A Challenge of Universal Coverage to HIV/AIDS Outpatients
Lilis Masyfufah
1
, Erwin Astha Triyono
2
1
STIKES Yayasan RS Dr. Soetomo, Karangmenjangan Street No. 12, Surabaya, Indonesia
2
RSUD Dr. Soetomo, Prof. Dr. Moestopo Street No.6-8, Surabaya, Indonesia
Keywords: Utilization, Universal coverage, Affordability, Adherence, HIV/AIDS.
Abstract: HIV/AIDS cases in East Java in 2016 were the largest (16.431) where the most AIDS cases took place in
Indonesia. The National Health Insurance in Indonesia commenced on January 1, 2014. BPJS utilization for
HIV/AIDS patients nowadays is still limited to inpatient service, whereas its utilization by the outpatients
still reaches around 30%. The objective of this research was to analyze the level of BPJS utilization and its
relationship with the level of HIV/AIDS outpatients’ adherence. The method in this research was
quantitative descriptive with a cross-sectional design. This research taken place in Dr. Soetomo General
Hospital, the tertiary referral hospital in Indonesia, and the higest HIV/AIDS referral ini East Indonesia. The
population of this research was HIV/AIDS patients at Dr. Soetomo General Hospital Surabaya’s
Outpatients. The sampling technique used was purposive sampling. The results of this research showed that
there were 31.7% patients who used BPJS to receive outpatient service at Dr. Soetomo General Hospital and
that there was a relationship between health costs affordability and the level of patients’ adherence. The
respondents claimed that BPJS utilization was considered too demanding because there were tiers to benefit
from it and which needed to be got through every month. It was expected that a particular policy on easy
accessibility will be applied to get HIV/AIDS services from the hospital.
1 INTRODUCTION
Human Immunodeficiency Virus (HIV) is a virus
infection which attacks human body’s immune
system. If a person who is infected with HIV shows
some indications, then the virus will be called
Accrued Immune Deficiency Syndrome (AIDS). The
findings of HIV/AIDS cases are increasing in
number, whether it is in Indonesia, East Java, or
Surabaya (Health Office of East Java Province,
2015). In 2016, East Java was ranked first in the
largest number of HIV cases in Indonesia. This
situation makes the Ministry of Health Republic of
Indonesia
(Kemenkes RI) sets the decreasing degree
of morbidity and mortality rates from HIV/AIDS as
one of the targets of Sustainable Development Goals
(SDGs) which are continuous on track targets up to
now. The government has also regulated the
problem of HIV/AIDS by declaring a Regulation of
Ministry of Health Republic of Indonesia
(Permenkes RI) No 782/MENKES/SK/IV/2011 on
Referral Hospitals for people living with HIV and
AIDS (PLWHA) which appoints Dr. Soetomo
General Hospital as the highest referral hospital for
PLWHA in the province of East Java (Ministry of
Health Indonesia Republic, 2016)
HIV/AIDS disease is incurable; however it can
be brought under control by taking anti-retroviral
(ARV) medicine regularly for a lifetime. The result
of a cohort study showed that morbidity and
mortality rates would decrease if PLWHA regularly
took ARV (Health Office of East Java Province,
2015). The same fact, HIV/AIDS was a chronic
disease but of which when it was well maintained
would give people living with HIV/AIDS (PLWHA)
a quality of life as high as the one of people who
were not infected by HIV’s (UPIPI, 2015). This is
proven by the dramatic drop in the degree of AIDS
patients’ mortality rate in the era of ARV.
The HIV treatment is applied by taking ARV
medicine for a lifetime according to the type and
dose prescribed by HIV service doctors. Indeed, this
lifetime ARV consumption does require extremely
high adherence. Patients’ adherence is categorized
into three based on how much ARV a patient needs
to take according to their doctor’s prescription,
namely low <80%, medium ≥ 80-95%, and high
adherence ≥ 95%. One main thing which the patients
need to do to maintain the adherence improvement
238
Masyfufah, L. and Triyono, E.
A Challenge of Universal Coverage to HIV/AIDS Outpatients.
In Proceedings of the 4th Annual Meeting of the Indonesian Health Economics Association (INAHEA 2017), pages 238-241
ISBN: 978-989-758-335-3
Copyright © 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved

and the quality of health is regularly going for a
medical check-up as well as getting the ARV
medicine once a month at the health centre they have
chosen before. ARV medicine in Indonesia were
free to achieve successful treatment in developing
countries. But a few patients admitted that the
obligation to pay a monthly visit to the health centre
for a lifetime could be such a burden that sometimes
they did not feel like doing it which then led to a
follow up failure (patients did not show up again at
the health centre for their scheduled following visit).
HIV/AIDS is a disease whose treatment falls into
the domain of advanced health facilities (hospitals).
