Policy Brief December 2017

Funds Interplay in
Public Health Centres
(Puskesmas)

ABSTRACT BOK-TP (health operational budgets disbursed directly by Ministry

of Health into facility bank accounts) into BOK-DAK (health
Since decentralisation of local service delivery in 2001 to local operational budgets disbursed by Ministry of Finance through
governments, district governments’ expenditure assignments district treasury to facility accounts) in 2016 resulted in further
have increased accordingly, and, in total, more than IDR 6,000 major changes to the way this funding is managed. Based on
trillion has been transferred in inter-governmental fiscal transfers the evidence from a small sample of Puskesmas, it seems likely
since then. Consequently, health sector budgets have also that the majority of funding for Puskesmas operations (excluding
increased and the roles and responsibilities at the service unit staffing costs) now derives from JKN capitation payments. In the
level in managing financing of primary health services have four Puskesmas studied in depth by the KOMPAK team, between
changed significantly. With the introduction of the national 61 and 89 percent of total Puskesmas financing in 2015 came
health insurance (Jaminan Kesehatan Nasional, JKN) in 2014, from JKN capitation payments. Conversely, funding from district
the financing landscape and the contributions from the different budgets (APBD) and BOK dropped from around 50-90 percent of
funding sources have shifted considerably. The reformulation of total Puskesmas funding in 2013, to around 6-20 percent in 2015.

KOMPAK is the partnership of Government of Australia and Government of Indonesia

and is managed by Abt Associates
 Policy Brief 2017

In other words, JKN financing is crowding out districts’ allocation INTRODUCTION

of their own budgets to Puskesmas financing. While the sample
size is very small, the magnitude and consistency of the changes In 2001 Indonesia devolved most service delivery responsibilities
across the different study locations suggests this phenomenon from central government (CG) to local governments (LGs), and since
is likely to be happening across Indonesia. Questions about then primary health services have been mostly managed by district
the ability of the district health office to enforce performance governments.1 The devolution of health sector responsibilities has
improvements and national priorities may arise as districts lose been challenging, complicated, and uneven among many districts.
influence as the frontline units become less dependent on district These challenges mainly relate to: (i) the transfer of ownership of
transfers. The shift to JKN also served to significantly increase the public health centres (Puskesmas) including physical assets and
allowance payable to Puskesmas staff: however, these payments human resources; and (ii) the transformation of the role of district
vary considerably across Puskesmas, from IDR 900,000 per governments and technical agencies from supporting central
doctor per month to IDR 4.5 million. The overall amount of these government ministries to managing and providing services to the
payments, and the variations across Puskesmas, are reported people in their jurisdiction, in addition to the districts’ ability to drive
to be generating perverse incentives and behaviours that may continuous improvement in service quality.
over time influence service delivery outcomes in certain areas.
Finally, the study hints that these new funding arrangements With the transfer of service delivery responsibilities, expenditure
may be leading to more inequitable distribution of funding, which assignments were devolved accordingly. Since the beginning of
may be self-reinforcing. The capitation payments are based on the decentralisation process, more than IDR 6,000 trillion has
the number of JKN members registered at the Puskesmas and been transferred to local governments in Indonesia through
on the level of service offered. Puskesmas with more qualified various forms of inter-governmental fiscal transfers (IGFT). The
staff and better equipment get more funding, while Puskesmas increase in IGFT over time is illustrated in Figure 1. However, the
in poorer areas with lower coverage of JKN registration get lower increase in transfers to the regions has not necessarily translated
allowances and operational budgets. This situation may become into significant improvements in service delivery. While a few
a vicious cycle if left unmanaged, and a review of the current local governments have managed to provide high quality and
‘formula’ for JKN payments and of the composition of Puskesmas accessible public services, the majority of local governments
revenue sources is needed. are still struggling to fulfil this main objective of decentralisation.

Figure 1. Historic Perspective of IGFT in Indonesia 2001–2017

800

700

600

500
IDR (Trillion)

400

300

200

100

0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

DBH-Combined DBH-Tax DBH-Nat. Resources DAU DAK Otsus and DIY Other Transfers Village Funds

Note: All of the data provided are nominal and derived from audited financial reports, except 2016 (revised APBN) and 2017 (APBN).

1
All Puskesmas and service units below the Puskesmas are the district’s responsibility, as well as category C hospitals. Category A and B hospitals are normally the responsibility of
provincial governments, as well as some larger city authorities. The district is also responsible for coordinating and regulating all private health service providers in their areas.

2 Funds Interplay in Public Health Centres (Puskesmas)

Policy Brief 2017

These shortcomings reflect the institutional, regulatory, and by Pusat Kebijakan dan Manajemen Kesehatan Universitas
human capacity challenges for both central and local governments Gadjah Mada (Centre for Health Policy and Management,
in translating the available fiscal resources into services in the Gadjah Mada University), reached the service unit-level, but only
frontline service delivery units. focused on challenges in financing the health services. Thus,
this policy brief aims to provide a comprehensive picture of how
This policy brief is based on a recent KOMPAK2 study of the flow Puskesmas manage funds that they receive or collect, including
of funds and governance arrangements in selected frontline their strategies for managing the uncertainty and complicated
health and education service delivery units, covering 11 districts procedures of the funds. The analysis also covers the three more
in five provinces.3 The objective of the study was to identify recent developments related to financing of Puskesmas services:
constraints to effective service delivery in frontline service units, (i) the roll-out of JKN in 2014; (ii) the transformation of the
particularly focusing on public financial management (PFM) and health operational assistance (BOK) fund (see Table 3 for more
other closely-linked governance arrangements. The analysis and information); and (iii) the emergence of Puskesmas with public
recommendations presented in this brief are based on qualitative service unit (BLUD) status.
and quantitative data obtained during the field work of 22 public
health centres (Puskesmas) across the 11 districts, and on an
Box 1. Puskesmas with BLUD status
in-depth analysis of four Puskesmas4 that focused on how these
service units manage various sources of funds and increasingly
A community health centre can become an autonomous local
complex procedures with limited staff. The four Puskesmas were government service unit (BLUD). This allows the Puskesmas
purposely selected for in-depth analyses based on the following to:
characteristics: (i) urban or rural; (ii) number of beneficiaries; (iii) • receive JKN funds directly from BPJS Kesehatan
financial capacity; and (iv) autonomous local government service • deposit service user fees to the Puskesmas account
unit (BLUD) status. Their profiles are described in Table 1. • manage their funds based on the annual business
plan, rather than the work plan of the district health
agency.
While other studies have analysed certain aspects of financial
management in Puskesmas, none have thoroughly reviewed BLUD status can only be obtained if a Puskesmas is
how these funds were managed in practice. Previous Public considered to have good standards, human resources, and
Expenditure Analysis (PEA) studies, initiated by the World Bank financial and asset management systems in place. The
and later adopted by other parties, have focused on provincial and assessment is conducted by a team comprising the health,
district health spending without ‘drilling down’ to the service unit finance, and planning agencies.
level. More specific studies, such as the 2015 study conducted

