Millions of Indonesians and participants of the JKN program are disadvantaged by idle capitation funds at community health centers (Puskesmas) as first-level healthcare facilities.
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KOMPAS/RYAN RINALDY
A nurse checks the blood pressure of a patient at a community health center (Puskesmas) in Tajur Halang, Bogor regency, West Java, on Saturday. The checkup was conducted before the patient consulted with the physician at the Puskesmas.
JAKARTA, KOMPAS – Millions of Indonesians and participants of the national health insurance (JKN) program are disadvantaged by idle capitation funds at community health centers (Puskesmas) as first-level healthcare facilities. Idle capitation funds at Puskesmas across Indonesia, which reached Rp 3.02 trillion (US$220.46 million) at the end of 2016, were not used to add more medical professionals. This is despite doctor-to-patient ratios at many Puskesmas being way below the ideal ratio. Lines of patients are often found in many Puskesmas.
Supreme Audit Agency (BPK) chief Moermahadi Soerja Djanegara said poor capitation fund absorption must be a serious concern and that planning and implementation mechanisms must be improved. “There must be standards of performance assessment. If something is not working, it must not be given budget allocation,” Moermahadi said after a meeting with President Joko “Jokowi” Widodo at the Presidential Palace in Jakarta on Thursday (5/4/2018).
National Social Security Council (DJSN) expert staff Hasbullah Thabrany said remaining capitation funds at Puskesmas put hundreds of millions of Indonesians and participants of the Health Care and Social Security Agency’s (BPJS Kesehatan) insurance program at a disadvantage. According to Hasbullah, budget allocation for improvements of healthcare service quality was ineffective. “Just look at services at Puskesmas. It remains the same after distribution of capitation funds,” Hasbullah said.
Kompas investigation of a number of Puskesmas in Karawang, Bekasi and Bogor regencies in West Java found that some doctors served up to 20,000 patients. BPJS Kesehatan Regulation No. 1/2017 stipulates that the ideal doctor-to-patient ratio is 1:5,000.
A large portion of capitation funds is used on medical services. In line with Health Ministerial Regulation No. 21/2016 on capitation fund management, at least 60 percent of capitation funds must be used for medical services, including paying for medical and other professionals. The remainder must be used for operational budget, namely to procure medicine and medical equipment and to pay for other activities.
Inadequate
Bekasi regency, for instance, with its idle capitation funds of Rp 51 billion, cannot hire more doctors for its Puskesmas. In Babelan Puskesmas, three general practitioners must serve 86,000 patients and BPJS Kesehatan participants. Each day, more than 100 patients gather at the Puskesmas.
Ulum, 60, needed to line up a long time to seek treatment at the Babelan Puskesmas. He spent one hour waiting for his turn to meet with the doctor since registering at the receptionist with a BPJS Kesehatan card.
Babelan Puskesmas head Ahmad Dimyati said the three doctors available at the Puskesmas were not enough to serve all patients. He said with the number of patients and BPJS Kesehatan participants reaching 86,000, ideally the Puskesmas should have at least 10 doctors. “It is still manageable. However, it can get a little too crowded in the morning. As a result, patients need to wait longer,” he said.
In Karawang regency, despite idle capitation funds of Rp 20.2 billion in 2016, there remain no additional medical professionals at local Puskesmas. Pakisjaya Puskesmas is one example. Its three doctors must cater to 26,000 patients and BPJS Kesehatan participants. However, since only two of the three doctors are available these days, each must cater to 13,000 patients.
In Bogor regency, there are 1.5 million BPJS Kesehatan contribution assistance recipients (PBI). Regulations say their health insurance only covers treatment at Puskesmas. However, only 200 doctors are available at the regency’s 101 Puskesmas. One doctor needs to serve 7,500 PBI patients, not to mention the individual BPJS Kesehatan recipients. Other than doctors, many Puskesmas do not have enough pharmacies.
A majority of hurdles in capitation fund absorption found by Kompas involved use of funds for operational costs, including procurement of medicine and medical equipment.
BPJS Kesehatan director Fachmi Idris said the BPJS Kesehatan could not reduce capitation fund distribution to Puskesmas, despite many Puskesmas having had huge idle capitation funds. “The funds can be used to improve medical care,” he said.
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