Implementation Challenges of Performance-Based Capitation in Indonesia: A Scoping Review Ayu Tyas Purnamasari*1.
Rizki Fadila2 1 2 D-3 Asuransi Kesehatan.
Jurusan Rekam Medis dan Informasi Kesehatan.
Poltekkes Kemenkes Malang Author's Email Correspondence ( * ): Ayutyasp97@gmail.
ABSTRACT
Performance-Based Capitation (KBK) is a payment system implemented in IndonesiaAos primary health care (PHC) to improve service quality through performance-based financing.
Despite its potential, various challenges have limited its effectiveness.
This study aimed to identify and synthesize evidence on the barriers to KBK implementation in Indonesia.
A scoping review was conducted following the PRISMA-ScR guidelines using data from Google Scholar.
PubMed, and Scopus.
A total of 14 studies published between 2019 and 2025 were included.
Data were extracted, charted, and analyzed thematically.
The findings were categorized into five major themes:
human resources, systems and infrastructure, program management and governance, technical capacity, and patient participation and engagement.
Interrelated challenges were identified in KBK implementation, including shortages and unequal distribution of human resources, inadequate systems and infrastructure, weak governance, limited technical capacity, and low community participation.
These factors collectively hinder the achievement of key performance indicators encompassing contact rate, the non-specialist referral ratio (RRNS), and controlled condition of Chronic Disease Management Program (RPPT) which underscoring the need for comprehensive strategies that strengthen workforce capacity, infrastructure, governance, and community engagement.
Keywords : Challenges .
contact rate .
primary healthcare .
RPPT .
RRNS
Published by:
Article history :
Tadulako University Received : 11 08 2025 Address:
Accepted : 19 12 2025 Jl.
Soekarno Hatta KM 9.
Kota Palu.
Sulawesi Tengah.
Indonesia.
licensed by Creative Commons Attribution-ShareAlike 4.
0 International License.
Phone: 6282197505707 Email: preventifjournal.
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INTRODUCTION
The implementation of National Health Insurance in Indonesia through Jaminan Kesehatan Nasional (JKN) scheme continuously strives to enhance health services for JKN participants, aiming to deliver high-quality health services, covering primary to advanced care services.
The sustainability of the JKN program is crucial, and one of the measures being implemented is quality and cost-controlled service techniques .
anaged car.
In implementing managed care, primary health care (PHC) or First Level Health Facilities (Fasilitas Kesehatan Tingkat Pertama Ae FKTP) serves a critical role as gatekeeper and the initial contact within the referral system, ensuring compliance with established standards of medical care.
Capitation is commonly used in primary care, where providers receive a fixed payment per person without regard to the type or volume of services delivered.
This payment method can promote cost containment but also enable the selection of low-risk patients or the underprovision of services in order to reduce costs.
To mitigate these unintended consequences and encourage the delivery of high-quality care, many countries have integrated capitation with performance-based payment systems.
Performance-based capitation in Indonesia has undergone some changes in Since 2019, performance-based capitation implemented Kapitasi Berbasis Kinerja (KBK) mechanism which tied to three indicators: the contact rate .
ngka kontak Ae AK), the non-specialist referral ratio .
asio rujukan non spesialistik Ae RRNS), and the controlled condition of Chronic Disease Management Program (Program Pengelolaan Penyakit Kronis - Prolani.
participant ratio .
asio peserta Prolanis terkendali Ae RPPT).
These indicators have respective targets of Ou150%.
O2%, and Ou5%, which have an impact on the amount of capitation.
PHC receive the full amount of capitation upon meeting the otherwise, the payment will be reduced in accordance with regulations.
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Several studies have reported challenges in the implementation of performancebased capitation in Indonesia.
These challenges were the insufficient number of PHC staff which led to unmet contact rate targets due to their dual burden in JKN programs, limited infrastructure such as the P-Care system and diagnostic tools affecting referral ratio indicators, and unclear technical guidelines on capitation fund allocation, particularly for programs like Prolanis that require separate budgeting.
Administrative constraints have also posed challenges in the implementation of performance-based capitation, as seen at the one of the clinics in East Jakarta, where a shortage of administrative staff hindered effective data collection on patient visits and affected the accuracy of performance .
