National Health Insurance Policy: Benefit-cost Analysis of Primary

Care Physician Education Program

Dian Purnama Sari

Department of Accounting,Widya Mandala Chatolic University Surabaya, Dinoyo Stree, 42-44, Surabaya, Indonesia

Keywords: National Health Insurance, Benefit-Cost Analysis, Primary Care Physician Education Program

Abstract: Indonesia's National Health Insurance holds several programs for society welfare improvement, especially

in health matters. One of the programs assumed to be still controversial is the education program for the

Primary Care Physician. Indonesian Physicians Association handling and managing professional doctor

licensing strongly refuses that program. This study applies a qualitative approach designed to make a

benefit-cost analysis of the education program for Primary Care Physician by employing mental accounting

theory. The result of the study shows that the doctors are enthusiastic about joining the program if it is free.

Unfortunately, the unfixed state of policy by the government brings about a doubtful consideration to deal

with the program. The benefit analysis indicates that the material benefit the doctor hopes is not sufficiently

covered. However, they still have the humane based benefits by implementing their knowledge and skill to

help society. One extraordinary struggle they must go on when taking the Primary Care Physician program

is their inmost welfare (satisfaction inside).

1 INTRODUCTION

The education program for Primary Care Physician

is one of the government's policies in case of health

improvement. Through Regulation Number 20 of

2013, the government has proclaimed that the

Primary Care Physician program is the continuation

of the professional medical program and internship

program equivalent to a specialist medical program.

That Regulation Number 20 of 2013 "obliges"

general practitioners to have an education to the

same degree of specialists for a better health care

service at the First Level Health Facilities such as

Community Health Centers and Outpatient Clinics.

This program is a part of the government’s National

Health Insurance managed by the National Social

Security for Healthcare since 2014.

The implementation of health care is one of the

basic needs of human beings in life. Each individual

of the society is expected to join the National Health

Insurance in order to get a primary service at the

First Level Health Facilities and hospitals. The First

Level Health Facilities consists of clinics, general

practitioners, dentists, and Community Health

Centers. The National Social Security for Healthcare

has emerged pros and cons in its implementation.

There have been many problems in the

implementation of National Health Insurance.

One of the spotlights of the National Health

Insurance is the arrear of the National Social

Security for Healthcare to pay the recommended

hospitals for patients holding the National Social

Security for Healthcare. Throughout 2018, there was

found a deficit of the National Social Security for

Healthcare reaching IDR 9,1 Trillion, and its

management has predicted that it would have

continued to occur, valued at IDR 16,5 Trillion, in

2019. The deficit was presented and discussed by

both the Ministry of Finance and the Legislative of

the Republic of Indonesia (Anwar, 2018). Thabrany

(2015) states that service expense of the National

Social Security for Healthcare is over 100%. While

in fact, a ratio claim above 90% is no longer ideal in

case of its social insurance principle. One of the

causes of the high claim by the hospitals is that the

quality service is lack at the First Level Health

Facilities. It is claimed to have high demands of

more significant recommendations at Further Level

Health Facilities.

The Ministry of Health (2015) records that the

healthcare cost at the First Level Health Facilities is

IDR 10,543 Billion or 17% by capitation system.

The healthcare cost at the Further Level Health

Sari, D.

National Health Insurance Policy: Beneﬁt-cost Analysis of Primary Care Physician Education Program.

DOI: 10.5220/0009399100110022

In Proceedings of the 1st International Conference on Anti-Corruption and Integrity (ICOACI 2019), pages 11-22

ISBN: 978-989-758-461-9

Facilities is IDR 45,535 Billion or 74%.The

significant difference experienced by both the First

and Further Level Health Facilities has indicated that

the National Social Security for Healthcare should

make some perfection. Kurniawan (2015) says that

healthcare at the First Level Health Facilities is

considered unwell implemented due to the lack of

facilities, even no facility provided for better care.

The other factor is that the competence of the

doctors handling patients at the Community Health

Centers is still low so that it leads to upper-level

recommendations for hospitals' treatment.

The improvement process is eventually sounded

by the government. It leads to one of the efforts to

advance the quality healthcare at the First Level

Health Facilities through requiring a condition that

doctors at the Community Health Centers should

have a level of Primary Care Physician as acted

under Regulation Number 20 of 2013. There have

been 17 universities in Indonesia state readiness for

opening the Primary Care Physician program.

Moreover, there has been a Primary Care Physician

program, which has been operating since 2016.

The effort of the government to improve the

quality of doctors through the Primary Care

Physician program is logically under a reason. Van

Peursem, Pratt & Lawrence (1995) state that the

qualities care can be seen through the organizational

structure and its service management. The

organizational structure is defined as a relatively

stable characteristic of care practitioners,

instruments, and human resource provided, and

physical and organizational setting in which they

work. The organizational structure is commonly

determined and stable, particularly in the

government. The service management or process is

defined as a set of activities operating in, and

between the practitioners and the patients. The

service management or process is an essential part of

the healthcare operation. Jacobs, Marcon, & Witt

(2004) reveal that a hospital or a clinic is not the

center point of healthcare, but a health practitioner (a

doctor). It means that service management or

process is done by a healthcare practitioner has a

vital determining role in the matter of healthcare

quality. To improve the healthcare service quality, it

is required for some improvements in the human

resource's quality, the doctors. In addition, this is a

solution implemented by the government and the

National Social Security for Healthcare.