Table 1. List of observed Puskesmas

No Puskesmas District Province Location Facility BLUD Status

1 Arjosari Pacitan East Java Rural In-patient Non-BLUD
2 Peusangan Bireuën Aceh Urban In-patient Non-BLUD
3 Kesesi I Pekalongan Central Java Rural In-patient BLUD (from 1/1/16)
4 Santong Lombok Utara NTB Rural Outpatient Non-BLUD

2
KOMPAK (Kolaborasi Masyarakat dan Pelayanan untuk Kesejahteraan – Community and Service Collaboration for Welfare) is a facility funded by the Australian Government to support a
number of Government of Indonesia programs in achieving the RPJMN 2015–2019 targets of reducing poverty by improving the quality and coverage of basic services and by increasing
off-farm economic opportunities for the poor.
3
The field work was conducted in January to March 2016 and covered the following areas: Lombok Utara, and Lombok Timur (West Nusa Tenggara (NTB) Province); Pemalang and
Pekalongan (Central Java Province); Pangkajene-Kepulauan and Bantaeng (South Sulawesi Province); Aceh Barat and Bireuen (NAD Province) and Malang, Pacitan, and Bondowoso (East
Java Province).
4
Puskesmas Arjosari (Pacitan District, East Java); Puskesmas Peusangan (Bireuën District, Aceh); Puskesmas Kesesi I (Pekalongan District, Central Java); and Puskesmas Santong
(Lombok Utara District, NTB).

Funds Interplay in Public Health Centres (Puskesmas) 3

 Policy Brief 2017

PUSKESMAS FUND FLOW – WHAT FINANCES Prior to 2014, the districts financed Puskesmas staff salaries/
PRIMARY HEALTH CARE SERVICES? allowances and contributed towards the operational budget
through their annual budget (APBD),5 while infrastructure
Although part of the district government, Puskesmas receive investments were financed through the physical Specific
funds from various government branches, as well as from non- Allocation Fund (physical DAK).6 Public health programs (UKM)
government sources. In addition to allocations from the district were primarily financed through BOK funds. The introduction of
government budget (APBD), Puskesmas receive national health the national insurance scheme (JKN) in 2014 and the transition
insurance (JKN) funds from the National Health Insurance Agency of BOK from TP (co-administration fund) to non-physical DAK
(BPJS Kesehatan) and direct fee payments from service users. in 2016 significantly changed financing of Puskesmas service
Referring to the existing regulatory framework and based on the delivery functions. The most substantial change was due to the
findings in the 11 visited districts, Puskesmas service delivery national health insurance (JKN) scheme. All Puskesmas now
is financed through up to seven different funds. Moreover, the obtain monthly capitation funds from BPJS Kesehatan. The
Puskesmas receives the various funds through several different amount received is based on the number of JKN beneficiaries7
financing mechanisms, as can be seen in Figure 2, which provides that are registered in a Puskesmas, and the applicable unit
a ‘simplified’ overview of the fund flow mechanisms for financing value per beneficiary, which ranges between IDR 3,000 and
of Puskesmas primary health services. 6,000 depending on number of doctors and dentists in each

Figure 2. Fund Flow Mechanisms for Financing of BLUD and Non-BLUD Puskesmas

Ministry Ministry Ministry Ministry

of Health of Finance of Health of Finance

Provincial
Ministry District/City Provincial
Ministry District/City
Villages Villages
Government
of Health Government Government
of Health Government

Ministry
BPJS Puskesmas Service Ministry
BPJS Puskesmas Service
Kesehatan
of Health Non-BLUD Users Kesehatan
of Health BLUD Users

Legends
Ministerial Budget JKN Non Capitation Funds
Transfers to Provinces and Cities/Districts JKN Capitation Funds
Deconcentration/Co-administrations (TP) Funds Health Operational Assistance (BOK) Funds
General District Budget Funding Village Funds (Dana Desa/DD)
Health Operational Assistance (BOK) Funds Village Spending
Physical DAK Service User Fees

5
Such financing was mainly financed through Dana Alokasi Umum (DAU) transfer from the central level, as is the case for most service delivery at the local level. The rest of the Puskesmas
operational budget is financed through service user fees or Dana Alokasi Khusus (DAK).
6
Dana Alokasi Khusus (DAK).
7
The figure is the number of registered BPJS participants in the Puskesmas work areas.

4 Funds Interplay in Public Health Centres (Puskesmas)

Policy Brief 2017

Puskesmas.8 The monthly transfer is adjusted every month, JKN capitation and non-capitation financing of primary health
based on the actual number of beneficiaries registered in the services. Reviewing Figure 3 also shows that the large increase
BPJS Kesehatan office. during this period is attributed to the JKN capitation and, to a
lesser degree, non-capitation funds. In terms of size, BOK funding
During the period between 2013 and 2015, all Puskesmas visited did not fluctuate significantly during the same period, although
had experienced significant increases in their overall available it proportionally decreased in terms of its overall contribution to
resources (as shown in Figure 3).9 The contribution from the health services, due to the increase in other Puskesmas funding
various funding sources also shifted considerably during the same sources. The data collected and used for this analysis is provided
period (see Table 2), mainly moving from general APBD funds to in Table 3.

Figure 3. Funding Trends in Four Observed Puskesmas 2013–2015

4
IDR (Billion)

0
2013 2014 2015 2013 2014 2015 2014 2015 2013 2014 2015
Puskesmas Peusangan Puskesmas Kesesi 1 Puskesmas Santong Puskesmas Arjosari

District APBD (Non-Salary) BOK JKN/JKA Capitation JKN Non-Capitation

Table 2. Types of Funds that Finance Puskesmas’ Spending

No Funds Main Funded Items Fund Manager Earmarking

1 General APBD funds (non-DAK) - Salary and allowance for civil servants - District treasury No
- Operational funds
2 Physical DAK - Facility construction or renovation - District treasury Yes
- Pharmacy supplies - District health agency
3 Non-physical DAK (BOK) - Public health programs (UKM) - District health agency Yes
- Puskesmas
4 Service user fees - Operational funds - Non-BLUD: District health agency No
- Medical supplies - BLUD: Puskesmas
- Service fees for medical workers
5 JKN capitation - Staff remuneration - Non-BLUD: District health agency Partially
- Pharmacy and medical supplies - BLUD: Puskesmas
- Individual health programs (UKP)
6 JKN non-capitation - Operational funds - Non-BLUD: District health agency Partially
- Medical supplies - BLUD: Puskesmas
- Service fees for medical workers
7 Village funds - Public health programs in villages - Village treasurer Yes

8
A Puskesmas with no doctor or dentist will receive a minimum of IDR 3,000 per month compared to a Puskesmas with at least two doctors and one dentist, which will receive a maximum
of IDR 6,000 per month.
9
Puskesmas Santong in Lombok Utara was only established in late 2013, which may account for the lower level of resources.

