EVALUATION OF THE IMPLEMENTATION OF THE PERFORMANCE-BASED CAPITATION POLICY (KBK) AT THE MERIAL HEALTH CLINIC OF DKI JAKARTA CITY IN 2020

. To improve the quality of health services at Primary Health Care (FKTP) in implementing the National Health Insurance Program in Indonesia, the government has issued a performance-based capitation payment (KBK) policy at the FKTP. This study aims to evaluate the performance-based capitation payment policy in Merial Health clinic from the aspects of effectiveness, efficiency, facilities and infrastructure, availability of human resources, adequacy, and legal compliance. This study performed in-depth interviews and document reviews. The results showed that the effectiveness of the policy has been optimal but is still constrained by the socialization of the KBK policy and visits to health numbers for BPJS Health participants. The efficiency of the KBK policy has been running optimally in increasing the capitation income of the Merial Health clinic. The adequacy of the policy is as expected because it improves the quality of health services. The availability of human resources is in accordance with the BPJS Health provider standards. Facilities and infrastructure are in accordance with cooperation rules as a BPJS Health provider. Legal compliance has been running optimally because it has met the applicable requirements. The study concludes that the implementation of the performance-based capitation policy at the Merial Health clinic has been running optimally.


INTRODUCTION
To improve the quality of health services at Primary Health Care (FKTP) in implementing the National Health Insurance Program in Indonesia, the government has issued a performance-based capitation payment (KBK) policy.KBK implemented through BPJS Health Regulation Number 7 of 2019 regarding Instructions for Implementing Performance-Based Capitation Payments in FKTP (1).This policy was issued to ensure that FKTPs remain optimal in carrying out their functions to contact participants of the National Health Insurance (JKN)-Healthy Indonesia Card (KIS).
Based on BPJS Health's 2018 national achievement report, the number of FKTPs in Indonesia implementing KBK is 8,712 Puskesmas.Until December 31, 2018, the KBK Puskesmas showed a contact rate ratio of 114.21 per mil.The ratio of Prolanis participants visiting FKTP was 40.57%, and the ratio of non-specialist referrals was 1.30% (1).
Based on data from the Merial Health clinic's KBK performance report, the target achievement of the KBK indicator at the Merial Health clinic is not optimal enough, which include 15% Contact Rate, Non-Specialized Referral Ratio 2% and Controlled Prolanis Participant Ratio ≥5% (2).Implementing the KBK policy can increase the effectiveness and efficiency of services as well as develop a quality control system and payment for FKTP (3).The capitation payment system is a reward and punishment for FKTP performance.Therefore, FKTP will continuously improve the quality of service and carry out its functions optimally as a gatekeeper for health services.Besides, JKN-KIS participants will still have their rights.The research results conducted by Alhamidah (2013) found a relationship between the capitation system and the reward for job satisfaction (4).This study aims to evaluate performance-based capitation policies (CBC) in Merial Health clinic from the aspects of effectiveness, efficiency, facilities and infrastructure, availability of human resources, adequacy, and legal compliance.

METHOD
The research design used in this study is qualitative research.There were four work processes for the data collection procedures: observation, interviews, document studies, and audiovisual (5).This study focused on the Performance-Based Capitation Policy (KBK) at Merial Health clinic by using variables modified from William Dunn's policy evaluation model, such as the aspects of effectiveness, efficiency, facilities, and infrastructure, availability of human resources, adequacy, and legal compliance.Effectiveness is the achievement of the target output, which was measured by comparing the expected output with the actual output, while efficiency means the between the sources used (input) and the results obtained (output).From November to December 2020, this research was conducting at the Merial Health clinic through in-depth interviews and document review.Primary data were obtained from in-depth interviews and FGDs.The selection of informants met the criteria of appropriateness and adequacy.The secondary data from this study were documents' review in regulations, performance reports, and Merial Health clinic's finances.Data processing is done by converting and compiling the results of in-depth interviews with informants into a transcript.The compiled data were searched for keywords, categorized, and compiled into a matrix form.In the data analysis, data reduction, data presentation, and verification of data conclusions were carried out.

