Hrev_master Healthcare in Low-resource Settings 2025; volume 13:12773 Exploratory study of factors influencing fraud in the national health service in Buton Islands from a hexagon model perspective Andi Yaumil Bay R. Thaifur Department of Health Policy Administration, Universitas Dayanu Ikhsanuddin, City of Baubau, Indonesia Abstract Fraud in National Health Insurance of Indonesia, known as Jaminan Kesehatan Nasional (JKN) services, is a problem that can potentially occur in all hospitals in Indonesia. This research aims to explore the factors that influence the occurrence of fraud from the perspective of the Hexagon model in JKN services in several hospi- tals in the Buton Islands. The Hexagon model, which consists of six key factors—opportunity, ability, arrogance, pressure, rationaliza- tion, and collusion—was used to systematically analyze the occur- rence of fraud. This research uses an exploratory study method with in-depth interviews with 30 key informants. The research results show that the factor that most influences the occurrence of fraud is opportunity, followed by ability and arrogance. Although the model suggests pressure and rationalization as contributing factors, these elements remain ambiguous in this study due to insufficient sup- porting data. Collusion plays an important role in fraud but does not always occur. The study resulted in the development of a prelimi- nary predictor model based on the findings, which can be used to identify risk factors for fraud in JKN services. This predictor model can be used to identify risk factors for fraud so that more effective prevention and response can be carried out. Introduction National Health Insurance of Indonesia, known as Jaminan Kesehatan Nasional (JKN), is a government program that aims to provide access to quality and fair health services for all Indonesian people.1 This program has been implemented since 2014 and has significantly benefited the community. However, this program also faces various challenges, including fraud. Fraud can have a negative impact on the sustainability of the JKN program, such as increasing program costs, decreasing service quality, and losing public trust. The complexity of managing such a large-scale health insurance system, particularly in areas with unique socio-econom- ic and geographic challenges, exacerbates these risks. The problem of fraud in all Indonesian hospitals has the poten- tial to occur anywhere, so this study is a challenge that has impli- cations for the sustainability of accountable JKN hospital admin- istration and excellent services. Several studies conducted in Indonesia, most of which have identified findings based on the detection of potential or risk of fraud in hospitals. At a General Pulmonary Hospital of RSUP. Dr. Soeradji Tirtonegoro,2 and at a Regional Hospital RSUD Tenriawaru,3 health workers and coders commit both intentional and unintentional forms of fraud. The results of this fraud are in line with previous findings, which emphasize problems related to the dissemination of policies and programs that have not been evenly distributed to regions and pol- icy aspects of service infrastructure in health facilities, referral systems, and HR and Capacity Building, financing aspects, and risk management of fraud.4,5 However, these studies often focus on more central regions, while fraud in more remote areas, such as the Buton Islands, remains underexplored. The Buton Islands were selected as the focus of this research due to their remote geographical location, limited access to health- care resources, and lower economic levels, which create a distinc- tive context for understanding fraud risk within the JKN program. These conditions present heightened challenges for monitoring and enforcing compliance, potentially increasing the opportunities and motives for fraudulent activities. By focusing on this region, this study aims to fill the gap in the literature concerning how geo- graphic and economic isolation may influence fraud in the context of national health insurance programs. The Hexagon Model is a comprehensive and holistic model for understanding the factors that influence fraud incidents. The Hexagon Fraud model has been used to detect fraudulent financial reporting in Indonesian state-owned enterprises.6 The Fraud Correspondence: Andi Yaumil Bay R. Thaifur, Department of Health Policy Administration, Universitas Dayanu Ikhsanuddin, City of Baubau, Indonesia. E-mail: andiyaumilbay.t@gmail.com Key words: fraud, hexagon model, hospital, national health insurance. Conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. Ethics approval: the Ethics Committee of Health Research from the Faculty of Public Health, Hasanuddin University, approved this study (Number 2743/UN4.14.1/TP.01.02/2022). Informed consent: all patients participating in this study signed a written informed consent form for participating in this study. Patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient infor- mation to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received: 3 July 2024. Accepted: 27 October 2024. Early access: 26 November 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13:12773 doi:10.4081/hls.2024.12773 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 32] [Healthcare in Low-resource Settings 2025;13:12773] Hexagon Theory proposed by Vousinas (2019) from the National Technical University of Athens, derived