189 Finance, Accounting and Business Analysis Volume 7 Issue 2, 2025 http://faba.bg/ ISSN 2603-5324 DOI: https://doi.org/10.37075/FABA.2025.2.05 Determinants of Fraud Prevention of Puskesmas Capitation Funds In The City of Mataram Khopipah Wandan Sari1* , Budi Santoso2 , Endar Pituringsih3 Department of Accounting, University Of Mataram, Mataram, Indonesia1 Department of Accounting, University Of Mataram, Mataram, Indonesia2 Department of Accounting, University Of Mataram, Mataram, Indonesia3 * Corresponding author Info Articles Abstract History Article: Submitted 29 January 2025 Revised 29 May 2025 Accepted 6 August 2025 Purpose: To explain how P-Care, corporate ethical culture, accountability, and the internal control system interact in preventing capitation fund fraud in Puskesmas in Mataram City. Design/Methodology/Approach: This study employs a quantitative approach using an associative research method. Data was collected through surveys using purposive sampling, selecting 66 respondents responsible for managing capitation funds in Puskesmas. Analysis was conducted using the Partial Least Square (PLS) method with SmartPLS 3.8 software. Findings: Accountability, the internal control system, and P-Care play significant roles in preventing capitation fund fraud in Mataram City Puskesmas. Corporate ethical culture hinders fraud prevention efforts, indicating that ethical culture alone is insufficient without strong supervision mechanisms. Practical Implications: Strengthening the internal control system and enhancing accountability can improve fraud prevention effectiveness. The implementation of the P-Care application as a monitoring tool can reduce the risk of capitation fund misuse in Puskesmas. Originality/Value: This study introduces P-Care as a new variable in capitation fund fraud prevention research, whereas previous studies mostly used qualitative approaches. Paper type: Research Paper Keywords: Accountability, internal control system, corporate ethical culture, P-Care, capitation fund fraud prevention JEL: H51, M42, Z13, D73 * Address Correspondence: E-mail: andansary05@gmail.com1 budisantoso@unram.ac.id2 endar07ringsih@unram.ac.id3 http://faba.bg/ https://orcid.org/0009-0003-0159-3063 https://orcid.org/0009-0009-5887-4716 https://orcid.org/0009-0008-7727-038X K. W.Sari, B. Santoso, E. Pituringsih/ Finance, Accounting and Business Analysis, Volume 7, Issue 2, 2025 190 INTRODUCTION Malpractices including corruption and fraud continue to plague Indonesia, causing harm to individuals and the nation as a whole. As a result of fraud's detrimental effects on society, the country, and the state, progress toward development is sluggish. Transparency International also explained that Indonesia's Corruption Perception Index (CPI) score has recorded a decline. Indonesia's Corruption Perception Index score in 2023 stagnated compared to the previous year. Indonesia obtained a score of 34 and its ranking decreased from 110 to 115. As a result, it is safe to say that corruption is still rampant in Indonesia. The Indonesia Corruption Watch (ICW) further clarified that the health sector is one area where corruption persists and has so far proven difficult to remove. Indonesia Corruption Watch (ICW) asserts that the management of health funds, which always increases every year, is still inefficient, making it prone to corruption and resulting in ineffective government health programs and the health status of the Indonesian people still does not show good performance. Fraud in health services is a method that is done intentionally by creating an undue benefit and can harm other parties. Fatimah et al. (2021) identified health fraud as having components pertaining to health services. It is common for fraud to happen throughout the process of implementing health insurance plans. Financial benefits from health insurance programs in the national social security system may be obtained through fraudulent acts that do not comply with the provisions when health officers, participants, healthcare providers, and suppliers of pharmaceuticals and medical devices knowingly engage in National Health Insurance fraud (Ministry of Health of the Republic of Indonesia, 2015). According to the 2018 Report to the Nations Acfe (RTTN) Association of Certified Fraud Examiners (ACFE), about 5% of the overall cost of health services in 2018 was lost to fraud (Permenkes RI Number 16 of 2019). Approximately 170,000 claims totaling Rp. 400 billion ($24.280.680 USD) were identified as fraudulent in Indonesia's BPJS (Social Security Administration for health) system in 2015 (Rahma 2019). The Supreme Audit Agency got an Audit Report on BPJS Health's performance in 2016. The report found that 9,767 health centers and other First Level Health Facilities in Indonesia received capitation money totaling Rp 13 trillion ($789.122.100 USD) in 2016. We want to finance services to 188 