Our study described how general practitioners (GPs) in the Indonesian Banyumas district perceive the gatekeeper role of primary care and it explored whether those perceptions were associated with personal characteristics of the GPs or with characteristics of the facilities where they worked. Findings showed that GPs scored relatively high in the domains of knowledge and performance, but lower in the attitude domain. No personal or facility characteristics were associated with GPs’ knowledge about the primary care gatekeeper function. Longer work experience and private rather than civil service employment were associated with higher attitude scores, and urban practice location with lower scores. Part-time employment was associated with higher scores on gatekeeping performance, while private practice was linked to lower scores.
Strengths and limitations
To the best of our knowledge, this is the first study in Indonesia to explore how GPs perceive the gatekeeper role of primary care and the factors associated with their perceptions. Only a few studies have assessed the physician perspective on primary care in Indonesia, with most prior studies focusing on the patients’ point of view. Our study sought to provide new insights and initial evidence on key areas that can facilitate primary care in performing its gatekeeping role.
Our study is not without limitations. Its relatively small sample size may raise concern about the power of the study and the robustness of our estimation. However, given the exploratory nature of our study and the flexibility of the statistical technique we employed in the data analysis, we believe the internal validity can be considered adequate. The sample size may also imply limited generalisability for our findings. We consider our study site (Banyumas district) to bear a good resemblance – in terms of demographics and socioeconomic, cultural and geographical background – to the majority of districts on the islands of Java and Sumatra, where around 70% of the Indonesian population lives. But the findings should be interpreted cautiously with regard to generalisability. Another issue is related to sample size for the validity test which may less than usually used in other studies. Another issue is related to sample size for the validity test which may be less than usually used in other studies. We acknowledge that resources constraint hindered our ability to reach a larger sample size for the questionnaire pre-test. However, since sample size is determined by the problem prevalence and power, our sample size in the validity test was able to generate sufficient power given the assumption that the prevalence problem in our study is quite large.
Interpretation
The findings indicated that GPs generally understood and carried out the gatekeeper role adequately, although they perceived the role less positively. Their less positive attitude was likely related to a perception that gatekeeping formed an additional burden in their daily duties. A study in Indonesia has found that GPs perceive increasing demand from patients as one of the barriers to performing optimally as primary care physicians [10]. Moreover, it has been reported that patients perceive the quality of primary care as low and that they view the gatekeeper as an access barrier to more advanced services perceived to be of higher quality [7]. This combination of gatekeeping-related factors likely leads to more tension in the doctor–patient relationship and a more stressful work environment for GPs. The gatekeeper role may also be perceived by GPs to be in conflict with their professional autonomy [18]. As part of that role, GPs are expected to consider additional aspects in their clinical decision making, such as costs for the patient. Studies in other countries have shown that physicians have negative attitudes to policies they perceive as interventions in their professional autonomy, particularly when those are based on economic motives [19-21].
We found no personal or facility characteristics that were significantly associated with the GPs’ knowledge about the gatekeeper function of primary care, although privately employed GPs tended to higher knowledge scores than those practising in public facilities. This was likely associated with the financial incentives system currently employed by the NHI agency. Primary care providers are paid by the agency under a capitation system, with payments adjusted to their performance as gatekeepers [4]. For private clinics and practices that rely mainly on those payments as their revenue source, that system will motivate them to a better understanding of the gatekeeper role. In public facilities, where most practising GPs are civil servants with salaries paid from government budgets, the motivation to understand the gatekeeper role may be lower, because there are no direct consequences for financial rewards. Although no studies have documented such an association in Indonesia, studies elsewhere have reported strong associations between financial incentives and physicians’ perceptions about the implementation of policies in practice settings [21, 22].
