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.