A quantitative descriptive study was conducted in two of 22 total Puskesmas in Padang City, West Sumatera, Indonesia. The units were classified into two groups- an urban and rural area with more than 10 dental patients per day. Puskesmas provide the primary healthcare and financed by the Indonesian government. The study was approved by The Committee of the Research Ethics, Faculty of Medicine, Andalas University (096/KEP/FK/2016). The data was collected in 2 months from April-June 2016.

The puskesmas were selected by random sampling, one representative for urban and rural the counterpart. A retrospective database analysis was conducted to retrace the puskesmas record database between January until December 2016. Two administrative officers were interviewed to ensure the appropriateness of data at each puskesmas and complete the supplementary information. The preliminary step, was to identify the dental health service pathway [Table/Fig-1] at puskesmas based on puskesmas medical record and annual puskesmas statistical data report.

[Table/Fig-1]:

Dental health service pathway at Puskesmas.

According to the purpose, Activity-Based Costing (ABC) method was used to calculate the unit cost on basic healthcare service at puskesmas [Table/Fig-2]. Firstly, identification of the dental service activities related to health workforce and the resource cost was done then grouping to the direct and indirect costs associated to dental services. Then data was classified into three activity levels, including unit level (direct activity inside dental treatment), batch level (direct activity outside the treatment), and organising-sustaining level (supportive activity). Thus, categorised each cost pool (cost group of the same activity level and cost driver) grouped by cost pool A-E based on the same activity level and cost grouping counterpart. Each cost pool A, B, C, D, E was determined by the specific grouping of level activity depending on direct or indirect cost at puskesmas. The direct group included cost pool A at the unit level (workforce costs; the cost of dental and medical consumables equipment). The indirect group consisted of cost pool B (pharmaceutical costs) and C (workforce costs) at batch level, cost pool D (routine expenditure costs) and E (workforce costs) at Organisation-Sustaining level. Total cost pool value was summarised by the whole of A, B, C, D, E cost pool. Secondly, cost driver formulated by the total cost pool divided entire patient visit per year at puskesmas Thirdly, a qualitative approach through in-deep interview was designed for the understanding of job desk per personnel, total salary and bonus. The annual mean cost per personnel resulted from total cost personnel divided by 12 months. Determination of the cost driver was used to calculate unit cost pool as changing cost factor. Cost driver using Cokins grouping was differentiated into activity driver and resource driver [20]. The last but not least was the calculation of the unit cost (total summary of unit cost pool) and expressed in the Indonesian Rupiah/Indonesia Dalam Rupiah (IDR).

[Table/Fig-2]:

Mapping of unit cost calculation using activity-based costing method on Dental Health Services.

Based on this study, there were 15 officers involved in dental services in urban puskesmas, of which there were four dentists and one dental assistant. Meanwhile 12 officers consisted of three dentists and one dental assistant were directly involved in dental healthcare at rural puskesmas. [Table/Fig-3] showed that investment and maintenance costs were being excluded; only operating cost included the unit cost calculation. The rest banned due to Act No. 28 of 2014 stated that the Indonesian government is investing in the building of puskesmas at the fist, thus excluded in capitation payment method [21]. Workforce cost was the most significant number of the cost recapitulation obtained from the cost tracking results at the urban and rural puskesmas.

Level activity based on unit level, batch level, and organising-sustaining level were classified and grouped into a direct and indirect cost [Table/Fig-4]. [Table/Fig-5] demonstrates average cost charges accumulated for each cost pool. Both urban and rural puskesmas had the highest cost pool A on dental health services.

Resource drive is a ratio of total of the dental and general patient; meanwhile, activity driver is a total of the dental patient [Table/Fig-6]. The cost driver is the measurable cost change factor that included total patient, ratio health service. [Table/Fig-6] described that the urban puskesmas resource driver which was relatively (0.0306) similar to rural puskesmas (0.0348). On the other hand, urban activity driver was bigger than rural puskesmas, means urban puskesmas had more patients than the rural counterpart.

All costs collected were divided by the cost drivers that have been specified. As the costs accumulated for cost pools A and B will be divided by the activity and accrued on the cost pool C, D and E will be multiplied by the resource driver and then shared by the activity driver. Based on [Table/Fig-7], determination of dental health services was measured by the summary of all cost pool. Cost pool A in both puskesmas was the highest among other with total unit cost pool in rural being higher than urban puskesmas.

