Duty Abundance Policy in Services of BPJS Kesehatan:

Health Services Study Based on Transcendental Value

By:

Siti Soekiswati*, Absori**

Program of Law Science, Postgraduate of Muhammadiyah University of Surakarta,

Email : soekiswati@gmail.com, absorisaroni@gmail.com

DOI :

Abstract
BPJS Kesehatan lost more trillions of rupiah during 2016. The main cause was the
lack of quality of primary health care at the level of Health Service Center level I in the
Puskesmas, so the number of referrals to the hospital increased high. Observing these
circumstances, authors used normative review method by describing data from documents,
the references reviewed and analyzed descriptively qualitative. Government policy was the
abundant task to overcome the shortage of doctors require paramedics who did not have
medical competence to perform medical authority. In countries that apply similar models
(Dutch, United States), the policy created new problems: the confusion of authority
between medical practice and paramedics. This was contrary to the education system that
prioritized the competence. Qatar and Cuba issued policies to increase the number of
doctors. From the statistics it was known that the health status of a country was directly
proportional to the number of doctors, which means the professionalism of health services,
so that both were among the best countries of health level. Indonesian government should
review the policy of the duty abundants at the Puskesmas so the health services became
professional. It was important to consider transcendental Islamic health services that were
more humanizing. In Islamic transcendental-based health services, all activities related to
health service were pursued optimally with the belief of divine responsibility so the quality
of health services would increase, corruption could be prevented and patient services
would be more professional.
Keyword : duty abundance, BPJS Kesehatan, islamic trancendental

Abstrak
BPJS Kesehatan merugi lagi triliunan rupiah selama tahun 2016. Penyebab utama
ditengarai karena kurangnya kualitas pelayanan kesehatan primer di tingkat PPK I (Pusat
Pelayanan Kesehatan tingkat I) diantaranya di puskesmas, sehingga angka rujukan ke
rumah sakit meningkat tinggi. Mengamati keadaan tersebut, penulis mengkajinya dengan
metode kajian normatif dengan mendeskripsikan data dari dokumen, referensi yang dikaji
kemudian dianalisis secara deskriptif kualitatif. Kebijakan pemerintah yaitu tugas limpah
untuk mengatasi kekurangan tenaga dokter mengharuskan paramedik yang tidak memiliki
kompetensi medik melakukan kewenangan medik. Beberapa negara yang menerapkan
model serupa (Belanda, Amerika), kebijakan tersebut justru menimbulkan permasalahan
baru, kerancuan kewenangan antara praktik medik dengan paramedik. Hal ini
bertentangan dengan sistem pendidikan yang mengutamakan kompetensi. Qatar dan Kuba
mengeluarkan kebijakan menambah jumlah dokter, karena dari statistik diketahui bahwa
derajat kesehatan suatu negara berbanding lurus dengan jumlah dokter. Berarti ada
profesionalitas pelayanan kesehatan, sehingga keduanya termasuk negara-negara terbaik
tingkat kesehatannya. Pemerintah Republik Indonesia harus mengkaji ulang kebijakan
tugas limpah di puskesmas agar pelayanan kesehatan profesional. Penting untuk
mempertimbangkan pelayanan kesehatan berbasis transendental Islam yang lebih
manusiawi. Pada pelayanan kesehatan berbasis transendental Islam semua kegiatan
terkait pelayanan kesehatan diupayakan seoptimal mungkin dengan keyakinan
pertanggung-jawaban ilahiyah sehingga kualitas pelayanan kesehatan akan meningkat,
korupsi dapat dicegah dan pelayanan pasien lebih profesional.

