Abstract
BACKGROUND: The impact of provider payment mechanisms under Indonesia's National Health Insurance (NHI) scheme on healthcare providers' behavior-particularly in tuberculosis (TB) service delivery- remains underexplored. This study examines the consequences of provider payment incentives on TB service provider behavior. METHODS: A mixed-methods study was conducted using quantitative analysis of NHI claims data from 2015 to 2016 and qualitative data from focus group discussions with healthcare providers-22 primary care facilities and 14 hospitals across five provinces-. Quantitative analysis examined TB service utilization patterns, assessed referral appropriateness based on case complexity, and claim of TB services. Qualitative data were thematically analyzed to explore factors influencing provider decision-making in the context of payment mechanisms and service delivery under the NHI scheme. RESULTS: Findings indicate that primary care facilities refer a high proportion of TB cases to secondary-level care, even for uncomplicated cases (81% of 782 visits). Secondary care recorded significantly more TB visits than primary care (5,249 vs. 1,094 visits), resulting in an estimated USD 14.1 million in potentially avoidable costs for the NHI program. If these cases had been managed at the primary level, potential cost savings could have been substantial. Qualitative analysis revealed that provider referral decisions were influenced by capitation-based payment structures, limited diagnostic tools, absence of dedicated TB rooms, lack of provider capacity, patient preferences, financial incentives favoring more profitable diseases, and providers' social ties. The high rate of up-referrals may negatively impact service quality and TB treatment outcomes. CONCLUSION: Current provider payment mechanisms under NHI contribute to inefficiencies in TB service delivery by incentivizing unnecessary referrals to secondary care. Optimizing payment methods and strengthening implementation by addressing weak provider capacity at the primary care level could enhance incentives for primary-level management of TB cases, improving cost-effectiveness and service quality.