Research Result

In Six Regencies of East Java Province and Eight Regencies of East Nusa Tenggara Province

Intended to:

-          The IX commission of House of Representatives

-          Ministry of Health

-          National Development Planning Board

-          Ministry of Finance

-          Ministry of Home Affairs

-          The Provincial Government of East Java and East Nusa Tenggara


The poor society have various challenges in using the benefits of healthcare service. The main challenge is the access problem, which is financial obstacle to attain the service. One of the governmental strategic policies to improve the degree of health especially for the poor society in order to protect this matter is through the Jaminan Kesehatan Masyarakat (Jamkesmas – Community Health Insurance) program and Jaminan Kesehatan Daerah (Jamkesda – Regional Health Insurance). However the course of these health insurances still has to face a lot of other challenges of access, such as infrastructure, service facilities, up to social cultural problems. Some of the poor society can not afford, are not able, or do not want to use the benefits of healthcare facilities although healthcare insurance is already available. This policy brief is intended to give policy recommendation for the central government concerning to policy on quality improvement and the availability of primary healthcare based on the Health Seeking Behaviour (HSB) study conducted in 14 regencies in East Java and East Nusa Tenggara provinces.

The Result of the Research

East Nusa Tenggara Province

1. The primary healthcare service that is used a lot by poor society in East Nusa Tenggara is polindes ( Village health polyclinic) and puskesmas (Community Health Center). The access problems of poor society to get primary healthcare service are still occur as the effect of the limited numbers of healthcare personnel (especially doctors) who work in primary healthcare service. As the result, some of the patients should be referred to hospitals or move to traditional medicine ( shaman).

2. East Nusa Tenggara Timor region that has downy geography characteristic and some parts are divided into islands, gives obstacles in using the benefits of primary healthcare service as well as when they should be referred. Difficult geographical contours which are not match with the adequate transportation infrastructures results in high expense that should be spent to get into the healthcare facilities and it is quite burdening the poor society in East Nusa Tenggara to access primary healthcare service as well as secondary (referred cases).

3. There is 15.4% of poor society in eight regencies of East Nusa Tenggara province that can not use Jamkesmas and Jamkesda cards when they use the benefits of healthcare service. It is caused by there is a perspective if they utilize free medical treatment, they will experience service discrimination. They think that when utilizing Jamkesmas card they will get worse service compared to paid service, despite the complicated administration requirements and quite long duration of waiting for the service.

East Java Province

1. Different from East Nusa Tenggara which has limited health personnel, the poor society in six regencies of East Java has various options to utilize government healthcare service as well as private. (Formal as well as informal).

2. There is 42.5% poor society in six regencies in East java province that do not utilize Jamkesmas and Jamkesda, since there is a perception toward the severity of the diseases and there is also anxiety toward differences in service (discrimination).

3. Free governmental healthcare service or services covered by Jamkesda or Jamkesmas are still considered to have low quality, especially on the medication. Poor society consider that medication that is wrapped and paid has better quality compared to free medication.

4. Despite the quality of the medication which is considered low, the administration process as well as the duration of waiting are also considered too long and complicated.

5. East Java poor society still trust the senior medical personnel more for their medical treatment with the consequence that they have to spend money. Some still utilize the service of shamans or take traditional medication when they are sick.

Analysis on the Utilizing Basic Healthcare Facilities Policy

Policy on the provision and improvement of basic healthcare service is based on the Laws No. 36/2009 about health. Health is the right for every people and government should ensure and provide the service for anybody without any differences in treatment (discrimination). In Health Ministerial Stipulation No. 128/ 2004 about Basic Policy of Puskesmas supported by article 1 verse 7 Laws No. 25/2009 about Manual on Service Organization and Reference of Public Service Quality Assessment. There are several matters that can be concluded from what happen in 14 regencies related to various policies on quality improvement and the availability of service resources above:

1. The availability of health personnel especially doctors in East Nusa Tenggara that possesses downy and islands geographical characteristic becomes a great obstacle to access the service.

2. The quality of basic/ primary healthcare service that occur in both province is exactly the opposite of what is instructed by Laws No. 36/2009. There are differences in perception about the quality of service given to patients of Jamkesmas/ Jamkesda compared to general patients. Health Insurance intended for poor society apparently is not utilized by all people. Some of the poor society chooses paid healthcare service, since the quality of medication and service of health insurance covered healthcare are considered low.

Both matters reflex the existence of problems on geographical and economical inequity in health insurance era. Jamkesda and Jamkesmas are not completely able yet to reduce the obstacles to utilize healthcare service for free. This condition is unexpectedly happen in the implementation of healthcare insurance.


Based on the result of the study and policy analysis, there are some policy recommendations for the central government as follow:

East Nusa Tenggara Province

1. Government needs to conduct investment to add facilities and health personnel in short, middle and long term. The needs of village midwives, midwives, doctors and medical specialist by doing group contract (lesson learned from Sister Hospital program), study assignment scheme and others. The fund for healthcare investment in East Nusa Tenggara (which has low fiscal capability) should be provided by Health Ministry (despite the PBI fund for BPJS, in the context of current JKN fund) as the nation’s responsibility for even distribution.

2. In the context of JKN implementation which still owns challenges related to acces, government should consider to accommodate transportation financing and the distribution of health personel for outreach service. In current JKN era context, the policy recommendation is conducted in Compensation Fund Scheme (which is instructed Laws of SJSN 2014, article 23 (3) and Health Ministerial Regulation No. 71/ 2013) to overcome matters related to the unavailability of service.

3. Optimizing service in primary level by improving the provision and distribution of medication to Polindes, scheduling polindes services that involve at least two teams, improving the interpersonal communication ability for health personnel and adjusting the service hours. Generally it also needs the service quality improvement.

East Java Province

1. Improving service quality which is covered by health insurance. Central government needs to strengthen the policies related to healthcare service quality assurance.  Quality improvement is expected to cover procedure practicality, service hours, the improvement of medication quality which is labeled as free. The quality improvement is very important since it influences the utilization of services for poor society.

2. The society’s comprehension towards benefit package of health insurance.

Cross- sector collaboration by formal and informal institutions (women empowerment, public figures, posyandu-integrated service station) needs to be done to distribute the knowledge about benefits of insurance system. In the context of this situation the organizer of health insurance needs to collaborate with the healthcare provider to optimize the promotion function to the society (Curative and promotive).

Generally, it is suggested also to do research periodically (especially in BPJS service era) to find out whether there is changes in the pattern of public service search toward expected situation.


Siwi Padmawati

Atik Triratnawati

Digna Purwaningrum

Laksono Trisnantoro

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