FOR OFFICIAL USE ONLY Report No: RES57817 INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT RESTRUCTURING PAPER ON A PROPOSED PROGRAM RESTRUCTURING OF NATIONAL HEALTH INSURANCE (JKN) REFORMS AND RESULTS PROGRAM APPROVED ON DECEMBER 15, 2021 TO THE REPUBLIC OF INDONESIA Health, Nutrition & Population Global Practice East Asia And Pacific Region Regional Vice President: Manuela V. Ferro Country Director: Satu Kristiina Jyrintytar Kahkonen The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) Regional Director: Alberto Rodriguez Practice Manager: Ronald U. Mutasa Task Team Leader(s): Zelalem Yilma Debebe, Somil Nagpal The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) ABBREVIATIONS AND ACRONYMS ANC Antenatal Care AWPB Annual Work Plan and Budget Badan Perencanaan Pembangunan Nasional (Ministry of National Development Bappenas Planning) BMGF The Bill and Melinda Gates Foundation BP Benefits Package BPJS-K Badan Penyelenggaran Jaminan Sosial-Kesehatan (National Health Insurance Agency) Badan Pengawasan Keuangan dan Pembangunan (Finance and Development BPKP Supervision Agency) CISA Certified Information System Auditor COVID-19 Coronavirus disease 2019 DFAT Department of Foreign Affairs and Trade (Australian Government) DG Directorate General DJSN Dewan Jaminan Sosial Nasional (National Social Security Council) DLI Disbursement-Linked Indicator DLR Disbursement-Linked Result DRG Diagnosis-Related Group E&S Environmental and Social e-Klaim Information-Technology Based Claims System from MOH ESCP Environmental and Social Commitment Plan F&C Fraud and Corruption Fasilitas Kesehatan Rujukan Tingkat Lanjutan (Advanced-Level Referral Health FKRTL Facilities/Hospitals) FKTP Fasilitas Kesehatan Tingkat Pertama (Primary-Level Health Care Facilities) FY Fiscal Year GA Grant Agreement GoI Government of Indonesia HSTA Health System Transformation Agenda HTA Health Technology Assessment IA Implementing Agency IBRD International Bank for Reconstruction and Development IHCA MDTF Indonesia Human Capital Acceleration Multi-donor Trust Fund INACBG Indonesia Case Base Group IPF Investment Project Financing ISM Implementation Support Mission ISR Implementation Status and Results JKN Jaminan Kesehatan Nasional (National Health Insurance) The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) Kementerian Koordinator Bidang Pembangunan Manusia dan Kebudayaan Kemenko PMK (Coordinating Ministry for Human Development and Cultural Affairs) Labkesmas Public health laboratory M&E Monitoring and Evaluation MoF Ministry of Finance MoH Ministry of Health MoHA Ministry of Home Affairs MTaPS Medicines, Technologies, and Pharmaceutical Services PAP Program Action Plan P-care BPJS-K’s primary health care information system PDO Program Development Objective PforR Program-for-Results PHC Primary Health Care Posyandu Pos Pelayanan Terpadu (Integrated Health Service Posts) PPK Pejabat Pembuat Komitmen (Commitment Making Cfficers) Pusat Kebijakan Pembiayaan dan Desentralisasi Kesehatan (Center for Health PusjakPDK Financing and Decentralization Policy) Puskesmas Pusat Kesehatan Masyarakat (Public Primary Health Centers) Pustu Puskesmas Pembantu (Puskesmas Helper) Q Quarter RA Results Area RETF Recipient-Executed Trust Fund Rencana Pembangunan Jangka Menengah Nasional (National Mid-Term Development RPJMN Plan) SIAF Sistem Informasi Akreditasi FKTP (FKTP Accreditation Information System) Sistem Monitoring dan Evaluasi Jaminan Sosial (DJSN Monitoring and Evaluation SISMONEV Dashboard) SISRUTE Sistem Rujukan Terintegrasi (Integrated Referral System) SOP Standard Operating Procedure SORT Systematic Operations Risk-Rating Tool TA Technical Assistance TB Tuberculosis TWG Technical Working Group Unit Kerja Pengadaan Barang/Jasa (Procurement Work Unit UKPBJ Goods/Services US$ United States dollar USAID United States Agency for International Development Virtual Klaim (information-Technology Based Application for Hospitals to Submit Billing V-klaim Claims to BPJS-K) The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) DATA SHEET (National Health Insurance (JKN) Reforms and Results Program - P172707) BASIC DATA Project ID Financing Instrument IPF Component P172707 Program-for-Results Financing Yes Environmental and Social Risk Classification (ESRC) (IPF Component) Low Approval Date Current Closing Date 15-Dec-2021 30-Sep-2026 Organizations Borrower Responsible Agency Republic of Indonesia Program Development Objective(s) The program development objective is to strengthen the quality and efficiency of Indonesia's National Health Insurance program. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing (US$, Millions) Net Approval Effectiveness Closing Ln/Cr/TF Signing Date Commitment Disbursed Undisbursed Date Date Date IBRD-93160 15-Dec-2021 17-May-2022 17-May-2022 30-Sep-2026 400.00 100.00 300.00 24-Nov- TF-B7496 16-Sep-2022 04-Oct-2022 31-Dec-2023 1.80 .72 1.08 2021 Policy Waiver(s) Does the Program require any waivers of Bank policies applicable to Program-for-Results operations? No Page 1 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) I. PROGRAM STATUS AND RATIONALE FOR RESTRUCTURING This restructuring Program Paper proposes three changes to the National Health Insurance (JKN) Reforms and Results Program (PforR): i) extension of the closing date for the Grant Agreement under the Investment Project Financing (IPF) component from December 31, 2023 to June 30, 2025, ii) restructuring of DLI1, and iii) restructuring of DLI 9. The Program, in the amount of US$400 million, aims to improve the quality of health services and efficiency of JKN. It was approved in December 2021 and became effective on May 17, 2022. The PforR is structured around 3 result areas (RAs) and consists of 9 Disbursement Linked Indicators (DLIs). The first RA is focused on strengthening the quality of care. This includes the development of a) a clinical decision support tool for Primary-Level Health Care Facilities (Fasilitas Kesehatan Tingkat Pertama; FKTPs), b) development of clinical pathways for the most common hospital level conditions, c) training frontline providers in utilizing the clinical decision support tool(s), and d) identifying tracer indicators to monitor compliance with clinical guidelines (DLIs 1 and 2). The second RA is about improving the efficiency of the National Health Insurance Program spending. This includes a) incorporating findings from Health Technology Assessments (HTAs) into benefits package (DLI 3), b) improving claims management and fraud detection processes (DLI 4), c) improving primary health care provider payment design (DLI 6), and d) improving implementation of Indonesia’s Case Based Group (INACBG) hospital provider payment system (DLI 7). The third RA supports JKN policy formulation and implementation by improving use of data in decision-making (DLI 5), improving policy formulation and oversight of JKN (DLI 8), and improving management and coordination of JKN across stakeholders (DLI 9). The Program includes an IPF component in the amount of US$2.33 million recipient-executed grant from the Bill and Melinda Gates Foundation (BMGF) through the Indonesia Human Capital Acceleration Multi-donor Trust Fund (IHCA MDTF). A Grant Agreement for US$1.8 million was signed on September 16, 2022 and became effective on October 4, 2022.1 This initial IPF grant component was envisaged to cover the first two years of the Program’s duration and had an original end date of December 31, 2023. The grant resource is meant to support (a) hiring a pool of consultants and specific technical experts for the Secretariat to provide technical support to other stakeholder agencies (including the MoH, BPJS- K, DJSN, MoHA, and Bappenas) for their implementation of the PforR; (b) enhanced coordination for JKN stakeholders, including regular communications and convening of Technical Working Groups (TWG) comprising representatives from all relevant units and departments within the key stakeholder agencies; (c) strengthening the Secretariat’s monitoring and evaluation function to track progress, learn, course-correct, and evaluate the program’s impact and effectiveness; and (d) generating knowledge and providing lessons learned for other countries for continuous learning, as well as to provide synthesized inputs into Government policy. There is satisfactory progress in implementation of the Program, particularly accounting for the Program’s effectiveness only by May 17, 2022. An advance amounting to 25% of the loan was disbursed on July 28, 2022. Following the effectiveness of the Grant Agreement the IPF component of the Program has, so far, disbursed US$724,400 of the available US$1.8 million (~40%). With the