A few patients preferred to go for a routine check-up
at Dr. Soetomo General Hospital as the highest
referral hospital, and which seems to have complete
facilities suitable for the needs of patients who are
exposed to opportunistic infections. Universal
coverage was the key of success of SDGs (Ministry
of Health Indonesia Republic, 2016).
Since the
commencement of National Health Insurance in
2014, according to an observation at Dr. Soetomo
General Hospital, the BPJS membership utilization
for HIV/AIDS patients nowadays has been limited to
inpatients service, meanwhile for outpatients has not
yet been optimally put on. On the other hand, both
parties, hospital and patients, are in fact liable to
benefit from outpatient service using BPJS.
Therefore this research needed to be carried out to
find out the degree of BPJS utilization which leads
to the adherence level of HIV/AIDS outpatients in
Surabaya.
2 METHODS
The type of this research is observational,
quantitative descriptive with a cross-sectional
research design. The population of this research was
HIV/AIDS outpatients at Dr. Soetomo General
Hospital Surabaya, who represented the general
condition of HIV/AIDS patients in Surabaya.
Patients at the hospital are an infinite population;
hence the formula used in sample calculation was
proportional estimation method. The technique
applied in sampling was purposive sampling. The
stages in this research were respondents filling in a
questionnaire on how they make payment and an
observation into medical record documents on the
level of patients’ adherence.
3 RESULTS
The results of this research were as follows:
Table 1: Distribution of How the Respondents Make
Payment
Underwrite
r
n %
Personal Expense 41 68.3
BPJS 19 31.7
Total 60 100
It could be seen from Table 1 that there were
31.7% respondents who regularly visited Dr.
Soetomo General Hospital’s Outpatients Care Center
using BPJS. This meant that the respondents
preferred to make a personal expense rather than
making use of their BPJS membership. As for the
amount of expense in one regular visit to the hospital
which the respondents paid is as follows:
Table 2: Distribution of Respondents’ Expense
Amount of Ex
p
ense n %
≥R
p
50,000 1 1.7
>R
p
26,000
–
49,000 6 10.0
≤Rp 25,000 53 88.3
Total 60 100
It could be seen form Table 2 that there were
88.3% respondents who admitted to spending ≤Rp
25,000 for their every visit to the hospital. The
amount was considered affordable by the
respondents. Meanwhile, the relationship between
costs affordability and the level of patients’
adherence is as follows:
Table 3: The Relationship between Costs Affordability and Respondents’ Adherence Level
Categories
Adherence Level
Total
p R
A3 A2 A1
n %n%n%n%
Not Affordable 0 0 1 1.7 0 0 1 1.7
0.010 0.327* Quite Affordable 2 3.3 14 23.3 24 40.0 40 66.7
Affordable 0 0 2 3.3 17 28.3 19 31.7
Information:
A1 : Adherence Level 1
A2 : Adherence Level 2
A3 : Adherence Level 3
A Challenge of Universal Coverage to HIV/AIDS Outpatients
239

It could be seen from Table 3 that there was a
relationship between costs affordability and the level
of adherence by the score of p: 0.010 and correlation
coefficient of 0.327*. This meant that the
relationship was positive and significant, where the
more affordable health costs were, the higher the
patients’ adherence level was.
4 DISCUSSION
BPJS is an institution that organizes Nastional
Health Insurance in Indonesia. Universal coverage
providing a specified package of benefits to all
members of a society with the end goal of providing
financial risk protection, improved access to health
services, and improved health outcomes. From the
result of this research, data which showed that the
respondents preferred to make a personal expense
rather than making use of their BPJS membership
(31.7%) were acquired. The reason behind this was
the respondents would rather spend a small amount
of money, that was <Rp 25,000, or Rp 15,000 to be
exact, than undergoing a tiered referral process
every month for a lifetime. The expense of Rp
15,000 was considered affordable by the
respondents.
However, basically service costs affordability
was not only related with one’s income, other costs
were also added to the list, for example
transportation costs, retribution payment, and the
loss costs when one paid a visit to the hospital.
Included in the loss costs were the cost of being
absent from work or the embarrassment one has to
endure for visiting the hospital every month. The
costs affordability in this research was the sum of
the underwriter’s expense, whether it is BPJS,
private or company or personal insurance and the
amount of costs one needed to pay when they made
payment by personal expense. As discussed before,
most of the patients made personal expense to get a
treatment although they had BPJS. In their opinion,
BPJS utilization was considered to be complicated
because they had to go to the health facilities of first
tier, second tier, then finally the third tier, which is
Dr. Soetomo General Hospital. Fees charged to the
patients to pay for the hospital retribution was Rp
15,000 and no charge for the ARV medicine. This is
because the declaration of a government program
about ARV medication. However, the patients
sometimes came to the hospital along with a relative
who was also infected by HIV, so that the fees paid
exceeded Rp 15,000. This situation was in fact what
burdened the patients because besides the fees there
were also transportation and consumption costs
which in total could be up to Rp 100,000. The other
research mentioned that one of the factors which
hindered the adherence in taking ARV was the costs
of treatment. High-cost and not affordable
treatments would make the patients feel reluctant to
visit the health facilities, and the other way around
applied (WHO,2015; Sugiharti et al, 2014).