On the contrary, side, many health practitioners

(doctors) refuse to have that program of Primary

Care Physician. Indonesian Physician Association,

as the legitimate organization of doctors in

Indonesia, goes against the program. On October

24, 2016, a group of doctors demonstrated in a

peaceful way to refuse the program (detik.com,

2016; tempo, 2016). There were several reasons to

contradict to the program. Firstly, it will take a

longer study to become a health practitioner or

doctor. After six years for a general practitioner title,

a doctor should undergo a 1-year internship program

in a specific region. If the Primary Care Physician

program taken, it will take around three more years

to complete it. By calculation, the length of the

study will increase up to at least ten years, not to

mention the extended period of study. If compared

to any other profession, the length of study is much

longer. Secondly, the Primary Care Physician

program does not have a clear curriculum. For a

general practitioner or a doctor's study, the

curriculum requires 144 diseases and diagnoses.

The same way to reach will be applied to the

Primary Care Physician program. As mentioned in

the general practitioner study program, a general

practitioner is proper for primary care practices.

Indonesian Physician Association is worried about

the overlapping curriculum applied in both general

practitioner study and Primary Care Physician

program. It is considered as improvidence.

Thirdly, Indonesian Physician Association

assumes that the budget is more properly to use for a

better improvement in many First Level Health

Facilities. In some cases, many doctors at the First

Level Health Facilities are sometimes not able to

make any action to handle the patients due to the

lack of instruments and facilities available for their

healthcare. It is not caused by the personal disability

of the doctors. That situation faced by the doctors

leads to the next step taken to recommend the

Further Level Health Facilities to take action in

relation to the needs of the patients' healthcare and

safety. The facilities improvement should be a

concern of the government to support the healthcare

at the First Level Health Facilities. Fourthly, the

tuition fee for medical education of general

practitioner is high enough. Moreover, it also shares

the same problem faced by many doctors when

required for joining a specialist program of medical

education. To achieve a title of a general

practitioner, hundred millions of rupiahs (IDR) are

budgeted for the tuition fee and all expenses during

the study. Meanwhile, the Primary Care Physician

program is equivalent to the specialist program. The

calculation claimed by the Indonesian Physician

Association indicates that every single student of the

Primary Care Physician program will have IDR 300

Million spent per year. If there are 110.000 doctors

ICOACI 2019 - International Conference on Anti-Corruption and Integrity

plotted to continue and register for the Primary Care

Physician program, the government must provide

special budgeting to support their study. The

estimated payment to fulfill the needs toward

achieving the level of the primary care specialist can

be very high. Besides that, taking a specialist

program has been a big problem in the case of

finance. Of course, it may personally affect on the

specialists’ burden if still required for joining that

program.

Some pros and cons concerning the Primary Care

Physician program have been following even though

the government has operated since before. The

Primary Care, Physician education program, is a

great topic to study through accounting analysis. The

study concerning medical education taking doctors

as the center point of view has still a few been done

in Indonesia. Medical education in Indonesia has

always been alleged as a study that requires a high

cost. A high cost of education is not always a

determining factor of having "qualified" graduates

with great benefit. Therefore, this study aims to

analyze the benefits of the Primary Care Physician

education program.

A human being is, in fact, doing some

accounting processes just like the activities operated

in a company in making a record and categorization

of expenses into some accounts in minds

Rospitadewi & Efferin, 2007). Human beings do

accountancy in their minds and consumption

decision-making evaluation. That human’s activity

reflects a work of a theory known as Mental

Accounting popularized by Thaler in 1985 (Thaler,

1999). Mental Accounting is a cognitive process in

which humans record, recap, analyze, and report the

financial events in order to investigate where the

money flows and control the expenses. Like

accounting in an organization, a human also

analyzes the Benefit-Cost aspects. The Mental

Accounting theory is very interesting and applicable

to this study.

The pro and cont issues about the Primary Care

Physician education program have a great possibility

to study (including in accounting as one perspective)

which may lead to some recommendations to take

by the government for better improvement of the

medical profession. The benefit-cost analysis viewed

from doctors' side regarding the Primary Care

Physician program is the focus of this study. The

reason for choosing the doctors' side is that the

purpose of the program is their improvement. By

doing this, the doctors have their own decision

whether or not to take or leave it. Through

accounting study, it will be a great practical

contribution to "good government," which helps the

government and Indonesian Physician Association

make policies concerning with the Primary Care

Physician education program.

2 THEORETICAL REVIEW

2.1 Good Governance

The policy of the government is one of the efforts to

improve Good Governance. Good Governance is a

set of processes applied to a public or private

organization in order to make decisions. Even

though Good Governance does not fully ensure its

perfect result, but it may reduce the number of

power abuse and corruption when applied. Good

Governance may comprehensively be understood by

holding its basic characteristics, namely: (a) active

participation, (b) law upholding, (c) transparency,

(d) responsive, (e) deliberation and consensus-

oriented, (f) justice and same treatment for all, (g)

effective and economical, and (h) accountable.