from the Pentecostal Theory (SCORE), includes Stimulus (pressure), Capacity (capabil- ity), Opportunity, Rationalization, and Ego.7 In the context of JKN services, these dimensions can manifest in various ways: for instance, ‘opportunity’ may arise from gaps in regulatory enforce- ment, ‘pressure’ from financial strains on healthcare providers, and ‘collusion’ through coordinated efforts between staff to exploit the system. In this research, the model consists of six interrelated dimensions: pressure, opportunity, capability, rationalization, arro- gance, and collusion. Each dimension can be a driving factor for fraud, both independently and mutually reinforcing. This research aims to identify specific dimensions of the Hexagon Model that are most prevalent in the Buton Islands, and to examine how these fac- tors interact with the local context. By doing so, this study con- tributes to a deeper understanding of fraud dynamics within the JKN system in remote regions and offers insights into more effec- tive prevention strategies tailored to such environments. Materials and Methods This study employed a qualitative exploratory design to iden- tify conceptual indicators as predictors of potential fraud in several Buton Islands hospitals by exploring information through in-depth interview activities focused on the hexagon model aspects. The research was conducted at 3 (three) Regional General Hospitals (RSUD) and 1 (one) Private Hospital in the Buton Islands, which were selected purposively, namely Buton District Hospital, South Buton District Hospital, Central Buton District Hospital, and Faga Husada Hospital. The selection of these hospitals was based on cri- teria including hospital size, geographical distribution, and the diversity of services provided, ensuring a comprehensive explo- ration of fraud risk in different healthcare settings. The development of dimensions and indicators through this exploratory study aims to capture the diverse perspectives of selected informants, who were hospital staff members, managers, and healthcare professionals, involved directly or indirectly in financial management or administrative duties. These perspectives serve as a foundation for preparing instruments that will contribute to a predictive model for fraud incidents (Table 1). The key infor- mants were selected using purposive sampling based on their role in the hospital, their involvement in financial or administrative processes, and their knowledge or exposure to fraud risk factors. The total number of key informants in this research was 30 people. The tools or instruments used in collecting qualitative data are as follows: i) In-depth Interview (Indepth-Interview) is a guide that is modified according to regional conditions and created based on identifying problems indicative of fraud; ii) Recording equipment consists of a notebook, a digital camera to record images during interviews, and a tape recorder to record the informant’s voice; iii) Informed Consent is a form requesting willingness to become an informant from the researcher and a consent form to become an informant from the informant. Data were collected through direct interview techniques using open-ended questions. In-depth inter- views were conducted when information obtained was incomplete or required further clarification for thematic analysis. The infor- mants were asked about their perceptions, experiences, and under- standing of fraud within the JKN system. Interviews were carried out in person or via telephone, and the results were documented into interview transcripts and matrices, which were then analyzed. Data analysis was conducted using content analysis, focusing on thematic coding, classification, and the identification of pat- terns in the responses. The process of classifying answers was guided by the research questions and fraud indicators identified in the Hexagon model. The data were further analyzed to predict potential areas of fraud based on informants’ responses. Validity testing was ensured through multiple measures: credibility (inter- nal validity) was established by triangulating data from different informants and sources, while transferability (external validity) was enhanced by providing detailed descriptions of the study con- text, allowing for replication in similar settings. Results Based on the qualitative study (Table 2), the factors influenc- ing the occurrence of fraud in JKN services in the Buton Islands are complex and interrelated. The most influential factor identified was opportunity, followed by capability and arrogance. Pressure was less conclusive, as some informants did not perceive it as a significant driver of fraud. Rationalization and arrogance often strengthen the primary factors, enabling individuals to justify fraudulent behavior. Collusion was identified as a supportive but not always necessary element for fraud to occur. Discussion Using the Hexagon model perspective, this qualitative study reveals the factors that influence the occurrence of fraud in National Health Insurance (JKN) services in various hospitals. These findings illustrate the complexity of the fraud phenomenon in the healthcare context. In alignment with previous studies, this research highlights how systemic factors such as internal hospital pressures and socio-economic conditions contribute to fraudulent behavior. In the context of pressure, research results show that