Secretariat Team Leader, M&E specialist and Financial and Procurement specialist now in place, the Secretariate has been executing its coordination role at a rapid pace. However, its function in hiring experts that provide technical assistance to implementing units and generating knowledge and providing inputs to policy making has not yet picked up. Progress towards achievement of the Program Development Objective (PDO) is satisfactory and the proposed restructuring will not involve changes to the PDO, or to the PDO indicators of the Program. The achievement of the PDO, 1 The remaining ~US$550,000 has been received by the Bank. The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) strengthening the quality and efficiency of Indonesia’s National Health Insurance program, is measured by the following PDO-level results indicators: (a) provider competence score in FKTPs; (b) member satisfaction rate; (c) percent of outpatient utilization among bottom two quintiles; and (d) more sustainable JKN claims ratio. As of the most recent Implementation Status and Results (ISR) reports, two of the four PDO indicators have shown improvement. JKN member satisfaction rate continues to be used as BPJS-K performance monitoring indicator, and has increased to 89.6%, surpassing the end line target for the program. Claims ratio also stands below the Program target of 98%. This surplus is, to a large extent, due to the COVID-19 induced decline in utilization of services and the upward revision of the contribution rates in 2020. After a significant decline to 68% in 2020, and 78.8% in 2022 (i.e increased surplus), the claims ratio is bouncing back, and stands close to 95% over the initial 6 months of 2023. This suggests a significant need to address the efficiency issues this program set out to achieve. The COVID-19 induced decline in utilization of outpatient care has also affected the utilization of the bottom 40% households in 2022. This is expected to improve as overall utilization rate is improving in the endemic phase of COVID-19. The first PDO indicator, improved provider competency score in FKTPs, is not yet due, as this is supposed to be measured as part of the roll-out of the clinical decision support tool under DLI 1. Table 1. DLI implementation progress DLI Implementation Progress DLI 1. Improved quality • MoH already developed the clinical decision support tool for primary care (with TA of care in primary care from the World Bank), which was on track to meet the current description of DLI 1. health facilities/ FKTPs However, the leadership has requested that the tool includes the MoH’s new Care Pathway for health promotion and preventive services at Posyandu, Pustu and Puskesmas level. The integration of the two tools and identification of tracer indicators is underway. The change in direction re vision of the tool delayed the achievement of both Year 1 and 2 targets for this DL1 and associated DLI 4 and 6. • This DLI is one of the DLIs proposed for restructuring- though it is expected to be back on track very quickly, despite the enhanced mandate. DLI 2. Improved quality • MoH has developed 9 hospital clinical pathways. However, the developed pathways of care at referral are currently not fully compliant with the minimum features set out in the hospitals/ FKRTLs Verification Protocol (VP), a key requirement being the concise algorithmic approach to patient management. There are ongoing discussions with higher level officials to ensure compliance to the original vision. The delay in this DLI has also affected progress in DLI4, which depends on the outputs from this DLI. DLI 3. HTA findings • MoH has already revised the Health Technology Assessment (HTA) guideline, which incorporated into the is a Year 1 target. The revised guideline has been published on PusjakPDK-MoH benefit package (BP) website. The revised HTA Guideline was led by the HTA committee at MoH, with close technical assistance and support from the World Bank and its partners International Decision Support Initiative and the Gates Foundation, and also drawing upon support from USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program and DFAT. The Year 2 target is slightly behind schedule, but 7 HTA studies are in the process (3 studies are expected to be completed by September 2023, 2 studies by December 2023 and, another 2 studies by February/March 2024). The pace of HTA production is expected to pick up further and overall the targets for the Program are expected to be on track. DLI 4. Improved claims • Year 1 target of revising and adopting manuals/guidelines and/or protocols for management and claims management, prevention of ineligible and unnecessary claims, and audit prevention of processes has been reported as achieved in 2022, and is expected to be submitted ineligible and for verification in October 2023. unnecessary claims • Year 2 target of integrating tracer indicators from DLI 1 and DLI 2 into the claims processing software is delayed due to the delays in outputs from the source DLIs. • Year 2 target of conducting 250 hospital claims audit […] has been reported as achieved, pending verification. The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) DLI 5. Improved use of • While substantial progress has been made in the integration of data systems for the data in decision Year 2 target, a roadmap that meets the requirements of the VP for the Year 1 target making has not been developed yet. MoH and BPJS are now coordinating to develop this, with some TA from the grant resource under the IPF component. • Integration of 3 of the 5 data systems required to be integrated in the lifetime of this PforR has been completed (e-Klaim and V-klaim, P-care and V-Klaim, Membership database and V-Klaim). Integration of V-Klaim with SISRUTE and SIAF (accreditation information system) is planned/ongoing. DLI 6. Improved design • MoH and BPJS-K have jointly developed and approved the roadmap for revising the & implementation of primary care payment system (Year 1 target), which includes milestones and the PHC payment methods timeline for the introduction of risk-adjusted capitation and piloting for the expansion of indicators under the performance-based capitation reform. • Permenkes 3 of 2023 has already introduced risk-adjusted capitation, revised the supply side readiness criteria for the base capitation (from doctor availability to doctor-to-member ratio) and special capitation tariff for facilities in remote areas. The revision was evidence based. • Progress towards Year 2 target is on track. MoH is planning a pilot in 2023 for the expansion of KBK indicators. BPJS will issue a regulation after the pilot and all 10 indicators will be applied at once. While Permenkes 3 of 2023 is already implemented, it does not include expansion of indicators for performance-based capitation. So, achievement of these targets will have to wait for the pilot implementation of performance-based capitation. DLI 7. Improved • Year 1 target is in progress, but a bit delayed. The cost-accounting template has implementation of been completed, and an application has been developed to collect cost data from hospital payments hospitals. A clinical coding audit protocol for tuberculosis (TB) and Pneumonia has been developed and used for coding audit in 11 randomly selected hospitals. This is now being used as a basis to develop the generic audit protocol (supported by TA from the World Bank). The clinical coding training course and the clinical coding guideline are still under revision. The latter will require issuing a Ministerial regulation. MoH plans to draft this and discuss with stakeholders latest by end of 2023. The curriculum revision will include amendments to the certification assessment test. • Year 2 target for the training and certification of at least one coder from 500 hospitals has been partially achieved and will be reported for verification in October. By end of September 2023, 350 will have been trained. DLI 8. Improved policy • Year 1 target of developing dashboard of key monitoring indicators is almost fully formulation and achieved. 