million people with these money. Health facilities still have inadequate governance, which leaves capitation payments open to fraud and other forms of abuse (BPK RI 2016). Capitation funds are one form of financing in the National Health Insurance system provided by social security organizing agency health to first-level health facilities, such as Puskesmas, clinics, and independent doctor practices. This capitation system aims to encourage efficiency, cost control, and improve the quality of health services by providing fixed payments based on the number of registered participants, regardless of the number of services they use. Capitation funds are used to fund various operational needs of the Puskesmas, including the purchase of consumables, medical devices, drug needs, as well as incentives for health workers. In addition, these funds also support promotive and preventive activities, which are an important part of improving the health status of the community. In its implementation, the capitation fund has a strategic role because it is directly related to the availability of basic health services for the community, especially in areas that depend on Puskesmas as the main provider of health services. However, various studies and monitoring reports show that the management of capitation funds often faces challenges, both in terms of transparency, accountability, efficiency of use, and compliance with laws and regulations. Problems such as delays in disbursement, lack of managerial capacity, and internal conflicts in the distribution of services are still often found in the field. These funds were chosen as the focus of the study because they often face various challenges in terms of management, accountability, and efficiency of use. In addition, capitation funds have a direct impact on the performance of health services at Puskesmas, so it is important to examine the extent to which their management is in accordance with the provisions and is able to support the achievement of JKN system objectives. Businesses may protect themselves against fraud by implementing a solid control system. Additionally, the internal control system will not function efficiently in the absence of principles or values, since this will lead to unethical actions, which in turn will impact the amount of agency irregularities. The findings are in agreement with those of Laksmi and Sujana (2019) who found that an effective internal control system may reduce the likelihood of fraud. The internal control system significantly impacts fraud prevention according to research by Rahmawati et al. (2020). The internal control system is an important mechanism in preventing fraud in the public sector. According to Batkunde et al. (2024) effective internal control includes risk assessment, control activities, information and communication, and continuous monitoring. Implementation of this system can identify potential fraud risks early and ensure that the use of funds is in accordance with applicable regulations. K. W.Sari, B. Santoso, E. Pituringsih/ Finance, Accounting and Business Analysis, Volume 7, Issue 2, 2025 191 The study by Rachman et al. (2021) shows that internal control has a significant influence on fraud prevention in hospitals, with strict supervision and clear procedures, organizations can minimize opportunities for fraud. Accountability is another measure that may be taken to prevent fraud. The agent holding the trust has a responsibility to the principal who established the trust to account for all actions taken by the agent including limited to reporting and disclosing relevant information. Rahmawati et al. (2020) found that accountability significantly affects fraud prevention, therefore this makes sense. Accountability in the management of capitation funds includes efficient and effective budget planning, use of funds according to regulations, and transparent and easy-to-understand financial reporting. Pratiwi et al. (2023) emphasized that high accountability in the public sector can prevent fraud by ensuring that every use of funds can be accounted for. In addition, a study by Aviva (2022) shows that an organization's commitment to accountability, supported by a strong internal control system, can significantly reduce the risk of fraud. When it comes to preventing fraud, health institutions need more than just an accountability system and an internal control system. They also need an organizational ethical culture. What we mean when we talk about an organization's ethical culture is the shared values and norms that everyone works to uphold. By behavior here we mean actions that are both ethically acceptable and legally valid. This is in agreement with the findings of Susandya et al. (2022) who demonstrated that an ethical culture inside a business may effectively reduce instances of fraud. Ethical culture in the organization plays an important role in shaping