Funds Interplay in Public Health Centres (Puskesmas) 5

 Policy Brief 2017

Table 3. Funding Composition in Four Observed Puskesmas

Puskesmas
Puskesmas Peusangan Puskesmas Kesesi 1 Puskesmas Arjosari
Funding Source Santong
2013 2014 2015 2013 2014 2015 2014 2015 2013 2014 2015
Total budget (IDR 2038.7 4133.2 5129.1 634.6 1970.4 2944.7 623.9 892.4 402.1 1021.6 1344.9
million)
District APBD (excl. 46.3% 4.0% 2.8% 86.6% 20.6% 9.0% 1.4% 2.0% 76.4% 20.9% 19.0%
salary/ allowance)
BOK 4.9% 2.3% 3.2% 13.4% 4.6% 3.3% 32.1% 8.6% 23.6% 9.8% 9.3%
JKN capitation 48.8% 78.0% 72.5% N/A 52.2% 68.2% 66.5% 89.4% N/A 62.5% 61.5%
JKN non-capitation N/A 15.8% 21.5% N/A 22.7% 19.5% 0.0% 0.0% N/A 6.8% 10.2%

Figure 4. Trends of Puskesmas Operational Budget in 2013–2015

3.0

2.5

2.0
IDR (Billion)

1.5

1.0

0.5

0
2013 2014 2015 2013 2014 2015 2014 2015 2013 2014 2015
Puskesmas Peusangan Puskesmas Kesesi 1 Puskesmas Santong Puskesmas Arjosari

District APBD JKN Capitation JKN Non-Capitation

When taking a closer look at actual funds available for operational facilities in the local health centres. At the opposite end of this
expenditures for Puskesmas, when payments for service fees/ spectrum, Puskesmas Santong in Lombok Utara has the lowest
incentives are deducted, the trend with regard to dependency on level fiscal resources; because of the relatively low number of JKN
JKN funds remains the same as illustrated in Figure 4. beneficiaries, it covers only two out of five villages in the Kayangan
sub-district, and it has no in-patient facility. However, while this
In addition to the overall trend, the fund composition also revealed rationale for the differences in fiscal resources seems reasonable,
significant differences in the total budget managed by each the variation between the ‘richest’ and the ‘poorest’ Puskesmas
Puskesmas. The analysis of each Puskesmas showed that the is perhaps not fully justified if one considers the number of actual
difference is mainly due to: (i) the number of JKN beneficiaries; patients treated per month and the significant differences in staff
(ii) the coverage area of Puskesmas; and (iii) the availability of in- incentives. As indicated in the recent KOMPAK Policy Brief The new
patient and birth delivery facilities. Puskesmas Peusangan in Aceh financing situation and human resource challenges in Puskesmas
has the highest fiscal capacity, because it fulfils all three criteria: (2017), the incentive payments are not based on actual patient
a high number of JKN beneficiaries due to the universal health numbers or other performance measures, but are simply the result
insurance coverage in Aceh10; coverage of the whole Peusangan of a formula based on BPJS membership numbers and technical
sub-district; and availability of both in-patient and birth delivery staff/services available at each Puskesmas.

10
The Aceh provincial government provides health insurance to the whole population in the province. They pay the premiums for those who are not covered by CG or by individual initiatives.

6 Funds Interplay in Public Health Centres (Puskesmas)

Policy Brief 2017

As part of the same KOMPAK study, findings in six different locations as they are not eligible for any Puskesmas-related incentives
indicate that incentive payments for staff vary substantially by in current positions.
staff type and Puskesmas location.11 The differences in average • Based on answers from the respondents, jealousy between
incentive payments between staff, and particularly between staff health agency staff and Puskesmas staff is emerging, and
in different Puskesmas, are significant. On average, in addition could potentially disrupt both individual and institutional
to their salary, doctors and dentists received approximately IDR relationships.
2.5 million per month in incentives, while midwives and nurses • Puskesmas may compete for more JKN beneficiaries, as this
were rewarded incentives of IDR 1.6 million, and administrative would result in greater JKN capitation and non-capitation
staff received IDR 0.9 million. However, across the six Puskesmas funds.
locations visited, incentive payments for the same staff type varied • Puskesmas situated in areas with few paying members might
considerably. For example, doctors and dentists in Puskesmas over time become poorer, unless the total number of BPJS
Selong received the highest incentives (IDR 4.1 million), which members increases and evens out between the various
were 4.6 times higher than the incentives awarded to doctors Puskesmas. This could potentially lead to inequities in actual
and dentists in Puskesmas Baruga (IDR 0.9 million). Similarly, operational budgets for medical equipment and medicine, in
midwives and nurses in Puskesmas Selong received the highest addition to less qualified and motivated staff considering staff
incentives (IDR 3.1 million), which were 2.8 times higher than the preferences.
average incentives paid to midwives and nurses in the other five
Puskesmas. The JKN funds will likely contribute more and more to
Puskesmas’ overall resources in the coming years. With the
Observations in the Puskesmas and district health agencies visited target of universal JKN coverage across the country by 2019,
revealed a number of perverse incentives from the increase and transfers of JKN funds to Puskesmas is anticipated to increase,
distribution of Puskesmas additional resources, including: as more people will become JKN beneficiaries. The Ministry of
• Medical workers and administrative staff tend to prefer Health (MoH) and district governments should anticipate this
working in Puskesmas with greater resources, as this growing number of JKN beneficiaries in certain areas, or lack
translates into higher financial incentives for individual staff. of such in others, to ensure the provision of accessible, high
• A number of health agency staff, including division and quality, and equitable health services remains or grows with the
section heads, are actively trying to relocate to Puskesmas, increasing numbers.

11
KOMPAK Policy Brief The new financing situation and human resource challenges in Puskesmas, 2017.

Funds Interplay in Public Health Centres (Puskesmas) 7

 Policy Brief 2017

ALLOCATIONS OF FUNDS government transfers that are channelled through APBD, such
as physical DAK and (since 2016) also BOK financing. JKN fund
District APBD Funds allocations for Puskesmas that do not have BLUD status are also
budgeted for in the district APBD.
The allocation of district APBD funds for Puskesmas follows the
district planning and budgeting cycle.12 The steps of the cycle Physical DAK and Non-Physical DAK (BOK)
related to Puskesmas financing are described in Figure 5. Prior to
the first step, health agencies are already involved in developing The allocation process of physical DAK is described in Figure
the annual work plan (RKPD) and budget ceiling (KUA-PPAS). 6. Since DAK should be budgeted in APBD, the timeline often
A smooth process would enable Puskesmas to commence the becomes an issue, because the estimated budget ceilings from
APBD-funded activities in February of the following fiscal year. the central government are usually only known in November,
This planning and budgeting cycle also affects other central when the district APBD is nearly or already approved.