These challenges may hinder the ability of primary healthcare providers to meet performance indicators and ultimately affect service quality.
Although several studies have examined aspects of performance-based capitation implementation in Indonesia, there is still a lack of comprehensive evidence that systematically maps and synthesizes the challenges across different settings and regions.
Existing studies tend to focus on specific indicators, facilities, or local contexts, resulting in fragmented understanding of the broader implementation barriers.
Therefore, this study aims to systematically identify, map, and synthesize the evidence on the challenges in implementing performance-based capitation (KBK) in primary healthcare facilities across Indonesia.
METHODS
This study employed a scoping review design based on the framework of Arksey and OAoMalley and was reported in accordance with the PRISMA-ScR guideline.
The research question was: AuWhat are the challenges in the implementation of performance-based PREVENTIF: JURNAL KESEHATAN MASYARAKAT VOLUME 16 NOMOR 3 capitation in Indonesia?Ay The search strategy was developed using the PCC (Population.
Concept.
Contex.
Table 1 PCC (Population.
Concept, and Contex.
Population Concept Context Primary Health Care Implementation challenges Performance-based capitation in Indonesia A systematic search was conducted in Google Scholar.
PubMed, and Scopus for articles published between 2019 and 2025 using keywords related to performance-based capitation, primary healthcare, implementation, barriers, and Indonesia.
The data searches began in 2019, coinciding with the implementation of performance-based capitation in Indonesia.
The terms ("kapitasi berbasis kinerja" OR "performance-based capitation") AND ("Puskesmas" OR "FKTP" OR "fasilitas kesehatan tingkat pertama") AND ("tantangan" OR "hambatan" OR "implementasi") AND ("Indonesia") used during the search.
The terms in English also used to search more relevant studies were ("performance-based capitation" OR "kapitasi berbasis kinerja") AND ("primary healthcare" OR "Puskesmas" OR "FKTP") AND ("implementation" OR "barriers" OR "challenges") AND ("Indonesia").
Figure 1 shows a PRISMA-ScR flow chart that describes the identification procedure.
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Identification Eligibility Included 235 articles are identified through database search Google Scholar = 154 Pubmed = 34 Scopus = 47 Records excluded based on inclusion and exclusion criteria .
= .
Abstract assessed for eligibility .
= .
Full text downloaded .
= .
Study included in review .
= .
Records excluded through full-text review .
= .
Reason for exclusion:
Not accessible Did not answer research Focused on performancebased capitation in general Focused on effect and performance-based capitation Figure 1.
Flowchart of PRISMA-ScR Studies were included if they examined challenges or barriers to the implementation of performance-based capitation in Indonesian primary healthcare settings, were written in English or Bahasa Indonesia, and were available in full text.
A total of 14 studies were included in the final review.
Data were extracted using a structured charting form and analyzed using a qualitative thematic synthesis approach.
Findings were organized into five themes: human resources, systems and infrastructure, program management and governance, technical capacity, and patient participation and engagement.
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RESULTS
Of the fourteen included studies, five identified themes discussed barriers and challenges in the implementation of performance-based capitation in primary healthcare in Indonesia, involving Human Resources.
Systems and Infrastructure.
Program Management and Governance.
Technical Capacity, and Patient Participation and Engagement.
The most frequently identified barriers were shortages and unequal distribution of human resources, inadequate systems and infrastructure, weak program management and governance, limited technical capacity of health workers, and low patient participation.
These challenges were found to affect the achievement of key performance indicators, particularly the contact rate, non-specialist referral ratio (RRNS), and the ratio of controlled Prolanis participants (RPPT).
A detailed summary of the included studies is presented in Table 2.
Table 2.
Summary of Selected Studies .
= .
Author.
Study Design Astuti, et al.
Qualitative with in-depth Augustian.
Ayuningtyas.
Mixed-method uantitative Study Setting Jambi.
Talang
Banjar PHC
189 PHC
facilities in East Jakarta data from 4 PHCs, 4 clinics.
BPJS Health, and District Purpose Result To analyze the input and process aspects in achieving performancebased capitation (KBK) To analyze performancebased capitation (KBK) achievement in East Jakarta Lack of dedicated KBK planning unit.
promotive or admin staff.
inadequate IT support.
unclear budgeting.