INTRODUCTION

The BPJS Kesehatan announced again its loss at the end of 2016. This time the
number of losses rose dramatically, more than 9 trillion rupiahs, as delivered by Budi
Hidayat, Professor of The Public Health Faculty of University of Indonesia at a working
meeting with Commission IX DPR RI, in Jakarta, Monday, March 7, 2016. (Afrianto,
BPJS Kesehatan Kolaps 2016, para.2). The BPJS Kesehatan deficit that reached trillions
every year happened since the beginning of this program was proclaimed. In 2015 then the
loss reached more than 6 trillion rupiahs. The main cause was the high number of patient
referrals to the hospital so that the cost for services in the hospital swelled enormously
(Santoso, 2016, BPJS Kesehatan Merugi, para. 1). Ministry of Health stated that it was
because the quality of service in Health Service Center 1 (HSC level I especially PHC) less
good, so it launched the study program of primary care physician.The conclusion of the
inappropriate analysis resulted in a strong reaction from IDI (Indonesian Doctors
Association) until a massive demonstration of October 24, 2016 (Kompas, Aksi Damai
2016 para.1).

The quality of health services in HSC 1 was bad due to the government's lack of
proper policies, namely the duty abundant. The practice of primary health care at the PHC
used a duty abundance model that paramedics performed doctor's authority in medication
(= medical service) in patients. This situation was due to the ratio of physicians to the
number of patients that were still very poor, so some patients in the PHC should be served
by paramedics (Syah, 2015; Soekiswati, 2014).
METHODS
The linkage of BPJS Kesehatan loss figured every year since the start of this
government program with the policy of duty abundance in the PHC became the first
problem. Then how similar circumstances were faced by other countries in the world who
were categorized as the best country of health level. The third problem was how to solve
the problem in Indonesia. This article used the method of study with the normative
approach of describing the data obtained from the documents. The references were
reviewed based on needs according to problems and then analyzed descriptively and
qualitatively.

DISCUSSION

Duty abundance, the term was ambiguous because it referred to the delegation of
authority by means of mandate, the procedure of devolution in the routine relationship
between superiors and subordinates. The responsibility and accountability lied with the
mandator (Syah, 2015). The proper term should be an abundance of authority. Authority
was a right owned by an officer or institution acting to exercise its authority under
applicable laws and regulations. Related to the importance of this position of authority,
F.A.M Stroink and J.G. Steenbeek referred to it as a core concept in the Law of State
Administration and Constitutional Law (Ridwan, 2013).

Not all authority could be delegated, especially authority related to a person's profession,
delegation could only be done to fellow professions in an equal relationship, not superior
and subordinate (Undang-Undang Praktik Kedokteran, 2004). Mastery of competency
standards for health personnel became very important because it was directly related to the
quality of health services (Furrow, 2001). The abundant duty policy was made due to the
inadequate and uneven distribution of doctors at the primary health center (PHC). Until
considered a form of discretion of health law as stated by Purnawan (2017). It was very
inappropriate because discretion is the completeness of the legal system, as a strategic
factor to avoid negative side effects. The role of the agent as a mediator of two interests,
namely law and society, prioritizing moral considerations rather than abstract rules
(Nurhadiantomo, 2013).

Health services by non-competent health professionals resulted in an increase in

Unwanted Events (UE). Unwanted events (UE = adverse events) in the relationship of
physician / health care personnel to patients were all incidents that didnt match the
expectations of the existence of these relationships, occured in patients during health care,
which was not favored by the patient and or his family. Unwanted events could be about
the physical and / or psychological aspects (Wujoso, 2008).
Active UE (active error), was a mistake action performed by doctors / health
workers. Whether it was negligence, intentional, and lack of skill (the inability of doctors /
health workers to apply their knowledge correctly to patients) (Carr, 2013). Lack of skill
was of two types, 1) under competence (and less competence) and 2) out of competence
(Beigi, et al., 2013). This active group of UE was called malpractice. It was unfortunate
also, there was no research related to UE in Indonesia, so as to secure the model of duty
abundance on health services (PHC) (Syahrul, 2012).

Obviously there were violations of human values (human rights) in health services.
Consensus in the Indonesian Constitution stated that the right to health was a fundamental
right for humanity. The basic philosophy of health right guarantee as human rights was the
raison d'entre of human dignity (Muhtaj, 2009).