pressure can be the main trigger for fraud, especially in individuals who feel a heavy workload or lack of well-being. Other research Article [Healthcare in Low-resource Settings 2025;13:12773] [page 33] Table 1. Operational definition of fraud dimension variables based on the hexagon model perspective. Variable Operational definition/objective framework Pressure Forms of encouragement (can be financial, targets, awareness, unclear regulations, work pressure, helping others) to commit fraud Opportunity Low self-awareness and internal control result in taking advantage of opportunities (weak monitoring and evaluation, lack of transparency, organizational structure problems, unclear rules) to commit fraud Capability The capability (position), intelligence, self-confidence, personality, rhetoric) of a person to commit fraud Rationalization The form of action of a person who justifies and feels it makes sense to carry out fraudulent activities Arrogance/Ego The nature of a person's ego or character that causes greed and feeling better than other people Collusion An agreement/cooperation/compromise that benefits one particular party results show that the pressure experienced by employees comes from internal hospital pressures and external hospital pressures, for example, family needs and lifestyle, salaries for employees as a whole, and take-home pay (basic salary, remuneration, and side dishes) for employees. Specific Time Employment Agreement.8 This finding echoes earlier studies, which suggest that socio-eco- nomic pressures are significant contributors to fraud in low- resource health systems. However, it cannot be seen as the only factor influencing the decision to commit fraud. Other roles, such as faith and work environment, influence fraud.9 Furthermore, opportunity is also an important factor in this research. The study results show that individuals are more likely to commit fraud if they perceive an opportunity to do so. Several fac- tors that can create this opportunity include poor management, lack of clarity in the distribution of financial services, and a weak supervisory system.10,11 In health systems, corruption, or the abuse of power for private gain, includes bribes and kickbacks, embez- zlement, fraud, political influence/nepotism, and informal pay- ments, among other behaviors. This aligns with broader research on healthcare corruption globally, where weak oversight and lack of transparency are recurring themes. Drivers of corruption include individual and systems-level factors such as financial pressures, poorly managed conflicts of interest, and weak regulatory and enforcement systems.12 Therefore, efforts to prevent fraud in JKN services need to pay attention to these aspects to reduce the oppor- tunity for fraud to occur. It is essential for policymakers to strengthen management protocols and increase transparency in hospital operations to minimize these opportunities. Capability is also an important factor in this study. The find- ings show that individuals with an interest, intention, or advantage in committing fraud are likelier to engage in such acts.13 Apart from that, not understanding the rules and feeling dissatisfied with what is received can also affect a person’s capability to commit fraud.14 This diverges slightly from other studies that have found dissatisfaction to be less of a driver compared to institutional weaknesses and lack of proper governance. Therefore, there is a need for actions that educate individuals about the rules and mon- itor their satisfaction with the JKN system. Individual rationality in committing fraud is also an important concern in this research. The findings show that most respondents see fraud as something unnat- ural, but some see it as an action that can be justified in certain sit- uations. This underlines the complexity of fraud’s moral and ethi- cal aspects.15,16 Arrogance also appears as a factor that can cause someone to commit fraud. An individual’s trait of arrogance may influence their decision to engage in actions that are detrimental to the organization or patients.17,18 Apart from that, external factors such as pressure from superiors and individual interests can also play a role in encouraging fraud. Collusion, or cooperation between individuals or entities that have the potential to commit fraud was also identified as an important factor. The findings show that collusion can be the main trigger for fraud.19 Pressure from superiors, feelings of threat, and cooperation triggered by mutual interests are examples of ways collusion can influence fraud in the context of JKN services in hospitals. This finding is particularly relevant in regions like the Buton Islands, where social bonds and networks may intensify the likelihood of collusion. The results of other research show that the pressure and ratio- nalization variables have a positive and significant effect on oppor- tunities, so improvements in the pressure and rationalization vari- ables will create improvements in the opportunity variables.20 The pressure, rationalization, and opportunity variables have a positive and significant effect on fraud prevention, so improvements in the pressure, rationalization, and opportunity variables will create improvements in the fraud prevention variable. This suggests that by addressing pressure and rationalization through policy interven- tions such as improving working conditions