SUMMARY

EVALUATION OF THE USE OF NATIONAL HEALTH

INSURANCE (JKN) CAPITATION FUND AT PRIMARY HEALTH
CARE OF SELUMA REGENCY PROVINCE BENGKULU

Submitted by:

Heriawan
14/371200/PKU/14466

To

GRADUATE PROGRAM
FACULTY OF MEDICINE
GADJAH MADA UNIVERSITY
YOGYAKARTA
2016
 VALIDITY SHEET

SUMMARY

Evaluation of the Use of National Health Insurance (JKN) Capitation

Fund at Primary Health Care of Seluma Regency Province Bengkulu

Submitted by:

Heriawan
14/371200/PKU/14466

Approved by:

Supervisor I

dr. Lutfan Lazuardi, M.Kes.,PhD Date.....................

Supervisor II

Dra. Retnasiwi Padmawati, MA Date.....................

 TABLE OF CONTENTS

SUMMARY..............................................................................................................i
VALIDITY SHEET................................................................................................ii
TABLE OF CONTENTS......................................................................................iii
ABSTRACT...........................................................................................................iv
INTRODUCTION..................................................................................................1
RESEARCH METHOD........................................................................................2
RESULTS AND DISCUSSION.............................................................................2
Characteristics of Respondents.........................................................................2
Regulations for Utilization of Funds Capitation JKN.......................................2
Facilities and Infrastructures.............................................................................4
Human Resources (HR)....................................................................................4
Capitation Fund Utilization Process.................................................................5
CONCLUSIONS....................................................................................................9
RECOMMENDATIONS.....................................................................................10
BIBLIOGRAPHY..................................................................................................11
 Evaluation of The Use of National Health Insurance (JKN) Capitation
Fund at Primary Health Care of Seluma Regency Province Bengkulu
Heriawan1, Lutfan Lazuardi2, Retnasiwi Padmawati3

ABSTRACT
Background of Knowledge: Primary Health Care of Seluma Regency is
generally not supported by adequate health workers. Tuition assistance recipients
(PBI) has not received National Health Insurance from BPJS (Social Security
Administrative Body). Primary health care has not been supported by adequate
health facilities and medical devices dan there are capitation fund use in Primary
Health Care which is not in accordance with Regulation of the Minister of Health
Number 19/2014 Article 5 paragraph 1 and 3(1). There are still some complaints
from community health care workers, especially from midwives and nurses on
the inequitable distribution of health services incentive of National Health
Insurance (JKN) capitation funds and lack of accountability in the use and
responsibility of capitation funds for operational support of primary health care
health services (40%).
Method: The design used was descriptive qualitative. It was a study of which
the observation was performed toward a number of subject characteristics based
on innature status without manipulation or intervention from the researcher(2).
This study used case study, in which the researcher investigated particular
program, incident, activity, process, or a group of individuals carefully(3).
Results: Capitation fund of national health insurance at primary health care of
Seluma Regency in the Fiscal Year 2015, is used for health service by 75%,
operational support for health service by 20%, for drug expenditure by 5%.
National Health Insurance capitation fund accountability in both Primary Health
Cares has been in accordance with the regulation, but the planning process is not
done properly and not based on priority issues. Realizational the use of capitation
funds in Kota Tais 96.4% and Seluma Timur 95.8%.
Conclusions: The use of National Health Insurance capitation fund in Primary
Health Cares Kota Tais and Seluma Timur has generally been in accordance with
the regulation, but there are still employees who have not been able to accept
regulation of the division of health services and there are still employees who
complained about the use of capitation funds have not been fair and transparent.
Keywords: national health service capitation fund, primary health care, health
funding system.

