Barriers to Treatment Adherence to Hypertension: A Comparison
Between Members and Non-Members of BPJS Kesehatan at
Pharmacy in Surabaya
Hanni P. Puspitasari, Desi Susanti, Maunah Maunah, Mufarrihah Mufarrihah, and Wahyu Utami
Department of Community Pharmacy, Faculty of Pharmacy, Universitas Airlangga Surabaya, Indonesia
Keywords: Hpertension, Treatment non-adherence, BPJS Kesehatan, Community pharmacy
Abstract: Non-adherence to hypertension treatment is reported as a major problem, leading to the increased incidence
of cardiovascular diseases. A qualitative exploratory multi-case study was designed to identify the factors
influencing treatment non-adherence for members and non-members of BPJS Kesehatan with hypertension
patients at two selected community pharmacies (pharmacy) in Surabaya. Semi-structured interviews were
conducted with three members (participants of the referring back program [PRB]) and three non-members
of BPJS Kesehatan who were purposively selected based on their prescribed medicines and the frequency of
visits to the selected pharmacy. Thematic analysis showed that the barriers to non-adherence identified by
PRB patients were their busy schedules and the common use of herbal medicines. Not only did the members
report both factors; non-members of BPJS Kesehatan also reported factors related to medicine (availability
and price), health provider (lack of information and two-way interaction), and the unavailability of the
health system to improve adherence. Moreover, non-members of BPJS Kesehatan were identified to have
other patient-related factors (misperception and poor knowledge about hypertension). Despite having more
barriers, the non-members of BPJS Kesehatan indicated unwillingness to participate as members due to
their understanding of the impracticability of the services. Therefore, BPJS Kesehatan needs to re-arrange
their programs to increase participation and to offer benefits for the hypertensive patients.
1 INTRODUCTION
It has been suggested in the literature that primary
health care is the most proper setting to address
challenges of chronic disease management
(Beaglehole, et al., 2008). Similar to other middle-
income contries, Indonesia has implemented the
development of a community health centre
(Puskesmas) in each district as a public health care
facility (WHO, 2008). Such a facility requires
support services either incorporated within the
facility or available independently, including clinical
laboratory and pharmacy units to allow for provision
of comprehensive health services (Indonesia
Ministry of Health, 2013a).
In terms of pharmacy, the number of private
community pharmacies (pharmacy) far out-weighed
that of public pharmacies within Puskesmas
(Kementerian Kesehatan RI, 2013b). As the number
of patients receiving health services from pharmacy
was more significant than those in the public sector,
there is a clear need for best quality pharmacy
services in pharmacy.
To enable improvement of access to health care
services and to reduce out-of-pocket health expendi-
ture, since January 2014 the Indonesian government
has set universal health coverage organized by
Badan Penyelenggaraan Jaminan Sosial Kesehatan
(BPJS Kesehatan) (WHO, 2014). In the manage-
ment of chronic diseases BPJS Health has provided
programs, such as PROLANIS (Program Pengelo-
laan Penyakit Kronis) and PRB (Program Rujuk
Balik) for its members (Kementerian Kesehatan RI,
2014). PRB is provided for patients with chronic
diseases who had received treatments from
specialists in the hospital setting to obtain a stable
condition but still requires continuity of care in the
community setting. Among chronic conditions,
hypertension has become a priority in the BPJS
Kesehatan programs because its prevalence has been
increasing.
Puspitasari, H., Susanti, D., Maunah, ., Mufarrihah, . and Utami, W.
Barriers to Treatment Adherence to Hypertension: A Comparison Between Members and Non-Members of BPJS Kesehatan at Pharmacy in Surabaya.
In Proceedings of the 4th Annual Meeting of the Indonesian Health Economics Association (INAHEA 2017), pages 333-336
ISBN: 978-989-758-335-3
Copyright © 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reser ved
333

Although the government has set a target to
reach participation of all Indonesians in the BPJS
Kesehatan by 2019, the current participation was
suboptimal (CNN Indonesia, 2017). In addition to
participation in the BPJS Kesehatan to all family
members, regular involvement of patients with
hypertension in treatments was stated by the
Ministry of Health as healthy family indicators
(Kementerian Kesehatan RI, 2016). However, based
on our unpublished work, nonadherence to
hypertension treatments was found among patients
who received pharmacy services in pharmacy either
members or non-members of BPJS Kesehatan. Our
findings also indicated that patients with hyper-
tension who were not members of BPJS Kesehatan
were unlikely to visit pharmacy for regular
treatments, in comparison to their counterparts. It
was unclear whether nonadherence among patients
with hypertension in pharmacy was associated with
factors related to patient, the disease, medicine,
health provider, health-system, and socio-culture, as
published earlier (WHO, 2003; Tsiantou, et al.,
2010; Albrecht, 2011; Osamor and Owumi, 2011).
