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Patients’ experience of using primary care services in the context of Indonesian universal health coverage reforms

Patients’ experience of using primary care services in the context of Indonesian universal health... Background: The World Health Organization ( WHO) recommendation on universal coverage has been implemented in Indonesia as Jaminan Kesehatan Nasional (JKN). It was designed to provide people with equitable and high-quality health care by strengthening primary care as the gate-keeper to hospitals. However, during its first year of implemen- tation, recruitment of JKN members was slow, and the referral rates from primary to secondary care remained high. Little is known about how the public views the introduction of JKN or the factors that influence their decision to enroll in JKN. Aim: This research aimed to explore patients’ views on the implementation of JKN and factors that influence a per - son’s decision to enroll in the JKN scheme. Methods: This study was informed by interpretative phenomenological analysis (IPA) methodology to understand patients’ views. The interview participants were purposively recruited using maximum variation criteria. The data were gathered using in-depth interviews and was conducted in Yogyakarta from October to December 2014. The inter- views were transcribed, translated and analyzed using IPA analysis. Result: Twenty three participants were interviewed from eight primary care clinics. Three superordinate themes: access, trust, and separation anxiety were identified which impacted on the uptake of JKN. Participants acknowledged that whilst primary care clinics were conveniently located, access was often complicated by long waiting times and short opening hours. Participants also expressed lower levels of trust with primary care doctors compared to hospital and specialist care. They also reported a sense of anxiety that the current JKN regulation might limit their ability to access the hospital service guaranteed in the past. Discussion: This study identified patients’ views that could challenge the implementation of the gate-keeper role of primary care in Indonesia. While the patients valued the availability of medical care close to home, their lack of trust in primary care doctors and fear that they might lost the hospital care in the future appears to have impacted on the uptake of JKN. Unless targeted efforts are made to address these views through sustained public education and further capacity building in primary care, it is unlikely that the full potential of the JKN scheme in primary care will be realized. Keywords: General practice, Primary health care, Indonesia, Access, Patients’ experience, Phenomenology Background access high-quality health services without financial bar - The WHO [ 1] has proposed that all member countries riers. This WHO recommendation of universal health implement universal health coverage to help people coverage was in-line with the Alma Ata declaration which aimed to provide people with accessible high- quality services in primary care [2, 3]. Responding to *Correspondence: fitriana_murriya@yahoo.co.id; fekawati@student. those global recommendations, Indonesia has established unimelb.edu.au Department of Family and Community Medicine, Faculty of Medicine, a universal insurance scheme, which is known as Jami Universitas Gadjah Mada, Yogyakarta, Indonesia nan Kesehatan Nasional (JKN) since January 2014. The Full list of author information is available at the end of the article © The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 2 of 10 JKN was the merger of four pre-existing public insurance requirement for GPs to undertake compulsory formal schemes (Askes insurance for civil servants, Jamkesmas training to improve their primary care practice. In 2015, insurance for poor citizens, Jamsostek as insurance for 168,823 doctors were registered with the Indonesian private sector workers and Asabri as Insurance for the Medical Council: 29,561 of them were specialist doctors, armed forces). The JKN was designed under the law of 29,665 were dentists, and 109,597 were recorded as GPs National Social Security to meet the people’s basic needs [13]. In Indonesia, doctors only need to undertake a four and contribute towards the realization of a prosperous year undergraduate degree plus a two years postgradu- and equitable Indonesia [4, 5]. With this insurance, it was ate Medical Doctor (MD) degree, national examination, expected that people would not face financial barriers and one year internship in hospitals and Puskesmas to to access health care and therefore increase their use of get the licence to practice as a GP in primary care [14]. health services. During the undergraduate degree, the students learn the The role of primary care as a gatekeeper to second - theory required to practise medicine. During the MD, ary and tertiary care has been strengthened in the JKN they complete two years of clinical practice in various implementation. It is expected that primary care doctors hospital departments; such as internal medicine, surgery, can fulfill the people’s basic health needs and ought to dermatology, and obstetrics. While the specialists have to be able to manage the majority of the patients’ problems complete an additional three to five years training at the [6]. In the JKN implementation, this sector is supported University hospitals, currently, no compulsory training under a capitation payment system [7]. It is a payment for GPs is available to upgrade their skills in primary care concept within which the private family doctors and practice. Therefore,  this level of training for Indonesian Puskesmas (Indonesian Public Primary Care Clinic) as GPs differs from the requirements in other similar coun - primary care providers are paid a set payment per num- tries that are implementing universal insurance cover- ber of registered patients, whether the patients come age. In Thailand for example, GPs have been required to to seek any medical help or not. This payment scheme undertake a formal postgraduate training in family medi- is intended to enable primary care services to focus on cine. This education scheme has been implemented since health promotion and illness prevention in addition to 20 years before the implementation of Thailand’s univer - curative measures [7]. sal coverage in 2001 [15, 16]. The JKN also introduced several new regulations of Some important issues arose during JKN’s first years of the health system compared to the previous insurance implementation, notably slow recruitment of new mem- schemes. Under the Askes and Jamkesmas schemes in the bers, which was identified at the first JKN mid-year eval - past, patients were free to access any primary care ser- uation. Compared to the total membership of the four vice. They also could easily obtain a referral letter from previous insurances schemes in 2012 (155 million mem- their general practitioner (GP) to access secondary care bers), the JKN membership had only reached 125 million in hospitals [8]. However, under the JKN scheme, patients members in mid-2014 [10, 17]. The target of doctors to have to formally register themselves at JKN offices or handle almost all of the primary care cases and only refer their appointed family doctor practice or Puskesmas. The less than 10% of the cases was also not being met. Nation- guidelines of conditions that could be appropriately man- ally, the overall JKN primary-to-secondary referral rate aged by the GPs-based on their competency standard [9] was 17%, but the referral rate in several provinces such as -had also been published [10]. The referrals could only in Yogyakarta, East Java and Jakarta was much higher, up be made on appropriate clinical judgements. Therefore, to 55% of cases [18, 19]. With this high referral rate, it is the patients have to comply with these procedures set likely that many of the referrals were inappropriate, such by the JKN, under which, JKN will not cover the cost of as essential hypertension, dyspepsia, and general physical any hospital treatment if the referral is made outside the examination [11], conditions which should be managed guidelines [11, 12]. On the other hand, the Indonesian at primary care level according to the Indonesian physi- government also supported the utilization of primary cians’ competency standards for primary care doctors [9, care under the JKN by disseminating information on JKN 17]. procedures to the public and preparing practice guide- Unfortunately, there has been little evidence available lines for primary care providers. The information was about the factors that underlie these emerging issues dur- spread by a massive media campaign including advertise- ing the initial implementation of JKN in primary care set- ments on TV and radio; while procedures were estab- tings. In particular, there is little known of patients’ views lished to make registration with JKN easier for patients. and experiences during JKN implementation, which may However, an additional policy that could contribute be important factors influencing their decision about significantly to the success of JKN primary care objec - whether to opt into the JKN. Information on the views tives has yet to be fully established. This relates to the of patients is important because patients are the actual Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 3 of 10 users of health care, and their views and experiences rep- were a parent or a caregiver. The only exclusion crite - resent the actual condition in practice settings [20, 21]. rion was if patients were unwilling to participate in the Current available evidence only shows that there are research. different satisfaction rates with the JKN program across The first author (FM) completed all of the interviews. Indonesian provinces. Gaghana, Siagian [22] found that Written informed consent was obtained from all study only 51.9% out of 106 patients were satisfied with JKN participants prior to the interview. All of the interviews implementation in Sulawesi. Putri [23] also found the were done in a private room in the clinics, except two implementation of JKN was not effective in primary care interviews which were done in FM’s office. None of the clinics in Padang city, West Sumatra. Putri found that the participants expressed any objection with the interview JKN improved service delivery for low socioeconomic place. FM had also anticipated that Yogyakarta people status patients, but the patients expressed dissatisfac- may be reluctant to speak openly about their views [25] tion with the staff responsiveness, credibility, medical or may be hesitant because FM is a GP from Yogyakarta. documentation, and medical access. However, neither of FM therefore explained to the participants that their par- these studies explored in depth the factors which contrib- ticipation was voluntary, their answers were confiden - uted towards the patients’ views nor their dissatisfaction. tial, and that their participation would not affect their Therefore, we set out to explore in depth the patients’ relationship with FM or with their care providers in the perspectives of primary care in this study, and the factors future. which contribute towards the slow recruitment and high During the interviews, FM began with an introduction. referral rates to secondary care [10, 17]. After that, she asked open-ended questions, such: ‘please tell me your experience in seeking health care’ or ‘where do Methods you usually go to seek health care.’ Then, these questions This research was informed by the interpretative phe - were followed up with more focused interview questions nomenological analysis (IPA) approach to allow a related to the participant’s experience with the primary deep and comprehensive understanding of the partici- care service and the JKN implementation. The partici - pants’ views and experiences [24]. Consistent with this pant responses were probed and clarified using prompt - approach, data collection was conducted using semi- ing sentences, summarizing sentences and or some structured interviews to allow greater opportunity for positive statements such as uhum…, or ‘yes ….’ and silent patients to express their views. pauses to allow time for participants to think about their The study was conducted in Yogyakarta province, cen - responses and respond. All but one interview was tape- tral Indonesia, from October to December 2014. Yog- recorded. Written notes of responses were taken for the yakarta is characterized by a range of socio-economic patient who was unwilling to be tape-recorded. All the status of its population, relatively easy access to health participants were given a small souvenir bag as a token of services and a high rate of referral to secondary care. A their participation. maximum variation sampling strategy was applied to The interviews were transcribed and then, translated ensure a range of perspectives. The clinic recruitment into English. Five translated texts were back translated process was done purposively in both private and pub- for translation validation. The data were analyzed using lic primary care clinics in the Yogyakarta region: at the IPA analysis. IPA is an analytical method to explore districts of Kulonprogo, Sleman, Yogyakarta city, Bantul, in depth the participants’ views, combined with the and Gunung Kidul. researcher’s interpretation of the participant’s meaning The recruitment process is described as follows: first, of a phenomena. The steps of IPA analysis were system - the practice manager/clinic owners were telephoned and atically applied according to the recommendations of were provided with Bahasa Indonesia plain language by Smith and Osborn [26]. FM and JG read all the tran- statement. When the practice manager/clinic owner had scribed texts independently until they were also familiar signed the consent form, first author (FM) then came with the patients’ views. They both then coded any nota - to the clinics to recruit patients for an interview. The ble quotes. The quotes were grouped into themes and patients were selected purposively from the patients’ reg- super-ordinate themes. The emerging themes were dis - istry during the interview day (at maximum three par- cussed and crosschecked amongst other researchers with ticipants at each clinic). The inclusion criteria included: primary care backgrounds. Indonesian citizen, JKN insurance member, and Yogya- karta resident. Then, the patients were selected based on Results the following purposive sampling criteria: age, income The proposed maximum variation sample design for level, the level of education, residential address, marital interview participants was fulfilled. The criteria for the status, and specific characteristics; such as whether they sample are listed in Table 1. All criteria were met with at Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 4 of 10 Table 1 The participants’ characteristic with 13 past members of Askes (civil servants scheme), and 6 were past members of Jamkesmas (free insurance Sample criteria Total number (N = 23) for low-income/poor). Almost all the participants were Types of clinic willing to fully participate right up until completion of Public clinic 5 the interview. One participant suddenly decided to stop Private clinic 3 in the middle of the interview process but did not wish to Gender withdraw completely from the study because of her wor- Male 7 ries that the interview would affect her treatment in the Female 16 clinics. Age group Three superordinate themes of Access, Trust, and Sep - 18–25 4 aration anxiety were identified from the analysis. Partici - 26–45 8 pants acknowledged the convenience of access to primary 46–65 7 care but were dissatisfied with the waiting time and phys - 66–85 4 ical structure of the clinics. The superordinate theme of Residential address Trust referred to participants who were dissatisfied with Urban area 11 the doctors’ general communication. They also expressed Rural area 12 doubt that the primary care doctors could treat more Education level severe diseases and preferred to receive a referral letter High education 13 to secondary care. Within the third superordinate theme, Low education 10 participants expressed their anxiety about whether they Income level would be able to continue to use specialist care services High income 6 at the hospital in the way they were previously used to. Middle income 12 Low income 5 Access Employment sector Many participants referred to the proximity between the Private sector 7 service and their home and the convenience of access to Public sector 16 primary care service and chose them as their usual means Frequency use of primary care of health care. This answer also came from many partici - Never 4 pants when being asked about their reason for attending primary care. For instance, Participant 21 in this study 1–5 visits/year 8 said “Yes, every month I go to Puskesmas. Because it is >5 visits/year 11 near, so that I can get the easily accessible service” (Par- Marital status ticipant 21, l.24–25). Married 18 However, later on, during the interviews, many partici- Single 5 pants commented that the long waiting time and facili- Diagnoses ties in the clinics were less convenient and limited their Acute illness 5 enjoyment of the service. In some cases, the participants Chronic illness 9 then preferred to leave the clinics or chose to attend a Healthy 9 private hospital rather than continue queuing. For exam- Specific attributes ple, Participant 9 said: “If in Puskesmas, I need to queue Only caregiver – for a long time. I have to queue before here and there. But, Parent 13 I need to go to fieldwork (working), so I decide to leave the Both of caregiver and parent 5 Puskesmas and go to private hospital” (Participant 9, l. None 5 38–39). In addition, participants also noticed deficiencies in the physical facilities at the clinic which influenced the ease minimum two participants in each category. 23 partici- with which they could see the doctor. They considered pants were recruited, the majority of whom were women that the clinic building could not accommodate them (n  =  17), had a high level of education (at minimum a well and caused them to wait longer to see the doctors, as bachelor degree) (n  =  13), were aged between 26 and stated by Participant 11: 65  years old, and of middle-income status/income per “If all patients need and go to Puskesmas, I believe month: 1–5 million IDR (n = 12). The majority of partici - that it is not only unbalanced, but it is impossible. pants were members of the previous insurance schemes, i Th s Puskesmas does not have enough room for that, Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 5 of 10 and we will wait longer and longer. The parking lot, one is given antibiotic”. (Participant 12, l. 68–72). Puskesmas also can’t provide an enough time for us Another prominent aspect of patients’ trust in their (Participant 11, l.57–65). GPs is that many participants also doubted if the GPs Some participants also commented on the facility could manage more severe problems. They considered inequalities across Indonesia’s geography. Participants 1 that the GPs’ current education could only equip them and 16 thought that service on the island of Java (where with skills to superficially understand the patients’ con - Yogyakarta is located) was actually better than the service ditions. Many of them expressed the opinion that their in other islands. They felt that although JKN had already GPs were unable to solve more serious illnesses, as was helped people with affordable medical cost, it still did not explained by Participant 8: resolve the inequalities and hindered access to high-qual- “The GP is a general doctor, their education is lim - ity medical care for people residing outside Java, due to ited. I think for the specific diagnosis, the internist’s the imbalanced and non-standardized health facilities in (diagnosis) is better, specific in the treatment as well. different geographic areas. The GP doctors, I believe they need to learn again” “Who gets the benefits, I think, once again are Java - (Participant 8, l. 61–62). nese, Can you imagine? In East Nusa-Tenggara, Furthermore, some participants insisted that the GPs’ on the top of the mountain, a member of JKN, she role should be to provide referrals to hospital. There was needs a bypass of her heart, can she? Because they a perception among patients that if a person was suffer - are people who cannot be served, they should have ing from any illness, they needed to see a specialist and the same rights; they should get the same, but in fact, the primary care doctors should give them referrals to they receive different service. Big fake as long as the hospital, as expressed by Participant 16: government does not think about the infrastructures, doctors’ distribution, hospitals and the nurses.” (Par- “I usually get referrals from here. A long time ago, ticipant 1, l.182–186). I must be inpatient in S hospital; I got the referral from here. I also once had a referral from here for a urinary infection. When my child was sick, I came Trust here. Sometimes I think the primary care is not Participants were initially unsure when asked about the needed, but the pediatrician. My child’s eyes were quality of the primary care doctors’ service. They usu - red and got swelling several times, which we are ally answered with comments such as ‘the doctors are referred to J hospital. My wife also comes here, my kind’ or ‘I feel comfortable with the doctors’ as their mother in law also gets the referral here” (Partici- first reply. However, when they were encouraged to pant 16, l. 41–48)”. give more description about what they expected from their GPs, they expected that GPs should have excel- Meanwhile, participants also considered that specialist lent communication skills and be able to explain more doctors were also superior because of their more com- about the patients’ condition. For instance, Participants prehensive facilities. Participant 6 stated that she was 11 and 12 were dissatisfied with the doctors’ service pessimistic with the clinic service because it had less because the doctors did not explain more about their medical facilities. She said that this made the GPs use less illnesses. They thought that the doctors only gave simi - effective medication and limited the help they could pro - lar pills for all patients without adequate information. vide for the patients’ problems, whereas, specialist care They expected the GPs to perform a comprehensive was always trusted as it was always complemented with individual examination and provide a complete expla- more advanced medication. Interestingly, Participant 6 nation of their condition so that they understood the also believed that diseases of certain body parts belonged purposes of the medication and trusted the doctors’ to certain specialist expertise. She thought that as nowa- treatment. days many patients suffered from internal diseases. She then expected the clinic to have an internist doctor. “So usually in Puskesmas, you see that after the doctor asks us, then he will give us some medi- “I think it will be good if you can provide an oph- cine? Then we do not know what is our disease is. thalmologist because you know, it is a pity for many So I think the doctor only treat our symptoms. So people here with cataract, an eye-wart, an eye spot, my hope is that we are asked comprehensively. So sometimes ago, they were here and could not be that we know our problem, not only fever, then the treated. For eye diseases in Puskesmas, we were only doctor gives us the fever drug. However, then we given an eye drop. I do not think Puskesmas can give develop an infection and not yet informed. Every- anything else for cataract patients, for now, I do not Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 6 of 10 know for the future. But with the eye drops, when I pier with Askes because we do not have our limit”. used it, I do not feel any improvement, Somewhat (Participant 21, l. 72–79). my eyes are getting bright but often darker, it is not Moreover, half of the participants also complained that working. Moreover, please, you may add this clinic clear information regarding JKN procedures was limit- with an internist. You know there are lots of patients edly available. They were unfamiliar with current JKN with internal diseases” (Participant 6, l. 78–90). transition systems in primary care. Even though there was increasing efforts to promote the changes that had been made, access to information in the primary care Separation anxiety setting was lacking. Moreover, the clinic’s staff failed to u Th s, with the JKN transition, half of the participants in assist patients in obtaining adequate information. For this study experienced JKN implementation in primary example, Participant 1 told of his experience in using a care as a challenging period because they no longer had referral to access hospital care without knowing that the the same access to the specialist services, which they regulations were changing. He was dissatisfied because regarded as superior to primary care-that they had been his referral to the hospital was no longer allowed and this guaranteed in the past. Many participants, who had been was not informed by the clinic’s staff. He was concerned managed by specialists for a long time, now had to visit that the same situation could be experienced by another the GPs for their routine care. They also claimed that JKN patient who needed urgent medical help. restricted the prescription of medicines and their referral access to the hospital. As they already had limited trust in “I came at noon, Oh My God, the hospital officer the GP’s ability (-as described at ‘Trust’ theme), patients showed me that referral was not working. She told worried if the GP care was less ideal than specialist care as me that the regulation was changing, I should go to expressed by Participant 2: the secondary hospital first. I mean, how about the other patients, if he was certain with the referral, “Well, this is just my opinion. You know that I should but it did not work? How about if there is a severe be referred to an internist because I have diabetes. patient, more serious than me, how is that?” (Par- Previously, I was happy in G clinic (specialist clinic), ticipant 1, l. 107–112). I could see the internist directly. You know if here, I have to use the referral system, which is once in every three months in the hospital. I need to see the GPs for Discussion months. I think that is too long. However, anyhow, I Our findings suggest that during the commencement of kept ask my doctor to refer me to specialist and now the JKN universal health coverage scheme, Indonesian the doctors refer me” (Patient 2, l. 49–52). primary care faces some challenges in achieving the aims of the program. The limitations in facilities and operation Participants were more emotionally discouraged because have constrained the fulfillment of the patients’ perceived JKN had also limited some hospital services which had pre- general health needs and reduced the public’s expecta- viously been covered by Askes insurance. Even though they tions regarding the JKN implementation in primary care. had already had referrals to the hospital, it did not mean that The findings regarding the clinics access are consist - JKN would cover the all the hospital medical expenses. Par- ent with existing research. Putri [23] found that patients ticipant 21 mentioned that some services were not fully cov- reported inadequate access to primary care clinics dur- ered by JKN anymore, compared to Askes insurance in the ing JKN insurance. Regarding this finding, one strategy to past. She also expressed her feeling that somehow she was improve the facilities and access standard of care by pro- happier with the old Askes insurance. viding an equal access of health care distribution [27] and “I think with Askes if we come to health facili- establishing an accreditation program so that the care ties whatever whenever, were not limited, but now, quality for the patients is warranted [28]. we have our limit. However, last month when my Even though still a distance from the ideal views of son had surgery, he should pay himself. It is stated those suggestion, however, the health care distribution at JKN paper that it is only covered for 15 million is currently the Indonesian priority. The government has so that he had to pay the gaps. You know, it would currently established an accreditation standards required not happen in Askes. That was different between for primary care practice. The Puskesmas and private them. For JKN, if the patient is not very ill and she is clinics that wish to contract with the JKN are expected referred hospital, it will not be covered. We have to to prepare and maintain their facilities to the required, pay, come to the emergency room and pay. However, specified standards of care, such as the fixed opening Askes was not. For me, they are different. I am hap - hours and patient care standard operating procedures. Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 7 of 10 However, this program is currently ongoing and focus- formal postgraduate training for the GPs. However, there ing on the Puskesmas [29], not yet involving the private has been an extensive debates among GPs’ and special- primary care practices accreditation. The health care pro - ist colleagues regarding the training time, resources, and viders availability is also continuing to improve through care collaboration. Concerns have been raised that the several programs, such as contract doctor, Nusantara postgraduate training would lengthen the GPs’ education Sehat [30] and local public agency program which enable to practice in primary care and that the training would Puskesmas to arrange and manage its own facilities [31]. be ineffective without ensuring adequate facilities were Another important finding in this research is that available in the primary care settings [41]. Therefore, rec - patient perceptions of the quality of the GPs practice ognition of prior learning (RPL) has been offered as an also significantly influenced their trust in primary care alternative, so that the current GPs will still be able to settings. While the JKN seeks to establish GPs as gate— practice while they have the training. Unfortunately, until keepers in primary care, patients expressed different now, the debate is continuing and is prolonging the delay views on the GP practice. Some key elements of primary to establish a formal GP training. This delay could hin - care, such as adequate communication, were less promi- der improvement in the quality of practice and prolong nent in comparison to the patients’ comments that the the uncertainty among patients on the quality of primary GPs should refer them to secondary care [32]. This find - care services [42]. ing about the GPs care complemented another study Besides by upgrading the GPs capability, there is also a findings on GPs experience that the they were currently need to establish a clinical pathway guidelines [27]. This focused on restricted policies in primary care practices guideline would be very important as the GPs reference and limitedly covered the trust issue between them and to provide a comprehensive care for their patients and the patients [33]. manage the patients’ referrals. Even though the Indone- Our result showed that the patients’ limited trust in sian Ministry of Health has published the Primary Care GPs was very likely correlated with their views on the Guideline for GPs in Primary Care [43], its improvement current doctors’ education that only enabled them to is needed, particularly to provide the a care collaboration manage mild illnesses as what had been said by Partici- for re-referral mechanism between GPs and specialist in pant 8. This finding is new and limitedly discussed in secondary care. Indonesian literature. Meanwhile, the patients’ trust In addition to the factors related to the primary care to their GPs was an important factor that contributed access and the GPs care discussed above, the patients’ towards the high referrals from primary care [17]. Like- experience during JKN implementation in this study wise, research in Central Asia [33], China [34] and Thai - was also influenced by their experience with previous land [35–38] showed that the GPs’ roles were diminished insurance schemes. Patients were unaware of the JKN because patients put less trust in them than specialists changes and frequently compared their JKN experience because of their shorter training. One strategy that could with Askes (former scheme for civil servants) insurance, help build the patients’ trust in GPs in these countries is so that when the JKN strictly regulated some aspects of to include family medicine education as a compulsory care, patients experienced dissatisfaction. Unfortunately, element of GPs’ postgraduate training. The training could the available information failed to assist the patients in focus on preparing GPs to perform person-centred com- understanding the aims of JKN transition and the new munication and to manage common cases in primary role of primary care service. Therefore, a more extensive care [33, 39]. In Thailand, this training was successful in public information campaign in television, radio, or at equipping the GPs to improve their gate-keeper role dur- any community meetings is essential so that people can ing the implementation of Thailand’s universal coverage understand what is JKN, what is covered, what is not scheme. The rate of inappropriate referral to secondary covered, and what are the GPs’ roles in the JKN scheme. care could be minimized, patients