Prolanis participation.
entry delegated to Low-performing KBK due to lacked diagnostic tools, promotive staff.
IT, and had poor accessibility.
Prolanis/home visits COVID-19 disrupted outreach.
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No Author.
Study Design
Study Setting Health Office
(DHO)
Secondary data from the BPJS Healthcare Security with a total of 28,301 PHCs in Indonesia in Aryani, et al.
Qualitative Structural Equation Modeling (SEM) Susanti.
Khairani .
Qualitative PHCs in Indonesia Cahyati, et al.
Qualitative with in-depth Five PHCs in Nganjuk that did not receive full Rosita, et al.
Qualitative with in-depth PHC in Banda Aceh Purpose Result To examine the between the of KBK and the performance of FKTP, as well as the factors influencing FKTP To examine performancebased capitation within JKN processes, and To explain the of the KBK payment policy in relation to standard factors, policy objectives, and social To examine how the Meuraxa PHC in Banda Aceh was Limited HR reduced contact rate achievement.
burden from participant and home visits.
staff distribution.
infrastructure and diagnostic facilities affected referral ratios.
Barriers included infrastructure gaps, resource inequality, weak coordination, low KBK readiness, poor health information systems, and legal, technical.
HR Data entry delays from auxiliary units.
lack of general practitioners.
RPPT targets.
internet issues.
social factors .
arming, agin.
affected Contact rate hindered by patient refusal, data entry issues, non-eligible services.
multiple program duties.
lack of lab facilities.
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No Author.
Study Design Explanatory mixed method Study Setting Rosida, et al.
Geodesi.
Wardani .
Febrianti, et al.
Fadila.
Purnomo Quantitative 33 PHCs in Pasuruan Regency Trisno, et al.
Quantitative Secondary data from the BPJS Healthcare Security in Pamekasan Qualitative with in-depth and document Mixed-method .
uantitative Four PHCs in Denpasar PHC in Jombang Makasar, three PHCs and four Purpose Result based capitation (KBK) To explore the KBK achievement at PHCs in Denpasar and pinpoint the internal and factors that impede and facilitate KBK fulfillment at these PHCs To investigate KBK indicators Prolanis follow-up.
unrecorded BPJS data.
Absence of planning low data entry financial incentives.
medicine stockouts.
patient-driven To describe the of Outpatient referral at the primary health To describe the causes of the high nonspecialist referral ratio at the Pasuruan PHC To investigate how the between the ratio of doctors to nonspecialistic High workload with limited HR.
patient referral RPPT hindered by staff shortages, task duplication, lack of transport for home visits.
Inadequate HR vs patient long queues.
non-functional drug shortages.
low referral system High referral ratios from lack of infrastructure/equipment.
incomplete service rooms.
only 75% met workforce shortages in key Non-ideal doctor-patient ratio .
%).
dual roles.
attractive work conditions.
weak gatekeeping increased unnecessary referrals.
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No Author.
Study Design Purnamasari.
Ningrum Lestari, et al.
Qualitative with in-depth review, and focus group Qualitative with in-depth Kasim .
Action
research with Consolidated Framework
Implementati on Research
(CFIR)
Study Setting Two PHCs in Malang Situbondo.
Panji and Panarukan PHCs Five PHCs in East Flores Purpose Result To explore the of PROLANIS during the COVID-19 pandemic at FKTPs in Malang Low RPPT target Prolanis staff.
no dedicated budget covered only 30 participants.
shared exercise To analyze the resources and factors that influence the achievement of the RPPT (Ratio of Prolanis Participants Serve.
To identify factors that influence the success of the Prolanis program in urban health centers in East Flores Few promotive staff.
dedicated RPPT personnel.
weak planning.
poor data no reminders.
limited KBK training.
Prolanis hindered by poor internet/device access.
limited HR and tech elderly access low participation from geographic and social need for better PCare and telemedicine use.
Human Resources Multiple studies indicated that most PHCs were experiencing lack of health workes, particularly doctors, dentists, and promotive staff.
Ae.
This situation forced health workers to have dual roles as medical personnel and performance-based capitation (KBK) team, contributing to workload burden and reduced program effectiveness.