employee behavior that upholds integrity and honesty. Soehaditama (2024) states that a strong organizational culture, characterized by ethical values that are internalized by all members, can prevent fraud. However, research by Wardah et al. (2022) found that an organizational culture that is not supported by an effective whistleblowing system and a lack of trust between employees can reduce the effectiveness of ethical culture in preventing fraud. Also, the p-care app is a great way to keep Puskesmas capitation monies safe from fraud. P-care is an information system for Puskesmas created by the Republic of Indonesia's Ministry of Health. Multiple components of the P-Care function for Puskesmas facilitate the administration of health care to BPJS patients and the administration of patient data. No dedicated app for preventing capitation fund fraud, the fraud prevention team can utilize online reporting tools like P-care to keep Puskesmas safe from capitation and JKN fund fraud. The theories of fraud triangles Skousen et al (2009) and agency, first proposed by Jensen & Meckling (1976), provide the basis of this study. Three things rationalization, opportunity, and pressure contribute to fraud, according to the fraud triangle hypothesis. The agency theory goes on to say that an agency relationship is a contract between a principal and an agent whereby the agent is hired to carry out the principal's instructions and make decisions on the principal's behalf. For this reason, fraud may happen in any business or organization when there is a mismatch in the amount of information available to the agent and the principal; Puskesmas are no exception. In order to avoid the possibility of capitation fund fraud at Puskesmas, it is crucial to establish a strong internal control system, hold employees accountable, foster an ethical culture inside the firm, and use the p-care program. According to the above explanation, there is room for more study that might address the issue of capitation fund fraud involving Puskesmas in Mataram City by using the p-care application as a unique research variable. In order to combat capitation fund fraud at the Mataram City health facility, researchers are encouraged to adopt a quantitative method. The innovation of the study lies in the variable usage of the p-care application. A qualitative technique is often used in research concerning the p-care application. Researchers are convinced that this study is vital to conduct due to the rising occurrence of capitation fund fraud. METHODS This study is an associative study with a quantitative approach. An associative study is a study that aims to determine the relationship between two or more variables (Sugiyono 2018). This type of study uses a causal relationship, which is a cause-and-effect relationship, where internal control systems, accountability, organizational ethical culture, and p-care influence the prevention of capitation fund fraud. The research location is a place where researchers obtain information about the required data. This research was conducted at Puskesmas in Mataram City in 2024, with a focus on Puskesmas that are directly involved in receiving capitation funds. The selection of Puskesmas in City X was due to the disclosure of a case related to capitation fund fraud located at Puskesmas Y in City X resulting in a government loss of Rp. 690 million. Workers from eleven major Puskesmas and seventeen auxiliary Puskesmas in City X who were responsible for administering capitation funds and the p-care app made up the population studied. Sugiyono (2018) explains that this study's sample method was purposive sampling, a method that K. W.Sari, B. Santoso, E. Pituringsih/ Finance, Accounting and Business Analysis, Volume 7, Issue 2, 2025 192 takes certain factors into account. This sample was conducted with the assumption that individuals with decision-making and financial-management power are familiar with the Puskesmas' capitation fund management practices. In addition, only employees who play a role in operating the p-care application understand the duties and functions of p-care for claiming capitation funds. Based on the purposive sample method, the sampling criteria used are: 1. Parties who have authority in financial management. 2. Parties involved in making financial management decisions. 