could benefit from While the literature showed that GPs also felt over- more appropriate care and the health financing system whelmed with the JKN working load [44], an insurance could be more efficient [16, 38]. specialist may also help to inform the patients about any Fortunately, the Indonesian government has also cur- JKN regulation changes at the clinics settings. rently proposed such family medicine training for the GPs, but the implementation is still pending. Primary Conclusion care training for GPs is already included in the Indone- In conclusion, this study filled in the gaps of literature sian Medical Education Act number 20 the year 2013 of patients’ views about the implementation of JKN [40]. The Indonesian National Board of Primary Care in primary care. This study concludes that the objec - Physicians’ which brings together representatives of tives of universal coverage in primary care have not yet 17 major faculties of medicines has been preparing the been fully realised in Yogyakarta. To strengthen the JKN Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 8 of 10 Authors’ contributions implementation, a change in public attitudes about uni- All of the authors were involved in the study. FM is an Indonesian. She is versal coverage and the role of primary care practice is working as a GP and academic at Universitas Gadjah Mada. FM and JG were required. The public’s preference for hospital care, and involved in the study design, data collection, interpretation of the data and analysis. SL supervised FM on her qualitative interviewing training. MC was trust in primary care, could be shifted by a better under- solely responsible for the FM fieldwork. MC, KH, SL, JF and JG provided essen- standing of the benefits of primary care services. Those tial comments during the analysis, the interpretation of the data and revised changes, obviously need the collaboration of all the par- the publication drafts. All authors read and approved the final manuscript. ties involved in the JKN transition, particularly to support Author details the primary care sectors to provide a high-quality service Department of Family and Community Medicine, Faculty of Medicine, for patients, including the role of media to support the Universitas Gadjah Mada, Yogyakarta, Indonesia. Department of Medical Edu- cation, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia. dissemination of information. Unless these issues of pri- Department of General Practice and Primary Health Care, University of Mel- mary care are addressed, universal care will be difficult to bourne, Melbourne, Australia. Nossal Institute of Global Health, University achieve, and the public medical expense will remain high of Melbourne, Melbourne, Australia. with inappropriate expense paid for unnecessary proce- Acknowledgements dures in secondary and tertiary care [6, 16, 45]. The authors would like to acknowledge the contribution of the Professor Adi This research has also provides a foundation for further Heru as the Head of Department of Family and Community Medicine, Univer- sitas Gadjah Mada for the legitimation letter and Riadiani for her administra- deep investigation into doctors’ views and experience tive assistance during our fieldwork in Yogyakarta. practicing with the Indonesian JKN as well as the Indo- nesian people’s opinions about postgraduate training in Competing interests All authors declare that they have no competing interests. primary care/family medicine. Availability of data and supporting materials Strengths and limitations Please contact corresponding author for any data and supporting materials requests. This study was a qualitative study with a relatively small sample of participants from Yogyakarta, and the findings Consent for publication should be interpreted and applied within the appropriate All the participants had given their consent for their participation and aca- demic publications using their pseudonyms. context, and might not represent the full range of done- sian geographic diversity. The recruitment process was Declarations able to achieve data collection from a range of sources, This study was approved by the Human Research Ethics Committee, The Uni- versity of Melbourne, Number 1442357. Research permits were obtained from and we are confident that our strategy to analyze the data Regional Development Offices (BAPPEDA) Number 070/REG/3548/S2/2014 in using interpretative phenomenology has strengthened Yogyakarta province as well as local health offices in all Yogyakarta regencies. the findings and conclusions. Funding This research was funded under the scheme of Australia Awards Scholarship from Department of Foreign Affairs and Trade, Australia. Abbreviations Askes: Asuransi Kesehatan (Insurance for Indonesian civil servants); GP: General Practitioner; Jamkesmas: Jaminan Kesehatan Masyarakat (Insurance for the Appendix poor citizens); Jamsostek: Jaminan Sosial Tenaga Kerja (Insurance for workers); See Table 2. JKN: Jaminan Kesehatan Nasional (Indonesin universal health coverage); IPA: Interpretative Phenomenological Analysis; Puskesmas: Pusat Kesehatan Masyarakat (Indonesian public primary care clinics). Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 9 of 10 Table 2 Detailed background of participants Participants Clinics origin Clinic charac- Gender Age range Education level Income level Residential Previous order teristic address insurance coverage 1 Clinic 1 Private Male 26–45 High Middle Urban None 2 Clinic 2 Public Male 46–65 Low Middle Rural Askes 3 Clinic 1 Private Male 18–25 High Middle Urban Askes 4 Clinic 3 Private Female 18–25 High Middle Rural None 5 Clinic 4 Public Male 46–65 Low Middle Rural None 6 Clinic 4 Public Female 46–65 Low Low Rural Jamkesmas 7 Clinic 4 Public Female 46–65 Low Low Rural Jamkesmas 8 Clinic 3 Private Male 46–65 High High Rural Askes 9 Clinic 3 Private Female 26–45 High Middle Rural Askes 10 Clinic 5 Public Female 18–25 High Middle Urban Askes 11 Clinic 5 Public Male 26–45 High High Urban None 12 Clinic 5 Public Female 18–25 High Middle Urban Askes 13 Clinic 6 Public Female 26–45 Low Low Rural Jamkesmas 14 Clinic 6 Public Female 26–45 High Middle Rural Askes 15 Clinic 2 Public Female 26–45 High High Urban Askes 16 Clinic 2 Public Male 26–45 High High Urban Askes 17 Clinic 1 Private Female 66–85 High High Urban Askes 18 Clinic 7 Public Female 66–86 Low Low Rural Jamkesmas 19 Clinic 7 Public Female 46–65 Low Low Rural Jamkesmas 20 Clinic 7 Public Female 26–45 Low Middle Rural Jamkesmas 21 Clinic 8 Private Female 66–86 Low Middle Urban Askes 22 Clinic 8 Private Female 66–87 Low Middle Urban Askes 23 Clinic 8 Private Female 46–65 High High Urban Askes High education: minimum undergraduate degree, low education: maximum senior high school; high income: average income per month above 5.000.000 IDR, middle income: Average income per month 1.000.000 IDR–5.000.000 IDR, Low income: average income per month less than 1.000.000 IDR; Rural area: living in a rural area (Respondents live more than 20 km from the CBD), Urban area: living in a urban area (Respondents live within a 20 km radius from CBD) Received: 13 December 2016 Accepted: 16 February 2017 Yogyakarta (Hubungan Antara Persepsi Keparahan Penyakit Dengan Kepatuhan Mengikuti Sistem Rujukan Berjenjang Di Poliklinik Penyakit Dalam Rsup Dr. Sardjito Yogyakarta). Yogyakarta: Sista Kanina; 2010. 9. Council Indonesian Medical, Indonesian Doctors’ Competency Standard; 10. Idris F. Evaluasi Pelaksanaan JKN. Angka rujukan bpjs 2014 di yogyakarta; References 1. Assembly World Health. Social health insurance: sustainable health 11. Kesehatan BPJS. Sistem Rujukan Berjenjang Jaminan Kesehatan Nasional, financing, universal coverage and social health insurance: report by the 1. Sect. Primary care. 2014. http://www.bpjs-kesehatan.go.id/bpjs/dmdoc Secretariat. 58th World Health Assembly. Geneva: World Health Assembly; uments/588c8bcc7941c2b6d0187435dbcaba61.pdf. 2005 May 16–25 2005. Report No. 12. Kesehatan BPJS. Panduan praktis Pelayanan Kesehatan. Jakarta: BPJS 2. WHO/UNICEF. Primary Health Care: report of the International Conference Kesehatan; 2014. http://bpjs-Kesehatan.go.id/bpjs/index.php/arsip/cat- on Primary Health Care, Alma Ata, USSR, 5–12 September 1978. Geneva: egories/OQ/manlak-jkn-bpjs-kesehatan. Accessed 5 May 2015. World Health Organization; 1978. 13. Council Indonesian Medical. Laporan Tahunan Konsil Kedokteran Indone- 3. WHO. Primary Health Care: now more than ever. Geneva: 2008. sia/Indonesian Medical Council Report 2015. Indonesian Medical Council 4. Indonesia the Parliament of Republic, Indonesia The President of Republic. The Indonesian Law Number 40 about National Social Security 14. Claramita M, Sutomo AH, Graber MA, Scherpbier AJ. Are patient-centered System. Jakarta 2004. care values as reflected in teaching scenarios really being taught when 5. Assembly Indonesian Parliament, Undang Undang Dasar Republik Indo- implemented by teaching faculty? A discourse analysis on an Indonesian nesia 1945/The Indonesian Law of Constition 1945. Sect. Preambule— medical school’s curriculum. Asia Pacific Fam Med. 2011;10(1):4. the Introduction; 1945. 15. Prueksaritanond S, Tuchinda P. General practice residency training pro- 6. Starfield B, Shi L, Macinko J. Contribution of primary care to health sys- gram in Thailand: past, present, and future. J Med Assoc Thail Chotmaihet tems and health. Milbank Q. 2005;3:457. Thangphaet. 2001;84(8):1153–7. 7. Indonesia the President of, the President’s Regulation No 12 Year 2013 16. Pongsupap Y. Family medicine and community orientation as a new about Indonesian Health Coverage, 1; 2013. http://www.jkn.kemkes. approach to quality primary and person-centered care in Thailand. Int J go.id/attachment/unduhan/Perpres%20No.%2012%20Th%202013%20 Pers Cent Med. 2014;3(3):243–7. ttg%20Jaminan%20Kesehatan.pdf. 17. Health Indonesian directorate general of health service. Sistem Rujukan 8. Sista Kanina. The correlation study of disease severity perception and Belum Optimal: Jakarta; 2014. obedience to follow referral procedure in internist clinic Sardjito Hospital Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 10 of 10 18. Ministry of Health Indonesia. Indonesian Health Profile (2014) in Bahasa 33. Rechel B, Ahmedov M, Akkazieva B, Katsaga A, Khodjamurodov G, McKee Indonesia. Jakarta: Ministry of Health; 2015. http://www.depkes.go.id/ M. Lessons from two decades of health reform in Central Asia. Health resources/download/pusdatin/profil-kesehatan-indonesia/Indonesia%20 Policy Plan. 2012;27(4):281–7. Health%20Profile%202014.pdf . 34. Zhou XD, Li L, Hesketh T. Health system reform in rural China: voices of 19. DJSN. Laporan perkembangan 1 tahun BPJS kesehatan, media release. healthworkers and service-users. Soc Sci Med. 2014;117:134–41. 2014. djsn.go.id. Accessed 14 May 2015. 35. Starfield B. Primary care: an increasingly important contributor to effec- 20. Arnstein SR. A ladder of citizen participation. J Amer Plan Assoc. tiveness, equity, and efficiency of health services. SESPAS report 2012. 1969;35(4):216–24. Gac Sanit. 2012;26:20–6. 