The National Social Security for Healthcare has

become one of the policies taken by the government

to deal with its responsibility for the fair and

effective healthcare of all Indonesian citizens that is

strongly based on mutual-cooperation principle. As

for the National Social Security for Healthcare,

Good Governance should also become a concern in

order to have better quality and accountability for its

activities before the government and society. By

doing so, the government has a standardized

measure to assess the performance of the National

Social Security for Healthcare.

2.2 Primary Care Physician Program

The Primary Care Physician program has essentially

been legalized by the government since 2015.

However, to deal with those pros and cons, this kind

of program has not been effective yet. In

Indonesia, there is only one medical faculty

accredited A which conduct such a program. As

resulted from the program at that single medical

faculty which runs the program, there are only 70

doctors claimed to be successful completing the

Primary Care Physician program. There is still a far

difference in ratio between the total doctors who

have finished taking the Primary Care Physician

program and the total doctors in Indonesia. It

indicates that the result has not covered a national

scale yet.

National Health Insurance Policy: Beneﬁt-cost Analysis of Primary Care Physician Education Program

The Primary Care Physician program emphasizes

preventive and promotive ways, even early detection

in its works. This sort of work is suitable for the

First Level Health Facilities covering Community

Health Centers, First Class Clinics, and Doctors’

Private Practice. If the patient’s illness cannot be

handled at the First Level Health Facilities, it can be

recommended to have tiered healthcare starting from

hospital type C or D, the next is hospital type B or

even type A. After cured with the suitable medical

actions, the patient may be re-recommended and

returned to the First Level Health Facilities. After

all, the rehabilitation can be treated to the patient at

the First Level Health Facilities.

The doctors graduated from the Primary Care

Physician program are given a provision to manage

the fund in relation to the capitation system of the

National Social Security for Healthcare. The

capitation system is based on the number of a family

member registered at the First Level Health

Facilities. The amount of capitation given by the

National Social Security for Healthcare ranges from

IDR 8,000-IDR 10,000 per member and multiplied

with the number of the registered member at the

First Level Health Facilities. The amount is

depended on the completeness and ability of the

First Level Health Facilities in serving the members'

need. The amount should have sufficed when a

member is found with illness, covering healthcare,

consultation, medicine, and laboratory needs. The

ability of financial management must be owned by a

doctor who also plays a role as a manager of the

First Level Health Facilities. Unfortunately, the

doctor with a clinically general practitioner

qualification often misunderstands about the

financial management authorized by the National

Social Security for Healthcare. There should be a

special ability of the doctor to get the operational

need sufficiently covered, even to have some

differences in returns (profit). That is why the ability

of financial management is a must in the time of the

National Social Security for Healthcare at the First

Level Health Facilities.

The other skills unlearned during the medical

graduate program will be studied in the Primary

Care Physician program, for instance, individual

approach and culture. Through a motto saying

"better to prevent than cure", doctors who have

completed the Primary Care Physician program may

have understandings about how to make the

individual approach as a preventive way. In fact, it

is sometimes found that the health problem cannot

be separated from the culture existing in a society.

Isniati (2013) exemplifies a patient with leprosy.

Claimed as a part of the culture, it is considered as a

curse in a society, ending up with exiling the ill

person with leprosy. As for the medical perspective,

leprosy is a disease that requires special treatment

(medicine). The Primary Care Physician program is

able to guide the doctors through understandings

about the societies and the culture differently living

in. For doctors at the First Level Health Facilities,

the approach done in the middle of society is one

thing very common. The culture should have its own

approach to deal with society's health problems since

it is a fundamental thing in life.

The patient recommended to have better care at

the Further Health Facilities, and got healed, will be

returned to the First Level Health Facilities were

firstly taken. The effort to rehabilitate and prevent

the illness and its recurrence is under the

responsibility of the doctors at the First Level Health

Facilities. The doctors at the First Level Health

Facilities do not realize that one thing. The Primary

Care Physician is claimed to be able to help the

doctors understand and conduct their actions in order

to press down the number of patient

recommendation for healthcare. The health handling

at primary care is the initial contact service

coordinated and comprehensive. Some studies

indicate that there is a link among the coordinated

health problem management, the health quality

improvement of patients, the number of

recommendation for healthcare, and the patient's

home care ranging from 8% through 46%. The

other study also signifies that through coordination

when handling patients will improve the

empowerment of the patients and their families in

dealing with the illness or disease by maintaining the

relation to the patients. Face-To-Face interaction

among the doctors, patients, families, and health

workers also contributes to the improvement of the

healthcare quality (Ministry of Health of the

Republic of Indonesia, 2018).

The Primary Care Physician program will be

analyzed through the investment calculation method

to see the cost-benefit used. The benefit gained

should have to be said effective and efficient with

the cost allocated. In the Primary Care Physician

program, the major reason for doctor quality

improvement at the First Level Health Facilities is to

reduce the cost amount of recommendations plotted

by the National Social Security for Healthcare

directed to the Further Level Health Facilities.

However, the cost for the Primary Care Physician

program is expensive. Therefore, the cost-benefit

analysis of the targeted investment should be taken.