10 of the 11 indicators are already included in the dashboard with the oversight of JKN corresponding disaggregation. The dashboard is functional and being used by DJSN in briefings and reports. The indicator capturing “% of claims that are rejected […]") is currently not in the dashboard because data is not shared by BPJS and BPJS does not characterize them as rejected claims, but, rather, as pending claims. The latter data has recently been shared and will be integrated in the SISMONEV dashboard. TA from the grant IPF component will be used to improve this dashboard for data management and communication in the coming months. • Year 2 target is delayed, as the externally published annual performance report on JKN has not been produced yet. DLI 9. Improved • Year 1 target is partially achieved. The JKN Secretariat has been established and coordination, impact, strengthened by MoF Decree No. 12/KMK.2/2023 regarding the Secretariat Team of and sustainability of the National Health Insurance System Grant Executing Agency (Reforms and Result JKN Project). This decree solidifies the structure and authority of the JKN Secretariat, ensuring its effective functioning and implementation of the JKN PforR. The Secretariat has also been staffed by a Team Leader, M&E specialist, and Finance & Administration specialists. • The Secretariat has requested to restructure DLI 9, by dropping DLR 9.2 and introducing 2 new DLRs. The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) Overall implementation progress is satisfactory. Each of the 4 implementing agencies has made good progress on Program activities spanning across all three RAs of the program, though there are some delays in key DLIs, one of which is being restructured (DLI 1). There has been substantial progress towards achieving Year 1 and Year 2 DLI targets, which will be verified by the third-party verification agency (the National Development and Financing Supervision Agency, or Badan Pengawasan Keuangan dan Pembangunan; BPKP) by December2023, with an expected disbursement of US$60.7 million by Q4 of FY24. The disbursement would bring the cumulative disbursement to 40 percent, which is close to projections for the Program at effectiveness. Although MoH has also made a lot of progress on DLI 1 and DLI 2 (the development of clinical decision support tool for primary care and clinical pathways for hospitals, respectively), the progress has been delayed due to two factors. First, the vision of the leadership on the content of DLI 1 has expanded to go beyond a focus on clinical management to also include preventive and promotive services deemed critical to ensure healthy population and ease financial burden on JKN. As such the tool already developed under DLI 1 had to be revisited to cater to this broadened vision (this is one of the proposed restructurings). Second, the referral health service unit of MOH has been pushing back on the vision of developing an algorithmic standardized clinical pathway under DLI 2 and insisted on proceeding with a checklist form which is not aligned to the original vision of the Program and importance of linking these pathways to claims processing software. These technical discussions took time to resolve. Due to the interconnected nature of DLIs, and the centrality of DLI 1 and 2, the progress in DLI 4 and DLI 6 has been delayed slightly. The program ratings are satisfactory, with the exception of fiduciary systems and E&S systems, which are rated Moderately Satisfactory; all legal covenants are complied with. There is no pending audit report. While all legal covenants are complied with and the technical Program Action Plan (PAP) relating to the establishment of a TWG is in place, the remaining PAP items are either not yet complete, or not yet due. This is mainly because of the delay in the establishment of the Secretariat, as well as in the appointment of a focal person to oversee the completion of the PAPs. The Secretariat has been requested to facilitate the appointment of focal persons to lead and/or oversee the completion/compliance of the PAPs, coordinate the mobilization of technical assistance (TA) and use grant resources to support the implementation of the PAP items (e.g., financing studies, technical workshops, and consultations). Completion of several of the PAP items and status update on all PAP items is expected by the next ISM in December 2023. On the IPF side, the ESCP milestones have been met and will continue to be monitored. II. DESCRIPTION OF PROPOSED CHANGES The first proposed change is extension of the closing date of the Grant Agreement (GA) for the RETF under the IPF component from December 31, 2023 to June, 30 2025. This extended timeline is within the existing program duration which is closing September 2026. The original grant for the IPF component was envisioned to support the implementation of the Program for the first two years. However, the Program and grant only became effective in May and October 2022, respectively. While the Secretariat has expedited the necessary coordination of stakeholders to ensure implementation progress, the important functions of facilitating TA needs, monitoring and evaluation of PAPs and knowledge generation activities have not taken off yet. As these are critical for the reform efforts, the grant resource availability beyond December 2023 will be important. In fact, the MoF requested extension till December 2025 (letter dated August 1, 2023). However, given the parent MDTF has an End-Disbursement-Date of December 2025, the RETF is expected to close by June 2025. As such, the longest duration of extension possible is June 2025. This has been communicated and agreed upon with the secretariat. The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) The second change relates to restructuring DLI 1 to accommodate recent policy priorities in the MoH. The focus of DLI 1 was to develop and implement a clinical decision support tool for primary care services, the core aspect of which was the case management/treatment course for those who present themselves with a symptom and/or healthcare need at FKTP level. However, the MoH’s Health System Transformation Agenda (HSTA) in 2022 placed significant emphasis on improving preventive and promotive health services starting from the household level. This renewed focus mandates the strengthening of Puskesmas/FKTPs in carrying out preventive, promotive, and screening services, with the objective of catching diseases before they become complicated. Aligned with this, the Honorable Minister directed the team to expand the vision of the tool developed under DLI 1 to go beyond clinical diseases management of patients who come to the health facilities for curative and preventive services and include Care Pathways for preventive and promotive health services starting from the household level—i.e., Posyandu, Pustu, and Puskesmas—to Referral Services. The proposed restructuring is critical for prevention and early diagnosis of diseases which in turn is expected to reduce the incidence of disease complications and utilization of expensive hospital level care and improve the financial position of JKN. Although a very important step for the achievement of the PDO, this new direction affects the timeline for the development, adoption, and training of providers in the tool, requiring restructuring of the two DLRs under DLI 1 (see Table 2). The third change relates to restructuring DLI 9 to address the lack of synchronization of timing for the achievement of DLR 9.2 target with the National Mid-Term Development Plan (Rencana Pembangunan Jangka Menengah Nasional; RPJMN) it was supposed to inform and put in place an accountability mechanism for MOF to ensure the annual work plan and budget of MOH and BPJS-K reflects activities needed to meet respective DLIs. DLR 9.2 requires the Program Secretariat to compile and analyze JKN data and provide recommendation on the JKN-related objectives for the new RPJMN in Year 4 of the program. Because RPJMN covering the period 2025-2029 is already under preparation and this is a Year 4 target for MoF, the client has requested to replace this DLR with a more impactful result that MoF can influence, namely ensuring i) the annual work plan and budget of the MoH and BPJS-K reflects activities for the achievement of year-specific JKN program objectives (revised DLR 9.2 but conceptually new DLR); and ii) the production and dissemination of evidence and policy briefs to improve JKN implementation and sustainability (new DLR 9.3 but conceptually similar to current DLR 9.2). The fact that the Secretariat is placed within DG Budget makes this conceptually new DLR a feasible and crucial result area to ensure budget availability for implementing units to execute activities critical for the respective DLIs. DLR 9.3 maintains the original vision to enable evidence-based decision making. As such, the WB team finds the request for restructuring justified and important for the overall achievement of the PDO. The restructuring of DLI 1 requires adjustment to the Results Framework, but there is no change to the Program boundary and allocation of loan across DLIs. As the roll out of the implementation of the Care Pathway and case management tool (DLI1) is