21. Sanders AR, van Weeghel I, Vogelaar M, Verheul W, Pieters RH, de Wit 36. Hanratty B, Zhang T, Whitehead M. How close have universal health sys- NJ, Bensing JM. Eec ff ts of improved patient participation in primary tems come to achieving equity in use of curative services? A systematic care on health-related outcomes: a systematic review. Fam Pract. review. Int J Health Serv Plan Admin Eval. 2007;37(1):89–109. 2013;30(4):365–78. 37. Green LA, Fryer GE Jr, Yawn BP, Lanier D, Dovey SM. The ecology of medi- 22. Gaghana VF, Siagian IET, Palandeng HMF, Monintja T. Tingkat Kepuasan cal care revisited. (Occasional Notes)(Statistical Data Included). N Engl J Pasien Universal Coverage Terhadap Pelayanan Kesehatan di Puskes- Med. 2001;2001(26):2021. mas Tuminting Manado. Jurnal kedokteran Komunitas dan Tropik. 38. Darin Jaturapatporn, Saipin Hathirat. Specialists’ perception of referrals 2014;2(1):21–6. from general doctors and family physicians working as primary care doc- 23. Putri NE. Efektivitas Penerapan Jaminan Kesehatan Nasional melalui BPJS tors in Thailand. 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Profesi Dokter Umum, A concern that primary care doctor program Thousand Oaks: Sage Publications, Inc; 2003. p. 51–80. would disadvantage the general practitioners. Jakarta: Indonesian 27. SEARO-WHO. Universal Health Coverage and Health Care Financing Constitutional Court; 2015. http://www.mahkamahkonstitusi.go.id/index. Indonesia. 2014. http://www.searo.who.int/indonesia/topics/hs-uhc/en/. php?page=web.Berita&id=10512#.VkFU_rcrLcs.Accessed 28 Nov 2015. 28. Hull TH. Reducing maternal and neonatal mortality in Indonesia: saving 42. Cynthia Haq, William Ventres, Vincent Hunt, Dennis Mull, Robert Thomp- lives, saving the future. Andover: Taylor & Francis; 2015. son, Marc Rivo, et al. Where there is no family doctor: the development of 29. Strengthening Australia Indonesia Partnership for Health System. Health family practice around the world. Acad Med. 1995;70(5):370–80. Financing and Universal Health Coverage Compilation of Policy Notes. 43. Daeng M, Faqih MH, Mahesa PMH, Vidiawati D, Trisna CM-FM, Dyah A Jakarta; 2015. Waluyo, Herqutanto, Ekayanti F, Hendarto J,.Andi Alfian Zainuddin, Ika 30. Health Indonesian Ministry of Nusantara Sehat-Membangun Kesehatan Hariyani. Panduan Praktik Klinis Bagi Dokter Di Fasilitas Pelayanan Keseha- Indonesia dari Perbatasan. 2016. http://nusantarasehat.kemkes.go.id/. tan Primer. 1, editor. Jakarta: The Indonesian Ministry of Health; 2013. Accessed 23 Dec 2016. 44. Syah NA, Roberts C, Jones A, Trevena L, Kumar K. Perceptions of Indone- 31. Indonesia The President of Republic, The Indonesian Government sian general practitioners in maintaining standards of medical practice at Regulation of Public Financial Management/PP Pengelolaan Keuangan a time of health reform. Fam Pract. 2015;32(5):584–90. Badan Layanan Umum. 2005. http://www.fti.itb.ac.id/wp-content/ 45. Starfield B. Primary care: an increasingly important contributor to effec- uploads/2015/06/501-650-PP_No._23_Tahun_2005_tentang_PKBLU.pdf. tiveness, equity, and efficiency of health services. SESPAS report 2012. 32. Cohen IJ. Structuration theory: Anthony Giddens and the constitution of Gac Sanit. 2012;26(Supplement 1(0)):20–6. social life: Houndmills, Basingstoke, Hampshire: Macmillan, 1989; 1989. Submit your next manuscript to BioMed Central and we will help you at every step: • We accept pre-submission inquiries • Our selector tool helps you to find the most relevant journal • We provide round the clock customer support • Convenient online submission • Thorough peer review • Inclusion in PubMed and all major indexing services • Maximum visibility for your research Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Patients’ experience of using primary care services in the context of Indonesian universal health coverage reforms

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Springer Journals
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Copyright © 2017 by The Author(s)
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
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10.1186/s12930-017-0034-6
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Abstract

Background: The World Health Organization ( WHO) recommendation on universal coverage has been implemented in Indonesia as Jaminan Kesehatan Nasional (JKN). It was designed to provide people with equitable and high-quality health care by strengthening primary care as the gate-keeper to hospitals. However, during its first year of implemen- tation, recruitment of JKN members was slow, and the referral rates from primary to secondary care remained high. Little is known about how the public views the introduction of JKN or the factors that influence their decision to enroll in JKN. Aim: This research aimed to explore patients’ views on the implementation of JKN and factors that influence a per - son’s decision to enroll in the JKN scheme. Methods: This study was informed by interpretative phenomenological analysis (IPA) methodology to understand patients’ views. The interview participants were purposively recruited using maximum variation criteria. The data were gathered using in-depth interviews and was conducted in Yogyakarta from October to December 2014. The inter- views were transcribed, translated and analyzed using IPA analysis. Result: Twenty three participants were interviewed from eight primary care clinics. Three superordinate themes: access, trust, and separation anxiety were identified which impacted on the uptake of JKN. Participants acknowledged that whilst primary care clinics were conveniently located, access was often complicated by long waiting times and short opening hours. Participants also expressed lower levels of trust with primary care doctors compared to hospital and specialist care. They also reported a sense of anxiety that the current JKN regulation might limit their ability to access the hospital service guaranteed in the past. Discussion: This study identified patients’ views that could challenge the implementation of the gate-keeper role of primary care in Indonesia. While the patients valued the availability of medical care close to home, their lack of trust in primary care doctors and fear that they might lost the hospital care in the future appears to have impacted on the uptake of JKN. Unless targeted efforts are made to address these views through sustained public education and further capacity building in primary care, it is unlikely that the full potential of the JKN scheme in primary care will be realized. Keywords: General practice, Primary health care, Indonesia, Access, Patients’ experience, Phenomenology Background access high-quality health services without financial bar - The WHO [ 1] has proposed that all member countries riers. This WHO recommendation of universal health implement universal health coverage to help people coverage was in-line with the Alma Ata declaration which aimed to provide people with accessible high- quality services in primary care [2, 3]. Responding to *Correspondence: fitriana_murriya@yahoo.co.id; fekawati@student. those global recommendations, Indonesia has established unimelb.edu.au Department of Family and Community Medicine, Faculty of Medicine, a universal insurance scheme, which is known as Jami Universitas Gadjah Mada, Yogyakarta, Indonesia nan Kesehatan Nasional (JKN) since January 2014. The Full list of author information is available at the end of the article © The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 2 of 10 JKN was the merger of four pre-existing public insurance requirement for GPs to undertake compulsory formal schemes (Askes insurance for civil servants, Jamkesmas training to improve their primary care practice. In 2015, insurance for poor citizens, Jamsostek as insurance for 168,823 doctors were registered with the Indonesian private sector workers and Asabri as Insurance for the Medical Council: 29,561 of them were specialist doctors, armed forces). The JKN was designed under the law of 29,665 were dentists, and 109,597 were recorded as GPs National Social Security to meet the people’s basic needs [13]. In Indonesia, doctors only need to undertake a four and contribute towards the realization of a prosperous year undergraduate degree plus a two years postgradu- and equitable Indonesia [4, 5]. With this insurance, it was ate Medical Doctor (MD) degree, national examination, expected that people would not face financial barriers and one year internship in hospitals and Puskesmas to to access health care and therefore increase their use of get the licence to practice as a GP in primary care [14]. health services. During the undergraduate degree, the students learn the The role of primary care as a gatekeeper to second - theory required to practise medicine. During the MD, ary and tertiary care has been strengthened in the JKN they complete two years of clinical practice in various implementation. It is expected that primary care doctors hospital departments; such as internal medicine, surgery, can fulfill the people’s basic health needs and ought to dermatology, and obstetrics. While the specialists have to be able to manage the majority of the patients’ problems complete an additional three to five years training at the [6]. In the JKN implementation, this sector is supported University hospitals, currently, no compulsory training under a capitation payment system [7]. It is a payment for GPs is available to upgrade their skills in primary care concept within which the private family doctors and practice. Therefore,  this level of training for Indonesian Puskesmas (Indonesian Public Primary Care Clinic) as GPs differs from the requirements in other similar coun - primary care providers are paid a set payment per num- tries that are implementing universal insurance cover- ber of registered patients, whether the patients come age. In Thailand for example, GPs have been required to to seek any medical help or not. This payment scheme undertake a formal postgraduate training in family medi- is intended to enable primary care services to focus on cine. This education scheme has been implemented since health promotion and illness prevention in addition to 20 years before the implementation of Thailand’s univer - curative measures [7]. sal coverage in 2001 [15, 16]. The JKN also introduced several new regulations of Some important issues arose during JKN’s first years of the health system compared to the previous insurance implementation, notably slow recruitment of new mem- schemes. Under the Askes and Jamkesmas schemes in the bers, which was identified at the first JKN mid-year eval - past, patients were free to access any primary care ser- uation. Compared to the total membership of the four vice. They also could easily obtain a referral letter from previous insurances schemes in 2012 (155 million mem- their general practitioner (GP) to access secondary care bers), the JKN membership had only reached 125 million in hospitals [8]. However, under the JKN scheme, patients members in mid-2014 [10, 17]. The target of doctors to have to formally register themselves at JKN offices or handle almost all of the primary care cases and only refer their appointed family doctor practice or Puskesmas. The less than 10% of the cases was also not being met. Nation- guidelines of conditions that could be appropriately man- ally, the overall