Questions and Answers from the second session of the webinar series "Benefit Package Design for Universal Health Coverage", organised by GIZ. 

Comments

QUESTION: Should we call it Ursu framework :) ? I mean is it published in peer review journal or plan to publish? So that it can be used to assess other countries (from Bhavesh Jain)

The framework has been developed by Mapping Health Ltd. It is planned to be published, yes. Should you need to refer it meanwhile, please ruse the GIZ Indonesia report. And yes, it can be used to assess other countries systems, challenges and develop solutions.

QUESTION: We know that out of pocket expenditure is a principal determinant of access to health care services, what are the measures put in place to reduce if not eliminate out of pocket expenditures (from Paul Mondoa Ngomba)

OOP can have multiple reasons and therefore there is no single answer to it. However, examining the pertinent root causes for OOP and inefficincies, the literature (compare e.g. the WHO World Health Report 2010 - Health systems financing: the path to universal coverage, pages 51-52; 62-63. http://www.who.int/whr/2010/en/) as well as current empirical evidence in Indonesia indicates that medicines and respective national systems are a good place to start. 

QUESTION: Given that access to health care has both demand and supply side requirements, one of which is the presence of the relevant health infrastructure, what is the health insurance scheme doing to bridge supply gaps (from Paul Mondoa)

Currently the role of the national health insurance in Indonesia does not take care of the supply side/ infrastructure. Those tasks remain with the MoH. However, the service reimbursement is executed by the insurance and as such part of the funding of providers is managed by the insurer.

QUESTION: Talking about the decison on the supplier, what is the criteria used to determine the best bidder (from Paul Mondoa)

In Indonesian national tenders the bidder offering the lowest price for a requested volume wins.

QUESTION: Is it ethically acceptable to have same people involved in 2 or more committe responsible for different functions? For example, a cardiologist is a member of Scientific review group AND DRG pricing committe. (from Muhammad Bhadaskoro)

Ideally, there should be no duplication of roles in various functions to avoid conflict of interests, promote transparency and objectivity of decisions. However, due to the limited HR with respective technical knowledge, some double-postings might be unavoidable. What should be avoided at all costs is the conflict of interest whereby the same clinical lead is part of some decision committee, and also involved  the clinical trials of the technology being evaluated.

QUESTION: Based on the framework which country has model which can termed as one of the good practices in a developing / emerging country context, apart from Thailand. Where countries like Vietnam, India or Kenya can learn from? How far is Philippines in this framework? (from Bhavesh Jain)

Mexico, Russia and China have made significant progress in building up their functions and respective information flows in recent years. Philippines is currently establishing the HTA unit and the respective methodology. It is on the way to have this function perform within the decision making flow this year. In parallel, they are looking at creating the flow of information, with a new UnderSecretary who is in charge of harmonising the decision flow for hospitals, devices, pharmaceuticals etc.

QUESTION: How is the integrity of the system? Any corruption issues in evaluation? (from Ousmane Niang)

This was not the main focus of our evaluation. 

Question: Regarding OOP expenditure and health insurance in this case (JKN). Can we say as well that increasing OOP can be interpreted of increasing access in to health care? (from Royasia Ramadani)

Just to clarify the context: In the report we did not state an explicit increase of OOP in Indonesia.
In general terms, OOP are classified as private spending for health care. Increased spending can mean more health care consumption, but also higher prices or lower coverage through pooled public resources. Moreover, OOP is the most unequal and regressive form of funding health care. Therefore the general response is: No, we cannot interpret higher OOP as a sign for greater equal access to health care.

QUESTION: It is a great framework and sequencing. How this framework can be applied to the existing benefit package? It seems like this framework is more appropriate for making decision over new interventions or new drugs into basic benefit package. Thanks (from Pandu Harimurti)

The framework can and should be applied to existing benefit packages. In fact, every country has a (or multiple) packages (implicit or explicit ones), no country starts from a blank canvas. The framework demonstrates key functions a sytsem should have to mantain and manage the package more explicitely. It covers products and technologies, but also addresses service pricing (through the linkage to reimbursement methods).

As such, for the operating package, the framework allows to

  1. Analalyse existing practice through the monitoring function, feeding back into the decision making flow and improving on high cost services (high cost due to high prices or high volumes)
  2. Analyse new interventions just coming into the natinal market.

Realistically, if we speak to decision makers about inclusion or exclusion criteria, the logical decision making goes from:
- Epidemiology/ burden of disease in a country, i.e. prevalence of a disease
- Clinical treatment options, ideally in form of guidelines
- Inputs which go into the treatment. Here, the biggest variance in the cost factor are the products and medicines used.

Considering that no country will exclude the treatment of a prevalent diease per se, it will search for treatment options. The options will depend on the available capacity of the system as well as the products the system is able to pay for.

We propose the framework as a practical step-by-step response to this issue, and we think it depicts a realistic approach to a continuous benefit package design process.