3. Parties who act as supervisors and are responsible for the operation of p-care. The instrument in this study is a questionnaire containing certain questions related to the variables studied. The instrument is compiled based on the indicators contained in the research variables which are described in question items. A questionnaire is the primary tool for gathering information in this study. This research makes use of quantitative methods by putting the hypothesis to the test with the help of the SmartPLS 3.8 software program and the Partial Least Square (PLS) methodology. PLS was used in this study because it is able to overcome multicollinearity, works well on small samples, does not require normal distribution assumptions, and focuses on prediction. RESULTS AND DISCUSSION For this investigation, the data was analyzed using the Sem-PLS approach in conjunction with the Smart PLS version 3.8 application. In Smart PLS 3.8, building a conceptual research model is the first step in data analysis. A reflecting outer model measurement model was used in this investigation. One term for the reflective measurement model is the primary factor model. It states that latent constructs may either affect the covariance of indicator measures or characterize the variance of latent constructs. By examining the loading factor, composite reliability, Cronbach's alpha, average variance extracted, discriminant reliability, and cross loading, this measurement approach ensures that the study indicators are valid and reliable (Ghazali and Latan 2015). One way to find out whether a questionnaire is valid is to run it through a validity test, which looks at how well the instrument measures each variable and how well each statement item explains the variable. The reliability test, on the other hand, involves checking how well the instrument (a questionnaire in this example) consistently measures variables and how accurate the measuring equipment is. You may view the exterior model in the picture below Source: Data Processed (2024) Figure 1. Outer model K. W.Sari, B. Santoso, E. Pituringsih/ Finance, Accounting and Business Analysis, Volume 7, Issue 2, 2025 193 Figure 1 shows that the Internal Control System variable is measured using 10 statements with indicators referring to Sulistyorini and Urumsah (2021) research including: control environment, risk assessment, control activities, information and communication, monitoring. The Accountability variable is measured by 6 statements with research indicators referring to research Rahmawati et al. (2020) including: Formulation of financial plans, implementation and financing of activities, and implementation of financial reporting. The Organizational Ethical Culture variable is measured by 10 statements among others: Superior congruence, employee congruence, transparency, discussion and sanctions. The P-Care variable is measured by 8 statements with research indicators referring to the benefits of the p-care application released by Rizka et al. (2018) including: Transparency, centralized patient data management, verification of ideality and validation of services and monitoring of the use of capitation funds. The Fraud Prevention variable was measured using 10 statements with research indicators referring to research Wardhani et al. (2021) among others: Management responsibility for evaluating fraud prevention, supervision of auditors, there is a clear separation of functions and responsibilities, providing a means of complaint. Evaluation of the Measurement Model (Outer Model) Testing the model's validity and reliability is the process of evaluating the measurement model, also known as the outer model. A reflective construct's validity may be assessed using convergent and discriminant validity tests. There need to be a strong correlation between all measures of each variable for there to be convergent validity. Each variable indicator displays its test result in the form of an outer loading value. As stated by Hair et al. (2021) if the outer loading value of any indication is more than 0.70, it may be deemed constrained. Here are the results of the Smart PLS 3.8 tests conducted using the PLS-SEM Algorithm: Source: Data Processed (2024) Figure 2. Outer model after elimination Figure 2 of the route diagram shows that some statements have been removed because their loading factor is below 0.7 while the loading factor limit for an indicator to be considered reliable is at least 0.7. So that the X2.5, X3.3, Y1.2, Y1.3, and Y1.4 indicator statements must be deleted because they are not reliable or the loading factor value is below 0.7. Once the faulty statement signs are removed, the data can be analysed further and another test can be run to determine the results of the study. K. W.Sari, B. Santoso, E. Pituringsih/ Finance, Accounting and Business Analysis, Volume 7, Issue 2, 2025 194 After that, you should strive for dependability, which you can do by checking for things like composite reliability, an average variance extract (AVE) value more than 0.50, and a Cronbach alpha value greater than 0.70. The following is the AVE value for each variable, as determined using the PLS SEM Algorithm: Table 1. Cronbach's alpha, and average variance extracted (AVE) Variable Cronbach's Alpha AVE SPI 0.961 0.743 AKT 0.925 0.772 BEO 0.943 0.685 PC 0.911 0.617 PF 0.896 0.618 Source: Smart PLS 3 Each indication has a Cronbach's alpha value more than 0.70, as shown in table 1. The reliability is considered