delayed, the provider competence related PDO indicator and intermediate results indicators will be adjusted to reflect that the baseline competency assessment will be established in 2024, rather than 2022. In addition to changes in the results framework due to restructuring of respective DLIs, the client requested to adjust one of the intermediate results indicators during the most recent Implementation Support Mission in June 2023 (i.e. The percent of hospital claims that are rejected/not verified…). The National Health Insurance Agency (BPJS-K) noted that there is no claim that is rejected per se but that it could be pending for more than the duration it is supposed to be settled by. As such, the client has proposed to change this indicator by ‘ percent of claims that were pending settlement for more than 14 days in a given month’. This newly proposed indicator is one of the 11 key indicators that are being featured in the National Social Security Council’s (DJSN) monitoring and evaluation (SISMONEV) dashboard. The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) Table 2. Summary of the proposed DLI changes Changes Current DLR Proposed DLR wording Comment on the New Verification Protocol in… wording changes DLI 1 - Improved quality of care in primary care health facilities/ FKTPs DLR 1.1 MoH has MoH has developed, The word “decision BPKP will carry out a desk review of the Care Pathway in two formats developed, approved, and adopted support tool” is – a hard copy and an electronic copy. At minimum, the case approved, and a care pathway for proposed to be management part of the tool should be searchable both by symptoms adopted a clinical promotive, preventive changed to “care and conditions, with additional guidance on how to address general decision support and screening services pathway for health visits and emergencies. Guidance should be arranged in concise tool for FKTP in and case management promotive, algorithms, with clear guidance on what questions to ask to assess Year 1. tool (care pathway) for preventive and patient history, what investigations or tests to conduct, how to FKTPs by the end of screening services interpret findings, and how to treat and manage patients based on Year 2023 and case diagnosis. The case management part of the tool should cover all management” common adult conditions encountered in an FKTP setting as agreed with the GoI. It should include guidance on when and where to refer DLR 1.1 is still a time patients. Finally, it should recommend tracer indicators to monitor bound DLR but rather compliance with standard treatment guidelines. than completion by Year 1 it is now expected to be The care pathway should also include approach to a healthy individual completed by end of for preventive (including screening) and promotive procedures Year 2023. appropriate to age, sex, and other attributes of the individual. In cases where screening results in the identification of any abnormal findings, or the patient already presents any symptoms, the case management part of the Care Pathway will be followed. The BPKP verification process will review the documents produced are in compliance with the care pathway description above, and include the preventive (including screening) and promotive procedures applicable to different groups of individuals, and the algorithm for evaluation of screening results. DLR 1.2 MoH has trained MoH has trained 90% The interim targets BPKP will review the training agenda, manual(s), and training 90% (cumulative) (cumulative) of all are adjusted because documentation, including the list of FKTPs and personnel participating The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) of all FKTPs on FKTPs on the of the delay in in the training exercise, and the assessment of provider competence the clinical implementation of the implementation. carried out before and after the training. At least 2 key front line decision support care pathway for personnel who have a role in seeing patients (e.g., doctors, nurses, tool. promotive, preventive In 2023, MoH will midwives) should participate in the training. BPKP may also verify and screening services develop the training training registration and receipts from training events, and randomly and case management curriculum and call participants (e.g., 0.05% of participants) to verify training took Target: tools. modules of care place. pathways 2023 – 10% Target: The percent of FKTPs that are trained to use the clinical decision support tool is defined as: 2024 – 50% 2023 – Numerator: Total number of public and private FKTPs (excluding solo 2025 – 90% 2024 – 30% practitioners) who had at least 2 of their key front line personnel 2025 – 90% trained in the use of the clinical decision support tool. Denominator: Total number of public and private FKTPs contracted with JKN (excluding solo practitioners). This DLI is scalable and in accordance to the number of FKTPs trained. DLI 1 The unit In addition to The new unit is added responsible responsible for Directorate of Primary because the focus on unit DLI 1 is Care Services, promotive, and Directorate of Directorate of Public preventive services Primary Care Health Governance will would require strong Services. be added as the coordination with responsible unit. Directorate of Public Health Governance. DLI 9 - Improved coordination, impact, and sustainability of JKN DLR 9.2 Program The Program The change is BPKP will carry out a desk review to verify that the approved Annual Secretariate Secretariat ensures the required because the compiles and Annual current DLR is Work Plan and Budget of the Ministry of Health and BPJS Kesehatan analyzes JKN data unsynchronized with includes all the activities relevant and necessary for the achievement and provides Work Plan and Budget the timing for the of the respective year DLI targets (including unachieved DLIs carried recommendation of the Ministry of preparation of the forward from previous years) are included and appropriately funded s on the JKN- Health and BPJS in accordance with the scope of the activity. The verification process related will review records and documentation pertaining to the secretariat The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) objectives for the Kesehatan is relevant next release of having undertaken discussions and assessed the activities necessary new RPJMN in for the RPJMN 2025 - 2029. for the achievement of the upcoming DLIs prior to the budget cycle. It Year 4. will also review records around the tracking and monitoring of achievement of the JKN performance during the implementation year vis-a-vis the AWPB. Reform PforR objectives. The amount The amount allocated allocated for DLR for DLR 9.2 is changed 9.2 is US$ to US$ 7,500,000 (i.e., 10,000,000. US$2.5 million for each year starting 2023). DLR 9.3 N/A Program Secretariat This is a new DLR BPKP will undertake a desk review of the analysis undertaken and the produces and synthesis of this analysis and verify that these evidence and policy disseminates with briefs were produced, and that the dissemination event with relevant authorities a participation of the relevant authorities took place through review of compendium of documentations. The verification will also examine whether the topic evidence and policy is relevant to JKN sustainability and implementation issues. briefs to improve JKN implementation and sustainability. The amount allocated for this new DLR 9.3 is US$2.5 million The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) III. SUMMARY OF CHANGES Changed Not Changed Change in Results Framework ✔ Reallocation between and/or Change in DLI ✔ Change in IPF Component ✔ Other Change(s) ✔ Change in Implementing Agency ✔ Change in Program's Development Objectives ✔ Change in Program Scope ✔ Change in Loan Closing Date(s) ✔ Change in Cancellations Proposed ✔ Change in Disbursements Arrangements ✔ Change in Disbursement Estimates ✔ Change in Systematic Operations Risk-Rating Tool ✔ (SORT) Change in Legal Covenants ✔ Change in Institutional Arrangements ✔ Change in Implementation Schedule ✔ IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_COMPONENTS_TABLE . The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) ANNEX 1: RESULTS FRAMEWORK . . Results framework Program Development Objectives(s) The program development objective is to strengthen the quality and efficiency of Indonesia's National Health Insurance program. Program Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 Strengthened quality (Action: This Objective has been Revised) Increased above baseline values for Improved provider competency score in To be determined in 2024 at least 70 percent of all