BACKGROUND: The Indonesian National Health Insurance Scheme (Jaminan Kesehatan Nasional, JKN) uses a gatekeeper system to control costs and rationalize care. Cases with no complications must be treated thoroughly by public or private PHC providers. Only cases that require specialist care can be referred to hospitals. A previous study on the JKN 2018 claims data indicated that 80% of HIV patients were treated in hospitals comprising 75% outpatient and 25% inpatient services. The research questions were whether the gatekeeping function fail to work properly, or whether the patient with HIV insisted to utilize hospital services. Finally, are PHCs ready to fully treat HIV patients with no complications?
METHODS: We conducted a study to healthcare providers in 16 municipalities using a mixed method fielded between April and November 2022. An online survey was first administered to 147 PHC providers, 722 PHC workers, and 561 PLHIV. Then, a focus group discussion and in-depth interview were conducted with 181 respondents comprising of municipal health officials, medical doctors in PHC, HIV program administrators, JKN administrators, people living with HIV (PLHIV), and peer groups of PLHIV. Descriptive and thematic analysis was undertaken to identify factors associated with an improved referral system.
RESULTS: We found that 62%, 76%, 46%, and 1% of PHC providers were consecutively able to provide HIV counseling, testing, treatment, and viral load (VL) tests. However, there were some constraints in fulfilling those services because reagents were reported stockouts in some areas. Thus, PHLIV were referred to hospitals. In addition, we also found that 64%, 68%, and 54% of PHC staff have received training on HIV counseling, testing, and treatment, respectively. In contrast, out of those staff who provided HIV services; 15%, 34%, and 9% have not received the relevant training, respectively. We also found that private providers had considerably less training rate compared to public ones.
CONCLUSIONS: We conclude that not all PHC providers are ready to implement a back-referral policy. We recommend that the government should strengthen the staff competency, both in public and private PHC, and ensure no constraint of supplies of reagents before requiring back-referral.

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