Figure 5. District APBD Budgeting Cycle Related to Puskesmas

End of November
September FY N-1 October FY N-1 January FY N-1
FY N-1

Step 1: Step 2: Step 3: Step 1:

Submission of draft Submission of draft LG Joint-approval of APBD Preparation and issuance
budget details (RKA) by budget (APBD) to by the district head and of budget execution
the health agency parliament parliament document (DPA)

Figure 6. DAK Budget Cycle

Before June July FY T-1 September October November December

FY T-1 FY T-1 FY T-1 FY T-1 FY T-1

Step 1: Step 2:
1: Step 3:
1: Step 4:
1: Step 1:
Announcement Step 1: of
Issuance
Submission of
Needs Submission of Submission of Submission
Joint approval
of of Submission
of final DAK of Submission
DAK guideline
of
draft budget by
assessment draft allocation
budget draft CG
budget
budget draft budget
APBN by draft budget
allocation draft budget
details
CG technical
(RKA) by details
to the Ministry
(RKA) by details (RKA)
(APBN) to by details (RKA)
President andby details (RKA) by details (RKA) by
the health and
ministries agency theFinance
of health agency the health agency
Parliament the health agency
Parliament the health agency the health agency
district health
agency

Table 4. Comparison of BOK Before and After 2016

Aspects 2010–2015 From 2016

Type of fund Co-administration fund (TP) Non-physical specific allocation fund (DAK)
Legal budget document Central Government budget (APBN) District budget (APBD)
Budget execution document Budget execution document (DIPA) of Ministry Budget execution document (DPA) of District
of Health Health Agency
Tranches One or more Four quarterly tranches
Treasury office National treasury office (KPPN) District Cash Office (Kasda)

12
Financial year in Indonesia is 1 January–31 December.

8 Funds Interplay in Public Health Centres (Puskesmas)

Policy Brief 2017

After a few years as part of MoH’s budget, as of Fiscal Year (FY) office for the claim to be processed. While the calculation of the
2016 the BOK funding is channelled through the district budget as JKN non-capitation fund is relatively simple, estimates related
non-physical DAK. The difference between the two mechanisms to actual available non-capitation resources and expenditures
is presented in Table 4. This transformation has had an impact remain challenging, as the numbers might fluctuate significantly
on the execution of UKM programs during 2016, because the from month to month. Some districts with non-BLUD Puskesmas,
districts were not informed about the regulatory framework for such as Malang, Pacitan, and Pekalongan, needed accurate
the new BOK grant until very late in 2015, when the 2016 budget estimates because the non-capitation revenues contribute to the
had already been approved. This meant that districts needed to overall operational budget of the Puskesmas.
find a way to be able to disburse the BOK funds, because they
were not part of the approved budget. Key Challenges

JKN Funds The field review of the allocation processes of each fund in the four
Puskesmas confirms the analysis above and the challenges the
JKN funds, he newest method for financing Puskesmas service Puskesmas have in estimating and budgeting for actual resources
delivery come in two forms: (i) a capitation share, which is paid in the during their planning and budgeting processes. Referring to the
beginning of each month as an advance; and (ii) a non-capitation actual timeline, as shown in Table 5, a majority of the Puskesmas
share, which is refunded based on services rendered and claims were only informed about their estimated budget envelope in
submitted by the Puskesmas. The monthly JKN capitation amount December 2015 for planning purposes for FY 2016. In addition,
seems to be relatively easy to predict for the Puskesmas staff, information regarding actual allocations for 2016 of all funds was
primarily because of the use of an IT-based application (Primary only provided in early 2016. This situation remains challenging
Care or P-Care), showing real-time information about the actual for Puskesmas, as the local APBD process is often already in
number of beneficiaries registered to each Puskesmas, and thus the final phase or completed by the time expenditure limits are
able to estimate the amount of capitation resources. advised, which makes it difficult to make adjustments to the plans
and budgets. This situation has led to the inability of Puskesmas
The P-Care system is now also used for non-capitation claims, to develop accurate work plans for physical DAK and BOK funded
mainly for in-patient treatments and birth deliveries, which allows crucial programs, such as infrastructure development, pharmacy
Puskesmas to submit claims online and which enables them to supplies, and other specialist public health programs, and this
track the progress of the payment. Nevertheless, the Puskesmas can delay budget execution until budget revisions take place in
is still required to submit a hardcopy to the BPJS Kesehatan September.

Table 5. Allocation and Disbursement Timeline for the Four Puskesmas, FY 2016

No Funds Allocation information Disbursement

Legal document Timeline Legal document Timeline Start of
disbursement
1 General APBD Local regulation (Perda) on December Budget execution January or February January or February
funding APBD 2016 2015 document (DPA) of 2016 2016
district health agency
2 Physical DAK Ministry of Finance regulation Early December DPA of district health January or February After February 2016
(PMK) on transfers to regions 2015 agency 2016
in 2016
3 BOK Special DPA for BOK Various
4 JKN Notification from BPJS Each month Special DPA for JKN January or February January 2016
Kesehatan capitation 2016

Funds Interplay in Public Health Centres (Puskesmas) 9

 Policy Brief 2017

for certain pre-approved expenditure categories. The eligibility

of expenditures against the various funds, as illustrated in Table
6, is quite promising, although complicated. At least four funds
are flexible for most spending items: general APBD funding, both
JKN capitation and non-capitation funds, and service user fees.13
Physical DAK is earmarked for facility development and pharmacy
supplies, while the health operational assistance (BOK) fund is
earmarked for public health programs (UKM). The Village fund
(Dana Desa) is a new source of funding since 2015, and the
fund can theoretically finance UKM programs or co-finance other
health-related expenditures benefiting the village communities.
However, substantive village contributions towards health service
expenditures are yet to materialise.

The JKN capitation and non-capitation funding is widely

considered as the most flexible funding source by the Puskesmas
WHAT CAN THE VARIOUS FUNDS BE USED FOR? staff interviewed. Respondents believe it complements the
previous two funding sources (APBD and BOK), particularly
In terms of fund purposes, some of the funds are earmarked, related to operational spending, and pharmacy and disposable
while others are quite flexible. Commonly the allocations from the medical supplies. Although the JKN capitation spending was
district APBD, which are non-DAK, can be used to fund all possible supposed to be for individual health programs (UKP), there seems
spending items. However, physical DAK and JKN capitation funds, to be some flexibility within the funding framework to also cover
on the other hand, are always earmarked and can only be used non-JKN members for promotion and prevention activities.

