Exploring general practitioners’ perceptions about the primary care gatekeeper role in Indonesia

Abstract

Background In the current healthcare delivery system funded by National Health Insurance (NHI) in Indonesia, the gatekeeper role of primary care services is critical to ensuring equal healthcare access for the population. To be effective, gatekeeping relies on the performance of general practitioners (GPs). However, the perceptions held by Indonesian GPs about their gatekeeper role are not yet well documented. This study describes the self-perceived knowledge, attitudes and performance of Indonesian GPs with respect to the gatekeeper role and explores associated factors. Methods We conducted a cross-sectional study of all primary care facilities (N = 75) contracted by the regional NHI office in the Banyumas district. The 73 participating GPs completed a written questionnaire that assessed their knowledge, attitudes and performance in relation to the gatekeeper role. Personal and facility characteristics were analysed in a generalised linear model as possible associating factors, as well as for the association between GPs’ knowledge and attitude with performance as gatekeepers. Results GPs scored relatively high in the domains of knowledge and performance but scored lower in their attitudes towards the gatekeeper role of primary care. In the full-adjusted model, no factors were significantly associated with the knowledge score. Work experience as GPs, private or civil service employment status and rural or urban location of the primary care facility were linked to attitude scores. Full- or part-time employment and type of facility were factors associated with the performance score. Attitude scores were positively associated with performance score. Conclusion GPs in Indonesia are knowledgeable and report that they adequately perform their function as gatekeepers in primary care. However, their attitudes towards the gatekeeper function are less positive. Attitudes and performance with respect to the primary care gatekeeper role are likely influenced more by contextual factors such as location and type of facility than by personal factors. Efforts to address contextual issues could include improvements in practice standards for privately practising physicians and public information campaigns about gatekeeping regulations. Such efforts will be crucial to improving the gatekeeper role of primary care in Indonesia and assuring efficient access to high-quality care for all.

Indonesian General Practitioners’ Experience of Practicing in Primary Care under the Implementation of Universal Health Coverage Scheme (JKN)

“…Compared to other literature about primary care practice in Indonesia, findings in this study complement results of some studies related to GP practice under JKN implementation. 4,21,22 Findings in this study combined with results of our previous study on interviewing patients 4 complementary demonstrate a sense of adaptation and separation anxieties from both patients and GPs in primary care. Before the JKN implementation, the setting was previously regarded as a place to proceed many unnecessary referral letters to hospitals, and now, under the JKN, it has to perform more appropriate gatekeeping functions.…”

“…Many patients still expect referrals even for mild illnesses that are manageable in primary care, while it seems that the roles of primary care are still underestimated in the health system. 9,21,22 This hospital-oriented phenomenon is not surprising and can not be separated from prominent hierarchical culture in Indonesian health system. The system often puts specialists on the top of the hierarchical level, which can be seen from the hospital oriented-disease management and the GP training that is limited to medical doctor (MD) program without any further compulsory postgraduate training.…”

Gatekeepers in the health financing scheme: Assessment of knowledge, attitude, practices, and participation of Malaysian private general practitioners in the PeKa B40 scheme

“…In a recent Indonesian study however, the scores on attitude towards the gatekeeper role by Indonesian GPs has attained lower values than knowledge. And the low level of attitude has influenced their performance [ 34 ]. This is in contrast to the findings of our study, in which the attitude component is more significant with higher scores than the knowledge factor.…”

Reasons for switching the primary health providers among national health insurance participants in Klungkung District, Bali Province, Indonesia

“…The external factors which can influence people such as encouragement from a reference group, namely neighbors around their house and co-workers. 9,16 While the other external reason comes from the BPJS Kesehatan policy where BPJS Kesehatan has the authority to switch NHI participants if there is a condition where the health providers used by NHI participants is no longer cooperates with BPJS Kesehatan. The BPJS Kesehatan has the authority to move participants to other health providers based on equal distribution perspectives such as the number of registered participants, the adequacy of doctors, health workers other than doctors and infrastructure at the health facilities.…”