Ae.
In some cases, staff felt less motivated and delegated their tasks even to volunteers.
Further it hindered performance of PHC to achieve KBK targets.
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Systems and Infrastructure Implementation of KBK was mainly obstructed by inadequate infrastructure.
Poor internet connectivity held staff for real-time data entry such as report through P-Care and entry the contact rate data.
,24,.
PHCs experiencing shortage of medical equipment and drugs had resulted in failure to achieve the KBK target.
Insufficient drugs made PHC failed to control the medical consumption of Prolanis patients.
In addition.
PHC was forced to refer to the hospital due to a lack of drugs.
Inadequate transportation facilities made it difficult for PHC to carry out prolanis activities because of the large area.
Program Management and Governance Many studies highlighted the absence of structured planning and guidance documents such as proposed activity plan (PAP), activity implementation plan (AIP), activity framework (AF), or standard operational procedure (SOP) related to KBK.
The lack of a dedicated management unit or team responsible for KBK implementation limited accountability and coordination.
Weak coordination among stakeholders also hindered PHC to achieve KBK targets.
Financial management issues, such as unclear budgeting for KBK activities and limited incentives for high performance, also discouraged staff motivation.
Technical Capacity Limited technical capacity was evident in inadequate training, low understanding of KBK indicators, and weak data management systems.
,24,.
Staff showed low commitment to data input, and many PHCs lacked automated systems for reminders and follow-up.
Some Prolanis team lacked competency in reporting systems like P-Care and telemedicine platforms, impeding monitoring and evaluation efforts.
Patient Participation and Engagement Limited patient engagement was a critical barrier in achieving performance targets.
Low participation in Prolanis programs, refusal of home visits, and requests for PREVENTIF: JURNAL KESEHATAN MASYARAKAT VOLUME 16 NOMOR 3 unnecessary referrals were frequently cited.
,19,.
Patient behavior was influenced by low awareness of the referral system, limited health literacy, and sociodemographic factors such as work schedules, aging populations, and limited geographic condition.
,21,.
Lack of participation and engagement caused unattainability of the non-specialist referral ratio and the controlled condition of Prolanis participant ratioAos targets.
DISCUSSION
This scoping review synthesized evidence from 14 studies on the implementation of Performance-Based Capitation (KBK) in Indonesia and identified five themes of challenges:
Human Resources.
Systems and Infrastructure.
Program Management and Governance.
Technical Capacity, and Patient Participation and Engagement.
Human Resources These findings on the challenges of implementation Performance-Based Capitation (KBK) in Indonesia highlighted insufficient numbers of health workers, unequal distribution, and dual roles that increased workload.
Medical personnel in PHC are not only responsible for providing direct patient care but are also expected to perform administrative tasks related to KBK, such as implementing Prolanis activities, conducting home visits, and ensuring accurate reporting in systems like P-Care.
When staffing levels are insufficient, these dual responsibilities increase workload and may divert time from essential service delivery, ultimately contributing to underachievement of key performance indicators such as the contact rate.
Global evidence shows that staff shortage resulted in heavy workloads and pushed frontline staff to multitask without fair compensation.
Ultimately, high workload is highly associated with reduced job satisfaction and affects performance like in Ghana, making the attainment of indicators like the contact rate a significant challenge.
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Systems and Infrastructure Infrastructure constraints such as lack of diagnostic tools, internet connectivity, and essential medicines directly affect indicator achievement.
The reporting of contact rate and Prolanis activities is highly dependent on stable internet connectivity, as data must be entered into digital platforms such as P-Care in real time.
In rural and remote areas, unstable internet access can delay reporting.
This challenge is compounded by limited IT Another critical infrastructure gap is the inconsistent availability of essential Patients who cannot obtain prescribed medicines at the primary care level are more likely to seek care at higher-level facilities, even for conditions that could be managed at PHCs.
Medicine stockouts affected RPPT and RRNS performance.
The availability of drugs in PHCs is very diverse, but some essential drugs are out of stock, especially in the eastern region of Indonesia.
With a capitation-based system, it is expected that funding should guarantee the availability of basic facility structures and essential equipment.
These serve as the foundation upon which performance-based incentives can effectively motivate healthcare providers to deliver high-quality services.
