Supporting primary health care facilities’ survival and endurance amid a difficult time

Ensuring primary health care facilities are well-resourced, supported, and motivated to provide quality care.

Nuzulul Putri


At the end of 2020, I called one of my friends, a clinic manager in Surabaya to discuss the psychological effects of the pandemic on health care workers in primary health care facilities. We have the same interest in primary health care management. For almost ten years, we have collaborated to help primary health facilities in Surabaya improve their health services. We have helped primary health facilities develop standard operating procedures for their services, conduct health program assessments as the baseline for their health programs, and conduct several capacity-building pieces and training for health workers and health cadres. I contacted her to discuss our plan to provide mental health support for health workers in Surabaya during the pandemic because so many health workers have suffered psychologically. The high workload during the pandemic has disrupted their work-life balance, and the isolation and exclusion from COVID-19 exposure has taken a toll on many workers.

When my friend picked up the phone, I just said, “Hello…” her first words were, “Hi. I am busy currently. Lots of private clinics here are collapsed. COVID-19 not only kill humans… it’s breaking our health care institutions.”

My plan to discuss mental health support for health care workers suddenly changed into an intense discussion about health financing. We talked about how this could happen, how this condition affected the quality of their services, and what could help them in their difficult conditions. This discussion with my friend underlies why I then focused more on private primary health care facilities in my fellowship.

Making sure their voices are heard

In my first two quarters at the Samya Stumo Fellowship, I listened to what private primary health care facilities struggled with in terms of capitation payments. During the pandemic, the income of these private clinics decreased because patient visits to health facilities decreased. Patients were afraid to come to health facilities and chose to delay treatment or use digital health facilities. Unfortunately, not all of these clinics are large clinics that can provide digital health facilities for their patients. On the other hand, the operational costs incurred by the clinic to serve patients are increasing because they have to provide various personal protective equipment (PPE). In contrast to government-owned primary health care facilities, which receive PPE assistance from the government on an ongoing basis, private clinics must procure PPE themselves. This condition occurs amid the scarcity and high market cost of PPE. As a health service provider for Indonesia National Health Insurance (JKN), this private clinic ultimately relies heavily on income from capitation payments. Paid with capitation payments means that private clinics are paid by BPJS Kesehatan (the agency that manages JKN) in a fixed amount of money each month based on the number of enrollees; however, private clinics feel that regulations in capitation payment are still not fair to them.

“We know that our utilization rate is lower than the public PHCs, but the number of enrollees is less than the public PHCs. We also never received any social aid from the government during this pandemic.”

―Head of Private Clinic Association in Surabaya

Under the capitation payment policy in JKN, clinic income from capitation will be reduced if the patient referral rate is high; however, because the distribution of JKN patients at these primary health facilities has never been evaluated, they do not know how urgently their patients require referral.

“We could not push down the referral rate since patients really need to be referred. However, why do we have more older enrollees with chronic diseases?”

―Primary health practitioner

“The capitation policy is too difficult for us. With a high number of patients with diabetes and coronary heart diseases, our referral rate is quite high. It was even worse during the pandemic since they were too afraid to visit our Prolanis (health promotion class).”

―Primary health practitioner

Even worse, the poor information on how urgently their patients need to be referred makes them unable to plan an effective intervention to minimize the referrals.

“P-Care (application used by BPJS Kesehatan) could not provide us with the information we need to create an effective health program. Moreover, our information system is not designed to produce such data.”

―Primary health practitioner

Primary health care facilities are left in the dark—they do not know how they should manage their patients under capitation.

Forging a new path to a fairer health system

Right now is a crucial moment for private clinics in Surabaya to advocate for BPJS Kesehatan about capitation. As the head of the private clinic association in Surabaya mentioned, they encourage BPJS Kesehatan to redistribute participants and review capitation policies.

“In the last several months, we have been forced by BPJS Kesehatan to implement a redistribution plan in Surabaya. We are collecting evidence to support our argument.”

―Head of Private Clinic Association in Surabaya

During the 3rd quarter of this fellowship, with the guidance of my mentor, I tried to document what I had obtained from rapid research on the challenges of primary health facilities in dealing with capitation policies. A simulation of a new risk-based capitation formula using the health utilization data of Surabaya provides them with a clear description of what suggestions should be made in the advocation clause. I also wrote an integrative review on what are the gaps between the basic concept of capitation with the one implemented in Indonesia. This review hopefully will share a basic understanding of how the capitation should be designed in the future. As I understand that not all of the health managers are comfortable reading such academic writing, I tried to translate it in a blog series with layman language style. I proposed this strategy to not only improve the health managers’ knowledge on capitation but also increase awareness of the public on the importance of capitation payment refinement for health facilities. Through this fellowship, I have been supported in pushing BPJS Kesehatan to prioritize improvements in its capitation policies.