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2.3 Mental Accounting Theory

Mental accounting as a model of consumer behavior

was firstly popularized by Richard Thaler in 1985

(Thaler, 1985). It is a consumer behavior model

developed from psychology and microeconomics

thoughts. Mental accounting is a cognitive process

used by the individual to organize, evaluate, and stay

in financial activities (Thaler, 1999). Three

components of accounting become a concern, as

follows:

a. to apprehend how a result will be figured out

and operated, and how a decision is made and

evaluated. Accounting system provides inputs

into cost-benefit analysis, through ex-ante and

ex-post.

b. to categorize the activities into specific

accounts which cover human resource and

financial use. The expenses are categorized

into some categories and sometimes spent

limited through implicit and explicit funds.

c. to focus on the evaluated account frequency and

classify the options (alternatives). The

accounts are daily, weekly balanced, and so

on.

Rospitadewi and Efferin (2017) say that humans

consider their expenses as experiences requiring

evaluation. Like in the organization accounting, an

individual will make a cost-benefit analysis. The

components of mental accounting theory consist of a

framing effect, specific account, self-control,

decision-making, self-report, and hedonic treadmill

(Rospitadewi and Efferin, 2017). The mental

accounting theory opens an understanding of the

individual's mind in comparing the cost and the

benefit of a decision. This theory is very fit to the

analysis to use in this study so that the doctors'

cognitive thoughts in the Primary Care Physician

program can be figured out through comparing the

cost and the benefit to obtain.

3 RESEARCH METHOD

This study uses a qualitative approach by taking

interpretative paradigms as the fundament. The

interpretative paradigm applied to this study aimed

to figure out the thoughts of the informants more

deeply. The result of this study provides analysis and

exposure naturally shared by the informants. The

informants in this study consist of the doctors who

have completed the Primary Care Physician program

and those of “obliged” to take the program.

The mental accounting theory is applied to data

analysis. Rospitadewi and Efferin 2017) employs

this theory to analyze the data to figure out the

humans’ thoughts in making a financial transaction,

ending up with achieving happiness. The

components of the mental accounting theory applied

to this study, namely:

a. Framing Effect. It has to do with the received

information forming a perception about what

is wanted and needed so that a person may

react to the information. The informants

search and get their rationalization about the

cost-benefit that they may obtain from their

previous experiences.

b. Specific Account(s). Humans usually mark

out a “label” to the source and purpose of

financial use to illustrate why, and whether or

not the expenses are needed to make.

Humans categorize their needs in relation to

finance and “record” them (in mind or written

based on their needs).

c. Self Control. Humans try to do self-control by

making a comparison between expenses and

allocations they own.

d. Decision-Making. Humans will make a

decision under their cognitive thought they

created. The decision-making will link to how

and whether or not the doctors make a

decision to join the Primary Care Physician

program.

e. Evaluation. The mind will evaluate the result of

the decision made by the individual. This

phase, by the writer, considered as a way to

determine a conclusion and an opinion in this

study so that it will contribute to the Primary

Care Physician program.

4 FINDINGS AND DISCUSSION

4.1 Framing Effect: Difficulties of

Introducing the Primary Care

Physician Program

The discussion of the Primary Care Physician

program has always been daily pros and cons just

right after its establishment through this time. Some

meetings discussing the Primary Care Physician

program are stuck and no solution very often. The

last meeting recommends an agreement that the

graduates of the Primary Care Physician education

program share the same level as a specialist degree.

However, some cons amongst the doctors do not

National Health Insurance Policy: Beneﬁt-cost Analysis of Primary Care Physician Education Program

stop here. For instance, Dr. Erwan, one of the

doctors at the First Level Health Facilities in

Lombok Island. Even though he knows about the

Primary Care Physician program, but he does not

figure out the essence of the program. Meanwhile,

the targets of the program are those doctors at the

First level Health Facilities. "My colleagues

graduated from the University of X (Dr. Erwan’s

generation comrades taking medical education

program) do not talk in a rush about in on social

media groups (Whatsapp). “They stay cool and

calm”, Dr. Erwan stated. In fact, many of his

colleagues work at the First Level Health Facilities,

like in many Community Health Centers in the

regions. Dr. Erwan, who is also a civil doctor in

Lombok Island, has taken an internship program

after graduated from his medical education program.

Once he met Dr. Nasa, who said, "How to introduce

it? When trying to socialize it, there was a warning

issued by the Indonesian Physician Association

giving no allowance for doctors to follow the

program". The socialization of the Primary Care

Physician program is very limited. It is because of

the obstacle happening between Ministry of Health

and the Indonesian Physician Association. "Before

this, there was a point jointly agreed by the

Indonesian Physician Association with all conditions

brought together. It's very tiring of that noise," Dr.

Nasa said.

The Indonesian Physician Association still stands

on its understanding that the general practitioners

have already held the high competences to give

service and care for the patients at the First level

Health Facilities. Actually, many recommendations

are made by the First Level Health Facilities, which

suggest the patients take further care at the Hospital

Type C, and Type D are still high. "Yes for sure, we

should recommend the patients since we lack of

medicine and healthcare equipment. The doctors are

capable, but they cannot do any action with such

conditions. What to do but giving the patients

further recommended healthcare?" Dr. Raha

revealed. “If the recommendation is returned back to

the Community Health Centers, it will be no

problem under a condition of enough medicine”, Dr.