RESULTS AND DISCUSSION
There are challenges and inputs obtained for improving the implementation of service commitment-based capitation.The development of the implementation of service commitment-based capitation into performance-based capitation is applied to all FKTPs, so that the implementation of performance-based capitation is effective and efficient.

Effectiveness
The practical aspect measured in this study is how the Performance-Based Capitation (KBK) policy achieves at the Merial Health clinic.Based on the results of in-depth interviews, started from the year of 2019, Merial Health clinic became a BPJS provider and implemented the Performance-Based Capitation (KBK) policy.This study indicates that KBK policy has several obstacles in its implementation in the field, including those related to administration and the number of capitations.In addition, to increase the effectiveness of the implementation of the Performance-Based Capitation (KBK) policy in FKTP during the Covid-19 pandemic, BPJS Health has issued a policy of Circular Letter BPJS Health No. 2 of 2020.
The results of interviews with informants found that the Performance-Based Capitation (KBK) policy at the Merial Health clinic has been running effectively.However, there are still several obstacles to data collection on patient visits and socialization to BPJS Health participants at the Merial Health clinic.Evaluation of the effectiveness of a policy is a means to determine how well the implementation of the policy is.An integrated approach is required to monitor the agreement, compliance, and resource complaint information.
The effectiveness in implementing the Performance-Based Capitation (KBK) policy at the Merial Health clinic has been going well even though there are still some obstacles, including the uneven distribution of socialization to BPJS Health participants.This lack of socialization has resulted in public confusion with the implementation of health services and the ignorance of JKN participants to take advantage of the Mobile JKN application.
From the problems that exist in the implementation of the socialization of the JKN program, some recommendations are increasing synergy and collaboration between stakeholders in implementing the socialization of the JKN program to the community through sharing of resources, facilities, and infrastructure, budgeting planning and the substance of socialization as well as strengthening the functions of each stakeholder in carrying out socialization in general and in particular (6).

Efficiency
The efficiency aspect in this study is how the economic benefits from the Performance-Based Capitation (KBK) policy at Merial Health clinic.The data collection results through in-depth interviews showed that the efficiency of the Performance-Based Capitation (KBK) policy at the Merial Health clinic was found to have provided benefits to Merial Health clinic's financial management.The informants knew about the standards of BPJS Health participants following the BPJS Health Regulations Number 7 of 2019 regarding Instructions for Implementing Performance-Based Capitation Payments in FKTP.
Based on a review of the documents in the KBK achievement assessment report for the BPJS Health East Jakarta Branch in November 2020, Merial Health clinic have received payments of 95% of the capitation norm that has been determined with a total achievement of 1.The efficiency of the Merial Health clinic Performance-Based Capitation policy is sufficient for the operational costs of the clinic and provides economic benefits to the community.The results of this study are in line with William Dunn's that efficiency is one aspect that affects the success of policy implementation (7).
Based on William Dun (2003; 430), efficiency, a synonym of economic rationality, is the relationship between effectiveness and effort.Monetary costs generally measure the latter.Efficiency by calculating the cost per unit of a product or service is usually determined.The policy that achieves the highest effectiveness at the lowest cost is called efficient (8).Efficiency is the achievement of maximum output with specific inputs or using the lowest inputs to achieve certain outputs.Efficiency compares output/input associated with performance standards or predetermined targets (9).