providers FKTPs (Text) assessed Action: This indicator has been Revised Improved member satisfaction rate and Above 82% Above 82% Above 82%(and continued as BPJS its continued use as a BPJS-K 0.82 (and continued as BPJS (and continued as BPJS performance performance indicator) performance monitoring indicator (Text) performance indicator) indicator) Enhanced Efficiency Page 13 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 Increase in the % of outpatient utilization among bottom two quintiles 13.20 14.20 15.20 (Percentage) More sustainable claims ratio (Text) 1.02 <98% <98% <98% PDO Table SPACE Intermediate Results Indicators by Result Areas RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 Improving quality The competence scores are Improved provider competency on Baseline to be determined increased for at least 70 percent of maternal care disaggregated (Text) the providers assessed. Action: This indicator has been Revised Share of FKTPs trained in using the clinical decision support tool 0.00 30.00 90.00 (Percentage) Action: This indicator has been Revised Number of clinical diagnostic, treatment, or referral guidelines formulated into 0.00 5.00 10.00 20.00 processes of care for FKRTLs (Number) Increase in the % of antenatal care visits in-line with clinical protocols Baseline in Year 2024 To be determined disaggregated by province (Text) Page 14 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 Action: This indicator has been Revised Number of maternal deaths caused by hypertension disaggregated by province 1,066.00 <900 (Text) Increase in the % of adults screened for diabetes and hypertension in-line with Baseline in year 2024 To be determined clinical protocols (Text) Action: This indicator has been Revised Improving efficiency Recommended tracer indicators embedded and automated in the claims 15 FKTP and 3 FKRTL tracer 15 FKTP and 7 FKRTL tracer verification software to monitor 0.00 indicators embedded and indicators (cumulative) embedded 25 (15 for FKTP and 10 for FKRTL) compliance with evidence-based care automated and automated (Text) Decrease in the % of claims that were pending settlement for more than 14 To be determined To be determined days (Text) Action: This indicator has been Revised Number of additional performance and quality indicators included in primary 3.00 8.00 13.00 care payment system (Number) Cumulative number of FKRTLs with trained and certified clinical coders 0.00 500.00 1,100.00 1,800.00 (Number) Support JKN policy formulation and implementation Page 15 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 Number of information systems To be determined by roadmap 0.00 integrated as per roadmap target (Text) Dashboard for internal policy use Improved policy formulation and DLI Annual report for previous year Annual report for previous year NA in place; Annual report for oversight of JKN (Text) 9.3 published published previous year published IO Table SPACE Disbursement Linked Indicators Matrix DLI IN01340988 ACTION DLI 1 Improved quality of care in primary care health facilities/ FKTPs Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 47,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - Until September 30, 2022 - 0.00 - Oct 1, 2022 to Sep 30, 2023 - 0.00 - Oct 1, 2023 to Sep 30, 2024 - 0.00 - Oct 1, 2024 to Sep 30, 2025 - 47,000,000.00 NA Page 16 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) DLI IN01340989 ACTION DLI 1.1 MOH has developed, approved and adopted a clinical decision support tool for FKTPs in Year 1 Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 20,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline Clinical decision support tool to develop A clinical decision support tool for FKTPs has been Until September 30, 2022 20,000,000.00 $20,000,000 by the end of Year 1 developed, approved and adopted in Year 1 Oct 1, 2022 to Sep 30, 2023 NA 0.00 NA Oct 1, 2023 to Sep 30, 2024 NA 0.00 NA Oct 1, 2024 to Sep 30, 2025 NA 0.00 NA Action: This DLI has been Revised. See below. DLI IN01357661 ACTION MoH has developed, approved, and adopted a care pathway for promotive, preventive and screening services and case DLI 1.1 management tool (care pathway) for FKTPs by end of year 2023 Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 20,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline Care pathway tool not developed Until September 30, 2022 NA 0.00 Page 17 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) A care pathway tool for FKTPs has been developed, Oct 1, 2022 to Sep 30, 2023 20,000,000.00 $20,000,000 by the end of Year 2 approved and adopted by end of year 2023 Oct 1, 2023 to Sep 30, 2024 NA 0.00 NA Oct 1, 2024 to Sep 30, 2025 NA 0.00 NA DLI IN01340990 ACTION DLI 1.2 MOH has trained 90% (cumulative) of all FKTPs on the clinical decision support tool Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 27,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline NA Until September 30, 2022 NA 0.00 NA US $300,000 for each one percentage MOH has trained 10% (cumulative) of all FKTPs on Oct 1, 2022 to Sep 30, 2023 3,000,000.00 point increase in FKTPs trained, up to the clinical decision support tool the maximum of $27,000,000 US $300,000 for each one percentage MOH has trained 50% (cumulative) of all FKTPs on Oct 1, 2023 to Sep 30, 2024 12,000,000.00 point increase in FKTPs trained, up to the clinical decision support tool the maximum of $27,000,000 US $300,000 for each one percentage MOH has trained 90% (cumulative) of all FKTPs on Oct 1, 2024 to Sep 30, 2025 12,000,000.00 point increase in FKTPs trained, up to the clinical decision support tool the maximum of $27,000,000 Action: This DLI has been Revised. See below. Page 18 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) DLI IN01357662 ACTION MoH has trained 90% (cumulative) of all FKTPs on the implementation of the care pathway for promotive, preventive and DLI 1.2 screening services and case management tools. Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 27,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline NA Until September 30, 2022 NA 0.00 NA Oct 1, 2022 to Sep 30, 2023 NA 0.00 US $300,000 for each one percentage MOH has trained 30% (cumulative) of all FKTPs on Oct 1, 2023 to Sep 30, 2024 9,000,000.00 point increase in FKTPs trained, up to the care pathway tool the maximum of $27,000,000 US $300,000 for each one percentage MOH has trained 90% (cumulative) of all FKTPs on Oct 1, 2024 to Sep 30, 2025 18,000,000.00 point increase in FKTPs trained, up to the clinical decision support tool the maximum of $27,000,000 DLI IN01340991 ACTION DLI 2 Improved quality of care at referral hospitals/ FKRTLs Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 40,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - Until September 30, 2022 - 0.00 - Page 19 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) Oct 1, 2022 to Sep 30, 2023 - 0.00 - Oct 1, 2023 to Sep 30, 2024 - 0.00 - Oct 1, 2024 to Sep 30, 2025 - 40,000,000.00 - DLI IN01340992 ACTION MOH has formulated and issued at least twenty (20) new clinical diagnostic, treatment, or referral guidelines into processes DLI 2.1 of care for FKRTLs. Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 40,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 $2,000,000 per each clinical diagnostic, MOH has formulated and issued five (5) new clinical treatment, or referral guideline Until September 30, 2022 diagnostic, treatment, or referral guidelines into 10,000,000.00 formulated, up to the maximum of processes of care for FKRTLs in Year 1. $40,000,000 $2,000,000 per each clinical diagnostic, MOH has formulated and issued five (5) new clinical treatment, or referral guideline Oct 1, 2022 to Sep 30, 2023 diagnostic, treatment, or referral guidelines into 10,000,000.00 formulated, up to the maximum of processes of care for FKRTLs in Year 2. $40,000,000 $2,000,000 per each clinical diagnostic, MOH has formulated and issued five (5) new clinical treatment, or referral guideline Oct 1, 2023 to Sep 30, 2024 diagnostic, treatment, or referral guidelines into 10,000,000.00 formulated, up to the maximum of processes of care for FKRTLs in Year 3 $40,000,000 MOH has formulated and issued five (5) new clinical $2,000,000 per each clinical diagnostic, Oct 1, 2024 to Sep 30, 2025 diagnostic, treatment, or referral guidelines into 10,000,000.00 treatment, or referral guideline processes of care for FKRTLs in Year 4 Page 20 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) formulated, up to the maximum of $40,000,000 DLI IN01340993 ACTION DLI 3 HTA findings incorporated into the benefit package (BP) Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process Yes Text 