Tuga said.

The researcher also finds out some data through

doctors’ specific social media groups. There are

many debates about the Primary Care Physician

program. Mostly, they accuse that the Primary Care

Physician program is merely a target to make

doctors as the ‘Doctors of the National Social

Security” who are prepared for giving service to and

under the provisions of the National Social Security

for Healthcare. Factually, in the future, Indonesian

citizens are plotted to join the National Health

Insurance managed by the National Social Security

for Healthcare.

The Primary Care Physician program has already

been over framed as a power abuse to force the

doctors to fulfill the wants of the National Social

Security for Healthcare. Obviously, the Primary

Care Physician program is able to improve the

doctors' preventive handlings based on the culture

living in and to help them manage the capitation

funds under the National Social Security for

Healthcare which is "very limited", but demanding

for "very optimum" result. Also, the Primary Care

Physician program is targeted to be able to develop

the palliative ability to handle recommended patients

in return through building a good habit in

maintaining their health after the treatment at the

hospital.

4.2 Specific Account(s): If Free, It Is

Fine

Indeed, humans are whether conscious or not

labeling their financial uses. However, it is naturally

widely known that costs spent on education are very

high. Besides the tuition fee for education, there are

also some costs that must be allocated for some

needs, for example, those who are taking studies out

of their local residence, would have thought about

their expenses for living costs at a temporary or

permanent home covering boarding house, house for

rent, or apartment (for sale or rent). Not to mention,

those doctors with family also should think about the

other costs out of their expenses for education. Of

course, the costs will get higher. "But, I am free

because I am granted for a scholarship", Dr. Nasa

answered. "For sure, there are some extra costs for

my transportation since my campus is quite far, at

the University of X. Though so, it's all fine," he

continued. Realizing that the cost for the Primary

Care Physician program is free, it then becomes a

consideration. Dr. Erwan said, "If free and already

a policy regulated by the central government, it is

then a must to do". When being asked about how if

the cost for that program will charge the student

around IDR 300 Million, he responded: "If the

program is free, there will be no reason". Free

meant here indicates that the minimum cost will be

from humans.

The expenses for the Primary Care Physician

program have been a spotlight discussion by many

sides. In a social media group, many doctors deeply

deplore the Primary Care Physician program in case

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of costs to spend. They One good reason is that the

funds for the program can be differently allocated

for some benefits, for instance improving the

facilities and infrastructure of the First Level Health

Facilities, optimizing the medicine distribution,

increasing the welfare of the colleagues who

struggle for healthcare at the regional, remote areas.

"Later on, for the First Level Health Facilities on

which Primary Care Physician program alumni

work, there will be 38 types of equipment to support

the activities,” Dr. Nasa farther said. The costs

spent by the government are for some improvement

in the facilities and infrastructure at the First Level

Health Facilities. Through adequate facilities and

infrastructure, of course, the First Level Health

Facilities have a chance to become the front

guardian of the health of society.

The result is in accordance with Kurniawan’s

(2015) discussing the doctors' service at the primary

health facilities through the family medical

approach. Kurniawan (2015) evaluates the

direction of government policy towards some cases

now faced at the First Level Health Facilities.

Through the Primary Care Physician education

program, the role of the First Level Health Facilities

and the family medical approach should be the

solutions for primary healthcare. The conclusion

withdrawn by the writer is that the solutions of the

primary healthcare, both the family medical

approach and the Primary Care Physician program,

share the same chance to serve primary healthcare

with a high cost-benefit ratio through minimum-

expenditure and maximum-result. The Primary Care

Physician education program is hoped to be a strong

point in order to reduce the number of

recommendations for hospitals' healthcare so that the

National Health Insurance budgeting management

can be "more secure". The deficit of the National

Social Security for Healthcare can be pressed-down.

The writer believes that as the managerial holder the

National Health Insurance, the National Social

Security for Healthcare is not allowed to have some

"profits" but "break event points" at least. "However,

the number of the doctors of the Primary Care

Physician program (70 doctors now) indicates that

the program is still not showing the optimum

result,", Dr. Nasa said. It is true that the deficit of the

National Social Security for Healthcare has been

IDR 6 Trillion since 2015, and continued to occur

through 2018 at IDR 9,1 Trillion. Even, it is

estimated that the deficit would probably reach IDR

16,5 Trillion in 2019”. The government effort

through the Primary Care Physician program is to

make the First Level Health Facilities as the front

guardian of the society healthcare so that the deficit

of the National Social Security for Healthcare can be

reduced. The program to cope with the deficit is not

merely depending on the Primary Care Physician

program. Some ways are also taken to give supports

like as tiered recommendations, monthly cost

increase, etcetera. The Primary Care Physician is not

a short term program to reduce the deficit. The

number of doctors (70 doctors) of the Primary Care

Program is not sufficient to handle all problems at

the First Level Health Facilities. The condition leads

to proof that the goal of the Primary Care Physician

program to minimize the number of

recommendations for Further Healthcare at the

hospital is still open for farther studies.