Katarina Tomasevski (1995) asserted that the scope of human rights to health as
follows:
Every human being has the right to an environment with minimum health risks, and
to have acces to health services that can prevent or alleviate their suffering, treat
desease, and help maintain and promote good health throughout the individuals
life.
Jonathan Montgomery as quoted by Katarina Tomasevski (1995) asserted there were
three levels of human rights standards in health: 1) individuality enforceable rights (aimed
to secure minimum standar); 2) aspirational rights (aimed at directing national policy
towards health improvement); dan 3) legal obligation to ensure conditions that make it
possible for citizens to chose to pursue maximal health.

Second, there was a very fatal legal rule. In the study of positive law regarding the
principle of the enactment of a Law, there was a conflict between applicable laws. The
Medical Practice Law and the Health Law prioritized the competence of each health
worker. Instead the Nursing Law actually regulated the abundance of duties, which meant
disregarding the rules of competence.
 The government apparently learned from the Netherlands and America (New York)
about the model of independent nursing practice, which is precisely in the country of
origin, eventually there was also a confusion of authority between the doctor's practice
with the nurse. Told by Ford, the health needs had not been fulfilled in the community so
that nurses were then prepared for these needs. But then the practitioner nurse's role
obscured the boundaries of the doctor's and nurse's authority which resulted in a confusion
of the authority of both professions. Thus, the authority of the nursing practice was
restrained (Kelling, 2015).

Purnawan in his thesis stated that people come to health workers at PHC without
knowing what their profession, whether doctors, nurses or Bachelor of Public Health, if
they work in Puskesmas meant they can cure (Purnawan, 2017). If the phenomenon of
competency confusion was allowed to take place, the health law was no longer useful to
regulate health problems. The enactment of the Health Act and all other laws would be
terminated due to customs that were contrary to the Act (Farkhani, 2014). Chaos in health
services would occur because there was no longer a rule of law that could certainly
manage health services. So what happens next was the deconstruction of health law
(Absori et al., 2013).

Statistics showed that countries with a high ratio of doctors per population were
always followed by high levels of health. Indonesia, which ranked the 90th level of health
in the world, had a ratio of doctors per 1000 population of 0.204. Singapore, which had a
ratio of doctors per 1000 population of 1.95, occupied the top ten health levels in the world
(Anugrapaksi, Apakah Indonesia Butuh Tambahan Dokter, 2016, para.1).

According to the 24/7 version of Wall St., Qatar, which ranked first the healthiest
countries in the world, had 7.7 doctors per 1000 population by 2015 (Indonesia had a ratio
of doctors per 100,000 population of 16.7 in the same year). Qatar was also the only
country out of the ten healthiest countries in the world who had not used a health insurance
system like BPJS Kesehatan in Indonesia (Pratiwi, 2015). As a Muslim country, Islamic
teachings became the philosophy of the state. Thus the Qatari government provided health
services based on Islamic transcendental values. Islam regulated the professionalism of
ministry because in the Qur'an an Nisa' verse 58 and the hadith narrated by Bukhary stated
that Allah Almighty ordered the Muslims to hand over the mandate to those who were
entitled to receive and surrender the affairs to the experts. It was also proven that to be the
healthiest country there was no need to have health insurance. The belief that the cure of
the disease rested on transcendent power beyond human power, that was, Allah Almighty.
The duty of man was only endeavor by seeking the experts and the state seek professional
health services with divine responsibility to God.