JKN primary-to-secondary referral rate aged by the GPs-based on their competency standard [9] was 17%, but the referral rate in several provinces such as -had also been published [10]. The referrals could only in Yogyakarta, East Java and Jakarta was much higher, up be made on appropriate clinical judgements. Therefore, to 55% of cases [18, 19]. With this high referral rate, it is the patients have to comply with these procedures set likely that many of the referrals were inappropriate, such by the JKN, under which, JKN will not cover the cost of as essential hypertension, dyspepsia, and general physical any hospital treatment if the referral is made outside the examination [11], conditions which should be managed guidelines [11, 12]. On the other hand, the Indonesian at primary care level according to the Indonesian physi- government also supported the utilization of primary cians’ competency standards for primary care doctors [9, care under the JKN by disseminating information on JKN 17]. procedures to the public and preparing practice guide- Unfortunately, there has been little evidence available lines for primary care providers. The information was about the factors that underlie these emerging issues dur- spread by a massive media campaign including advertise- ing the initial implementation of JKN in primary care set- ments on TV and radio; while procedures were estab- tings. In particular, there is little known of patients’ views lished to make registration with JKN easier for patients. and experiences during JKN implementation, which may However, an additional policy that could contribute be important factors influencing their decision about significantly to the success of JKN primary care objec - whether to opt into the JKN. Information on the views tives has yet to be fully established. This relates to the of patients is important because patients are the actual Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 3 of 10 users of health care, and their views and experiences rep- were a parent or a caregiver. The only exclusion crite - resent the actual condition in practice settings [20, 21]. rion was if patients were unwilling to participate in the Current available evidence only shows that there are research. different satisfaction rates with the JKN program across The first author (FM) completed all of the interviews. Indonesian provinces. Gaghana, Siagian [22] found that Written informed consent was obtained from all study only 51.9% out of 106 patients were satisfied with JKN participants prior to the interview. All of the interviews implementation in Sulawesi. Putri [23] also found the were done in a private room in the clinics, except two implementation of JKN was not effective in primary care interviews which were done in FM’s office. None of the clinics in Padang city, West Sumatra. Putri found that the participants expressed any objection with the interview JKN improved service delivery for low socioeconomic place. FM had also anticipated that Yogyakarta people status patients, but the patients expressed dissatisfac- may be reluctant to speak openly about their views [25] tion with the staff responsiveness, credibility, medical or may be hesitant because FM is a GP from Yogyakarta. documentation, and medical access. However, neither of FM therefore explained to the participants that their par- these studies explored in depth the factors which contrib- ticipation was voluntary, their answers were confiden - uted towards the patients’ views nor their dissatisfaction. tial, and that their participation would not affect their Therefore, we set out to explore in depth the patients’ relationship with FM or with their care providers in the perspectives of primary care in this study, and the factors future. which contribute towards the slow recruitment and high During the interviews, FM began with an introduction. referral rates to secondary care [10, 17]. After that, she asked open-ended questions, such: ‘please tell me your experience in seeking health care’ or ‘where do Methods you usually go to seek health care.’ Then, these questions This research was informed by the interpretative phe - were followed up with more focused interview questions nomenological analysis (IPA) approach to allow a related to the participant’s experience with the primary deep and comprehensive understanding of the partici- care service and the JKN implementation. The partici - pants’ views and experiences [24]. Consistent with this pant responses were probed and clarified using prompt - approach, data collection was conducted using semi- ing sentences, summarizing sentences and or some structured interviews to allow greater opportunity for positive statements such as uhum…, or ‘yes ….’ and silent patients to express their views. pauses to allow time for participants to think about their The study was conducted in Yogyakarta province, cen - responses and respond. All but one interview was tape- tral Indonesia, from October to December 2014. Yog- recorded. Written notes of responses were taken for the yakarta is characterized by a range of socio-economic patient who was unwilling to be tape-recorded. All the status of its population, relatively easy access to health participants were given a small souvenir bag as a token of services and a high rate of referral to secondary care. A their participation. maximum variation sampling strategy was applied to The interviews were transcribed and then, translated ensure a range of perspectives. The clinic recruitment into English. Five translated texts were back translated process was done purposively in both private and pub- for translation validation. The data were analyzed using lic primary care clinics in the Yogyakarta region: at the IPA analysis. IPA is an analytical method to explore districts of Kulonprogo, Sleman, Yogyakarta city, Bantul, in depth the participants’ views, combined with the and Gunung Kidul. researcher’s interpretation of the participant’s meaning The recruitment process is described as follows: first, of a phenomena. The steps of IPA analysis were system - the practice manager/clinic owners were telephoned and atically applied according to the recommendations of were provided with Bahasa Indonesia plain language by Smith and Osborn [26]. FM and JG read all the tran- statement. When the practice manager/clinic owner had scribed texts independently until they were also familiar signed the consent form, first author (FM) then came with the patients’ views. They both then coded any nota - to the clinics to recruit patients for an interview. The ble quotes. The quotes were grouped into themes and patients were selected purposively from the patients’ reg- super-ordinate themes. The emerging themes were dis - istry during the interview day (at maximum three par- cussed and crosschecked amongst other researchers with ticipants at each clinic). The inclusion criteria included: primary care backgrounds. Indonesian citizen, JKN insurance member, and Yogya- karta resident. Then, the patients were selected based on Results the following purposive sampling criteria: age, income The proposed maximum variation sample design for level, the level of education, residential address, marital interview participants was fulfilled. The criteria for the status, and specific characteristics; such as whether they sample are listed in Table 1. All criteria were met with at Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 4 of 10 Table 1 The participants’ characteristic with 13 past members of Askes (civil servants scheme), and 6 were past members of Jamkesmas (free insurance Sample criteria Total number (N = 23) for low-income/poor). Almost all the participants were Types of clinic willing to fully participate right up until completion of Public clinic 5 the interview. One participant suddenly decided to stop Private clinic 3 in the middle of the interview process but did not wish to Gender withdraw completely from the study because of her wor- Male 7 ries that the interview would affect her treatment in the Female 16 clinics. Age group Three superordinate themes of Access, Trust, and Sep - 18–25 4 aration anxiety were identified from the analysis. Partici - 26–45 8 pants acknowledged the convenience of access to primary 46–65 7 care but were dissatisfied with the waiting time and phys - 66–85 4 ical structure of the clinics. The superordinate theme of Residential address Trust referred to participants who were dissatisfied with Urban area 11 the doctors’ general communication. They also expressed Rural area 12 doubt that the primary care doctors could treat more Education level severe diseases and preferred to receive a referral letter High education 13 to secondary care. Within the third superordinate theme, Low education 10 participants expressed their anxiety about whether they Income level would be able to continue to use specialist care services High income 6 at the hospital in the way they were previously used to. Middle income 12 Low income 5 Access Employment sector Many participants referred to the proximity between the Private sector 7 service and their home and the convenience of access to Public sector 16 primary care service and chose them as their usual means Frequency use of primary care of health care. This answer also came from many partici - Never 4 pants when being asked about their reason for attending primary care. For instance, Participant 21 in this study 1–5 visits/year 8 said “Yes, every month I go to Puskesmas. Because it is >5 visits/year 11 near, so that I can get the easily accessible service” (Par- Marital status ticipant 21, l.24–25). Married 18 However, later on, during the interviews, many partici- Single 5 pants commented that the long waiting time and facili- Diagnoses ties in the clinics were less convenient and limited their Acute illness 5 enjoyment of the service. In some cases, the participants Chronic illness 9 then preferred to leave the clinics or chose to attend a Healthy 9 private hospital rather than continue queuing. For exam- Specific attributes ple, Participant 9 said: “If in Puskesmas, I need to queue Only caregiver – for a long time. I have to queue before here and there. But, Parent 13 I need to go to fieldwork (working), so I decide to leave the Both of caregiver and parent 5 Puskesmas and go to private hospital” (Participant 9, l. None 5 38–39). In addition, participants also noticed deficiencies in the physical facilities at the clinic which influenced the ease minimum two participants in each category. 