4.3 Self-control: Nonstop Benefit in the

Value of “Money”

Humans always make some efforts to do self-control

by considering the purposes of the finance use and

the budget they have. "It is no problem whether or

not to increase welfare after graduated. If it is a

policy of the central government, it will then be

taken,", Dr. Erwan answered. When someone has an

effort to make some self-upgrades, it will surely be

concerned about welfare for him and his

environment. Dr. Nasa stated, "certainly we can

manage the Community Health Center or clinics

based on its capitation funds. The capitation fund

can be reached at IDR 10,000,- if the facilities and

the infrastructure are complete. In the Primary Care

Physician program, we are taught to manage it to be

enough to use". There is specific learning through

the Primary Care Physician program. There is a

science benefit for those who have completed the

Primary Care Physician program.

The First Level Health Facilities successfully

optimized the capitation fund gifted by the National

Social Security for Healthcare are those of with the

ability to manage the funds and the activities

supported by the National Social Security for

Healthcare's budgeting. For example, a therapy

group connected to palliative activities is "a plus

profit" that the National Social Security for

Healthcare also gets. The recommended patients for

better healthcare at the hospital and returned to the

First Level Health Facilities, and would take a

continuous control for healthcare and medicine at

the First Level Health Facilities are no longer

requiring hospital healthcare.

In relation to that benefit, Dr. Nasa further said,

"Many friends now have a chance to do more works

in their places. Some create a therapy group for

National Health Insurance Policy: Beneﬁt-cost Analysis of Primary Care Physician Education Program

patients with diabetes and other illnesses. As for this

kind of palliative work, there is an additional fund

provided by the National Social Security for

Healthcare. It has been working with those doctors

of the Primary Care Physician program. Work is one

of the benefits obtained from the program. Of

course, work cannot be valued in forms of money

since the writer also believes that the benefit does

not stop for a money-oriented result. The welfare is

not merely about the economy (money), but it has to

do with internal satisfaction (inmost welfare). For

those who join the Primary Care Physician program,

actualized as doctors at the First Level Health

Facilities bringing more benefits for the society,

there is inmost welfare for themselves. The heartily-

call in the doctors' soul should exist (Sari, 2014) so

that the tasks are operated under the guidance of the

heart.

4.4 Decision-Making: The Primary

Care Physician Program, More

Advantages or Disadvantages

Doctors who have decided to take the Primary Care

Physician program have, of course, some

considerations. "Indonesia is already left behind

tens of years compared to the other countries. In

regional of ASEAN, Indonesia is mentioned to be

one of the countries that have not developed the

family doctor. In many foreign countries, family

doctors have been increasing in number. Indonesia

is really left too far," Dr. Nasa expressed. Actually,

the Primary Care Physician program is a part of the

family doctor development in Indonesia. It allows

an individual approach, including cultural approach

in a specific environment. "The doctors of the

Primary Care Physician program are targeted from

the Community Health Centers, clinics, or any

others labeled as the First Level Health Facilities.

For those who do not work at the First Level, Health

Facilities are not necessary for taking the program.

If interested to join any other specialist program, it is

wide open. So, the program actually does not

burden the doctors with more hours in learning, but

is specifically aimed at those who work in the

Community Health Centers or clinics”, Dr. Nasa

explained. The Primary Care Physician program is

commonly addressed to those doctors who operate at

the First Level Health Facilities (Community

Health Centers or clinics) with a total of 50.000-

60.000 in Indonesia. Through that program, the

doctors professionally working at the First Level

Health Facilities are able to serve the society with

good care so that there will be no recommendation

taken if not necessary.

The pro and cons following the Primary Care

Physician education program have not ended yet.

Even though the alumni of the Primary Care

Physician program have got a direct certification

given by the Ministry of Health, the documents for

having a medical practice permit are in the authority

of Indonesian Physician Association and Collegiums

(for those with specialist status). This situation has

also become the doctors' concern at the First Level

Health Facilities who are still unsure about taking

the Primary Care Physician program. "The

residential school of the Specialist Medical

Education Program usually takes 4-5 years with a

single specialty. The skill improvement during the

specialist program is claimed to have limited time.

How about that Specialist Program of the Primary

Care Physician? What about General Practitioner

Specialists? In what skill which makes different and

highlighted?” Dr. Erwan asked back. The curriculum

of the Primary Care Physician program is indeed a

special focus since it has overlapped design as that

of the general practitioner program. The highlighted

offerings can be seen in the fund's management and

the individual approach, just like the family doctors'.

Dr. Erwan even wishes that the Primary Care

Physician program will not be divisive among

Indonesian doctors for a certain group's interest. He

does not continue to mention the specific group he

meant. In reality, there are still many doctors who

agree and disagree with the program. Though a

tough mediation has been done for many times, both

sides are still contradicted to each other. Even there

is a perception coming up among the doctors who

disagree with the Primary Care Physician program.

It is said that the program is purely squandering the

national budget for the interest of the National

Social Security for Healthcare.

In regarding the situation, whether or not to join

the Primary Care Physician education program lies

in the doctors' decision. Its cost side indicates that

there are still many doctors in the program get the

minimum cost or free due to the cost coverage borne

by the national budgeting. The free cost offered has

attracted the enthusiasm of the doctors to take part in

the program. It will be another case if the cost of the

program is no longer free. In accordance with the

benefit, many doctors realize that the Primary Care

Physician program does not help much for their

welfare (economy improvement). However, the

benefits taken in forms of works and self-

actualization may be assumed as the results of the

program.