Table 6. Eligible Puskesmas Spending Categories Based on Funding Source

District Budget JKN

Service Village
Spending Item Physical BOK (TP/ Non-
Non-DAK Capitation User Fees Fund
DAK DAK) Capitation
Personnel expenses
Civil servants √ √ √ √
Honorary staff √ √ √ √
Training/capacity building √ + √
General operations (electricity, water, etc) √ + √ √
Facility
Development √ √ + √ √
Maintenance √ + √ √
Pharmacy √ √ √ √ √ √
Medical equipment √ √ √ √
Public health programs (UKM) √ √ + √ √ √
Individual health programs (UKP) √ √ √ √

Note: + indicates eligibility in BLUD Puskesmas only.

13
A few districts still applied service fees for non-JKN or Jamkesda members, which could later be used for most spending items.

10 Funds Interplay in Public Health Centres (Puskesmas)

Policy Brief 2017

Table 7. Disbursement and Management Mechanisms for Puskesmas Funds

Puskesmas
Source of
No Funds Disbursement Mechanism Management
Fund
Responsibilities
1 Salary and allowance for civil servants District budget Monthly transfer to individuals from district Indirectly
account.
2 Operational and administrative District budget Direct payment from district account based on Directly
budget execution document (DPA) and fund
disbursement request (SP2D).
3 Health operational assistance (BOK) District budget Quarterly transfer from district account to Directly
Puskesmas BOK account.
4 Physical specific allocation fund (DAK) District budget Direct spending by the district health agency. Indirectly
5 National health insurance/JKN (including BPJS - Capitation funds: Monthly advance transfer from Directly
top-up by provincial/ district government) BPJS Kesehatan to Puskesmas JKN account,
- Capitation funds based on number of JKN beneficiaries and
- Non-capitation funds capitation tariff category.
- Non-capitation funds: Monthly transfer from
BPJS Kesehatan, based on verified claims to
district account (for non-BLUD Puskesmas) or
directly to Puskesmas BLUD account.
6 Service user fees Service users Non-BLUD Puskesmas has to deposit the fees Directly
collected into the district account and then the
funds will be made available to the Puskesmas
through the usual disbursement mechanism for
operational budgets.
7 Village funds Village budget Direct spending by village administrators. N/A

Note: + indicates eligibility in BLUD Puskesmas only.

DISBURSEMENT AND FUND MANAGEMENT are rather predictable, disbursement of APBD depends on the
MECHANISMS issuance of the DPA. Problems arise if the DPA misses important
spending items, as such disbursements will then have to be
The Puskesmas have to deal with predictable and less predictable postponed until the DPA is revised, usually in July. BOK funding,
disbursement schedules for the various funds, as shown in Table which is the main source for UKM activities, has been known
5. Further, as seen in Figure 2, the various funds originate from for its disbursement delays due to budgeting, treasury, and
central and district governments with different disbursement administration-related bottlenecks when it was still a TP under
mechanisms and schedules. While most funds are managed the MoH DIPA (see Table 3). Based on interviews with the BOK
directly by the service unit, others only indirectly involve the treasurers and heads of Puskesmas, the disbursement delays
Puskesmas, such as salary and allowances for civil servants, did not affect the UKM program executions, because they pre-
physical DAK, and village funds. Table 7 provides a summary financed them from their personal funds.
overview of the various funds, disbursement mechanisms, and
management responsibilities by Puskesmas. Transformed to non-physical DAK starting in 2016, the BOK
disbursements faced another set of challenges. In the 11 districts
The findings from the four Puskesmas showed that while surveyed, none of the districts had initially included DAK BOK
the general funds from the APBD and JKN capitation funds funds in their 2016 budgets, because of the uncertainties
were disbursed relatively smoothly, challenges and delays surrounding the changes to the BOK regulations during the 2015
in disbursement of the other three funds have had negative planning and budgeting processes. The districts have tried to
implications on the delivery of health services. While APBD funds cope with this in different ways. Six of the 11 districts decided

Funds Interplay in Public Health Centres (Puskesmas) 11

 Policy Brief 2017

to postpone disbursement of funds until after the budget revision rigorous checks on all claims submitted by Puskesmas. This often
process (APBD-P) is concluded, usually in September; while the required a back-and-forth process, and a few claims are reported
other five visited districts in Java were attempting to revise the to have taken more than three months to be processed. As the
DPA prior to APBD revision. Hopefully, in two or three years, the non-capitation claims also included fees for medical workers,
BOK can at least mirror the school operational assistance (BOS) midwives and nurses often needed to wait for more than three
practices. This means that the funds are received by the service months before they received the fees.
units in each quarter and the Puskesmas staff will ‘only’ need to
pre-finance UKM programs for one or two months. ABSORPTION CAPACITY

The physical DAK, which is managed by the district health The financial reports in the four Puskesmas visited indicate that
agency, has its own formidable challenges. The fund, the main their absorption capacity of their overall budget is relatively good.
funding source for Puskesmas infrastructure and pharmacy While APBD and BOK funds are normally fully spent by the end of
supplies, is transferred quarterly from MoF to district accounts, the year, JKN funds remain underspent in all but one Puskesmas,
similar to BOK. The execution of both spending items usually resulting in budget surpluses.15 This is consistent with statements
requires a procurement process, which can take months to made during the interviews, where Puskesmas staff indicated
complete. The delay in disbursement of funds often results in that, because of strict APBD and BOK funds eligibility criteria,
scarce pharmacy supplies and neglected maintenance of the spending against these funding sources were normally prioritised.
health facilities. As can be seen from Table 8, all four observed Puskesmas
fully absorbed APBD and BOK funds during 2013–2015, while
Interestingly, considering the rather short time JKN capitation remaining unspent budget allocations are from JKN capitation
funds have been operational, this financing mechanism is fund categories. Reviewing the expenditure figures in more
considered by the respondents as the most predictable transfer, detail, all four Puskesmas fully absorbed the service fee share
as it is usually received at the beginning of each month. The claim- of the capitation funds, while the operational budget for general
based non-capitation funds are also reported as predictable upon support, and pharmacy and disposable medical supplies, was
completion of documents and claim submission from Puskesmas underspent by 50 percent or more.16 This underspending of JKN
to BPJS. However, payments of JKN non-capitation funds were funds led to surpluses in all of the visited Puskesmas by end of
often delayed in 2014–2015 due to administrative issues. 2015. Pekalongan, Malang, Pacitan, Pemalang, and Bondowoso
As reported in all 11 surveyed districts, the claim submission Districts had already decided that the surplus could be spent in
through the P-Care application did not significantly streamline the following fiscal years, while the remaining districts were still
the process. As of early 2016, BPJS Kesehatan still conducted undecided when interviewed in early 2016.