Thus, a study was designed to identify barriers to
adhere to hypertension treatments for either
members or non-members of BPJS Kesehatan in
pharmacy.
2 METHODS
A qualitative multi-case study was applied to
explore factors influencing treatment nonadherence
for patients with hypertension. Patient data were
collected retrospectively (from March to August
2016) from one pharmacy with BPJS Kesehatan
network using an existing software for PRB patients
(Group A) and one pharmacy without BPJS
Kesehatan network using prescription files (Group
B). Potential patients for the study were then
selected based on criteria: 1) having frequency of
pharmacy visits five times or less during the study
period, 2) full home address was recorded in the
prescription files, and 3) willing to participate in the
study. Each selected patient was provided verbal and
written information about the study. Once a patient
had agreed, an arrangement of a date and time for a
face-to-face, semistructure interview was made at
the patient’s convenience, and a consent form was
completed. An interview protocol was used during
interviews, which was developed based on a
literature review of published articles (WHO, 2003;
Tsiantou, et al., 2010; Albrecht, 2011; Osamor and
Owumi, 2011) on factors related to nonadherence.
All interviews were audio-recorded and transcribed
ad verbatim. After coding the data using thematic
analysis, the researchers verified themes.
3 RESULTS
GROUP A: A total of 449 patients with
hypertension were recorded in the PRB software,
104 of them (23,2%) were identified as adherent
patients to visit pharmacy to get medicines. In
addition to the above selection criteria, an auxiliary
step was needed to select three out of 335 patients,
based on types of prescribed medicines received.
Patients receiving Angiotensin Converting Enzyme
Inhibitor agents, either alone or in combination with
other antihypertensive agents were a priority. A list
of priority participants was prepared prior to home
visits to finally interview three informants.
Case 1: A 51-year old female who was diagnosed
with hypertension since she was 42 years old. She
had family history of hypertension. Initially, she had
been prescribed with a brand name of lisinopril
10mg tablets, that was replaced with a generic name
of lisinopril 10mg tablets since she become a PRB
patient. Although the number of prescribed
medicines received (30) facilitated her to make
regular visits to her family doctor and pharmacy, she
sometimes felt lazy to take her medicines. Despite
that, she understood that hypertension could only be
controlled by taking regular medicines and adopting
a healthier lifestyle. When she felt an increased
blood pressure and thought that her prescribed
medicines was unable to give a rapid reduction, she
made and took herbal medicines in addition to
consumption of prescribed medicines. Since she was
a staff member of a hospital, she had an easy access
for blood pressure checking at her workplace. She
was unaware of PROLANIS.
Case 2: A 52-year old female who was diagnosed
with hypertension since she was 47 years old as well
as diabetes mellitus and hyperlipidaemia. She had
family history of hypertension. A generic name of
lisinopril 5mg tablets that had been initially
prescribed for her hypertension were replaced with a
brand name of nifedipin 30mg tablets. Although the
number of prescribed medicines received (30)
facilitated her to make regular visits to her family
doctor and pharmacy, she sometimes visited other
pharmacies to get medicines without prescription.
She understood that hypertension could be
controlled with regular consumption of medicines,
supported by having a healthier lifestyle. She was
unaware of PROLANIS.
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Case 3: A 51-year old male who lived with
hypertension in the last 15 years. A brand name of
lisinopril 10mg tablets that had been initially
prescribed were replaced with a generic name of
lisinopril 10mg tablets. He worked as a staff member
in a hospital so he had an easy access for blood
pressure checking at his workplace. The number of
prescribed medicines received (30) facilitated him to
make regular visits to his family doctor and
pharmacy. He sometimes stopped taking his
prescribed medicines to check whether or not he
could reduce his dependence on the medicines. He
also often substituted prescribed medicines with
individually made herbal medicines. She was
unaware of PROLANIS.
GROUP B: During six months of the study
period, six prescription files for patients with
hypertension were found to meet selection criteria.
A list of priority participants was prepared prior to
home visits. As three patients could not be
contacted, interviews were finally conducted with
the remainders.
Case 4: A 50-year old female who was diagnosed
with hypertension two years ago, as well as hyper-
cholesterolaemia and hyperurecemia. She had been
prescribed with propranolol 20mg tablets, hidro-
chlorothiazide 25mg tablets, isosorbid dinitrate 5mg
tablets, simvastatin 10mg tablets and allopurinol
10mg tablets for a 30-day treatment. She frequently
could not afford to pay for her doctor service and
prescribed medicines, leading to nonadherence to
make routine visit and take medicines. Despite that,
she was reluctant to be a member of BPJS
Kesehatan because she had observed that the
services were unsatisfactory. When her prescribed
medicines were running out, she preferred to get her
medicines from any pharmacy without prescription
despite receiving no medicine information from the
pharmacist. Alternatively, she took individually
made herbal medicines. She was unaware of
unhealthy food that triggers high blood pressure.