However, in practice, the allocation for operational cost support is capped at a maximum of 40% of capitation This limited proportion may not be sufficient to maintain infrastructure, upgrade equipment, ensure consistent drug supply particularly in large geographic location, and conduct promotional and preventive activities.
Program Management and Governance Strong program management and effective governance are essential to ensure that KBK become into measurable improvements in primary healthcare.
The absence of structured operational guidelines, incomplete planning documents, and undefined leadership roles in some PHCs has been linked to inconsistent program implementation.
Weak coordination between stakeholders further complicates performance monitoring and PREVENTIF: JURNAL KESEHATAN MASYARAKAT VOLUME 16 NOMOR 3 follow-up actions.
These governance gaps can lead to fragmented execution and reduced Weak commitment of governance can be seen from the reduction of allocated budget for Prolanis per total national health budget every year.
Performance-based health financing experiences in other countries illustrate similar In Nigeria, the lack of clear operational frameworks and inconsistent communication between national and local implementers diluted the intended impact of performance incentives.
In Cambodia, performance-based financing was most effective when accompanied by detailed implementation manuals, transparent fund flow processes, and regular joint reviews between central and district health teams.
The regulatory framework for example Ministry of Health Regulation No.
6/2022 provides broad guidance for capitation but leaves flexibility in operational details to local governments.
PHCs requires comprehensive regulations for the execution of KBK, which have yet to be .
Technical Capacity Technical capacity including the knowledge, skills, and systems needed to implement and monitor KBK.
PHC staff must not only understand indicator definitions but also navigate digital platforms such as P-Care and balance these tasks alongside clinical Without sufficient training and ongoing support, these demands can lead to reporting delays, incomplete records, and suboptimal performance monitoring.
In Tanzania.
A threeyear Performance-Based Financing training program in Rungwe District significantly improved health workersAo management, planning, and customer care skills.
Staff applied these skills to develop job descriptions, create business plans, establish facility boards, and negotiate supply contracts.
This shows that capacity-building can drive innovation, community engagement, and problem-solving like in Tanzania.
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Patient Participation and Engagement Patient engagement plays a pivotal role in achieving PBC indicators, particularly in programs like Prolanis.
Limited patient participation showed as low attendance at Prolanis activities, refusal of home visits, and demands for unnecessary referrals can directly hinder the achievement of the RPPT and RRNS.
Low engagement is often linked to limited health literacy, aging, and geographical reasons.
A study highlighted the low Prolanis participations in outside Java since two-years implementation due to lower rate of PHCs .
Study in Iran reported that barriers to community engagement include community trust, organizational structure, and perceptions about participatory initiatives in the community and among health professionals and it is necessary to take steps to remove barriers to community participation in the primary healthcare system.
CONCLUSIONS AND RECOMMENDATIONS
PHCs in Indonesia face substantial challenges in implementing Performance-Based Capitation (KBK), starting from shortages and unequal distribution of human resources that lead to excessive workloads and hinder the attainment of all three KBK indicators.
Inadequate systems and infrastructure, including unstable internet connectivity, limited diagnostic tools, and inconsistent essential medicine supply, disrupt data reporting for contact rate and RPPT, and contribute to higher RRNS.
Weak governance and poor program management such as the absence of technical guidelines, unclear operational frameworks, and limited coordination further constrain effective implementation.
Limited technical capacity, due to insufficient training and understanding of KBK indicators, reduces data quality and undermines performance monitoring.
These operational barriers are compounded by low community participation, influenced by geographic constraints, aging populations, and poor awareness of the referral system, resulting in persistent underachievement of RPPT and elevated RRNS.
Addressing these multifaceted challenges PREVENTIF: JURNAL KESEHATAN MASYARAKAT VOLUME 16 NOMOR 3 requires integrated strategies that strengthen workforce capacity, infrastructure, governance, technical skills, and community engagement to ensure the sustainability and effectiveness of KBK in improving primary healthcare performance.
This scoping review was limited to published studies from selected databases and focused only on the Indonesian context, which may have resulted in the exclusion of relevant evidence.
The variation in study designs and indicators also limited the comparability of findings.
BIBLIOGRAPHY