1
Staff of District Health Office in Seluma
2
Graduate Program of Health Management Information System, Public Health
Department, Faculty of Medicine Gadjah Mada University
3
Educator Department of Public Health, Faculty of Medicine Gadjah Mada
University
 INTRODUCTION

There are still obstacles and problems in National Health Insurance

Program Implementation in primary health care at Seluma Regency Bengkulu
Province conducted by Health Department, Tais District Hospital, primary health
care and Social Securities Administrative Bodies (BPJS), in the form of both
health service quality and the attitude of health workers. Health workers and non-
health workers, who are still complaining the method of health service distribution
only on the basis of education and attendance, do not count the performance and
working period. The lack of accountability of national health service capitation
fund usage for operational support for health service also becomes the issue in
JKN program implementation in primary health care in Seluma Regency that
affects health workers performance in primary health care which eventually
affecting overall primary health care organization performance.
Based on Audit Board for Bengkulu Province Representative, the issues on
National Health Insurance Program implementation in fiscal year of 2014 in
Primary Health Care at Seluma Regency are: (1) Endorsement Letter of Revenue
and Expenditure is not used as the basis of bookkeeping of Revenue and
Expenditure in Budget Realization Report, (2) the use of JKN capitation fund is
not in accordance with the allotment based on Regulation of Health Minister
Number 19 of 2014(1).
Based on study conducted by Wulandari, it are found out that there are so
many complaints arose in the community, such as they do not know in first level
health facility where they are registered as participants, they think they do not
receive maximum and excellent service, they only receive standard medicine,
there are early repatriation due to expired claim, and many others (4). The lack
efficiency in fund utulization in primary health care is caused by the fund
allotment that has not been based on problems priority. Based on study conducted
by Dionne in talk, it are found that problems priority determination is based on
resources, politics, organizational culture and management capacity allocation(5).

1
 RESEARCH METHOD

The research was descriptive qualitative using case study design. It was the
study of which the observation was performed on a number of subject
characteristics based on innature status without manipulation or intervention from
the researcher(2). In qualitative the researcher investigated particular program,
incident, activity, process, or a group of individuals carefully. The cases were
limited by time and activities, and the researcher completely collected information
using various data collection procedurs based on specified time(3). In this research
20 subjects were interviewed and the data was collected until saturation.

RESULTS AND DISCUSSION

Characteristics of Respondents
Respondents of the research in primary health cares of Kota Tais total of
10 people and Seluma Timur ten people consisting of structural officer two
people, administrators and application four people, the official general polyclinic
four people, officials clinic mothers and children four people, field officer four
people and midwives two people.

Regulations for Utilization of Funds Capitation JKN

In capitation fund use in Kota Tais and in Seluma Timur referred to the
regulation issued by central government and local government in Seluma
Regency. JKN program implementation, especially capitation fund use in 2015 in
Primary Health Cares in Kota Tais and Seluma Timur Seluma Regency had not
experienced meaningful problems in the aspect of implementing regulations.
However, there were regulations which based on workers had not fulfilled sense
of justice and not transprance, those were:

1. Regulation of Health Minister Number 19 of 2014, which based on most

respondents that points’ calculation in the basis of education and attendance
had not met sense of justice and there should be an increase in performance

2
 points. In addition, the respondents stated that the range of points between
medical staff and other health workers was too wide.
2. Decision of the Head of Health Department in Seluma Regency Number 1152
of 2014, which based on respondents with temporary and honorary work status,
it did not meet sense of justice because their educational points were just a half
from those with civil servants status. In addition, this regulation contradicted
with Regulation of Minister of Health Number 19 of 2014 which stated that
there was no difference in educational points between civil servants and
temporarty and honorary workers.
3. Decision of the Head of Health Department of Seluma Regency Number
440.1/217.A/II/2015 which defined that transport cost of JKN capitation fund
outdoor was only Rp50,000 while the activities resulted from Operational
Support Health (OSH) fund, the transport cost was Rp100,000.
4. Based on Purnadi Purbacaraka and Soerjono Soekanto legislation from the
lower order levels, a more detailed elaboration or formulation of legislations
that higher levels of order. It will also mean that the legislation should be
subject to lower and must not conflict with the laws and regulations of higher(6).
This feeling of injustice will certainly affect the performance of an employee to
perform tasks that will ultimately affect the quality of health services to the
community. Understanding of the regulatory context of a policy is particularly
important for the implementation of the National Health Insurance program,
especially the use of capitation funds in health centers. This is consistent with
the statement Savedoff & Gottret in his book states that the participation of the
executive (head of puskesmas) should strengthen the decision-making systems
that support the implementation of the mandatory health insurance(7).
5. Based on Van Meter & Horn there were some causes that made regulations
issued by governements did not work well, those were: first, it was caused by
the too wide program fields and the complex goals. Second, it was caused by
the unclear and contradiction in fundamental regulation statements and goals(8).
So that researchers can draw a red thread that implementation of the well a
program is the result of the commitment and the executors of understanding of