Table 8. Fund Absorption in Four Selected Puskesmas

Puskesmas Peusangan Puskesmas Kesesi 1 Puskesmas Santong Puskesmas Arjosari

Funding Source
2013 2014 2015 2013 2014 2015 2014 2015 2013 2014 2015
District APBD (non-salary) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
BOK 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
JKN/JKA capitation 100% 80.2% 79.3% N/A 87.1% N/A 60.0% 58.6% N/A 56.9% 100.3%
Surplus/deficit (IDR 0 637.4 771.4 0 132.7 N/A 166.1 330.25 0 275.4 –2.15
millions)
Surplus/deficit 0 15.4% 15.0% 0 6.7% N/A 0 37.0% 0 27.0% –0.2%
(% of budget)

15
The absorption of physical DAK and JKN non-capitation funds was not analysed, because the former was not managed directly by Puskesmas and the latter was often combined as
APBD funds.
16
According to the MoH regulation (Permenkes) No. 19/2014, JKN capitation funds should be spent at least 60% on service fees for Puskesmas staff, while the rest is for operational
support, and pharmacy and disposable medical supplies.

12 Funds Interplay in Public Health Centres (Puskesmas)

Policy Brief 2017

As all Puskesmas and health agencies are still adjusting to the Combining the revenues and absorption capacity of Puskesmas,
new JKN regime, the underspending on non-service fee items of there is strong indication that Puskesmas have sufficient funding
JKN capitation funds can be explained as follows: for practically all spending items. This is suggested by: (i) the
• Pharmacy supplies were usually financed by DAK or APBD overall operational budget increasing significantly between 2013
funding and distributed to Puskesmas by Dinas based on and 2015, which has often led to budget surpluses; (ii) the
request or availability. growing number of JKN beneficiaries, and subsequent operational
• Considering the special circumstances of the finance budgets, which has enabled Puskesmas to allocate additional
management procedure of capitation funds, district health funds for UKM programs covering not only JKN members but
agencies may need time to find a proper way to use the funds. also non-members; and (iii) despite certain administrative and
• Puskesmas, even those with BLUD status, are not authorised procurement problems, which have led to significant unspent
to procure, and thus rely on the health agencies. While district funds, there seem to be sufficient funds to purchase pharmacy
health agencies in Central and East Java have relatively supplies.
advanced procurement capacities, those in Aceh and NTB
tend to be slower in procuring pharmacy and medical supplies. MANAGEMENT OF PUSKESMAS OWN-SOURCE
Interviews with health agency officials indicated that this was REVENUES
likely caused by their unfamiliarity with the procurement
process through e-catalogue, which is a relatively new Revealed during the field work, districts vary in how they managed
practice. Puskesmas own-source revenues, which comprise service user
• By end of 2015, none of the observed Puskesmas had fees and JKN non-capitation funds. The main variations are
obtained BLUD status.17 As a result, they did not have the between districts that applied the BLUD and those that applied
flexibility to use the unabsorbed capitation funds for other non-BLUD Puskesmas, and between non-BLUD Puskesmas in
purposes, such as medical equipment and infrastructure. terms of how the district ties or does not tie own-source revenues

17
Puskesmas Kesesi I obtained BLUD status in January 2016.
18
Perpres XXXX [insert the relevant perpes].
19
Achievement of target will add or reduce the APBD allocation for the following fiscal year.

Funds Interplay in Public Health Centres (Puskesmas) 13

 Policy Brief 2017

Figure 7. Service User Fees and Flow of JKN Funds in Non-BLUD (Left) and BLUD (Right) Puskesmas

Ministry Provincial District/City Ministry Provincial District/City

of Finance Government Government of Finance Government Government

Ministry
BPJS BPJS Puskesmas
Kesehatan
of Health Kesehatan BLUD
Puskesmas
Non-BLUD
JKN Account
Service Users Service Users
APBD Account

Legends
JKN Non-Capitation Funds JKN membership fee
JKN Capitation Funds User charges not covered by JKN

Table 9. Reporting Requirements of Each Fund

No Funds Reporting/accountability mechanism Submitted to

1 General APBD funding Common financial accountability (SPJ) procedure District Health Agency
2 Physical DAK DAK technical and financial report District Health Agency
3 BOK Monthly realisation report District BOK Management Team in the district health agency
4 JKN Common financial accountability (SPJ) procedure District Technical Agency
5 Service user fees Common financial accountability (SPJ) procedure District Technical Agency

and APBD operational funds. As illustrated in Figure 7, BLUD each Puskesmas, without consideration of their BLUD status.18
Puskesmas have less complex revenue management procedures For non-BLUD Puskesmas, the usage of the monthly capitation
than non-BLUD Puskesmas. All revenues are managed directly fund still must refer to DPA and requires authorisation by the
by the Puskesmas and can be used according to the needs of district health agency office, which was considered as a non-
individual Puskesmas, as per work plan and fund eligibility. The issue in all 11 visited districts.
situation for non-BLUD Puskesmas is significantly more complex,
because all revenues are required to be deposited in the district The second variation is exclusively among districts with non-BLUD
treasury office before they are ‘transferred back’ to the Puskesmas Puskesmas. This is related to whether or not the Puskesmas
as part of general district APBD funding. The transfers of such own-source revenue (service user fees and JKN non-capitation)
revenue may take months to process, because they are mixed determines the district APBD allocation of operational funds to
with other APBD funds, excluding DAK. Before the JKN era, this the Puskesmas. Visited districts in East Java and Central Java
undermined the service delivery provision, as Puskesmas relied tied revenue targets to the APBD allocations, where performing
solely on APBD funds for operational expenditures. In the JKN era, Puskesmas can receive up to 80–100% of the total estimated
the JKN capitation funds can be used to anticipate such potential APBD allocation if they meet their set targets of own-source
delays. Although this also constitutes district revenue, JKN revenue collection. Differently, the districts in Aceh, South
capitation funds are transferred directly from BPJS Kesehatan to Sulawesi, and NTB do not link Puskesmas own-source revenues
and district allocations, and operational funds are determined

