General Practitioners’ Autonomy in the Management of Non-Communicable Diseases (NCDs) in the JKN Era: Is It Feasible?

Abstract

Demographic, epidemiological, and nutritional transitions increase life expectancy, changes in lifestyles and behaviors of Indonesian people. These changes are resulting in a growing contribution of non-communicable diseases (NCDs) to morbidity and mortality, especially metabolic disorders, such as type 2 diabetes mellitus (DM), hypertension, and dyslipidemia. Approximately 10.9% of the Indonesian population above 15 years old suffers from type 2 DM (21.2 million) and 34.1% have hypertension (66.3 million) in 2018. These figures increase significantly from 2013 figure; 6.9% and 25.8% respectively1. The metabolic disorders, which in turn, are responsible for vascular problems such as renal failure, stroke, and heart attack. Not surprisingly, then, 60% of Indonesian national health insurance (JKN) funds are spent on the NCDs. This condition causes a deficit and threatens the sustainability of the JKN program.

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…”

“…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.…”

“…Our findings confirm that primary care practice is also challenged by the current GP training, extensive JKN regulations, and limited facilities in primary care. 4,9,21,26,27 Therefore, with the increased work but limited training and practice supports, the GPs felt overwhelmed and unable to meet their patient demands. These feelings were worsened when the JKN also regulates a list of 155 diseases managed in primary care which creates an inflexible practice compared to managing patients without JKN.…”

The effect of health insurance and socioeconomic status on women’s choice in birth attendant and place of delivery across regions in Indonesia: a multinomial logit analysis

“…16 However, around 20% of delivery-associated JKN reimbursement at the hospital level was for normal deliveries, 17 which translates to around US$42 million spent for services that could essentially be delivered at the primary healthcare settings. 16 Anecdotal evidence indicated that this might be due to incorrect referrals and bypassing of the referral system due to the lack of confidence of the patients in the quality of care provided at primary health facilities, [18][19][20][21][22] particularly among urban population and those from the wealthier economic background. This may be due to perceived low quality among pregnant women towards primary health facilities, 23 24 which is in line with a recent World Bank study 25 where most Indonesia PHCs have limited basic amenities and SBAs compared with secondary healthcare facilities.…”