perfect when Cronbach's alpha is greater than 0.90. High reliability is indicated by a value between 0.70 and 0.90. Moderate reliability is indicated by a value between 0.50 and 0.70. The internal control system, accountability, corporate ethical culture, and p-care variables all have flawless reliability, as shown by a Cronbach's alpha value greater than 0.90. The fraud prevention variable is quite reliable. Structural Inner Model Evaluation In order to ascertain if the connection is appropriate and the model is excellent, an examination of the internal structural model is conducted. The f-square, r-square, and q-square values are examined in many steps throughout this assessment (Hair et al. 2021). - F-Square To determine the impact of variables on a structural level, the F-square test is used. According to Hair et.al. (2021), there are three categories for the f-squared value: low (f=0.02), moderate (f=0.15), and high (f=0.35). Each variable's f-square value is as follows: Table 2. F-Square variable F-Square X1 0.103 X2 0.195 X3 0.057 X4 0.376 Source: Smart PLS 3 Table 2 shows that there is a moderate internal control system, a poor organizational ethical culture, and a high f-square value for p-care. After analyzing the structural model, it is clear that p-care has a significant impact, corporate ethical culture has a moderate impact, and internal control and accountability have a modest effect. - R-Square To find out how well the independent variable can explain the dependent variable, researchers employing smart PLS use the R-Square test. According to Ghazali & Latan (2015) an R-Square value of 0.67 is considered excellent, 0.3 is considered moderate, and 0.19 is considered poor. In the following table, we can see the study's R-Square value: Table 3. R-Square R-Square 0.527 Source: Smart PLS 3 Table 3 shows that the model's R-Square value for p-care, corporate ethical culture, accountability, and internal control system for fraud prevention is 0.527. With a value of 0.527, R-Square is considered modest. Accordingly, p-care, corporate ethical culture, accountability, and the internal control system all have a moderate impact on fraud prevention, accounting for 52% of the total. Other characteristics not K. W.Sari, B. Santoso, E. Pituringsih/ Finance, Accounting and Business Analysis, Volume 7, Issue 2, 2025 195 included in this study's model account for 48% of fraud prevention. - Hypothesis Test To determine the impact of interdependent latent variables, the following inner model test employs the bootstrapping technique (Ghozali and Laten 2015). The path coefficients table includes the p-value and t-statistic, which reveal the significant value. At the 5% alpha level, the hypothesis's significance value is one-tailed. In addition, the t-statistic is larger than 1.66, allowing us to accept the hypothesis. The p-values corroborate this, especially when the alpha is set at 5% (0.05). Hence, the hypothesis may be accepted if the p-values are less than 0.05, and rejected if the p-values are more than 0.05. The original sample table also shows the direction and size of the study impact. In Table 4 below, the following scholars provide the findings from the study of latent variables: Table 4. Hypothesis Test Results Original Sample T Statistic P Values Conclusion X1 -> Y 0.243 2.685 0.007 positive X2 -> Y 0.313 4.340 0.000 positive X3 -> Y 0.177 1.365 0.173 negative X4 -> Y 0.454 5.095 0.000 positive Source: Smart PLS 3 The results of the hypothesis test after the use of Smart PLS 3.8 are detailed in Table 4. We accept as true the first hypothesis which states that the internal control system helps to reduce the likelihood of fraud. The internal control system has a positive effect on fraud prevention as shown by a p-value of 0.007 which is less than 0.05. This effect can also be seen by comparing the t-statistic values in the table which must be greater than 1.66. Based on the results of the tests, the internal control system does a good job of preventing fraud t-statistic = 2.685> 1.66. The internal control system is a process designed to provide reasonable assurance regarding the achievement of organizational objectives, including in terms of the reliability of financial reporting, compliance with laws and regulations and operational effectiveness and efficiency. In this research, the internal control system consists of five main indicators: control environment, risk assessment, control activities, information and communication, and monitoring. Consistent application of these five components will reduce the risk of fraud in the Puskesmas. This system not only reduces opportunities, but also increases awareness that every action will be monitored and have a legal impact. Both hypotheses are accepted, with the second one explaining how responsibility helps avoid fraud. There is a positive relationship between accountability and fraud