35,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline NA Until September 30, 2022 - 0.00 - Oct 1, 2022 to Sep 30, 2023 - 0.00 - Oct 1, 2023 to Sep 30, 2024 - 0.00 - Oct 1, 2024 to Sep 30, 2025 - 35,000,000.00 NA DLI IN01340994 ACTION DLI 3.1 MOH has developed, approved, and formally adopted the Revised HTA Guidelines Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 5,000,000.00 0.00 Period Value Allocated Amount (USD) Formula MOH plan to develop, approve, and formally adopt Baseline the Revised HTA Guidelines MOH has developed, approved, and formally Paid in full upon achievement of DLI Until September 30, 2022 5,000,000.00 adopted the Revised HTA Guidelines target Page 21 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) Oct 1, 2022 to Sep 30, 2023 - 0.00 - Oct 1, 2023 to Sep 30, 2024 - 0.00 - Oct 1, 2024 to Sep 30, 2025 - 0.00 - DLI IN01340995 ACTION MOH has completed fifteen (15) additional HTA studies in accordance with the Revised HTA Guidelines and disseminated DLI 3.2 the findings of such studies to the public Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 15,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - Until September 30, 2022 - 0.00 - MOH has completed five (5) additional HTA studies during Year 2, in accordance with the Revised HTA $1,000,000 per HTA study up to the Oct 1, 2022 to Sep 30, 2023 5,000,000.00 Guidelines and disseminated the findings of such maximum of $15,000,000 studies to the public. MOH has completed five (5) additional HTA studies during Year 3, in accordance with the Revised HTA $1,000,000 per HTA study up to the Oct 1, 2023 to Sep 30, 2024 5,000,000.00 Guidelines and disseminated the findings of such maximum of $15,000,000 studies to the public. MOH has completed five (5) additional HTA studies during Year 4, in accordance with the Revised HTA $1,000,000 per HTA study up to the Oct 1, 2024 to Sep 30, 2025 5,000,000.00 Guidelines and disseminated the findings of such maximum of $15,000,000 studies to the public. Page 22 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) DLI IN01340996 ACTION DLI 3.3 At least five (5) of HTA studies completed under DLR 3.2 have informed the revision of the Benefit Package Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 15,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - Until September 30, 2022 - 0.00 - Oct 1, 2022 to Sep 30, 2023 - 0.00 - Oct 1, 2023 to Sep 30, 2024 - 0.00 - At least five (5) of HTA studies completed under DLR Paid in full upon achievement of DLI Oct 1, 2024 to Sep 30, 2025 3.2 have informed the revision of the Benefit 15,000,000.00 target Package DLI IN01340997 ACTION DLI 4 Improved claims management and prevention of ineligible and unnecessary claims Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 70,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - Until September 30, 2022 - 0.00 - Oct 1, 2022 to Sep 30, 2023 - 0.00 - Page 23 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) Oct 1, 2023 to Sep 30, 2024 - 0.00 - Oct 1, 2024 to Sep 30, 2025 - 70,000,000.00 NA DLI IN01340998 ACTION BPJS-K has revised and adopted the specified manuals, guidelines, and/or protocols for claims management, prevention of DLI 4.1 ineligible and unnecessary claims, and audit processes Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 20,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline NA BPJS-K has revised and adopted the specified manuals, guidelines, and/or protocols for claims Paid in full upon achievement of DLI Until September 30, 2022 20,000,000.00 management, prevention of ineligible and target unnecessary claims, and audit processes Oct 1, 2022 to Sep 30, 2023 NA 0.00 NA Oct 1, 2023 to Sep 30, 2024 NA 0.00 NA Oct 1, 2024 to Sep 30, 2025 NA 0.00 NA Page 24 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) DLI IN01340999 ACTION BPJS-K has embedded and automated the recommended tracer indicators into the claims verification software within 12 DLI 4.2 months of MOH’s issuance of the relevant tool/pathway Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 30,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - Until September 30, 2022 - 0.00 - (a) Based on the FKTP’s clinical decision support tool developed under DLR 1.1, BPJS-K has embedded and automated fifteen (15) of the recommended tracer indicators into the claims verification software (a) $10,000,000 Paid in full upon within 12 months of MOH’s issuance of a clinical achievement of target (b) $2,000,000 Oct 1, 2022 to Sep 30, 2023 decision support tool for FKTPs under DLR 1.1; and   16,000,000.00 per tracer indicator embedded and (b) Based on the FKRTL’s processes of care automated within 12 months formulated under DLR 2, BPJS-K has embedded and automated 3 of the recommended tracer indicators in the claims verification software within 12 months of MOH’s issuance of guidelines under DLR 2; (b) Based on the FKRTL’s processes of care formulated under DLR 2, BPJS-K has embedded and (b) $2,000,000 per tracer indicator automated 4 more of the recommended tracer embedded and automated within 12 Oct 1, 2023 to Sep 30, 2024 8,000,000.00 indicators in the claims verification software within months of MOH’s issuance of 12 months of MOH’s issuance of guidelines under guidelines DLR 2; (b) Based on the FKRTL’s processes of care (b) $2,000,000 per tracer indicator Oct 1, 2024 to Sep 30, 2025 formulated under DLR 2, BPJS-K has embedded and 6,000,000.00 embedded and automated within 12 automated 3 more of the recommended tracer Page 25 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) indicators in the claims verification software within months of MOH’s issuance of 12 months of MOH’s issuance of guidelines under guidelines DLR 2; DLI IN01341000 ACTION At least 250 FKRTL claims have been subjected to the detailed claims audit in each calendar quarter of Years 2-4, using the DLI 4.3 revised claims audit protocol developed under DLR 4.1. Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 20,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline NA Until September 30, 2022 NA 0.00 NA At least 250 FKRTL claims have been subjected to the detailed claims audit in each calendar quarter of 4 quarters @ $2,000,000 for each Oct 1, 2022 to Sep 30, 2023 8,000,000.00 Years 2-4, using the revised claims audit protocol calendar quarter developed under DLR 4.1. At least 250 FKRTL claims have been subjected to the detailed claims audit in each calendar quarter of 4 quarters @ $2,000,000 for each Oct 1, 2023 to Sep 30, 2024 8,000,000.00 Years 2-4, using the revised claims audit protocol calendar quarter developed under DLR 4.1. At least 250 FKRTL claims have been subjected to the detailed claims audit in each calendar quarter of 2 quarters @ $2,000,000 for each Oct 1, 2024 to Sep 30, 2025 4,000,000.00 Years 2-4, using the revised claims audit protocol calendar quarter developed under DLR 4.1. Page 26 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) DLI IN01341001 ACTION DLI 5 Improved use of data in decision making Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 30,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - Until September 30, 2022 - 0.00 NA Oct 1, 2022 to Sep 30, 2023 - 0.00 NA Oct 1, 2023 to Sep 30, 2024 - 0.00 NA Oct 1, 2024 to Sep 30, 2025 - 30,000,000.00 NA DLI IN01341002 ACTION (a) Roadmap for better data use for decision making including plan for data system integration developed & approved; (b) DLI 5.1 Information systems are integrated as per the targets identified in roadmap Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 30,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - MOH has ensured that roadmap for better data use Paid in full upon achievement of DLI Until September 30, 2022 for decision making, including plan for data system 10,000,000.00 target integration is developed and approved; Page 27 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) MOH has ensured that information systems are $10,000,000 for each year in which integrated and better data use for decision making information systems are integrated as Oct 1, 2022 to Sep 30, 2023 10,000,000.00 is undertaken as per the target identified in the per the targets identified in the roadmap for Year 2 roadmaps MOH has ensured that information systems are $10,000,000 for each year in which integrated and better data use for decision making information systems are integrated as Oct 1, 2023 to Sep 30, 2024 10,000,000.00 is undertaken as per the target identified in the per the targets identified in the roadmap for Year 3 roadmaps Oct 1, 2024 to Sep 30, 2025 - 0.00 - DLI IN01341003 ACTION DLI 6 Improved design and implementation of primary health care payment methods Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 