and reinforcing ethical standards opportunities for fraud can be significantly reduced. In the context of the Buton Islands, socio-economic and cultural fac- Article [page 34] [Healthcare in Low-resource Settings 2025;13:12773] Table 2. Qualitative study results from the perspective of the Hexagon model. Dimension Responses Summary/Key Findings Pressure Thirteen informants said that fraud should not be committed; five informants Pressure was found to be a contributing factor stated they did not agree with fraud but were pressured by the patient's condition; in a subset of cases, particularly linked to workload five said fraud was due to pressure; two said fraud was committed out of ignorance, and superior influence. with other varied responses. Six informants stated there was no pressure to commit fraud; five mentioned pressure from superiors; two said the pressure could be managed. Ten informants said pressure did not influence fraud, while nine said it did, and five were uncertain. Other factors included heavy workload, lifestyle, income, claims system, and helping patients. Opportunity Twenty-one informants said that opportunity influenced fraud occurrence; Opportunity emerged as the most significant factor five said it "maybe" did; the remainder indicated empathy. driving fraud, due to poor oversight and managerial Factors included poor management, nepotism, weak monitoring, issues. severity level manipulation, and position/authority misuse. Capability Twenty-seven informants agreed that capability influenced fraud; Capability plays a central role in fraud, particularly three said there might be an influence. Factors included authority, attitude, among individuals with authority and personal intelligence, personality traits, and faith. Other factors: dissatisfaction, motivations. lack of understanding of rules, and desire for profit. Rationalization Twelve informants said perpetrators always rationalize their actions; Rationalization helps justify fraudulent actions, others gave varied responses. Fifteen informants said deliberate fraud was abnormal, though views on its normality are mixed. while several said it was normal depending on the situation. Arrogance Twenty-two informants agreed arrogance could cause fraud; five said "maybe," Arrogance enhances fraud tendencies, particularly two disagreed, and one was unsure. Arrogance was tied to selfishness, greed, among individuals with positional power. and authority abuse. Collusion Twenty-two informants said collusion played a role; seven said "maybe," Collusion is a facilitative factor but not always and one said "no." Collusion typically occurred due to peer pressure or superior influence. present. tors also play a unique role in influencing fraud. The remote geo- graphic location and lower economic development of the region may exacerbate pressures on healthcare workers, leading to higher instances of fraudulent activities. This underscores the importance of considering regional variations when designing anti-fraud poli- cies for JKN services. Overall, this research illustrates the com- plexity of factors contributing to fraud in JKN hospital services. Understanding these factors is important in preventing and addressing fraud in this critical health sector. Based on the find- ings, specific strategies for fraud prevention should include strengthening oversight mechanisms, enhancing transparency in financial management, and providing regular ethical training for healthcare workers. Additionally, policies aimed at improving staff welfare and reducing socio-economic pressures can serve as pre- ventive measures against fraud. This study contributes to under- standing fraud behavior in the healthcare context and can assist policymakers and practitioners in developing strategies to combat effective fraud. Conclusions This research succeeded in identifying six key factors that influ- ence the occurrence of fraud in National Health Insurance (JKN) ser- vices in several hospitals, namely pressure, opportunity, capability, rationality, arrogance, and collusion. These factors interact with each other and form a complex framework for understanding the phe- nomenon of fraud in the health sector. The findings highlight the importance of addressing opportunity and capability as the primary drivers of fraud, supported by influences from rationalization, arro- gance, and collusion. Based on these findings, several actionable recommendations can be made to mitigate fraud in JKN services: i) Strengthen the supervision and monitoring systems, hospitals should enhance internal control mechanisms, ensuring transparency in financial management and reducing the opportunities for fraud; ii) Improve staff welfare and working conditions, reducing pressures related to workload and financial strain, such as by providing fair compensation and better working conditions, may alleviate the stress that leads to fraud; iii) Enhance ethical training and education, regu- lar training programs that focus on ethics and the risks of fraud should be implemented to raise awareness among healthcare work- ers, particularly in remote regions like the Buton Islands; iv) Implement stricter sanctions for fraud, clear and consistent conse- quences for fraudulent activities should be established to deter potential offenders and reinforce accountability within the health- care system. 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