We observed that GPs who had longer work experience and those who were privately employed had more positive attitudes towards the primary care gatekeeper function. The more experienced GPs may have been exposed to more learning activities, such as specific training that shapes their attitudes more positively towards specific roles or issues such as gatekeeping [23, 24]. Just as with the gatekeeping knowledge scores of private providers, financial incentives may play a part in the higher attitude scores of GPs in private employment. The rapid increases in NHI coverage have prompted more private providers to rely on NHI capitation funding as their main revenue sources. However, competition among private providers is relatively high, as they are allowed to register only non-subsidised NHI beneficiaries. Subsidised (lower-income) beneficiaries are automatically registered at the nearest public primary healthcare centre [4]. Given that NHI capitation is calculated on a per capita basis and adjusted to the performance of private providers, including in gatekeeping, this arguably influences privately employed GPs to have more positive attitudes towards the gatekeeper function. It also implies a potential of private providers to provide better primary care services in terms of quality, access and efficiency, presuming the right incentives are forthcoming from government.
The association between urban GPs and low gatekeeper attitude scores may be explained by differences in the composition of the populations of NHI beneficiaries who live in rural and urban areas. The majority in urban areas are non-subsidised beneficiaries of relatively high socioeconomic status [3]. This segment consists mostly of workers in formal economic sectors who are known to be more demanding, having enjoyed more flexible benefits from their previous insurance schemes before these were subsumed under the NHI [25]. Perceiving primary care to be of low quality, urban patients often request direct referral to secondary care facilities [7]. Currently, the strict regulations applying to NHI beneficiaries for accessing healthcare curtail such swift referrals and lead to more tension in physician–patient relationships [10, 26]. Such frequent conflicts may generate additional stress for GPs, thereby inducing more negative attitudes towards the gatekeeping function. These critical issues need to be urgently addressed, in order to avoid a further negative impact on the geographical accessibility of primary care (urban–rural disparities), on perceived quality due to low patient satisfaction, and on low efficiency caused by unnecessary referrals to secondary care.
The association between part-time employment status and higher scores on gatekeeping performance can be explained by the characteristics of part-time working relationships in Indonesian GP practice. It is legal, and common practice, that GPs work at multiple sites (up to three different facilities) [3]. Such GPs usually practise in one main facility in full-time employment and part-time in one or more other facilities. In facilities where GPs are working part-time, the working arrangements between the facilities and GPs are usually more flexible [10]. Such an environment reduces the work pressure of the GPs [9], which arguably may favourably influence their performance in carrying out the gatekeeping function.
Our final key finding was that GPs in private practice were likely to score lower on gatekeeping performance. This may be attributable to the different practice standards applied by the NHI agency to this type of practice. The NHI agency has contracted private practices because of the inadequacy of other primary care facilities to cope with the additional demand for healthcare that arose after the rapid expansion of NHI coverage [27]. However, the required standards in terms of services such as supporting equipment or office hours are somewhat lower than those for the public and private clinics [4]. This may impair the private GPs’ ability to carry out of the gatekeeper function. Moreover, private practice physicians usually work in solo GP practices without specific support from a management team. This may considerably impede implementation of the gatekeeper function in comparison with healthcare facilities that have monitoring and evaluation mechanisms in place to ensure that the function is adequately carried out. A systematic review of studies in low- and middle-income countries has found that individual private healthcare providers showed lower adherence to regulations than institutional providers [28].
Conclusions and policy implications
Our study demonstrates that GPs in Indonesia are knowledgeable and that they adequately carry out the function of gatekeeper in primary care. However, their attitude towards that function is less positive. Contextual factors such as location and type of facility likely play a major role in influencing GPs’ perceptions towards the gatekeeper function, although individual characteristics such as work experience might also be determining factors. Considering a longer working experience may determine the attitude of GPs toward gatekeeper role, a continued support to GPs which create a more positive working experience may improve the attitude of GPs toward the gatekeeper role. These include routine continuing medical education (CME) and continuing professional development (CPD). Since GPs in urban areas had lower attitude scores and this likely related to a more tense doctor-patient relationship in urban setting, effort to improve the doctor-patient relationship in the context or gatekeeping function become crucial. This includes a social marketing programme about NHI gatekeeping regulations which targeted particularly amongst higher-income NHI beneficiaries living in urban areas. As private providers particularly GP solo practice scored lower in performance toward gatekeeper role, policies to support the improvement of practice standards in private practices particularly for solo GP practice may be useful in increasing their compliance with the gatekeeper function of primary care in the current system. Future studies which use more comprehensive approaches such as a mix-method may provide a better insight on the association between knowledge, attitude, and performance of GPs toward gatekeeper role in Indonesia.