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

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 implementation, 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 person'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 interviews 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.