Jayawijaya

Tapanuli Selatan

Jakarta Timur

Jayapura

Jember

A study to assess how JKN regulations in primary care have been implemented at district level, particularly regulations on capitation fund management. Capitation is a prospective payment system paid by BPJS Kesehatan to primary health care facilities to provide health services to JKN members enrolled in those facilities regardless of the type and frequency of delivered service. The data was collected in June 2016.

Logic Model: JKN and Primary Health Care

Study Sites and Management of Capitation Fund in Puskesmas

Regent Regulation 3/2016 stipulates:- 60% for service fee- 15% for drugs, medical consumables and equipment- 25% for other operational support

Governor Regulation 165/2012 on BLUD Management. All PHC have BLUD status, so MoH Regulation 19/2014 does not apply here. The use of capitation fund is flexible and fully planned by Sub-District PHC. Governor Regulation 108/2016 prohibits civil servants in Jakarta to receive service fee from capitation. Capitation fund is used for non-civil cervant incentives, drugs, medical consumables and equipment, etc in accordance with PHC needs.

Regent Regulation 1.1/2015 stipulates:- 60% for service fee- 40% for drugs, medical consumables and equipment, and other operational support.

Regent Regulation No 99/2016 stipulates different proportion for service fee and operational support in 13 PHC considering the different condition in each PHC.

MoH Regulation 19/2014 (which later was replaced by MoH Regulation 21/2016) states that no less than 60% of total capitation fund is to be used for service incentives, and the remaining is for operational

supports (drugs, medical consumables and equipments, fuel and stationery).

Mayor Regulation on 128/2014 stipulates:- 60% for service fee- 35% for drugs, medical consumables and equipments- 5% for other operational support

JKN 1. More enrolled patients2. Increased PHC utilization

Higher capitation amount to PHCs

1. Increased PHC staff2. More motivated PHC staff3. More medicine, equipment, supplies4. Improved facilities5. Greater outreach6. Less Burdensome financial management

1. Increased PHC Provider Satisfaction2. Improved PHC service delivery3. Fewer referrals4. Increased patient satisfaction5. Less patient financial hardship6. More efficient financial management

1. Improved population health2. More efficient use of health spending

BPJS Kesehatan pays approximately Rp 8 trillions to primary health care facilities each year, expecting that there will be significant improvement on quality of service delivery

Local government is not allowed to recruit new civil servants

Service incentives from capitation fund can only be distributed among civil servants, government employees with contract agreement (P3K – pegawai pemerintah dengan perjanjian kontrak) and contract employees (PTT – pegawai tidak tetap)

Estimated service incentives received by doctor per patient per month

10.000

20.000

30.000

40.000

50.000

60.000

70.000

Jayawijaya Jayapura Jember Jaktim Tapsel

80.000

Average

500

1.000

1.500

2.000

2.500

3.000

Jayawijaya Jayapura Jember Jaktim Tapsel

3.500

Average

Estimated number of patients per doctor per

month

10

20

30

40

50

60

70

80

90

Jayawijaya Jayapura Jember Jaktim Tapsel

100

Increasing

Remain

Decreasing

Number of doctors in Puskesmas, 2014 - 2015

dal

am p

erse

ntas

e

How Capitation Affects Doctor’s Motivation and Performance?

Why most doctors are not satisfied?

Only 25% of doctors are satisfied with their income after JKN due to:

Service incentives and workload disparity among doctors within a districtService incentives do not sufficiently compensate the increasing workload

1.

2.

Why The Number of Doctors Remains Unchanged?

Capitation Fund Has Little Effect to The Increasing Number of Doctor

Not Satisfied 43%Neutral 25%

Satisfied 25%

Do not know 7%

This condition happens due to:

The diverse local regulation on capitation fund management affect the amount of unutilized fund

- Not utilized to purchase medical equipments due to previous negative experinces in procurement- Suppliers in e-catalogue often fail to fulfill order- Puskesmas have different capability in utilizing the fund for conducting outreach activities

Not utilized to purchase drugs, medical consumables and equipments because of unclear regulation, about procurement with capitation fund.

Remaining of IDR 8 - 12 billion in Sub-District Puskesmas (BLUD account)*), because:- Cannot be used for paying esrvice incentives- Fund utilization based on appropiateness principle

0 %

0 %Jayawijaya

Unutilized Fund2014

Jayapura

Jember

Jaktim

Tapanuli Selatan

22%

0%

18%

17%

19%

36%

Unitilized Fund 2015

How capitation fund affects availability of drugs and medical supplies?

Our status is not BLUD, thus we are hampered by the absence of procurement officer in Puskesmas. Head of Puskesmas

We have many shortages of medicine in the past, but now our medicine is complete using capitation fund for operational needs. head of Puskesmas.

We can buy many additional items (drugs) now. At first we didn’t know much about the procurement process, but later we try to find the solution (by procuring) through pharmacies. Many regulations have been simplified. The most important one is pharmacist licensing. (Head of Puskesmas)

As for capitation fund, we in DHO can’t purchase DMCE or anything, because the fund has been transferred directly to Puskesmas. We have consulted The Financial Audit Board and they did not recommend DHO to, let’s say, purchase anything with Puskesmas’ money, because the local government has not set any regulation, because we do not find any national regulation (for it) as a reference. Before MoH Regulation 19/2014, the capitation fund is transferred to district account. At that time, we can freely use the fund to purchase DMCE. DHO.

*) the exact amount can’t be calculated because capitation is merged with other funds in BLUD account

High Referral Rate

5.0

10.0

15.0

20.0

25.0

30.0

35.0

2014 2015

dal

am p

erse

ntas

e

Ratio of total visit to total referral of JKN patients in 2014 - 2015

TapSel

JaktimJember

JayapuraJayawijaya

The Consequenses:

“Drugs and equipments are not available in Puskesmas, so we have to refer the patients in order for them to get proper treatments” (Head of Puskesmas)

How Capitation Contributes to TB and HIV /AIDS services?

Jakarta Jayapura Jayawijaya

TB Case Detection

Purchase TB Sputum pot

- Delivering patients to hospital for CD4 examination- Pick up ARV from DHO- Pick up TB - MDR drugs and supplementary food for HIV/AIDS and TB

Transportation:

Purchase TB drugs in case out of stock

Purchase CD4 examina-tio kit (limited supply

from DHO)

TB Surveilance

The “Knocking Door Team”

BLUD FUNDS

The Cost for HIV /AIDS and TB service is funded by local budget (APBD)

In Jayapura and Jayawijaya, funding for home visits, detection of TB and other outreach services is allocated in BOK