AUTHOR=Wenang Supriyatiningsih , Schaefers Juergen , Afdal Andi , Gufron Ali , Geyer Siegfried , Dewanto Iwan , Haier Joerg 

TITLE=Availability and Accessibility of Primary Care for the Remote, Rural, and Poor Population of Indonesia

JOURNAL=Frontiers in Public Health

VOLUME=Volume 9 - 2021

YEAR=2021

URL=https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2021.721886

DOI=10.3389/fpubh.2021.721886

ISSN=2296-2565

ABSTRACT=Background. Adopting Universal Health Coverage for implementation of a national health insurance system (JKN/BPJS) healthcare for Indonesia’s population of 255 million is targeted. Availability, accessibility and acceptance of healthcare services are most important challenges during implementation. Referral behavior and utilization of primary care structures specifically for underserved (rural/remote regions [3T], poor) populations are key guiding elements.
Results. Based on demographic, reimbursement and BPJS membership data usage and availability of infrastructure and human resources (HRH) was evaluated using principle component factorial and cluster analysis. ANOVA was used comparing reimbursement indexes for primary (FKTP) and advanced care (FKRTL). Usage of primary care resources was analyzed comparing clustered provinces, BPJS membership groups and utilization indexes differentiating poor (PBI membership) and non-poor population (non-PBI). 3T regions cover 27.8% of districts/municipalities. Distribution of overall poor population and PBI participants are highly correlated (r² >0.8; p<0.001). Three clusters of provinces (3T Poor [N=13], 3T Low Poor [N=15], Non-3T [N=5]) were identified. Canonical discrimination enabled >82% correct clusters classification of infrastructure and HRH-related factors. Standardized HRH (nurses, general practitioners) availability showed significant differences between clusters (p<0.01) whereas availability of hospital beds is weakly correlated. Usage of primary care (FKTP) was ~2-fold of FKRTL usage and non-PBI members utilized FKRTL 4- to 5-fold more frequently than PBI members. Referral indexes (r²=0.94; p<0.001) for PBI, non-PBI and FKRTL Utilization Rates (r²=0.53; p<0.001) are highly correlated.
Conclusion. HRH availability is intensively related to the extent of 3T population, but not numbers of poor population. FKTP access points are mainly used by poor population and in 3T regions whereas other population groups (non-PBI and non-3T) prefer direct access to FKRTL. Guiding referral and utilization of primary care will be a key success factor for effective and efficient usage of available healthcare infrastructure and achievement of universal health coverage in Indonesia.