When related to the patients’ adherence to take
ARV medicine, costs affordability showed a positive
and significant relationship by the score of p: 0.010
and correlation coefficient of 0.327. Medication
adherence of patients with chronic condition is
highly important so that the factors which support
patients’ adherence must be optimized. Beside of
cost affordability, incorporating a behavioural
component to adherence interventions may increase
potential efficacy of ARV (Dean et al, 2014). The
purpose of ARV medication is to stop HIV virus
from multiplying thus the immune system will
improve. Eventually the viral load (the amount of a
virus in the bloodstream) will decrease even to the
level of undetectable and the other way around, CD4
cell will increase.
HIV/AIDS patients are obliged to go for a
general medical check-up at least once every six
months. The check-up includes complete blood test
and CD4, as well as viral load once a year. As
discussed before, there were patients who did not go
alone when paying a visit to the hospital, but also
along with some relatives which made the costs not
affordable so that they needed BPJS. On the
contrary, most of the respondents claimed that BPJS
utilization was considered too complicated and
demanding because there were tiers to benefit from
it which needed to be got through every month.
Therefore, an innovative health financing program,
especially HIV/AIDS, which is one of the targets of
SDGs. With this innovative program, universal
coverage could be achieved effectively and
efficiently. It is expected that a particular policy on
tiered service will be applied to patients with a
chronic disease, such as HIV/AIDS, who are obliged
to visit the hospital once a month for a lifetime. One
of the possible applicable policies is giving a longer
time period on the referral letter from the first tier
health facility so that HIV/AIDS patients do not
need to get the letter every month. This becomes a
mental burden for the patients because up to now
HIV/AIDS disease carries its own social issue
regarding stigma and discrimination (Schwartlander
et al, 2011).
INAHEA 2017 - 4th Annual Meeting of the Indonesian Health Economics Association
240

5 CONCLUSION
The results of this research showed that there were
merely 31.7% patients who utilized BPJS to receive
outpatient service at Dr. Soetomo General Hospital.
HIV/AIDS patients preferred to make a personal
expense because the costs were considered
affordable. There was a relationship between costs
affordability to visit the hospital and the level of
patients’ adherence. Therefore, a particular policy is
needed in a form of easy accessibility for patients to
get HIV/AIDS service in the hospital. The
government needs arranged a budget to promotive
and preventive programs to save the country's
expenditure on HIV/AIDS. Because the cost of
HIV/AIDS treatment was much greater than its
prevention program.
REFERENCES
Carrin G, Evans D, Xu K., 2007. Designing health
financing policy towards universal coverage. Bull
World Health Organ;85(9):652.
Dean AJ, Walters J, Hall A., 2010. A systematic review of
interventions to enhance medication adherence in
children and adolescents with chronic illness. Arch Dis
Child;95(9):717–23.
Dye C, Reeder JC, Terry RF., 2013. Research for
universal health coverage. American Association for
the Advancement of Science.
Handajani YS, Djoerban Z, Irawan H., 2012. Quality of
life people living with HIV/AIDS: outpatient in
Kramat 128 Hospital Jakarta. Acta Med
Indones;44(4):310–6.
Ministry of Health Republic of Indonesia, 2016. Laporan
Perkembangan HIV AIDS TW 2 2016
Masyfufah L., 2017. Upaya Social Marketing Guna
Meningkatkan Adherence Minum Obat Pasien Upipi
Rsud Dr. Soetomo Surabaya. J Manaj Kesehatan
Yayasan RS Dr Soetomo;2(1):82–95.
Permenkes tentang RS Rujukan ODHA.
Schwartländer B, Stover J, Hallett T, Atun R, Avila C,
Gouws E, et al., 2011. Towards an improved
investment approach for an effective response to
HIV/AIDS. Lancet;377(9782):2031–41.
Souteyrand YP, Collard V, Moatti JP, Grubb I, Guerma
T., 2008. Free care at the point of service delivery: a
key component for reaching universal access to
HIV/AIDS treatment in developing countries.
Aids;22:S161–8.
Sugiharti S, Yuniar Y, Lestary H., 2014. Gambaran
Kepatuhan Orang Dengan Hiv-Aids (Odha) Dalam
Minum Obat Arv Di Kota Bandung, Provinsi Jawa
Barat, Tahun 2011-2012. J Kesehatan
Reproduksi;5(2):113–23.
WHO., 2016. World Health Statistics 2016: Monitoring
Health for the SDGs Sustainable Development Goals.
World Health Organization.
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