The Challenges of Monitoring TB Expenditure in Indonesia
In many countries tuberculosis (TB) control programs are scaling-up the detection and treatment of TB cases to reduce the burden on patients, their families and society. This will result in significantly increased costs over the next few years until prevalence begins to fall. At the same time, donor funding is reducing in some of these countries and the challenges of generating domestic resources for financial sustainability are starting to be recognized. To ensure that domestic financing is increasing in line with the needs it is important to monitor expenditures in a timely and regular fashion. This can, however, be difficult as health programs are often financed from several different sources and some of these expenditures are difficult to monitor. This is even more difficult in countries where government is decentralized and where private providers play a significant role.
In Indonesia, the National TB Control Program (NTP) monitors domestic TB expenditures so that it can advocate in areas where financing is too low. The NTP is also required to report domestic expenditure to the Global Fund against AIDS, TB and Malaria to show how program sustainability is progressing. Since the Indonesian Government is decentralized this includes collecting data from 33 provinces and 486 districts. Unfortunately, the provincial and district reporting rates are very low and the figures are sometimes unreliable. Also only government budget expenditures are reported due to difficulties in collecting information from non-government organizations (NGOs) and from insurance schemes. An alternative data collection system, District Health Accounts, which is being rolled out in Indonesia, could provide a more comprehensive view but is not a viable alternative to the NTP data collection system in the medium term as they do not cover all TB expenditures, they are only conducted in a few districts every year, and it takes a long to time to prepare them.
An analysis of the data collection options and challenges indicates that it is not feasible to monitor some elements of domestic TB expenditures in a routine and timely way – namely TB expenditures made by private for-profit and non-profit organizations, expenditures made by patients and expenditures at public health centres. The only TB expenditures that can be monitored in a routine and timely way are those made from government TB budgets and hospital reimbursements for TB made from the national social health insurance scheme.
We recommend continuing to use the NTP data collection and reporting system but it should be strengthened. This includes making improvements to the provincial and district data collection forms, following up on non-submitted forms and greater analysis of the reports and feedback to the provinces and districts. We also recommend removing the requirement for provinces and districts to provide data on non-government expenditures.
We recommend, however, that the NTP collect data from the national health insurance provider on hospital TB claims and payments. Unfortunately, since public and private primary care providers are paid on a capitation basis, it will not be possible to collect TB expenditure data for those providers. However, the total of government budget expenditures and hospital insurance payments should cover a large part of domestic expenditures on TB and can serve as a good indicator of government commitment. Additional analysis of the overall financing picture can be performed using a costing and financing model.