By: Nuzulul Putri
“I do not think I want to work in the primary healthcare centre in my hometown” this is a frequent statement that I commonly hear from the first-year students in my university.
It reminds me of what happened to me when deciding my career path. Ten years ago, when I finished my bachelor’s degree in public health, I applied to be a health worker in Puskesmas in remote areas under a national pilot project which aimed to diminish the disparity between the region in Indonesia. Successfully passing the selection, I cancelled the trip because my parents were worried about me living in an area with poor living infrastructures.
Today, I am a lecturer in the School of Public Health at a government-owned university in Indonesia. Those personal experiences and my students’ statements make me interested in understanding how the health system works and serves the underserved population.
At a glance
In Indonesia, primary healthcare services are provided by Puskesmas (government-owned health facilities in sub-districts), private clinics, and private doctor’s offices. However, Puskesmas are most used by the community. Puskesmas are also responsible for providing preventive and promotive community health services. Unfortunately, there are significant gaps in the availability, condition, and readiness of Puskesmas to provide services. The ratios of Puskesmas to population remain below WHO standards and lags other Asia-Pacific countries. Puskesmas outside Java, especially in the eastern part of Indonesia, such as Papua, Sulawesi, and Nusa Tenggara, have no electricity. In addition, the poor condition of housing for health workers has led to a shortage of health workers to work in rural areas.
Indonesia is the biggest archipelago country in the world. We have more than 17,000 islands with more than 270 million citizens. Even though not all these islands are inhabited, the infrastructure disparity between islands is quite significant. I live on Java Island, the main island where the country’s capital is located. In Java, all primary health centres have at least one medical doctor, while in Papua – the most eastern part of Indonesia with the lowest HDI index nationwide, almost 43.5% of its primary health centres do not have any medical doctor.
In 2014, Indonesia started implementing National Health Insurance (JKN) to achieve Universal Health Coverage. The local governments previously managed health insurance for the poor with different benefits according to their fiscal capacity. These local-based and employer-sponsored health insurances are merged into JKN under a single health purchaser, BPJS Kesehatan. All populations must join JKN to ensure that they can access equal health services without financial hardship. Unfortunately, many studies reported that health infrastructures still hinder access to health services, even under JKN.
When primary health care is not the primer
Imagine when you work so hard to earn money, but you are careless in spending it. No matter how much money you make, it will never be enough to support your life. The same things also apply to health financing. Health financing is not only about collecting the fund but also how to effectively spend the fund. Indonesia’s health budget in 2021 reached more than 169,073 billion rupiahs or around 6.2% of total state spending. The size of this health budget always increases every year. Hence, an appropriate allocation and ways to spend the money is needed to ensure that this enormous amount of money can improve health system performance.
Under the JKN, patients are not allowed to go directly to the hospital for treatment, and they must first be examined at primary healthcare facilities. Only certain diseases and severity will be referred to the hospital for further health care. If they do not follow this procedure, patients will have to pay for all medical expenses with their own money. At the health facility level, health facilities’ spending is also crucial to ensure the health facilities provide not only cost-effective healthcare for their patients but also able to motivate health workers to ensure the service quality.
Primary healthcare facilities are paid with capitation. Being paid using capitation means primary healthcare facilities receive a fixed amount of money per patient monthly even before the physician deliver health care services. Primary healthcare facilities must serve the patients with specific services listed in the contract between health facilities and BPJS Kesehatan as payers. Health facilities could not ask for more money outside the capitation fund when agreeing to be paid with capitation. As a result, when primary healthcare facilities want to improve their profitability under capitation, their practices must become more cost-efficient. It simply makes primary healthcare facilities take care of their population better because if they are healthy, less expensive services are provided, and there is more money for them to improve their infrastructure.
DRGs and capitation mechanisms are regulated nationwide, including the rate. However, while the DRGs rate of the hospital has been amended at least three times since 2014, the capitation rate for primary healthcare services has never been reviewed.