3
 the rules / policies that exist and to be able to make policy - local policies to
strengthen program delivery in health centers JKN.
Facilities and Infrastructures
Based on the observation results obtained from Primary Health Cares at
Kota Tais as first level health facility (FKTP), it had had good and adequate
facilities and infrastructures to implement health service toward community of
JKN participants. Seluma Timur Primary Health Care has not had internet
network facility, so P-care application could not be operated there. This problem
had been submitted to the Department of Health and a representative office BPJS
Seluma but until now there has been no research real solutions, only suggested by
the BPJS to run the application after the return of health centers that house officer
P-care applications.

Human Resources (HR)

Kota Tais Primary Health Care was one of primary health cares in Seluma
Regency which had even and adequate health workers for non-care Primary
Health Care category with 36 health workers, but Kota Tais Primary Health Care
was still lacking two general practitioners. Seluma Timur Primary Health Care has
not had even Human Resources (HR) as standard determined by Social Securities
Administrative Bodies (SSAB), however the number of overall health workers
was more than enough. The type of health workers which were not available yet
or had not met the number needed in Seluma Timur community health center were
civil servant of general practitioners, dentist, health analyst, environmental health
workers, medical record workers and nutritional workers. As stated by Yasilis
Ilyas, human resources were unique creatures and having multi-complex
characteristics, and this could be seen from various aspects, those were: (a) HR
was a critical component, (b) HR was not instant, (c) HR was not available in
stock, and (d) HR was an absolute subject (9). The lack of health workers was the
real root causes(10). Human resources in Kota Tais and Seluma Timur is Midwives
and Nurses, so many midwives and nurses do work that is not his competence as
became treasurer, medical records and officers p-care applications. Human

4
resources in Kota Tais and Seluma Timur had enough of in terms of quantity but
in terms of quality and competency has not been sufficient. For financial
management officers capitation funds is also not competent because because it is
still done by midwives and public health scholars and not done by accountants.
However, for the development of future programming which coverage of
participants JKN increasing and budgets are managed health centers increasingly
large, expected to Puskesmas Kota Tais and Seluma Timur can increase the
quantity of medical personnel and the quality of non-medical mainly
administrative personnel finances by making the proposal manpower needs to the
Head of Department of Health and Regent Seluma.

Capitation Fund Utilization Process

The amount of capitation fund of Kota Tais Primary Health Care in 2015
determined by BPJS was Rp5000/respondent and Seluma Timur Primary Health
Care was Rp4,500/respondent.

Tabel 1: Capitation fund realization of Kota Tais and Seluma Timur Primary
Health Care of 2015

Source: The Financial Report of Seluma regency Health Department in the

Fiscal Year of 2015.

Kota Tais and Seluma Timur Primary Health Cares had not implemented
financial management with local agency for general service system, so the
Primary Health Care Capitation Fund still belonged to Budget Working Plan
(BWP) and Budget Implementation Document (BID) of Seluma Regency Health
Department. Capitation fund budget in the Budget Implementation Document
(DPA) Health Department Seluma, yet detailed described up with details of