prevention, as shown by a p-value of 0.000, which is less than 0.05. Accountability positively affects fraud prevention, as shown by the t-statistic result of 4.340> 1.66. Accountability in Puskesmas is demonstrated through systematic and responsible practices for the use of funds and program implementation. The accountability indicators used in this context are conducting budget planning to design programs with the principles of efficiency and effectiveness, using capitation funds based on applicable regulations, not withdrawing fees from participants that should have been guaranteed in the capitation fee, and the financial reports submitted contain clear and easy-to- understand information. If all indicators are applied, the opportunity to commit fraud will be small. Accountability is not just a report, but also an attitude of responsibility that is evidenced through transparency and compliance with the rules. Puskesmas employees will think twice before misusing funds or manipulating reports, because all use of resources is openly accounted for. Claiming that an organization's ethical culture aids in preventing fraud, the third hypothesis is deemed false. The results of the hypothesis test showed that the ethical culture of the business has a negative effect on fraud prevention p-value = 0.173 indicating a significance level > 0.05. A t-statistic score of 1.365 < 1.66 indicates that the organization's ethical culture hinders efforts to avoid fraud. Theoretically, the ethical culture of the organization is seen as one of the important factors in preventing fraud. However, in its implementation, ethical culture can actually have a negative impact on fraud prevention if existing ethical values are not applied consistently and thoroughly. Organizational ethical culture will have a negative impact on fraud prevention if its values are not consistently applied, not accompanied by exemplary leadership, not supported by an effective reporting system, and not equipped with strict sanctions. In these conditions, ethical culture only becomes a formal symbol that is unable to function as a controller of organizational behavior, thus opening up opportunities for fraud to occur repeatedly. The acceptance of the fourth hypothesis indicates that p-care does help reduce instances of fraud. There is a positive relationship between p-care and fraud prevention, as shown by a p-value of 0.000, which is less than 0.05. Because p-care has a positive effect on fraud prevention, the t-statistic result is 5.095> 1.66. K. W.Sari, B. Santoso, E. Pituringsih/ Finance, Accounting and Business Analysis, Volume 7, Issue 2, 2025 196 P-Care (Primary Care) is a technology-based information system developed by Social Security Administration for health to facilitate first-level health services. In the context of capitation fund management in health care facilities such as Puskesmas, the application of P-Care contributes significantly to the prevention of fraud. This is supported by several key indicators, namely: transparency and activity tracking, centralized patient data management, monitoring the use of capitation funds, and ease of audit reporting. The implementation of P-Care directly has a positive impact on the prevention of capitation fund fraud. Through the features of transparency, data integration, fund monitoring, and efficient reporting, the system strengthens the accountability of fund management and minimizes potential irregularities. Therefore, P-Care can be seen as a strategic instrument in supporting clean and accountable financial governance in the primary health care sector. CONCLUSIONS Mataram City's Puskesmas capitation funds are the focus of this empirical investigation of the role of p-care, organizational ethics, accountability, and the internal control system in preventif fraud such that the following inferences may be made from the conducted research: 1. When it comes to the city of Mataram's capitation money for Puskesmas, the internal control mechanism helps to avoid fraud. This demonstrates how effective the Puskesmas' internal control mechanism is in preventing the theft of Puskesmas capitation monies. 2. The prevention of fraud involving the city of Mataram's capitation money for health clinics is aided by accountability. This demonstrates how effective responsibility for the use of Puskesmas capitation money is in preventing fraud using these monies. 3. The prevention of fraud involving the capitation money for Puskesmas in Mataram is hindered by the organization's ethical culture. As a result, it is evident that an organization's ethical culture is not enough to avoid fraud, especially in the absence of a clear supervision structure and the capacity to identify and counter unethical activity. 4. Mataram City's Puskesmas are less likely to have their capitation fees stolen thanks to P-care. 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