14 Funds Interplay in Public Health Centres (Puskesmas)

Policy Brief 2017

based on estimated actual needs and overall district fiscal management rules, which vary among districts. While some
capacity. The first option provides stimulation for each Puskesmas districts could accommodate the common BOK practices, some
to achieve a certain target, but might lead to further variation others need to revisit their finance management rules, particularly
in Puskesmas fiscal capacity.19 The second option seems to for issues related to transportation and daily allowance within
equalise the fiscal capacity, but may not motivate Puskesmas to sub-districts.
raise additional revenues.
According to non-BLUD Puskesmas staff interviewed, about 80
REPORTING AND FINANCIAL ACCOUNTABILITY percent reported that their overall workload had nearly doubled
with the introduction of BOK and JKN program implementations.
Considering the various sources of funding for Puskesmas As reported in the 11 survey locations, all non-BLUD Puskesmas
services, each funding mechanism has separate planning, visited did not have dedicated finance officers or treasurers
allocation, disbursement, and reporting requirements, although with qualifications and technical competency in accounting
some follow similar mechanisms and are submitted to the same and computer-related fields. To compensate, Puskesmas health
receiving agency. This often leads to unnecessary confusion and workers perform functions as treasurers for JKN and BOK funds
additional work for Puskesmas staff. Table 9 provides an overview in addition to other administrative and clinical functions.
of these requirements for non-BLUD Puskesmas. Remarkably,
Puskesmas with BLUD status have less complex reporting CONCLUSION
procedures, as JKN and service user fees can be reported
together as part of the BLUD financial reporting. Reviewing all of the various income sources received and
managed by the Puskesmas surveyed, all four Puskesmas have
Further, from 2016 most districts needed to adopt common BOK sufficient financial capacity to deliver mandated primary health
finance management procedures. Previously, as TP funds, BOK services. The main challenges for the district health agency and
finance management procedures referred to MoH’s guideline. Puskesmas are not insufficient resources, but rather related to
However, the new DAK BOK has to follow district finance challenges in how to effectively manage and use the available

Funds Interplay in Public Health Centres (Puskesmas) 15

 Policy Brief 2017

funds to deliver equitable, high quality and accessible primary • District government needs to review the coverage and facilities
health services. To improve this situation, central government and of each Puskesmas, as the growing number of JKN members
district stakeholders should respond to emerging issues related may lead to a higher demand for primary health services.
to the challenges observed, which concern implementation of Lombok Utara and Pekalongan may provide an example for
JKN, BLUD Puskesmas, and BOK transformation to non-physical how to expand coverage and capacity with their solution of
DAK. one in-patient and one or more out-patient Puskesmas per
sub-district.
JKN Fund Review • Review and mitigate the emerging negative trends caused by
the current JKN capitation allocation formula with the aimof
The district health agency should anticipate the implications including actual service performance, and actual number of
of the JKN financing mechanisms for primary health services. patients served (rather than only focusing on BPJS members),
It seems that the first two years of JKN implementation have as well as redistribution of funds or allocating more APBD
provided Puskesmas with abundant funds that are far greater operational and facility budgets to ‘poorer’ Puskesmas, and
than its predecessor Jamkesmas. With the current JKN coverage allowing Puskesmas to hire necessary finance staff as their
of around 60 percent of the total population , Puskesmas have finance management needs grow in line with the higher
already a sizable surplus from both JKN capitation and non- income.
capitation funds. This surplus will presumably increase further
with the aim of universal coverage. In addition, uneven fiscal Regulate and Expand the Numbers of BLUD Puskesmas
resources among Puskesmas have led to unhealthy competition
and resource distribution among the Puskesmas. MoH and the Considering the varied funding sources, Puskesmas, particularly
districts may mitigate these problems in the following ways: those that provide in-patient care, may perform better if they
• District health agencies should improve the management of have local public service agency (BLUD) status. Based on the
procurement and distribution of pharmacy and disposable regulatory framework and desk study, BLUD Puskesmas may
medical supplies. solve the following problems:

16 Funds Interplay in Public Health Centres (Puskesmas)

Policy Brief 2017

• Puskesmas with BLUD status have more flexibility in using JKN 2. The transformation should start with current in-patient
capitation funds. Unabsorbed funds could be used to improve Puskesmas, because they usually have greater resources,
the facility and to conduct capacity building programs. receive JKN non-capitation funds, and have more complex
• JKN non-capitation funds and service user fees are managed operations. The out-patient Puskesmas may follow later when
directly by the Puskesmas, and are immediately available the system is already running well.
to cover service costs, and operational or maintenance 3. The BLUD Puskesmas should have a strong financial manager
expenses, as they do not need to be deposited in the district to ensure implementation of a sound financial management
Puskesmas account and returned through APBD transfers. system that covers funds from different sources.
• Puskesmas with BLUD status can more easily hire medical 4. The health agency and management agency should monitor
workers and finance staff in accordance with actual needs closely the management of BLUD Puskesmas to anticipate
and available funds. and mitigate problems as they occur.

Despite the potential advantages of BLUD status, districts should BOK Transformation to Non-Physical DAK Needs Further
also be cautious in establishing BLUD Puskesmas. The service- Consideration
unit BLUD is still relatively new and not yet sufficiently regulated.
This leaves large and critical issues at the discretion of district Districts have different responses related to the new status
governments, the health agency, or even Puskesmas. The of BOK as non-physical DAK, which might compromise the
transformation of BLUD may take the following steps: execution of UKM programs in Puskesmas. Observations from
1. The health agency and financial management agency may the first few months in 2016 revealed that none of the visited
develop a sound understanding of the BLUD Puskesmas districts had incorporated BOK in their APBD. This inevitably led
system and ensure that they have the required capacity to to disbursement delays that may be responded to differently by
perform the roles. Puskesmas staff, compared to the past BOK delays. While the

Funds Interplay in Public Health Centres (Puskesmas) 17

 Policy Brief 2017

previous delays provided assurance that staff could reimburse main challenge is that the guideline could only be issued
the pre-financing of BOK activities later, the current BOK does not. after the Presidential Regulation on APBN execution is signed,
Naturally, it would deter the Puskesmas staff from conducting any which is usually in November or even December. Also, sharing
UKM activities financed by BOK. To respond to these issues, MoF the draft with all districts might not be effective, as the final
and MoH could take the following actions: guideline might differ from the draft and any difference will
• The implementation of this new BOK mechanism needs to be lead to confusion in districts. Considering these two issues,
reviewed in 2017, so that the mechanism can be fine-tuned, the three ministries might involve all provincial health
if necessary, for 2018 and beyond. agencies from the start. They may be consulted during the
• Rather than being channelled through the districts, the DAK formulation and be informed about the initial draft. Once the
BOK may be channelled through the provincial government. guideline is finalised, they should be informed and later lead
Similar to the practice of the school operational assistance the dissemination to all districts.
(BOS) fund, coordination of the various processes and
reporting requirements may be easier, as MoH only needs to In sum, the financing of Puskesmas service delivery is complex
deal with 34 provincial health agencies, compared with 512 and each Puskesmas needs to manage several funds with
district agencies. separate disbursement mechanisms and procedures. Simplifying
• To ensure streamlined implementation across the country, and streamlining the many funding sources and requirements
MoH may include costing information of UKM programs in its should be considered to make financing of the Puskesmas
annual DAK guideline. more transparent and accountable, in addition to becoming less
• To ensure that all districts are well informed about DAK BOK, resource-intensive for the Puskesmas staff, and freeing up time
and also the non-physical DAK, MoH, MoF, and MoHA may for actual service delivery functions.
work more effectively in disseminating the guideline. The