5
activities and details of the type of expenditure, so that the Primary Health cares
must make Plan of Implementation Activities (RPK) Capitation funding either
annual or monthlyBased on the respondents statements, in the fiscal year of 2015,
Kota Tais and Seluma Timur Primary Health Cares had created monthly Activity
Work Plan (AWP), however they could not provide the document when the
researcher asked for it. According Hutubessy & Chisholm cost-effectiveness
analysis is very important help in making the right decision in an effort to provide
health services although in practice the decision was influenced by political,
economic, social and personal interests(11). he does not have plan documents
exercising activities capitation funds in due not to analyze the effectiveness and
efficiency of the budget made by the head of the health center and not the
functioning of the head of Administration (TU), so planning activities were made
by each of the treasurer and even then not based on the proposals worked out by
each - each program and not based priroritas health problems in their working
area.
There was no obstacle in the proses of JKN capitation fund disbursement
in Kota Tais and Seluma Timur Primary Health Cares because the primary health
care has had checking account respectively to relocate JKN capitation fund and
non-capitation (delivery service claim) which was directly transfered from Health
SSAB account every month.
JKN capitation fund in the fiscal year of 2014 in Seluma Regency Primary
Health Care was used as much as 60% for health service, 40% for operational
support for health service and for drug purchases. In 2015 based on the decision
of the Regent Seluma No. 440.73 In 2015, the allocation of capitation funds JKN
converted is 75% for health services, 20% for operational support health services,
drug and 5% for BHP. Capitation fund for health service was only for workers
working in main primary health care while for those who work in supporting
primary health care, village health post and midwives were not received health
service. In educational point calculation, there was also a difference between civil
servants workers and temporarty and honorary workers, where non-civil-servant
workers only obtained 50% of educational point from the points obtained by civil
servant workers. JKN capitation fund for operational support in Kota Tais and

6
Seluma Timur Primary Health Cares was mostly used for the transport of the
workers conducting outdoor activities like health education, free treatment, house
visits, neighborhood health center, growth and development detection for school
children, vitamin A sweeping and others. In addition to the transport, capitation
fund for health operational support was used for office equipment purchasing,
payments of telephone/speedy bills, fuel for mobile transportation of primary
health care.
Based on Effendy health centers established to support the achievement of
national health development goals, namely to increase awareness, willingness and
ability to live a healthy life for people residing in its territory in order to realize
better health status(12). Services provided to participants JKN in first-level health
facilities (health centers) should be able to educate patients and families about
preventive promotive efforts, such as a clean and healthy lifestyle, particularly
diet and exercise. Their execution of the undertakings of Public Health (SME) is
optimal in the clinic can reduce the number of sick people, thereby reducing
individual health efforts (UKP) which in turn will have an impact on BPJS that
will be easier to control the quality and cost
Based on Rivai incentive is a form of direct compensation granted to
employees / outside the fixed salary and the amount depends on the performance
and workload(13). According to this theory it is clear that the basic division of
capitation funding is not right and does not satisfy the sense of justice, because it
is not based on performance but only by a diploma and course attendance.
According to Kutzin & Saxenian, a powerful incentive payment method will
affect the efficiency, equity and quality of provider incentives(14). Capitation funds
payment method in the clinic to date have not been good, so there are still many
health workers in primary health cares complain, because it is unfair, inefficient
and simply aligned to one of the professions of health workers.

There was no obstacles in the accountability process of JKN capitation

fund in Kota Tais and Seluma Timur Primary Health Cares in fiscal year of 2015
and it had been in accordance with Presidential Regulation 32 of 2014 and
Circular Letter of Minister of Home Affairs Number 900/2280/SJ on 5th May