23 partici- with which they could see the doctor. They considered pants were recruited, the majority of whom were women that the clinic building could not accommodate them (n  =  17), had a high level of education (at minimum a well and caused them to wait longer to see the doctors, as bachelor degree) (n  =  13), were aged between 26 and stated by Participant 11: 65  years old, and of middle-income status/income per “If all patients need and go to Puskesmas, I believe month: 1–5 million IDR (n = 12). The majority of partici - that it is not only unbalanced, but it is impossible. pants were members of the previous insurance schemes, i Th s Puskesmas does not have enough room for that, Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 5 of 10 and we will wait longer and longer. The parking lot, one is given antibiotic”. (Participant 12, l. 68–72). Puskesmas also can’t provide an enough time for us Another prominent aspect of patients’ trust in their (Participant 11, l.57–65). GPs is that many participants also doubted if the GPs Some participants also commented on the facility could manage more severe problems. They considered inequalities across Indonesia’s geography. Participants 1 that the GPs’ current education could only equip them and 16 thought that service on the island of Java (where with skills to superficially understand the patients’ con - Yogyakarta is located) was actually better than the service ditions. Many of them expressed the opinion that their in other islands. They felt that although JKN had already GPs were unable to solve more serious illnesses, as was helped people with affordable medical cost, it still did not explained by Participant 8: resolve the inequalities and hindered access to high-qual- “The GP is a general doctor, their education is lim - ity medical care for people residing outside Java, due to ited. I think for the specific diagnosis, the internist’s the imbalanced and non-standardized health facilities in (diagnosis) is better, specific in the treatment as well. different geographic areas. The GP doctors, I believe they need to learn again” “Who gets the benefits, I think, once again are Java - (Participant 8, l. 61–62). nese, Can you imagine? In East Nusa-Tenggara, Furthermore, some participants insisted that the GPs’ on the top of the mountain, a member of JKN, she role should be to provide referrals to hospital. There was needs a bypass of her heart, can she? Because they a perception among patients that if a person was suffer - are people who cannot be served, they should have ing from any illness, they needed to see a specialist and the same rights; they should get the same, but in fact, the primary care doctors should give them referrals to they receive different service. Big fake as long as the hospital, as expressed by Participant 16: government does not think about the infrastructures, doctors’ distribution, hospitals and the nurses.” (Par- “I usually get referrals from here. A long time ago, ticipant 1, l.182–186). I must be inpatient in S hospital; I got the referral from here. I also once had a referral from here for a urinary infection. When my child was sick, I came Trust here. Sometimes I think the primary care is not Participants were initially unsure when asked about the needed, but the pediatrician. My child’s eyes were quality of the primary care doctors’ service. They usu - red and got swelling several times, which we are ally answered with comments such as ‘the doctors are referred to J hospital. My wife also comes here, my kind’ or ‘I feel comfortable with the doctors’ as their mother in law also gets the referral here” (Partici- first reply. However, when they were encouraged to pant 16, l. 41–48)”. give more description about what they expected from their GPs, they expected that GPs should have excel- Meanwhile, participants also considered that specialist lent communication skills and be able to explain more doctors were also superior because of their more com- about the patients’ condition. For instance, Participants prehensive facilities. Participant 6 stated that she was 11 and 12 were dissatisfied with the doctors’ service pessimistic with the clinic service because it had less because the doctors did not explain more about their medical facilities. She said that this made the GPs use less illnesses. They thought that the doctors only gave simi - effective medication and limited the help they could pro - lar pills for all patients without adequate information. vide for the patients’ problems, whereas, specialist care They expected the GPs to perform a comprehensive was always trusted as it was always complemented with individual examination and provide a complete expla- more advanced medication. Interestingly, Participant 6 nation of their condition so that they understood the also believed that diseases of certain body parts belonged purposes of the medication and trusted the doctors’ to certain specialist expertise. She thought that as nowa- treatment. days many patients suffered from internal diseases. She then expected the clinic to have an internist doctor. “So usually in Puskesmas, you see that after the doctor asks us, then he will give us some medi- “I think it will be good if you can provide an oph- cine? Then we do not know what is our disease is. thalmologist because you know, it is a pity for many So I think the doctor only treat our symptoms. So people here with cataract, an eye-wart, an eye spot, my hope is that we are asked comprehensively. So sometimes ago, they were here and could not be that we know our problem, not only fever, then the treated. For eye diseases in Puskesmas, we were only doctor gives us the fever drug. However, then we given an eye drop. I do not think Puskesmas can give develop an infection and not yet informed. Every- anything else for cataract patients, for now, I do not Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 6 of 10 know for the future. But with the eye drops, when I pier with Askes because we do not have our limit”. used it, I do not feel any improvement, Somewhat (Participant 21, l. 72–79). my eyes are getting bright but often darker, it is not Moreover, half of the participants also complained that working. Moreover, please, you may add this clinic clear information regarding JKN procedures was limit- with an internist. You know there are lots of patients edly available. They were unfamiliar with current JKN with internal diseases” (Participant 6, l. 78–90). transition systems in primary care. Even though there was increasing efforts to promote the changes that had been made, access to information in the primary care Separation anxiety setting was lacking. Moreover, the clinic’s staff failed to u Th s, with the JKN transition, half of the participants in assist patients in obtaining adequate information. For this study experienced JKN implementation in primary example, Participant 1 told of his experience in using a care as a challenging period because they no longer had referral to access hospital care without knowing that the the same access to the specialist services, which they regulations were changing. He was dissatisfied because regarded as superior to primary care-that they had been his referral to the hospital was no longer allowed and this guaranteed in the past. Many participants, who had been was not informed by the clinic’s staff. He was concerned managed by specialists for a long time, now had to visit that the same situation could be experienced by another the GPs for their routine care. They also claimed that JKN patient who needed urgent medical help. restricted the prescription of medicines and their referral access to the hospital. As they already had limited trust in “I came at noon, Oh My God, the hospital officer the GP’s ability (-as described at ‘Trust’ theme), patients showed me that referral was not working. She told worried if the GP care was less ideal than specialist care as me that the regulation was changing, I should go to expressed by Participant 2: the secondary hospital first. I mean, how about the other patients, if he was certain with the referral, “Well, this is just my opinion. You know that I should but it did not work? How about if there is a severe be referred to an internist because I have diabetes. patient, more serious than me, how is that?” (Par- Previously, I was happy in G clinic (specialist clinic), ticipant 1, l. 107–112). I could see the internist directly. You know if here, I have to use the referral system, which is once in every three months in the hospital. I need to see the GPs for Discussion months. I think that is too long. However, anyhow, I Our findings suggest that during the commencement of kept ask my doctor to refer me to specialist and now the JKN universal health coverage scheme, Indonesian the doctors refer me” (Patient 2, l. 49–52). primary care faces some challenges in achieving the aims of the program. The limitations in facilities and operation Participants were more emotionally discouraged because have constrained the fulfillment of the patients’ perceived JKN had also limited some hospital services which had pre- general health needs and reduced the public’s expecta- viously been covered by Askes insurance. Even though they tions regarding the JKN implementation in primary care. had already had referrals to the hospital, it did not mean that The findings regarding the clinics access are consist - JKN would cover the all the hospital medical expenses. Par- ent with existing research. Putri [23] found that patients ticipant 21 mentioned that some services were not fully cov- reported inadequate access to primary care clinics dur- ered by JKN anymore, compared to Askes insurance in the ing JKN insurance. Regarding this finding, one strategy to past. She also expressed her feeling that somehow she was improve the facilities and access standard of care by pro- happier with the old Askes insurance. viding an equal access of health care distribution [27] and “I think with Askes if we come to health facili- establishing an accreditation program so that the care ties whatever whenever, were not limited, but now, quality for the patients is warranted [28]. we have our limit. However, last month when my Even though still a distance from the ideal views of son had surgery, he should pay himself. It is stated those suggestion, however, the health care distribution at JKN paper that it is only covered for 15 million is currently the Indonesian priority. The government has so that he had to pay the gaps. You know, it would currently established an accreditation standards required not happen in Askes. That was different between for primary care practice. The Puskesmas and private them. For JKN, if the patient is not very ill and she is clinics that wish to contract with the JKN are expected referred hospital, it will not be covered. We have to to prepare and maintain their facilities to the required, pay, come to the emergency room and pay. However, specified standards of care, such as the fixed opening Askes was not. For me, they are different. I am hap - hours and patient care standard operating procedures. Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 7 of 10 However, this program is currently ongoing and focus- formal postgraduate training for the GPs. However, there ing on the Puskesmas [29], not yet involving the private has been an extensive debates among GPs’ and special- primary care practices accreditation. The health care pro - ist colleagues regarding the training time, resources, and viders availability is also continuing to improve through care collaboration. Concerns have been raised that the several programs, such as contract doctor, Nusantara postgraduate training would lengthen the GPs’ education Sehat [30] and local public agency program which enable to practice in primary care and that the training would Puskesmas to arrange and manage its own facilities [31]. be ineffective without ensuring adequate facilities were Another important finding in this research is that available in the primary care settings [41]. Therefore, rec - patient perceptions of the quality of the GPs practice ognition of prior learning (RPL) has been offered as an also significantly influenced their trust in primary care alternative, so that the current GPs will still be able to settings. While the JKN seeks to establish GPs as gate— practice while they have the training. Unfortunately, until keepers in primary care, patients expressed different now, the debate is continuing and is prolonging the delay views on the GP practice. Some key elements of primary to establish a formal GP training. This delay could hin - care, such as adequate communication, were less promi- der improvement in the quality of practice and prolong nent in comparison to the patients’ comments that the the uncertainty among patients on the quality of primary GPs should refer them to secondary care [32]. This find - care services [42]. ing about the GPs care complemented another study Besides by upgrading the GPs capability, there is also a findings on GPs experience that the they were currently need to establish a clinical pathway guidelines [27]. This focused on restricted policies in primary care practices guideline would be very important as the GPs reference and limitedly covered the trust issue between them and to provide a comprehensive care for their patients and the patients [33]. manage the patients’ referrals. Even though the Indone- Our result showed that the patients’ limited trust in sian Ministry of Health has published the Primary Care GPs was very likely correlated with their views on the Guideline for GPs in Primary Care [43], its improvement current doctors’ education that only enabled them to is needed, particularly to provide the a care collaboration manage mild illnesses as what had been said by Partici- for re-referral mechanism between GPs and specialist in pant 8. This finding is new and limitedly discussed in secondary care. Indonesian literature. Meanwhile, the patients’ trust In addition to the factors related to the primary care to their GPs was an important factor that contributed access and the GPs care discussed above, the patients’ towards the high referrals from primary care [17]. Like- experience during JKN implementation in this study wise, research in Central Asia [33], China [34] and Thai - was also influenced by their experience with previous land [35–38] showed that the GPs’ roles were diminished insurance schemes. Patients were unaware of the JKN because patients put less trust in them than specialists changes and frequently compared their JKN experience because of their shorter training. One strategy that could with Askes (former scheme for civil servants) insurance, help build the patients’ trust in GPs in these countries is so that when the JKN strictly regulated some aspects of to include family medicine education as a compulsory care, patients experienced dissatisfaction. Unfortunately, element of GPs’ postgraduate training. The training could the available information failed to assist the patients in focus on preparing GPs to perform person-centred com- understanding the aims of JKN transition and the new munication and to manage common cases in primary role of primary care service. Therefore, a more extensive care [33, 39]. In Thailand, this training was successful in public information campaign in television, radio, or at equipping the GPs to improve their gate-keeper role dur- any community meetings is essential so that people can ing the implementation of Thailand’s universal coverage understand what is JKN, what is covered, what is not scheme. The rate of inappropriate referral to secondary covered, and what are the GPs’ roles in the JKN scheme. care could be minimized, patients could benefit from While the literature showed that GPs also felt over- more appropriate care and the health financing system whelmed with the JKN working load [44], an insurance could be more efficient [16, 38]. specialist may also help to inform the patients about any Fortunately, the Indonesian government has also cur- JKN regulation changes at the clinics settings. rently proposed such family medicine training for the GPs, but the implementation is still pending. Primary Conclusion care training for GPs is already included in the Indone- In conclusion, this study filled in the gaps of literature sian Medical Education Act number 20 the year 2013 of patients’ views about the implementation of JKN [40]. The Indonesian National Board of Primary Care in primary care. This study concludes that the objec - Physicians’ which brings together representatives of tives of universal coverage in primary care have not yet 17 major faculties of medicines has been preparing the been fully realised in Yogyakarta. To strengthen the JKN Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 8 of 10 Authors’ contributions implementation, a change in public attitudes about uni- All of the authors were involved in the study. FM is an Indonesian. She is versal coverage and the role of primary care practice is working as a GP and academic at Universitas Gadjah Mada. FM and JG were required. The public’s preference for hospital care, and involved in the study design, data collection, interpretation of the data and analysis. SL supervised FM on her qualitative interviewing training. MC was trust in primary care, could be shifted by a better under- solely responsible for the FM fieldwork. MC, KH, SL, JF and JG provided essen- standing of the benefits of primary care services. Those tial comments during the analysis, the interpretation of the data and revised changes, obviously need the collaboration of all the par- the publication drafts. All authors read and approved the final manuscript. ties involved in the JKN transition, particularly to support Author details the primary care sectors to provide a high-quality service Department of Family and Community Medicine, Faculty of Medicine, for patients, including the role of media to support the Universitas Gadjah Mada, Yogyakarta, Indonesia. Department of Medical Edu- cation, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia. dissemination of information. Unless these issues of pri- Department of General Practice and Primary Health Care, University of Mel- mary care are addressed, universal care will be difficult to bourne, Melbourne, Australia. Nossal Institute of Global Health, University achieve, and the public medical expense will remain high of Melbourne, Melbourne, Australia. with inappropriate expense paid for unnecessary proce- Acknowledgements dures in secondary and tertiary care [6, 16, 45]. The authors would like to acknowledge the contribution of the Professor Adi This research has also provides a foundation for further Heru as the Head of Department of Family and Community Medicine, Univer- sitas Gadjah Mada for the legitimation letter and Riadiani for her administra- deep investigation into doctors’ views and experience tive assistance during our fieldwork in Yogyakarta. practicing with the Indonesian JKN as well as the Indo- nesian people’s opinions about postgraduate training in Competing interests All authors declare that they have no competing interests. primary care/family medicine. Availability of data and supporting materials Strengths and limitations Please contact corresponding author for any data and supporting materials requests. This study was a qualitative study with a relatively small sample of participants from Yogyakarta, and the findings Consent for publication should be interpreted and applied within the appropriate All the participants had given their consent for their participation and aca- demic publications using their pseudonyms. context, and might not represent the full range of done- sian geographic diversity. The recruitment process was Declarations able to achieve data collection from a range of sources, This study was approved by the Human Research Ethics Committee, The Uni- versity of Melbourne, Number 1442357. Research permits were obtained from and we are confident that our strategy to analyze the data Regional Development Offices (BAPPEDA) Number 070/REG/3548/S2/2014 in using interpretative phenomenology has strengthened Yogyakarta province as well as local health offices in all Yogyakarta regencies. the findings and conclusions. Funding This research was funded under the scheme of Australia Awards Scholarship from Department of Foreign Affairs and Trade, Australia. Abbreviations Askes: Asuransi Kesehatan (Insurance for Indonesian civil servants); GP: General Practitioner; Jamkesmas: Jaminan Kesehatan Masyarakat (Insurance for the Appendix poor citizens); Jamsostek: Jaminan Sosial Tenaga Kerja (Insurance for workers); See Table 2. JKN: Jaminan Kesehatan Nasional (Indonesin universal health coverage); IPA: Interpretative Phenomenological Analysis; Puskesmas: Pusat Kesehatan Masyarakat (Indonesian public primary care clinics). Ekawati et al. Asia Pac Fam Med (2017) 16:4 Page 9 of 10 Table 2 Detailed background of participants Participants Clinics origin Clinic charac- Gender Age range Education level Income level Residential Previous order teristic address insurance coverage 1 Clinic 1 Private Male 26–45 High Middle Urban None 2 Clinic 2 Public Male 46–65 Low Middle Rural Askes 3 Clinic 1 Private Male 18–25 High Middle Urban Askes 4 Clinic 3 Private Female 18–25 High Middle Rural None 5 Clinic 4 Public Male 46–65 Low Middle Rural None 6 Clinic 4 Public Female 46–65 Low Low Rural Jamkesmas 7 Clinic 4 Public Female 46–65 Low Low Rural Jamkesmas 8 Clinic 3 Private Male 46–65 High High Rural Askes 9 Clinic 3 Private Female 26–45 High Middle Rural Askes 10 Clinic 5 Public Female 18–25 High Middle Urban Askes 11 Clinic 5 Public Male 26–45 High High Urban None 12 Clinic 5 Public Female 18–25 High Middle Urban Askes 13 Clinic 6 Public Female 26–45 Low Low Rural Jamkesmas 14 Clinic 6 Public Female 26–45 High Middle Rural Askes 15 Clinic 2 Public Female 26–45 High High Urban Askes 16 Clinic 2 Public Male 26–45 High High Urban Askes 17 Clinic 1 Private Female 66–85 High High Urban Askes 18 Clinic 7 Public Female 66–86 Low Low Rural Jamkesmas 19 Clinic 7 Public Female 46–65 Low Low Rural Jamkesmas 20 Clinic 7 Public Female 26–45 Low Middle Rural Jamkesmas 21 Clinic 8 Private Female 66–86 Low Middle Urban Askes 22 Clinic 8 Private Female 66–87 Low Middle Urban Askes 23 Clinic 8 Private Female 46–65 High High Urban Askes High education: minimum undergraduate degree, low education: maximum senior high school; high income: average income per month above 5.000.000 IDR, middle income: Average income per month 1.000.000 IDR–5.000.000 IDR, Low income: average income per month less than 1.000.000 IDR; Rural area: living in a rural area (Respondents live more than 20 km from the CBD), Urban area: living in a urban area (Respondents live within a 20 km radius from CBD) Received: 13 December 2016 Accepted: 16 February 2017 Yogyakarta (Hubungan Antara Persepsi Keparahan Penyakit Dengan Kepatuhan Mengikuti Sistem Rujukan Berjenjang Di Poliklinik Penyakit Dalam Rsup Dr. Sardjito Yogyakarta). 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Journal

Asia Pacific Family MedicineSpringer Journals

Published: Mar 21, 2017

References