (BPJS). Similarly, the cetuximab study found that if this drug is removed from the benefits package, BPJS could save up to USD 8.4 million without any significant impact on health outcomes.

Taken together, these four studies show that around USD 32 million could be saved through more rational prescribing practices; this sum could be invested instead in interventions that have a significant, proven impact on improving health outcomes. Following the studies’ recommendations, the decision to remove cetuximab and bevacizumab from the benefit package has already been made and other recommendations are under deliberation by policy makers.

Reaching UHC in Indonesia is a major task, one that will place a huge fiscal burden upon the UHC provider. Thus, along with strong political commitment, low and middle-income countries need to develop local capacity for health priority setting to strategically purchase and negotiate the price of medical technologies, and to make decisions that are relevant to the context. This will help in preventing waste of healthcare resources, strengthening health systems, and ultimately safeguarding public interests.

About the Authors:

Manushi Sharma, International Cooperation Officer, HITAP and Yot Teerawattananon, Founding Leader, HITAP.