7
2014(15). The only obstacle and constrain in the accountability process of JKN
capitation fund based on workers’ statement in Seluma City and Seluma Timur
Primary Health Cares was SP3B submission process by Health Department and
publication of SP2B by DPPKAD that needed very long time.
Primary Health Cares in Seluma Regency had not conducted financial
management with Local Agency for General Service system, so the primary health
cares had not being required to create financial statement like financial statement
which in general consisted of Notes to the Financial Statement (NFS), Budget
Realization Report (BRR) and Balance Sheet because Primary Health Care’s
financial statement still belonged to financial statement of Seluma Regency
Health Department.
Capitation fund use in Kota Tais Primary Health Care in 2014 has not in
accordance with regulation based on Audit Board and FDSA for Bengkulu
Province representative and those things were approved by respondents. In 2015,
the use, administration and accountability of capitation fund in Kota Tais and
Seluma Timur Primary Health Cares had been in accordance with the regulation.
The use, administration and accountability of capitation fund in Kota Tais and
Seluma Timur Primary Health Cares in 2015, based on some respondents’
statements above had been better and in accordance with applicable rules,
however from the result of interview with the other primary health care workers, it
was found that capitation fund use had not met the sense of justice, not transparent
and only profitable for JKN capitation fund financial management of primary
health care. Based on Kutzin, the purpose of health financing system was
achieved if the equity, efficiency, qualified, transparent and accountability
elements were satisfied(16). Based on those theory, the purpose of capitation fund
financing in Kota Tais and Seluma Timur Primary Health Cares had not been
achieved because it had not been trasparent and had not satisfied the sense of
justice for all health and non-health workers in Primary Health Care. Corruption
in the health sector either in the form of money or theft of health resources such as
medicines, will affect the health system that ultimately result in low quality of
public health services(7). He utilization of capitation funds JKN is not fair,

8
efficient, effective, transparent and accountable due to the lack of guidance from
the Department of Health Seluma in an effort to control the cost and effectiveness
of health care in the form: a meeting with the heads of health centers and financial
operators to provide guidance for cost control efforts, monitoring and evaluation
of services and coordinate with related parties include Inspectorate, BPJS, BPK
and BPKP Representative Bengkulu.
Based on financial statement of Health Department in Seluma Regency
(2015), the realization of JKN capitation fund use of Kota Tais Primary Health
Care in the fiscal year of 2015 which was Rp320.374.715,- (96,4%) with
remaining fund per 31st December 2015 was Rp11.886.469,-. The realization of
JKN capitation fund in Seluma Timur Primary Health Care was Rp254.379.925,- (
95, 85%) with the remaining fund was Rp10.989.847,-.

CONCLUSIONS

1. Regulations on legislated by the central government and local governments

Seluma are in accordance with the needs and already can be guide health
centers community to conduct a series of activities in the utilization of
capitation funds JKN, although there are still some rules that can not be
accepted by health center staff because they do not satisfy the justice.

2. The process of utilization, administration and accountability of capitation funds

JKN in Puskesmas Kota Tais and Seluma Timur has been going well and
according to the rules, but there are still some respondents who complained
about the distribution of health services capitation funds JKN not fair and not
transparent because money received does not match the receipts and
explanation from the head of the health centers and treasurer of capitation
funds JKN not satisfactory.

3. The allocation of capitation fund the National Health Insurance to support

health care operations mostly used to transport personnel in the health-care
activity outside the building. The generally an increase in health care activities
outside the building in Kota Tais and Seluma Timur, but these activities remain

9
 focused on individual health (UKP) and not the activism efforts of Public
Health (UKM) such as extension activities.
4. The composition of the use of capitation funds JKN in the year 2015 was
mainly used for health services (75%), for operational support of health care
(20%) and for drugs (5%). Performance of health and non-health workers in
Seluma Timur and Kota Tais is good enough in the use of capitation funds
JKN, this can be seen from the high rate of absorption of JKN capitation
funding in fiscal year 2015 that is above 95%.

RECOMMENDATIONS

1. Head of primary helath cares can further optimize the function of head of
administration in making the Plan of Implementation Activities (RPK) JKN
capitation funds so that the use of capitation funds more effectively and
efficiently.
2. Head of primary helath cares and treasurer of capitation funds JKN more
equity and transparant in the management of JKN capitation funds for
operational support and health services for drug expenditure.
3. Head of primary helath cares should reduce the free treatment because the
village already has health officials and outside of the building activities more
activities of a public health efforts.
4. Head of Seluma District of Health review legislation regarding the variable in
the distribution of healthcare services JKN capitation funds because they are
less fair to non-civil servants puskesmas.
5. Head of Seluma District of Health adding doctors and dentists in the Seluma
Timur and Kota Tais thus acceptance of capitation funds JKN in the clinic can
be a maximum that is Rp.6.000 / participant.