The COVID-19 pandemic has had a devastating impact on Indonesia’s primary health care centre. Puskesmas, the primary healthcare centre owned by the government, must deal with the increasing workload for contact tracing, testing, and treating the COVID-19 patients. At the same time, private clinics must suffer from the increasing cost of PPEs which the capitation fund does not cover. Primary healthcare clinic associations complain about the low capitation rate and the increasing operational cost in treating JKN patients. However, there has been no attempt both from the government and BPJS Kesehatan to revise the capitation rate used. Moreover, BPJS Kesehatan implemented the “Performance-Based Capitation” procedure, which corrected the capitation amount to be lower if the primary healthcare facilities did not achieve specific service indicators.
To further describe the inequities, the official report of the National Planning Board (BAPPENAS) in 2019 mentioned that there is an unfair rate between primary health centres in remote areas (which commonly have a small population) and non-remote areas (which commonly have a large population). Consequently, people in remote areas tend to lack incentives from the capitation fund, which means it is far less attractive for health workers to work in these remote areas. It indeed widens the gap of health infrastructure itself.
My students are examples of this. They do not want to work for the public health centres in these remote areas.
“Working in a private hospital is cool.”…. “The ladder to achieve great things primary health centre is limited, and also there is no financial incentive.”…. “I will go to the Puskesmas, but just for working experience.”
Working in primary health services seems to be the last option for my students. They think working in a hospital is more valuable for their life. It gives them money and opportunity to grow, while primary healthcare centres are just a place to learn something and move on from.
The shortage of health workers in rural areas affected the poor health access in the rural population. Every year data from the Central Statistics Agency shows that the unmet need for health services in rural areas is always higher than in urban areas and tend to increase annually. The unmet need in rural areas in 2020 shows that there are 6.16% of rural residents do not get healthcare services when they need it, while in cities, only 4.87%. Moreover, only 92.05% of the population in rural areas gave birth in health facilities, while in urban areas, it has already reached 97.7%.
There is an urgent need to figure out how we can ensure that the modification and adjustment of capitation payments are beneficial in tackling health disparities in Indonesia. We need to make it more sustainable for health workers to work across Indonesia, especially during COVID -19.
Science communication is not only for educating the layperson but also for engaging the future leaders
As an early-career academic, I dream that my scientific works will not just live in a drawer. I believe that scientific work must affect the health system. I hope that my works will provide information on underlying strategic decisions in health. Furthermore, I expect my students to have a robust vision of using their knowledge to diminish Indonesia’s health disparities in the future.
For the last nine years, I have been educating the importance of science communication in public health, and I found it very powerful to engage more people to support a policy. Recently, I managed a digital class to educate mothers during the pandemic. It is one of the real examples of the power of science communication during this difficult time. It is an initiative that falls under the women supporting women movement that we encourage in our school. We use WhatsApp groups and Instagram to reach and educate these women on basic health practices for the family. We simplify the health protocol language and share active discussions to combat various COVID-19 misinformation. It is simple but powerful to educate mothers to protect their families from COVID-19 transmission.
Not all primary healthcare facilities managers understand well the concept of health financing, including capitation itself. Most of these managers are clinicians who learn about health facility management after being appointed as managers in healthcare facilities. Moreover, most health financing references are written in English, which could be very difficult to understand. Indonesia is not an English-speaking country, and its English Proficiency Index only ranked at 78 among 100 countries in 2020. Those obstacles have pushed the primary healthcare facilities managers into blank spaces on being more cost-efficient.
My project analyzes the adjusted capitation system for primary healthcare facilities in Indonesia. First, the project will document any evidence on how the existing capitation system has impacted the primary health facilities. Second, the project will communicate the findings to health managers in primary healthcare to empower them to negotiate with the payers. The insufficient knowledge on how to deal with the capitation-related policies released by the payer makes them unable to negotiate with the payer when they are aggrieved. It will minimize the knowledge gap related to the capitation policy and boost managers of primary healthcare facilities and the association’s awareness of this issue.
“Open research” is the vision that inspired my project. Every discussion I have had with my students have led me to this point. I do not want to let them stay in a world where primary healthcare facilities are not essential to serve.
My project will equip the health managers to create the ideal future for primary healthcare. At the same time, targeting the student through science communication work will help them better understand how they should perform as health practitioners. No one will think that primary healthcare service is less critical than referral healthcare service.
I am glad that I have been selected to be one of the Samya Rose Stumo Memorial Fellowship for Global Health fellows. It has helped me be a science communicator in health financing. I can be mentored by a prominent researcher and communicate health financing research that impacts the health system.