ICOACI 2019 - International Conference on Anti-Corruption and Integrity

4.5 Evaluation: The Primary Care

Physician Education Program, A

Dilemma

The evaluation phase in this study focuses on how

the writer makes a conclusion after some

perspectives and data presented. This study was

initially inspired by many programs offered by the

National Social Security for Healthcare that induce

the pro and cons, not only in the middle of the

society, but also among health practitioners (doctors

or First Level Health Facilities, and hospitals) under

the management of the National Social Security for

Healthcare. The National Social Security for

Healthcare is claimed to effortless "drive" to the

direction of health policies in Indonesia. A good

intention sometimes does not end up with a positive

result. The limitation regulated by the National

Social Security for Healthcare aims to reach shared

health goals. However, the National Social Security

for Healthcare should "realize" and learn to deal

with the circumstances in the field. One of the

programs allegedly directed for the benefit of the

National Social Security for Healthcare is the

Primary Care Physician education program.

The news following the problems faced by the

Primary Care Physician program is mostly among

medical practitioners (doctors in particular). A

doctor is a central figure in healthcare as said by

Jacobs, Marcon & Witt (2004). The doctors become

the target of the Primary Care Physician program.

That is why; the decision to join the program is

under the doctors' control. The trouble comes when

the government's policy under Regulation Number

20 of 2013 proclaims that the Primary Care

Physician program is the continuation of the Medical

Professional Program and the internship equivalent

with the Specialist Practitioner program. It

"demands" for the general practitioners to continue

to taking education as same as the specialist program

so that they have the ability to give healthcare at the

First level Health Facilities covering Community

Health Centers and Outpatient Clinics.

Unfortunately, only 70 of hundred thousands doctors

have joined the Primary Care Physician program in

Indonesia. Why is the number of doctors who have

completed the program very low?

The first reason is the cost of the Primary Care

Physician program. Dr. Nasa is indeed one of the

doctors granted for free education for the Primary

Care Physician program. The cost for the program

is supported by the National Budget, allocated by the

Ministry of Health so that many doctors are given a

chance to have free. On another side, the Indonesian

Physician Association makes a calculation and

believes that the Primary Care Physician program

will require IDR 300 Million funds per student

(participant). Based on the calculation, the budget

for the Primary Care Physician education program

allocated by the government is not a little. Medical

education is one of the studies widely known for its

high cost in Indonesia. For those who are not able to

take the Primary Care Physician program, the

required high cost will be one consideration. If it is

free, of course, many doctors may have the

enthusiasm to join the Primary Care Physician

education program with some conditional policies

by the central government, as mentioned by Dr.

Erwan. The cost spent on the program is always a

serious problem. For the doctors, the further

education that is free may become a good choice

when necessary to take. The cost is still a burden in

mind for them. Through free education offered by

the government in taking the Primary Care Physician

program, the doctors remain enthusiastic.

The second reason is that there is disagreement

shown by some doctors and an organization

corroborating them, namely Indonesian Physician

Association. The refusal influences on the decision

of the doctors with enthusiasm to join the program.

It is very dilemmatic for them. If the doctors manage

themselves to join the program, there would be some

consequences they probably face. They can be

rejected in the community of doctors. They also

may not get the Indonesian Physician Association’s

recommendation for Practice Permit. Another

trouble that may come up is their the colleagues do

not admit their specialty as specialists. The inmost

welfare becomes a measure for the problems. “It is

tiring with the noise,” Dr. Nasa said. The fragment

indicates that the framing made for the Primary Care

Physician program is exclusively for the interest of

the government, the National Social Security for

Healthcare in this case. The term “National Social

Security for Healthcare doctors” tends to be weird

when it refers to those doctors who operate all

activities under the wants and policies of the

National Social Security for Healthcare. The inmost

welfare is not common in public. Sari et al. (2016)

states that there are values out of money of the

doctors' income, and one of them is the feeling

satisfied by the patient's successful recovery.

Though different in meaning, but the inmost feeling

also needs for welfare. Because of the inmost

welfare, those doctors who have not taken the

program may wait for the acceptance shown by their

colleagues or Indonesian Physician Association or

after the government comes up with a must-to-do

National Health Insurance Policy: Beneﬁt-cost Analysis of Primary Care Physician Education Program

policy binding all doctors at the First Level Health

Facilities. If not so, many doctors (general

practitioners) decide not to join the program for their

inmost welfare. For those who have completed the

program, the inmost welfare they wish to gain is

being comfortable when doing the profession with or

without their colleagues' acknowledgment. They

should do their profession in accordance with the

study they have taken during the Primary Care

physician education program.