10
 BIBLIOGRAPHY

1. BPK RI Perwakilan Propinsi Bengkulu. Laporan Pemeriksaan LKPD Seluma

Tahun Anggaran 2014. Bengkulu; 2015.
2. Pratiknya AW. Dasar-dasar Metodologi Penelitian Kedokteran dan Kesehatan.
Jakarta: PT Rajagrafindo Persada; 2010.
3. John W. Creswel. Research Design Pendekatan Kualitatif, Kuantitatif, dan
Mixed. Edisi Keti. Yogyakarta: Pustaka Pelajar; 2010.
4. Wulandari RI. Pelaksanaan Program Jaminan Kesehatan Nasional di
Kabupaten Tumenggung. Journal of Chemical Information and Modeling.
2014;53:160.
5. Dionne F, Mitton C, Smith N, Donaldson C. Decision maker views on
priority setting in the Vancouver Island Health Authority. Cost Effectiveness
and Resource Allocation [Internet]. 2008;6(1):13. Available from:
http://www.resource-allocation.com/content/6/1/13
6. Purnadi Purbacaraka dan Soerjono Soekanto. Peraturan perundang-undangan
dan Yurisprudensi. Cetakan Ke. Bandung: PT. Citra Aditya Bakti; 1989. 7-11
p.
7. Savedoff WD, Gottret P. Governing Mandatory Health Insurance: Learning
from Experience [Internet]. Washington, D.C.: World Bank, 2008, pp. xv,
227. 2008. 2-xv, 227 p.
8. Meter, Donald Van CVH, Horn VM dan Van. The Policy Implementation
Process: A Conceptual Framework dalam Administration and Society.
London: Sage Publicatian, Ltd; 1975.
9. Ilyas Y. Perencanaan SDM Rumah Sakit: Teori, Metoda, dan Formula. Edisi
revi. Depok: Pusat Kajian Ekonomi Kesehatan Fakultas Kesehatan
Masyarakat Universitas Indonesia; 2004.
10. Meliala A. Desentrlisasi Manajemen Sumber Daya Manusia Kesehatan:
Pengalaman Implementasi di Daerah Istimewa Yogyakarta, Desentralisasi
Kesehatan di Indonesia dan Perubahan Fungsi Pemerintah. Yogyakarta: Gama
Press; 2005.
11. Hutubessy R, Chisholm D, Edejer TT. Cost Effectiveness and Resource
Allocation priority-setting in the health sector. Cost Effectiveness and
Resource Allocation. 2003;1:1–13.
12. Efendi F, Ferry Efendi. Keperawatan Kesehatan Komunitas: Teori Dan
Praktek Dalam Keperawatan. Jilid 1. Jakarta: Salemba Medika; 2009.
13. Vethzal Rivai AF. Performance Appraisal: Sistem yang tepat untuk menilai
kinerja karyawan dan meningkatkan daya saing perusahaan. Jakarta: PT. Raja
Grafindo Persada; 2005.

11
14. Joseph Kutzin, Helen Saxenian HB. Incentives and Provider Payment
Methods. Health (San Francisco). 2004;
15. Kemendagri RI. Petunjuk Teknis Penganggaran, Pelaksanaan dan
Penatausahaan, serta Pertanggungjawaban Dana Kapitasi Jaminan Kesehatan
Nasional pada Fasilitas Kesehatan Tingkat Pertama Milik Pemerintah Daerah.
2014;1 of 24.
16. Kutzin J. Conceptual framework for analysing health financing systems and
the effects of reforms. Europe [Internet]. 2010;21:411. Available from:
http://www.euro.who.int/en/what-we-publish/abstracts/implementing-health-
financing-reform-lessons-from-countries-in-transition
17. Dinas Kesehatan Kabupaten Seluma. Laporan Keuangan SKPD Dinas
Kesehatan Kabupaten Seluma Tahun Anggaran 2015. Seluma; 2015.

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