In order to successfully facilitate the ambitious UHC initiative, HFG, with leadership from the Center for Health Policy and Management (CHPM) at Universitas Gadjah Mada, conducted implementation research to understand how JKN regulations for primary care are being implemented at the district level. The aim of the research is to help strengthen primary care for JKN, and to support Indonesia’s progress toward universal health coverage.

The research team reviewed the various JKN and other regulations affecting primary care; interviewed more than 100 respondents in 88 primary health care facilities, and conducted focus group discussions among representatives of the District Health Office, Financing Office and Inspectorate, and Health Social Security Agency (Badan Penyelenggara Jaminan Sosial – Kesehatan/ BPJS) in each district. Consultations with national and district-level stakeholders were held to confirm the findings and their implications.

IR Results from Cycle 1

The IR results illustrated a few key takeaways that must be addressed to effectively close gaps in policies and implementation factors in order to bolster JKN:

1. The capitation payment system has not yet achieved its desired impact. According to JKN policy, capitation payment is applied at the primary care level, in which the majority of this fund is allocated as an incentive to health workers to motivate them and improve their performance. However, findings from respondent interviews indicate that the additional incentive revenue from capitation has helped to incentivize staff to be more disciplined in terms of attendance and working hours, but much remains to be done to strengthen primary care.
2. The district health offices’ (DHOs’) authority to ensure that resources are spent to produce desired health outcomes is ambiguous. The DHO has the authority to determine how resources are spent to improve health, but currently BPJS regulations state BPJS has the duties and authority to perform the same tasks. The role of the DHO must be clarified to ensure that the program is administered efficiently.
3. BPJS has a centralized structure, but is operating in a decentralized health system. The goal of Indonesia’s laws on decentralization has been to empower local governments to take responsibility for their own development based on their individual needs and priorities. In our initial analysis of JKN regulations affecting primary care, we found there is a misalignment between Indonesia’s policies for decentralized health service provision and the national regulations of BPJS as a financial institution with a centralized structure.

The gaps outlined above have implications for the implementation of health policies and must be addressed to effectively roll out the UHC. Efforts to minimize or close these gaps fall into two categories: (1) policy gap minimization; and (2) implementation gap minimization. Various possibilities for these efforts were discussed during the Dissemination Meeting of JKN Implementation Research Results on 20-21 October 2016 in Jakarta.

Dissemination Meeting of JKN Implementation Research Results

The deep-dive workshop on the results of the first cycle of implementation research for UHC (IR for UHC) in Indonesia was attended by national (P2JK, MOH and BPJS) and district stakeholders and local university partners. The objectives of the workshop were to:

• Disseminate the results of the implementation research focusing on JKN at the primary care level in 5 districts (Jember, Tapanuli Selatan, Jayapura, Jayawijaya and Jakarta Timur);
• Engage stakeholders in discussion of and learning from the findings;
• Produce actionable recommendations for strengthening JKN policy and regulations on primary care and the conditions for their effective implementation,
• Provide input for the second cycle of IR for UHC.

The workshop presentations, plenary sessions and group discussions focused on the two kinds of gaps explored in the IR: gaps between ‘best practice’ UHC policy and regulations on primary care and the reality of JKN policy and regulations (day 1), and gaps between JKN policy and regulations on primary care and their implementation (day 2).  There was overall agreement among the national and district stakeholders with the policy and implementation gaps identified in the first cycle of IR.

Recommendations to strengthen JKN policy ranged from clarifying specific regulations and improving communication and information sharing between local government and BPJS, to adjusting capitation to local contexts and distributing incentives based on individual performance (as opposed to education and experience).  In order to continue these discussions, follow-up presentations and consultations are planned with national- and district-level stakeholders to dive deeper into IR cycle.