Table 10. Recommendations

No Description of Challenges Suggested Actions Agency in Charge

1 CG regulations, particularly the DAK DAK guidelines should be issued for multiple years MoF-DJPK & MoH
guidelines, are often delayed, and so and published two months before the start of the
UKM programs in Puskesmas cannot be fiscal year.
executed in the first months. Some delays
MoH should brief the provincial health agency one MoH
are inevitable because of the wait for
month before the new fiscal year.
parliamentary approval of the CG budget
(APBN). The provincial health agency should brief the district Provincial health agency
technical agency two weeks before the new fiscal
year.
Establishment of online discussion forums MoH and provincial health agency
2 A few districts still face major challenges in The DAK guideline should also mention how LGs MoH
incorporating additional CG fiscal transfers should incorporate it in the APBD.
that are only decided late in the year to
A MoHA circular letter should be issued to give clarity Ministry of Home Affairs (MoHA)—
APBD, particularly on DAK.
to LGs in incorporating additional fiscal transfers in DG Regional Finance
APBD.
3 There are significant variations in the A guideline on the size and coverage of Puskesmas MoH
size and coverage of each Puskesmas should be formulated.
in one district, which leads to different
MoH and provincial health agency should monitor MoH and provincial health agency
remuneration for each individual
districts’ policies in managing the Puskesmas.
Puskesmas.

18 Funds Interplay in Public Health Centres (Puskesmas)

Policy Brief 2017

No Description of Challenges Suggested Actions Agency in Charge

4 Despite efforts from CG to address regional Districts should put more emphasis on APBD District health agency
disparities, Puskesmas in rural areas allocation to rural Puskesmas.
have less financial resources, but greater
Physical DAK should be directed for Puskesmas with MoF-DJPK, MoH, and district health
challenges in providing primary health
inadequate fiscal resources. agency
services.
5 In the first year of implementation, districts The BOK channelling mechanism may be done MoF-DJPK and MoH
had different responses to the new status through provincial government to Puskesmas, similar
of BOK as non-physical DAK, which might to BOS practices.
compromise the execution of UKM programs
The BOK implementation regulation should MoF-DJPK and MoH
in Puskesmas.
contain the unit costs of UKM activities to ensure
consistencies among Puskesmas.
6 The BLUD status provides flexibility to MoH and MoHA may develop a guideline on MoH and MoHA (DG Regional
Puskesmas, but districts should ensure transforming Puskesmas from local technical Finance)
the readiness of Puskesmas and health implementing unit (UPTD) to BLUD.
and finance agencies before executing the
MoF and MoH may develop specific training modules MoF-DJPK and MoH
transformation.
on Puskesmas BLUD.
MoF and MoH may train provincial staff on the MoF-DJPK, MoH, provincial health,
Puskesmas BLUD training modules. finance, and training agencies
Districts should work with the provincial health Provincial and district health, and
agency on the transformation plan, particularly in finance agencies
ensuring the readiness of Puskesmas.
7. Puskesmas with local public service agency MoH should lead in formulating regulations on the MoH, MoHA, and MoF (DJPK)
(BLUD) status are not well regulated yet, and management of Puskesmas BLUD.
leave large critical issues to the discretion of
The district health agency should review in detail the District health agency
LG, the health agency, or even Puskesmas.
Puskesmas work plan in detail and conduct periodic
monitoring.
8 JKN non-capitation claims are often delayed, District health agency should reach an agreement District health agency
as the overall process is not lean and with the BPJS office on the claim processing and
efficient. disbursement procedures.
9 No Puskesmas have an integrated annual A national-level regulation needs to be formulated MoH, supported by MoF-DJPK,
plan and none have an integrated reporting that requires Puskesmas to develop and publish MOHA, and BPJS Kesehatan
system. integrated planning and reporting documents.
Provincial and district health agency should build Provincial and district government
Puskesmas’ capacity to develop and publish
integrated planning and reporting documents.
10 Despite the significant increase in BPJS Kesehatan may tie the scale of capitation funds BPJS Kesehatan
fiscal capacity of Puskesmas due to the with the service performance.
national health insurance (JKN), there is
The district health agency should guide Puskesmas MoH
little indication that health services have
in planning and executing the individual health
improved.
programs (UKP).

Funds Interplay in Public Health Centres (Puskesmas) 19

 Policy Brief 2017

LIST OF REVIEWED REGULATORY FRAMEWORKS

1. Law No. 33/2004 on Fiscal Balance 13. Minister of Home Affairs (MoHA) Regulation (Permendagri) No.
2. Law No. 40/2004 on National Social Security System 13/2006 on Local Financial Management (and its revisions)
3. Law No. 24/2011 on Social Security Administration Agency 14. Permendagri No. 61/2007 on Local Public Service Body
(BPJS) (BLUD)
4. Law No. 5/2014 on State Civil Apparatus 15. Minister of Health (MoH) Regulation (Permenkes) No. 69/2013
5. Law No. 6/2001 on Village on the JKN Service Costs
6. Law No. 23/2014 on Local Government 16. Permenkes No. 71/2013 on Health Services under JKN
7. Government Regulation (PP) No. 58/2005 on the Guidelines 17. Permenkes No. 19/2014 on the Utilisation of JKN Capitation
of Local Financial Management Funds for Health Service Provisions and Operational Funds on
8. PP No. 43/2014 and PP No. 47/2015 on the Implementation LG Primary Health Facilities
of Village Law 18. Permenkes No. 27/2014 on Technical Guidance of INA-CBG
9. PP No. 60/2015 and PP No. 22/2015 on Village Funds from 19. Permenkes No. 28/2014 on JKN Implementation Guideline
CG Budget 20. Permenkes No. 59/2014 on JKN Tariffs
10. Presidential Regulation (Perpres) No. 12/2013 on Health 21. Permenkes No. 82/2015 on the Technical Guideline of Specific
Insurance Allocation Fund (DAK) in the Health Sector in 2016
11. Perpres No. 111/2013 on the Revision of Perpres No. 22. Ministry of Finance (MoF) Regulation (PMK) No. 22/2016 on
12/2013 Disbursement of the Health Operational Assistance (BOK) and
12. Perpres No. 32/2014 on the Management and Utilisation of Family Planning Operational Assistance (BOKB) Funds.
JKN Capitation Funds on LG Primary Health Facilities

The findings, interpretations and conclusions in this report are those of the authors and do not necessarily reflect the views of the Kolaborasi
Masyarakat dan Pelayanan untuk Kesejahteraan (KOMPAK), the Government of Indonesia or the Australian Government.

Support for this study and publication was provided by the Australian Government through KOMPAK.

You are welcome to copy, distribute and transmit this work for non-commercial purposes.

To request a copy of this policy brief or for more information, please contact KOMPAK Communications Team ([email protected]).
This policy brief is also available on the KOMPAK website.

KOMPAK
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20 Funds Interplay in Public Health Centres (Puskesmas)