HEALTH CARE WITH GRADUAL REFERRAL SYSTEM

IN THE NATIONAL HEALTH INSURANCE

A. INTRODUCTION

I. BACKGROUND

In accordance with Laws No: 44 year 2009 section 42 concerning

Hospital Referral System of health care is the implementation of health care regulating

the transfer of duties and responsibilities of health care services on a reciprocal basis

either vertically or horizontally which must be conducted by the participants of health

insurance or social health insurance, and the entire health facilities.

JKN Program (National Health Insurance) Since January 1, 2014 has been

implementing the gradual referral system which is still not optimal either in primary care

facilities as the referral giver such as public health centers, family doctors and clinics or

in Referral Giver Facilities, i.e, Hospital resulting health care priority for patients can not

be done well.

Especially in Province of Aceh with Health Insurance Program (JKA) organized

by Aceh local government which was officially integrated into the Health Insurance

Social Agency (BPJS) on January 1, 2014 as well as experienced many difficulties in

the implementation of Gradual Referral System.

II. FORMULATION OF PROBLEM

Entering the 2nd year of JKN implementation with gradual referral system which

is still not optimal due to several things such as: Referral Non Specialistic from primary

health facilities to high referral health facilities, the uneven infrastructure of health

facilities, the related rules and regulation are not being conducted in maximum.

III. OBJECTIVE AND BENEFIT

By the implementation of the gradual referral system properly, it will result the

qualified and on target services as well as the effective and efficient costs can be

achieved in both primary health service and secondary / tertiary health care which will

definitely improve the health of all people in Indonesia and particularly in the province of

Aceh that has universal coverage.

B. DESCRIPTION

Referral system in the National Health Insurance program managed by Health

Insurance Social Agency has been running but it is not maximized, until the first quarter

of 2015, recorded 9.5 percent of the total number of patients who became the program

participants turned out to be considered wrong referral, which is a non specialistic

referral, which means should not need to be referenced and can be completed in the first

level of health facilities.

In Province of Aceh as a pilot project JKN since June 2010 that have universal

coverage for health insurance for all its people in terms of gradual referral experiencing

similar problems that can be seen from the number of visits to referral hospital which is

extremely high resulting in long queues and even the over number of patients either in

province hospital or district hospital.

Results of coordination with relevant parties in this case with the Department of

Health and primary service facilities found that high non specialistic referrals caused,

one of them, by function of primary health facilities as Gate Keeper is not optimal due to

the capacity of human resources in the level of primary facilities is not adequate.

Infrastructures of Health Care Facilities that are not evenly distributed in the

province of Aceh for the entire First Level of Health Care is also a cause of the high

number of referrals to the advanced health care facilities in the district continues to the

referrals of Province if the same thing happens.

Another cause is regulation of gradual referral that has been set by both the central

government and local governments that have been issued, however, the implementation

has not been run properly by the parties.

C. CONCLUSION

The high number of the unnecessary referrals causes the accumulation of the patients in

the hospital which is still occur until now. Services to be disrupted because of a long line

of patients. Meanwhile, the human resources at a referral hospital is limited. Ideally, only

10 percent of patients referred to secondary care than 155 diseases, however, the current

number of referrals to secondary care reached 15.3 percent based on the BPJS health

data.

D. SUGGESTION

From the description above, we expect there will be improvements with some suggestions

that could be considered by the parties include:

a. Optimization of primary health facilities as a gate keeper in terms of improving the

competence of human resources SDM in primary health facilities.

b. Support by the central and local governments for infrastructure equity throughout health

care facilities based on the needs analysis of related health facilities such as based on

majority disease (endemic TB, pneumonia patient)

c. Establishment of referral regionalization system can be immediately implemented by the

parties.