The country that took a fundamental policy by meeting the needs of doctors to
improve the health of its citizens other than Qatar was Cuba, which was economically
similar to the Indonesian government. Opinion titled Education in a Poor Country which
was published in Republika on July 3, 2004 written together with Prof. Samsuridjal Djauzi
(Lecturer of Faculty of Medicine in Universitas Indonesia) and writing entitled
Strengthening Puskesmas Service published in Suara Pembaruan Daily 11 July 2004. One
of the books entitled Development Within Underdevelopment? New trend in Cuban
Medicine, Prof. Ernesto Mario Bravo (1998) could also be a reference for comparing
Indonesia's health system with the health system in Cuba. The Cuban government
provided a large budget to provide general practitioners in health services by providing
free medical education to general practitioners (Darmawan, 2005).
Primary health care or first-rate health services in Cuban communities started from
the smallest scope by placing a family doctor serving 100-150 families comparable to 500-
750 residents or covering a neighborhood. So the total direct health budget provided by the
government was worth 12%, while in Indonesia only about 2 - 4% (Darmawan, 2005). In
contrast to Qatar, Cuba as a communist socialist state, adopted the policy based on positive
law and fulfilled its scientific value without any transcendental foundation. Level of
health, Qatar was healthier than Cuba.

The authority in relation to the execution of the duties of health workers was
important to understand because it brought consequences to violations of administrative
law, civil law and criminal law. This should be studied juridically because it was academic
related to the competence of each medical personnel. This authority should be arranged in
a clear and detailed manner so that it can run professionally. But the reality of the Ministry
of Health did not share detailed duties and authorities and sanctions if there are violations
related to these authorities (Suriatmadja, 2015).

Actually, it was a strong reason for the government to immediately fix health care
policy in Indonesia Because the target is human life (patient). The public was entitled to
legal protection from the state in the practice of health services. Satjipto Rahardjo stated
that the protection of the law was to provide a human rights guidance harmed by others
and the protection was given to the community to enjoy all rights granted by law
(Rahardjo, 2005).

Learning from health services in Qatar, a clear transcendental value-based service of

Islam regarding professionalism (Q.S An-Nisa ': 58 and Hadith narrated by Bukhar about
amanah or responsibility). The professional meaning in transcendental paradigm was not
as rigid as in positive law, as health workers worked with patient perceptions of salvation
as a form of responsibility to God the Almighty. The relief of the patient was based on a
high esteem on human life which would be accounted for in the Who Created human.
Similarly, all efforts towards improving the degree of health were seriously pursued as a
divinely accounted struggle, so there was no corruption Health BPJS funds. All medical
facilities and infrastructure in the country for the purpose of providing and saving the
budget. All activities are based on the concept of divine responsibility. All health-related
infrastructure facilities including medicines and medical equipment should be produced
domestically to facilitate the provision and saving of the budget. All activities are based on
the concept of thinking of divine responsibility (Absori, 2017).

The priority scale that had to be taken by the government was the adequacy of the
ratio of doctors with patients to provide transcendental Islamic health-based services with
emphasis on divine professionalism and responsibility. Based on Islamic transcendental
values doctors would be willing to be deployed throughout the country as a manifestation
of struggle in the way of Allah. Of course, the availability of adequate facilities and
infrastructure was also provided by the government as a manifestation of government
responsibility to the people, where a leader would be held accountable from which he led
in the presence of God Almighty.

The concept of this transcendental Islamic base could be incorporated into the
curriculum of prospective health professionals, in the softskill workshops of health
workers and policy makers in health services. Understanding / patterns of perception based
on transcendental Islam were also given to the patient so that the patient could be
responsible for his health.

CONCLUSION
 It was time for primary health care in Indonesia to be addressed with the
fundamental law-oriented fundamental issues, not patchwork with the model of duty
abundance. Proven in the country of origin where duty abundance performed, the policy
actually rose chaos in primary health care, and overlapping authority. The thing concerned
was because the target of service was human life (patient). So the policy of health services
in the future would be better if based on the transcendental paradigm of Islam which
clearly prioritized professionalism with divine responsibility, not just accountability on the
positive law that existed.
The divine concept stated that the healer is God, the state's obligation was to provide
professional health care with a belief in what was divinely accounted for. In this way the
state could grant the legal protection rights of each member of the community and might
prevent the loss of a larger BPJS Kesehatan.