The third reason is that the central government

policy is vaguely regulated. The Primary Care

Physician program is through Regulation Number 20

of 2013 and agreed by 17 universities opening the

program. It is not fully a mandatory (whom the

program aims to?) In relation to the program, the

unfixed state of regulation has made those doctors

doubt. Of all medical faculties accredited A, only a

single university that runs the program. It then

becomes a worry among the doctors. They are afraid

of the change of the leader that may lead to the

change of regulation. Dr. Erwan’s answer signalizes

his readiness to join the program if "it is already a

policy of the central government). The statement

illustrates the inmost feeling and shows the reason

that many doctors have not comprehensively

understood and intended to join the Primary Care

Physician program. In fact, the regulation remains an

uncertainty.

The fourth reason is that the lack of socialization

about the distinguished roles of both the General

Practitioners and the Primary Care Physicians. The

overlapping duties operated by both are still high.

Dr. Erwan ever questioned about,” In which skill are

they distinguished?” Dr. Nasa explained that

financial management at the First Level Health

Facilities under the National Social Security for

Healthcare is very important since that sort of

learning is never taught during the General

Practitioner Program. The other points, the cultural

approach and individual approach (closely related to

the term “family doctor”) are also studied in the

program. Annisa Putri and Yuristo (2013) may have

the answer to the fourth reason. Some parts show the

differences. In the family doctor concept, a general

practitioner only focuses on learning the concept,

knowledge, and healthcare principle of the family

doctor. In the Primary Care Physician program,

besides those learnings, the understandings about job

description and function as the Primary Care

Physician, and the influence of the family,

community, and environment, is also studied. In the

Division of Family Doctor Clinic Management, a

general practitioner has not studied (will be studied

in the Primary Care Physician program) about

Human Resources Management, facilities

management, information management, and

financial management. In the Division of Clinic

Skills, a general practitioner has known non-surgical

clinic skill, specific clinic skill, and surgery medical

skill. Through the Primary Care Physician program,

the other skills added to the Division of Clinic Skill

are general clinic management and supporting

facilities management. In the Division of Science

and Knowledge, through the Primary Care Physician

program, a general practitioner will have some

improvement in cases of Age Category-Based

Health and Specific Category-Based Health that may

be applied in accordance with the circumstances of

each First Level Health Facility. The lack of

understandings requires further socialization. The

scientific benefits gained from the Primary Care

Physician program refuses the term "overlapping."

However, those rejections in many regions indicate

that the framing of the Primary Care Physician

program is hard to change. The activators of the

Primary Care Physician program cannot go on, but

cannot step back as well.

The fifth reason is that the outputs of the Primary

Care Physician program are not clear. Actually, the

goal of the program is to develop the First Level

Health Facilities as the front guardian in the primary

healthcare so that the number of recommendations to

the further healthcare (hospital) can be minimalized.

The long-term target that the National Social

Security for Healthcare wants to achieve is the

deficit reduces. For doctors, it remains unclear. In

the matter of economic welfare, whether or not the

doctors at the First Level Health Facilities fairly paid

as those specialists or the same amount as the

general practitioners have. It is still questionable.

Nevertheless, the other outputs have just come up to

the surface. “Some colleagues have begun operating

therapy groups for diabetes and some other illnesses’

patients, Dr. Nasa said. It means that the doctors

who graduated from the program have tried their

best to make benefits in the society where they have

patients to care. The benefits represent the real

outputs of the program. The doctors of the program

do not only make benefits in the financial

management of the First Level Health Facilities, but

also in the society for better healthcare. Sari et al.

(2016) also state that the doctor is a humane

characterized profession and cannot measure

material meanings. The benefit analysis found in

this study shares the same meanings with Sari's

findings (not material only, but humane).

ICOACI 2019 - International Conference on Anti-Corruption and Integrity

Those five reasons lead to some findings in this

study. Through the mental accounting theory, one of

the findings is that the doctors also analyze the cost-

benefit in making the decision whether or not to join

the Primary Care Physician education program.

5 CONCLUSION

For doctors, further studies are widely open. Besides

master degree, there are some Specialist Programs

that they may take based on the interests and

abilities required in their profession. One of the

programs, the Primary Care Physician, remains pros

and cons among the doctors. The cost-benefit

analysis in the doctors' thought leads them to

decision making towards the program. The result of

the study shows that the doctors are enthusiastic

about joining the program if it is free.

Unfortunately, the unfixed state of policy by the

government brings about a doubtful consideration to

deal with the program. The benefit analysis indicates

that the material benefit the doctor hopes is not

sufficiently covered. However, they still have the

humane based benefits by implementing their

knowledge and skill to help society. One

extraordinary struggle they must go on when taking

the Primary Care Physician program is their inmost

welfare (satisfaction inside). The result of the study

also signifies that the Primary Care Physician

programmed by the government needs more time to

have a better implementation. The prioritized work

to do is the clear certainty of the policy so that those

who want to participate in the program can achieve

the inmost welfare. Besides those problems, the

number of recommendations through the Primary

Care Physician program requires more studies. The

government and the National Social Security for

Healthcare should think more alternatives following

the circumstances.

This study is still probably limited. The data

seem to be the major limitedness. It is hard to collect

more data since there are only a few doctors who

open themselves to join the program. Therefore, this

qualitative design of the study has limited

informants. It has an effect on the result of the

study. The generalization cannot be taken. Even

though it has become a new start opened for further

studies, particularly in case of the Primary Care

Physician program or any other policies made by the

National Social Security for Healthcare.

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