58,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - Until September 30, 2022 - 0.00 - Oct 1, 2022 to Sep 30, 2023 - 0.00 - Oct 1, 2023 to Sep 30, 2024 - 0.00 - Oct 1, 2024 to Sep 30, 2025 - 58,000,000.00 - Page 28 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) DLI IN01341004 ACTION DLI 6.1 MOH and BPJS-K have jointly developed and approved the roadmap for revising primary care payment system  design Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 20,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - MOH and BPJS-K have jointly developed and Paid in full upon achievement of DLI Until September 30, 2022 approved the roadmap for revising primary care 20,000,000.00 target payment system design Oct 1, 2022 to Sep 30, 2023 - 0.00 - Oct 1, 2023 to Sep 30, 2024 - 0.00 - Oct 1, 2024 to Sep 30, 2025 - 0.00 - DLI IN01341005 ACTION MOH has ensured that ten (10) additional performance and quality indicators are included in the primary care payment DLI 6.2 system in line with the roadmap approved under DLR 6.1 Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 20,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - Until September 30, 2022 - 0.00 - Page 29 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) MOH has ensured that five (5) additional $2,000,000 paid for each additional performance and quality indicators are included in performance and quality indicator Oct 1, 2022 to Sep 30, 2023 10,000,000.00 the primary care payment system in line with the included in the primary care payment roadmap approved under DLR 6.1 system MOH has ensured that five (5) additional $2,000,000 paid for each additional performance and quality indicators are included in performance and quality indicator Oct 1, 2023 to Sep 30, 2024 10,000,000.00 the primary care payment system in line with the included in the primary care payment roadmap approved under DLR 6.1 system Oct 1, 2024 to Sep 30, 2025 - 0.00 - DLI IN01341006 ACTION MOH has ensured that 90% of FKTPs are implementing the revised primary care payment system as per the roadmap DLI 6.3 approved under DLR 6.1 by Year 4 Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Percentage 18,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Until September 30, 2022 0.00 0.00 - $200,000 paid for each additional percentage point of FKTPs which are Oct 1, 2022 to Sep 30, 2023 30.00 6,000,000.00 implementing the revised  primary care payment system $200,000 paid for each additional percentage point of FKTPs which are Oct 1, 2023 to Sep 30, 2024 60.00 6,000,000.00 implementing the revised  primary care payment system Page 30 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) $200,000 paid for each additional percentage point of FKTPs which are Oct 1, 2024 to Sep 30, 2025 90.00 6,000,000.00 implementing the revised primary care payment system DLI IN01341007 ACTION DLI 7 Improved implementation of hospital payments Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 78,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - Until September 30, 2022 - 0.00 - Oct 1, 2022 to Sep 30, 2023 - 0.00 - Oct 1, 2023 to Sep 30, 2024 - 0.00 - Oct 1, 2024 to Sep 30, 2025 - 78,000,000.00 - DLI IN01341008 ACTION MOH has developed and adopted (a) clinical coding guidelines and audit protocol; (b) clinical coding training course; and (c) DLI 7.1 standardized cost accounting template Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 25,000,000.00 0.00 Period Value Allocated Amount (USD) Formula MOH plan to develop and adopt (a) clinical coding Baseline guidelines and audit protocol; (b) clinical coding Page 31 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) training course; and (c) standardized cost accounting template MOH has developed and adopted (a) clinical coding (a) 10,000,000 (b) 5,000,000 (c) guidelines and audit protocol; (b) clinical coding 10,000,000. Amount allocated to the Until September 30, 2022 25,000,000.00 training course; and (c) standardized cost respective DLR sub-target paid in full accounting template upon achievement. Oct 1, 2022 to Sep 30, 2023 - 0.00 - Oct 1, 2023 to Sep 30, 2024 - 0.00 - Oct 1, 2024 to Sep 30, 2025 - 0.00 - DLI IN01341009 ACTION DLI 7.2 MOH has arranged for training and certification of at least one coder in each of 1,800 FKRTLs (cumulative) by Year 4; Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 18,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Until September 30, 2022 0.00 0.00 - $ 10,000 per each FKRTL where the Oct 1, 2022 to Sep 30, 2023 500.00 5,000,000.00 coders are trained and certified $ 10,000 per each FKRTL where the Oct 1, 2023 to Sep 30, 2024 1,100.00 6,000,000.00 coders are trained and certified $ 10,000 per each FKRTL where the Oct 1, 2024 to Sep 30, 2025 1,800.00 7,000,000.00 coders are trained and certified Page 32 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) DLI IN01341010 ACTION DLI 7.3 MOH has randomly assessed 40 FKRTLs for coding accuracy during Years 3 and 4 Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 10,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - Until September 30, 2022 - 0.00 - Oct 1, 2022 to Sep 30, 2023 - 0.00 - $250,000 for each one of FKRTLs MOH has randomly assessed 20 FKRTLs for coding Oct 1, 2023 to Sep 30, 2024 5,000,000.00 randomly assessed during Years 3 and accuracy during Year 3 4, up to the maximum of $10,000,000 $250,000 for each one of FKRTLs MOH has randomly assessed 20 FKRTLs for coding Oct 1, 2024 to Sep 30, 2025 5,000,000.00 randomly assessed during Years 3 and accuracy during Year 4 4, up to the maximum of $10,000,000 DLI IN01341011 ACTION MOH has revised, adopted and published on its website INACBG tariffs in line with cost accounting data and any other DLI 7.4 relevant evidence. Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 25,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline NA Until September 30, 2022 - 0.00 - Page 33 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) Oct 1, 2022 to Sep 30, 2023 - 0.00 - Oct 1, 2023 to Sep 30, 2024 - 0.00 - MOH has revised, adopted and published on its Paid in full on achievement of the DLI Oct 1, 2024 to Sep 30, 2025 website INACBG tariffs in line with cost accounting 25,000,000.00 target data and any other relevant evidence. DLI IN01341012 ACTION DLI 8 Improved policy formulation and oversight of JKN Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 22,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - Until September 30, 2022 - 0.00 - Oct 1, 2022 to Sep 30, 2023 - 0.00 - Oct 1, 2023 to Sep 30, 2024 - 0.00 - Oct 1, 2024 to Sep 30, 2025 - 22,000,000.00 - DLI IN01341013 ACTION DJSN has developed a dashboard of key monitoring indicators from JKN and other relevant data sources, and such DLI 8.1 dashboard is in use by DJSN Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 10,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Page 34 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) Baseline - DJSN has developed a dashboard of key monitoring Paid in full on achievement of the DLI Until September 30, 2022 indicators from JKN and other relevant data sources, 10,000,000.00 target and such dashboard is in use by DJSN Oct 1, 2022 to Sep 30, 2023 - 0.00 - Oct 1, 2023 to Sep 30, 2024 - 0.00 - Oct 1, 2024 to Sep 30, 2025 - 0.00 - DLI IN01341014 ACTION DLI 8.2 DJSN has produced and published on its website an annual performance report on JKN in each of Years 2-4 Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 12,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline NA Until September 30, 2022 - 0.00 - $4,000,000 for each report published in DJSN has produced and published on its website an Oct 1, 2022 to Sep 30, 2023 4,000,000.00 Years 2-4, up to the maximum of annual performance report on JKN in Year 2 $12,000,000 $4,000,000 for each report published in DJSN has produced and published on its website an Oct 1, 2023 to Sep 30, 2024 4,000,000.00 Years 2-4, up to the maximum of annual performance report on JKN in Year 3 $12,000,000 $4,000,000 for each report published in DJSN has produced and published on its website an Oct 1, 2024 to Sep 30, 2025 4,000,000.00 Years 2-4, up to the maximum of annual performance report on JKN in Year 4 $12,000,000 Page 35 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) DLI IN01341015 ACTION DLI 9 Improved coordination, impact, and sustainability of JKN Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Text 20,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - Until September 30, 2022 - 0.00 - Oct 1, 2022 to Sep 30, 2023 - 0.00 - Oct 1, 2023 to Sep 30, 2024 - 0.00 - Oct 1, 2024 to Sep 30, 2025 - 20,000,000.00 - Action: This DLI has been Revised. See