Table 3.

Participants’ quotes for each of the themes.

Theme	Sub-theme	Quotes
Powerlessness	Negotiating practice as patients’ orientation of disease management is still hospital-based	“JKN brings a valuable contribution to help patients access medical care. However, there is a kind of ‘consumerism’ amongst our patients. They all want to go to specialists. They thought that once they paid for the insurance, they could get everything from here. Then I need to explain again, which one is covered and is not covered by the JKN, which cases that we can appropriately refer to, which cases that we can manage in primary care. Even when I think the referrals are unnecessary, I need to explain again. However, I think I can give up my practice if I need to discuss everything with them during the encounter. I JKN has to help us by explaining its regulations to patients” (Doctor 10).
	JKN inadequately acknowledge GPs’ experiences	“One day I had to refer many patients because they had to see specialists in Prolanis program. My referrals were so many, and it was nearly in the size of one-bus group. Can you imagine? Many of them also complained of the JKN long referral process, but I could not do anything more for their prescription. Then we discussed with JKN so that for very simple hypertension, we can manage patients ourselves in primary care” (Doctor 8).
	Lists of diseases set by JKN in primary care limits the GPs’ practice	“Often, some diseases in the JKN list are very challenging to work on in our practice. I had a difficult case of ear wax removal. I have done many tricks, but still, I cannot get the wax out. When I decide to refer the patients to hospital as I could not handle it myself, P-Care wrote the diagnosis with ‘red letters’ stating that we cannot refer it. Oh No! No matter how hard we try to manage it” (Doctor 7).
Clinical resources	Limited medicines available in primary care	“The problem is we do not have any angiotensin receptor blocker pills in Puskesmas. We only have modest antihypertension medication such as furosemide, thiazide, and amlodipine. There was nothing we could do other than to refer back this patient to the hospital” (Doctor 11).
	Limited numbers of GPs in Puskesmas	“Ideally, we only provide service for 5,000 capitation members as we only have two GPs. However, our capitation member is 25 thousand. Every day we see 60-70 patients and often we ended up having only one doctor because another doctor had to go for a meeting. I felt overwhelmed when I do my practice alone as nowadays patients love to come to Puskesmas for any illnesses they have” (Doctor 19).
Administration	Small capitation payment compared to patient cost	“Sometimes, I calculate. . . to treat patients with trauma and lacerations on their skin, I would use my own needle, threads, local anaesthesia, pain killers, and antibiotics when I need to suture the wounds. Those (the prices) are too much for a patient (to purchase the needle and local anaesthesia), compared to just refer them to the hospital. I have to think of my take-home income too” (Doctor 3).
	Complicated paperwork	“The JKN administration requirement was difficult in the field. I had to fill in the (hard-copy) medical records, online medical records, having coordination with midwives, and I had to fill in four administrative papers, such as patient consent, laboratory, and invoice if I order my patient to have a laboratory exam. I need to ask for her consent and many things. The joy of practicing with well-paid income from JKN seemed only a wish” (Doctor 7).