Cost pool A as the most significant cost pools included workforce expenditure. [Table/Fig-8] describes that the deduction of unit cost pool A and total unit cost at urban puskesmas was not differed from rural puskesmas and ranged from 5-7%. with the smallest deduction found in the urban puskesmas (4,893). The total unit value is strongly influenced by the current costs in cost pool A and impacted a small amount of other cost pool. It may be caused by investment and maintenance costs being excluded in the unit cost calculation at puskesmas.

Cost pool A being directly involved in dental services, consisted of workforce cost, equipment, and dental consumables cost, and general medical consumables for dental services cost. [Table/Fig-9] showed that the workforce cost is the largest cost of cost pool A. Only about 10% is used for others including equipment and dental consumables, and general medical consumables in urban and rural puskesmas.

[Table/Fig-10] demonstrated that the average cost per year for dental health services at rural and urban puskesmas almost similar and ranged from 84 to 88 million/year. Meanwhile, the dental caretaker cost in rural (IDR 90,840/service) was higher than urban counterpart (IDR 72,771/service).

The evolution of Indonesian Healthcare System might be unique. Since the reformation of the NHI era, the Indonesian government has launched universal health insurance managed by BPJS. The funding was delivered to the primary healthcare (puskesmas and Pratama clinic) and advance healthcare (hospital). Puskesmas were established to improve the integrative program of preventive and curative healthcare. The funding of basic healthcare service financed by the Indonesian government is only allocated for operational costs and services. Meanwhile, investment and maintenance costs are excluded, so it is only considerate for the operating cost on cost recapitulation by cost usage [Table/Fig-3] [1,2,4]. Furthermore, we calculated the unit cost of dental health service based on capitation method in general and not per case. This result has a significant difference with Vo TQ et al., in Vietnam that analysed estimating cost resource from one case then calculated the cost based on the resource utilisation [20].

By using the ABC methods, we could evaluate the most significant cost value for dental service; it gives a lot of information about the dental health services-unit cost value of each primary health care and provide the detailed cost of one service to each activity after NHI era. The result revealed that the unit cost of dental service in urban puskesmas was IDR 86.652 and rural was IDR 108,721 with the total mean of the unit cost at puskesmas being IDR 97,686. Unit cost calculation by Indonesian Dental Association study before NHI era covered by Indonesian insurance was IDR 98.404 and estimation of Indonesian government calculation was IDR 98.522. Both of the calculation result are in range with our study result. Therefore, the result of this study was accurate and gave a detailed explanation of primary health care at puskesmas in the urban and rural area. Hence, our research could help the Government to analyse the kind of cost in primary health care that impacted the unit cost after the NHI era [9,10].

This study showed that there was a average difference of dental health service-unit cost between urban (IDR 86,652) and rural (IDR 108,721,63) due to the unequal distribution of the total officers at each puskesmas. According to the result, the highest cost value for a dental service comes from dental health personnel cost with low income from dental health service at puskesmas in a year. Viewed from mean cost per person per years, rural puskesmas (IDR 87,865,198) spend more cost than urban puskesmas (IDR 84,619,028). Based on the job desk per personnel, urban puskesmas had a higher workload than rural puskesmas. It means that rural puskesmas spend more money on one activity of one dental officer than urban puskesmas. This disparity can be explained mainly by the inexactitude distribution of dental caretaker, as well as inequitable and inadequate access to oral healthcare services in the rural and urban area [17-19].

This finding has some restraint that should be lightly interpretated that average cost only concentrated on cost calculation per type of treatment not per case due to capitation method, by the Indonesian government. Furthermore, each activity was independently gathered with general and medical health services, so all the dental services must be specifically stratified. Besides, the result of the annual unit cost calculation will be different according to each activity per year.

Unit cost calculation based on ABC method can help the decision makers to provide accurate and precise information about improving the efficiency and effectiveness of each officer’ workload and designing strategies that could be implemented to improve the quality of dental healthcare service. The result of this study also helps the Indonesian government to determine the reasonable Indonesian capitation value.

NHI National Health Insurance; BPJS Badan Penyelenggara Jaminan Sosial/Social Security Administering Board; PUSKESMAS Community-based health service; PDGI Persatuan Dokter Gigi Indonesia/Indonesian Dental Association; ABC Activity Based Costing; IDR Indonesia Dalam Rupiah/Indonesian Rupiah.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and or publication of this article.