Theory-practice gap of capitation payment in the Indonesian national health insurance: toward universal health coverage

Abstract

PurposeThis study aims to present a comprehensive integrative review of capitation payment for primary healthcare (PHC) in the Indonesian national health insurance (Jaminan Kesehatan Nasional,JKN).Design/methodology/approachWhittemore and Knafl’s integrative review method is used within this review and analysis framework. Multiple types of academic literature were included in this review, including all studies related to capitation payment in the JKN from 2014 until 2022.FindingsThis review found that several practices of capitation payments in the JKN in Indonesia deviate from basic economic concept of capitation. It does not yet incentivize PHC to create a competitive environment in attracting members and it does not incentivize health promotion and prevention. Moreover, the capitation model uses the same scope of primary care services for all PHC throughout the country – which in fact has disparities in providing 155 medical conditions as required competencies for PHC. The authors recommend that the JKN apply bottom-up costing and pricing methods to set market prices of capitation rates.Originality/valueThis is the first study that reviews theory-practice gap of the capitation payment model using an integrative review that covers academic literature, journal articles and regulations in Indonesia.