Adequacy
The adequacy of implementing policies is how far a level of effectiveness satisfies needs, values, or opportunities in solving problems in FKTP (8).The results of data collection through in-depth interviews related to the adequacy of the Performance-Based Capitation (KBK) policy at the Merial health clinic are supported by the monitoring and evaluation of BPJS Health towards the Merial Health clinic.
This study found that the Performance-Based Capitation Policy (KBK) has succeeded in encouraging the leadership of an FKTP to be more optimal in achieving performance and improving the management function of an FKTP.Based on the results of in-depth interviews, the Performance-Based Capitation (KBK) policy affects the success of achieving the quality of health services.Implementing the Performance-Based Capitation (KBK) policy at the Merial Health clinic can provide significant benefits and influence, especially in improving the quality of health services and capitation income.
The adequacy of the policy achieved was sufficient in various ways.The results of this study were supported by measuring the effects and impacts of a program/policy on society, rather than measuring efficiency, implementation honesty, and others related to implementation standards.The purpose of the policy itself is to produce an impact/change, so it is natural for that evaluation to be carried out (10).

Facilities and infrastructure
Aspects of facilities and infrastructure in this study include health facilities at the Merial Health clinic.The results of in-depth interviews with informants found that health facilities, including work equipment and several other health service facilities, were essential elements to support the implementation of KBK in Merial Health clinic.The facilities and infrastructure at the Merial Health clinic had met the standards provided by BPJS Health.For the monitoring and evaluation mechanism from BPJS Health to the Merial clinic in charge of the National Health Insurance (JKN) program, credentialing is carried out on Merial Health clinic from BPJS Health every year.
Based on a review of the East Jakarta BPJS Health, the results of the re-credentialing report document to the Merial Health clinic in 2020 were 78,043.Regarding the assessment of facilities and infrastructure, the Head of Primary Benefit Guarantee of BPJS Health, the facilities, and infrastructure in an FKTP were assessed based on credentialing at the beginning of the FKTP collaborating with BPJS Health.
The results of the credentialing assessment process carried out by BPJS Health East Jakarta in 2020 at the Merial Health clinic were 74,043, which means that the Merial Health clinic category is in category B or recommended.The completeness of the facilities and infrastructure owned by FKTP is also physical evidence that can affect the quality of services provided (11).FKTP can work together with the Health Office to help provide adequate facilities and infrastructure because it indirectly affects the achievement of KBK indicators in FKTP.
Facilities and infrastructure in implementing the Performance-Based Capitation (KBK) policy at the Merial Health clinic has been going well because the facilities and infrastructure were following regulations, namely Regulation of the Minister of Health Number 9 of 2014 regarding clinics.In the service process of implementing KBK, the availability and compliance of officers with service standards and the behavior of serving officers can also affect the achievement of KBK indicators (12).

Human Resource Availability
This study's availability of human resources (HR) is the completeness of health personnel resources at the Merial Health clinic in implementing the Performance-Based Capitation (KBK) policy.The results of in-depth interviews with the principal director of the Merial Health clinic showed that the health workers at the Merial Health clinic had complied with the standards of BPJS Health.
The implementation of the Performance-Based Capitation (KBK) policy by all HR at the Merial Health clinic explains that all HR personnel at the Merial Health clinic have been involved in implementing the KBK policy.In addition, regarding the mechanism for evaluating HR personnel at the Merial Health clinic, it was found that HR evaluation is carried out regularly every three months by the Merial Health clinic.
The results of the assessment of the Merial Health clinic for HR staff had met the standards as a primary health facility providing BPJS health providers.The availability of human resources at the Merial Health clinic has been optimal in supporting the Performance-Based Capitation (KBK) policy.In implementing the KBK at the Merial Health clinic, it is necessary to prioritize the human resources involved for administrative staff because one of the obstacles faced was related to administrative issues.Therefore, it is necessary to provide education or training to existing human resources to improve officers' performance as the training will strengthen gatekeepers (13).
In the service process of implementing KBK, the availability and compliance of officers with service standards and the behavior of serving officers can also affect the achievement of KBK indicators (12).Human Resources or staff is the primary resource in policy implementation.The effectiveness of human resources is assessed quantitatively based on their number and qualitatively seen from their competence (14).A policy/program may fail to achieve the expected impact even though the implementation process succeeds in realizing the outputs demanded by the program.However, it fails to achieve its outcomes because one of the reasons is inadequate resources (15).