below. DLI IN01341016 ACTION Program Secretariat is strengthened with additional technical experts and consultants in accordance with the Operations DLI 9.1 Manual; Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 10,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Program Secretariat plan to strengthen its capacity Baseline with additional technical experts and consultants in accordance with the Operations Manual; Page 36 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) Program Secretariat is strengthened with additional Paid in full on achievement of the DLI Until September 30, 2022 technical experts and consultants in accordance 10,000,000.00 target with the Operations Manual; Oct 1, 2022 to Sep 30, 2023 - 0.00 - Oct 1, 2023 to Sep 30, 2024 - 0.00 - Oct 1, 2024 to Sep 30, 2025 - 0.00 - DLI IN01341017 ACTION Program Secretariat compiles and analyzes JKN data and provides recommendations on the JKN-related objectives for the DLI 9.2 new RPJMN in Year 4 Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 10,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - Until September 30, 2022 - 0.00 - Oct 1, 2022 to Sep 30, 2023 - 0.00 - Oct 1, 2023 to Sep 30, 2024 - 0.00 - Program Secretariat compiles and analyzes JKN data Paid in full on achievement of the DLI Oct 1, 2024 to Sep 30, 2025 and provides recommendations on the JKN-related 10,000,000.00 target objectives for the new RPJMN in Year 4 Action: This DLI has been Revised. See below. Page 37 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) DLI IN01357584 ACTION The Program Secretariat ensures the Annual Work Plan and Budget of the Ministry of Health and BPJS Kesehatan is relevant DLI 9.2 for the achievement of the JKN Reform PforR objectives. Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 7,500,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline - Until September 30, 2022 - 0.00 - The Program Secretariat ensures the Annual Work Plan and Budget of the Ministry of Health and BPJS Paid in full on achievement of the DLI Oct 1, 2022 to Sep 30, 2023 2,500,000.00 Kesehatan is relevant for the achievement of the JKN target for the year Reform PforR objectives. The Program Secretariat ensures the Annual Work Plan and Budget of the Ministry of Health and BPJS Paid in full on achievement of the DLI Oct 1, 2023 to Sep 30, 2024 2,500,000.00 Kesehatan is relevant for the achievement of the JKN target for the year Reform PforR objectives. The Program Secretariat ensures the Annual Work Plan and Budget of the Ministry of Health and BPJS Paid in full on achievement of the DLI Oct 1, 2024 to Sep 30, 2025 2,500,000.00 Kesehatan is relevant for the achievement of the JKN target for the year Reform PforR objectives. Page 38 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) DLI IN01360328 ACTION Program Secretariat produces and disseminates with relevant authorities a compendium of evidence and policy briefs to DLI 9.3 improve JKN implementation and sustainability. Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 2,500,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline NA Until September 30, 2022 - 0.00 Oct 1, 2022 to Sep 30, 2023 - 0.00 Oct 1, 2023 to Sep 30, 2024 - 0.00 Program Secretariat produces and disseminates with relevant authorities a compendium of evidence Paid in full on achievement of the DLI Oct 1, 2024 to Sep 30, 2025 2,500,000.00 and policy briefs to improve JKN implementation target and sustainability Action: This DLI is New Page 39 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) ANNEX 2: PROGRAM ACTION PLAN . . PAP_NOT_CHANGE_TBL Action Description Source DLI# Responsibility Timing Completion Measurement Develop data protection and record management measures, data system integration and digitization, in line with international good Assessment of data security practices. This status and interventions to includes data address it have been undertaken, sharing protocols, including SOPs for data routine updates, protection, system debug report oversight, etc. Director Decree on record sanctions and management regulating secure secure access to Environmental and Social access, retention, preservation records. Systems DLI 4.1 BPJS-K Recurrent Continuous and disposal. Ensure representativenes s of sampling analyses in terms of geographical coverage, demographic characteristics, and disease burdens to inform select reforms (i.e., reforms to capitation, revisions in DRG tariffs, development of clinical pathways Environmental and Social Evidence of inclusivity of sampling etc. Systems DLI 2 MOH Recurrent Continuous in forms of analysis, reports etc Technical Working Group (TWG) comprised of technical-level focal points from the stakeholder teams and units responsible for implementing DLIs Minutes of the first meeting of is set up, including Technical DLI 8 MOF Due Date 31-Jan-2022 the TWG are available. Page 40 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) from different teams within MOH, BPJS-K, MOF, DJSN, Bappenas, Kemenko PMK, and MOHA Enhance public communication on patients’ rights and responsibilities through: - production of communication materials, protocols, and training of staff. - increasing Production and dissemination of availability and communication materials on accessibility of patients’ rights and information to JKN Environmental and Social responsibilities and relevant members etc. Systems DLI 7 DJSN, BPJS-K Recurrent Continuous capacity building Enhance stakeholder engagement and public participation processes under JKN, incorporating the following measures: - Inclusive public engagement - Public disclosure of relevant information - Development of a mechanism to solicit public Environmental and Social BPJS-K, DJSN, perceptions Systems DLI 7 MOH Recurrent Continuous evidence of public consultations Periodic evaluation of the existing JKN complaint Publication of periodic review of handling channels Environmental and Social BPJS-K, DJSN, JKN complaint handling through Systems MOH Recurrent Continuous mechanism(s) Page 41 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) consultative processes to inform relevant system enhancements and disclosure of grievance reports and settlements Promote inclusivity of the delivery of frontline provider training, including development of alternative media and training modalities as Environmental and Social relevant. Systems DLI 1 MOH Due Date 31-Dec-2023 Post-training evaluation report All the Program IAs to require Procurement Service Working Units (UKPBJs)/Procure ment Officers and Commitment making officers (PPK) to check the Semi-annual reports provided to Bank’s debarment the Bank on the verification (www.worldbank. checks and the results to ensure org/debarr) and that guidance provided to temporary UKPBJ/Procurement Officers/PPK suspension lists is implemented and no such and record in bid contract under the Program is evaluation Fiduciary Systems All IAs Recurrent Semi-Annually awarded All the Program IAs to inform the Bank promptly of all credible and material allegations or other indications of Fraud and Corruption in connection with the Program that Semi-annual reports provided to come to its the Bank on allegations of F&C attention, under the Program received or together with the registered during such period, as investigative and well as any related investigations other actions Fiduciary Systems All IAs Recurrent Semi-Annually and actions taken MoH to report on Results of the internal audit a semi-annual Fiduciary Systems MOH Recurrent Semi-Annually received Page 42 of 44 The World Bank National Health Insurance (JKN) Reforms and Results Program (P172707) basis the results of the internal audit conducted by its Inspectorate General on health insurance subsidy as the main expenditure of the Program BPJS-K will take action to remove any regulatory obstacles that would interfere with the requirements of the existing Indonesian law on public information The requirements of the law are disclosure Fiduciary Systems BPJS-K Due Date 31-Dec-2022 confirmed to be complied with. BPJS-K to improve the capacity of internal audit unit for better internal control: (a) assessment on capacity needed for CISA certified internal auditor; and (b) competency in conducting continuous audit on BPJS-K Measures to improve the capacity information of the internal audit unit are systems Fiduciary Systems BPJS-K Due Date 31-Dec-2023 reported. BPJS-K to improve its records management practice and regulation to ensure secure access to records and retain, preserve and Measures taken to improve dispose of records records management are appropriately Fiduciary Systems BPJS-K Due Date 30-Jun-2023 reported. . Page 43 of 44