Case 5: A 60-year old female who lived with
hypertension in the last 10 years, after being
diagnosed with stroke and diabetes mellitus. She had
been prescribed with amlodipin 10mg tablets and
furosemid 10mg tablets for a 30-day treatment. She
believed that antihypertension agents should not be
taken when blood pressure readings were normal.
Although she was a member of BPJS Kesehatan, she
never took its benefits for her regular hypertension
treatment due to its long queue for getting services
and its long distance from home. She preferred to
get her medicines without prescription at a reachable
pharmacy although she was unlikely to receive
information about medicines from the pharmacist.
Case 6: A 53-year old female who lived with
hypertension in the last 13 years. She sometimes
missed to take her medicines but did not think to be
a problem because she believed that
antihypertensive medicines should only be taken
when needed, i.e. if she got dizziness. She had been
prescribed with a generic name of amlodipin 5mg
tablets, so the price of medicines was not a cause of
nonadherence. Therefore, being a member of BPJS
Kesehatan was not believed to be important,
especially because there was a near pharmacy to get
medicines without prescription. When the medicines
were running out, she sometimes consumed
individually made herbal medicines.
4 DISCUSSION
The findings of this study indicated that six barriers
to treatment adherence as published earlier (WHO,
2003; Tsiantou, et al., 2010; Albrecht, 2011; Osamor
and Owumi, 2011) were also reported by our
informants either members or non-members of BPJS
Kesehatan who visited pharmacy for pharmacy
services. Interestingly, factors related patient and
socio-culture were found to be predominant for both
groups, while factors related to medicines, health
provider and health-system only seemed to influence
non-members of BPJS Kesehatan.
Barriers to adherence that were related to patient
reported by our informants in both groups included
their laziness, busyness, forgetfullness and boredom
to take medicines for a long period of time, as
commonly found in previous studies (WHO, 2003;
Tsiantou, et al., 2010; Albrecht, 2011; Osamor and
Owumi, 2011). In addition, non-members of BPJS
Kesehatan were likely to have poor knowledge and
inaccurate perception of hypertension and its
treatment. As reported by our infor-mants who were
members of BPJS Kesehatan that they received
prescribed medicines for a 30-day treatment, they
tended to have regular visits to their family doctor
and pharmacy. This indicated that their frequent
interactions with healthcare providers enable them to
get more information related to the disease and its
treatment. Moreover, monthly visits as regulated by
BPJS Kesehatan, especially for PRB patients, allow
health care providers to provide information and
monitor patients’ conditions.
It should also be noted that medicine and
hypertension-related information was unlikely to be
given to our informants who were non-members of
BPJS Kesehatan when they visited pharmacy to get
Barriers to Treatment Adherence to Hypertension: A Comparison Between Members and Non-Members of BPJS Kesehatan at Pharmacy in
Surabaya
335

medicines without prescription. A possible
explanation for this was because the pharmacist or
pharmacy staff may have perceived that patients
collecting types of medicines for long-term
treatment have already had a proper understanding
about their medicines and condition. Similar to our
informants in another study (BPJS, 2015) that
patient knowledge was associated with interaction
between health providers and patients.
As reported elsewhere (BPJS, 2015), the use of
herbal medicines was common among patients with
hypertension either those who regularly took
prescribed medicines or those who were not. Health
care providers should consider such a phenomenon
in Indonesia (Pujianto, 2007) as inappropriate use of
herbal medicines may lead to further health
problems related to their potential interaction with
prescribed medicines.
Another interesting finding was the high cost of
prescribed medicines that were usually unaffordable
for non-members of BPJS Kesehatan, preventing
them to nonadhere to collect and take their
medicines. Interestingly, although they understood
that BPJS Kesehatan would cover their medicine
costs, they were not interested to join BPJS
Kesehatan as they directly or indirectly observed its
unsatisfactory services. BPJS Kesehatan may have
developed strategies to improve their services
(BPJS, 2016), but they would fail without
convincing evidence that all members of BPJS
Kesehatan would get the most benefits from BPJS
Kesehatan, in comparison to those who have not
joined.
5 CONCLUSION
Barriers to hypertension treatment adherence among
patients who were non-members of BPJS Kesehatan
widely varied, in comparison to their counterparts
members of BPJS Kesehatan. This may indicate that
programs offered by BPJS Kesehatan seemed to
enhance patient adherence to treatment for chronic
diseases. Despite that, strategies for improvements
are urgently required to offer great benefits for their
members. Similarly, flexibility and simplification of
services should be taken into consideration to
increase memberships of BPJS Kesehatan in order to
achieve universal health coverage by 2019.
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