E. Referrences
Absori, Kelik Wardiono, Saepul Rohman, 2015, HUKUM PROFETIK: Kritik Terhadap
Paradigma Hukum Non-Sistematik, Yogyakarta: Genta Publishing, Cetakan I.

Absori, Pemikiran Hukum Transendental dalam Konteks Pengembangan Ilmu Hukum

Indonesia, dalam TRANSENDENSI HUKUM Prospek dan Implementasi,
Yogyakarta: Genta Publishing, 2017, Cetakan I.

Arlene W. Kelling, 2015, Historical Perspectives on an Expanded Role for Nursing, OJIN:
The Online Journal of Issues in Nursing,Volume 20, Number 2, Manuscript 2

Claudia Carr, 2013, Medical Negligence, Medical Law and Ethics, Course Notes-
Routledge, First published 2013, 2 Park Square, Milton Park, Abingdon, Oxon
OX14, 2013: 4 - 9.
Ede Surya Darmawan, Implementasi Sistem Kesehatan: Belajar dari Sistem Kesehatan
Kuba Disajikan dalam Seminar Kesehatan: Strategi Pelayanan Kesehatan dan
Pemberdayaan SDM Kesehatan untuk Mewujudkan Indonesia Sehat 2010 di FIKES
UHAMKA 14 Juni 2005

Farkhani, 2014, Pengantar Ilmu Hukum, Salatiga: STAIN Salatiga Press, Cetakan III.
Furrow, Barry R. 2001. Pain Management and Provider Liability: No More Excuses, The
Journal of Law, Medicine & Ethics; Spring 2001; 29, 1; Arts & Humanities
Database

Indra Bastian dan Suryono. 2011. Penyelesaian Sengketa Kesehatan. Jakarta: Penerbit
Salemba Medika.

Hari Wujoso, 2008, Analisis Hukum Tindakan Medik, Surakarta: UNS Press, Cet. 1.

Hudi Purnawan, 2017, Diskresi Pelimpahan Wewenang Tindakan Medik dari Dokter
kepada Perawat di Kotawaringin Timur, tesis, Sekolah Pasca Sarjana Universitas
Muhammadiyah Surakarta.

Katarina Tomasevski. 1995. Health Rights, dalam Asborjn Eide, et.al (ed), Economic,
Social and Cultural Rights; A Textbook (Boston: Martinus Nijhoff Publishers).

Marjan Beigi, Leila Asadi, Mahbube Valiani, Fardin Mardani, 2013, Evaluating Different
Types of Malpractices in Midwifery that were Referred to the Forensic Medicine
Commission and the Medical Council between 2006 and 2011 in Isfahan Pro vince,
Isfahan-Iran. (Downloaded from http://www.ijnmrjournal.net on Thursday,
December 22, 2016, IP: 202.67.46.23).

Mahda El Muhtaj. 2009. HAK ASASI MANUSIA DALAM KONSTITUSI INDONESIA:

Dari UUD 1945 Sampai Dengan Amandemen UUD 1945 TAHUN 2002. Jakarta:
Kencana. Edisis Pertama, Cetakan I

Nur A Syah, Perceptions of Indonesian General Practitioners in Maintaining Standards of

Medical Practice at a Time of Health Reform, Family Practice Advance Access
Nurhadiantomo, 2013, Materi Kuliah Sosiologi Hukum, Sekolah Pasca Sarjana Universitas
Muhammadiyah Surakarta, Surakarta.
Mahmud, Syahrul. 2012. Penegakan Hukum dan Perlindungan Hukum bagi Dokter yang
Diduga Melakukan Medikal Malpraktik. Bandung: Karya Putra Darwati

Ridwan HR. 2013. Hukum Administrasi Negara. Jakarta: PT Raja Grafindo Persada.

Soekiswati,Siti, 2014, Kebijakan Pelayanan Kesehatan, Studi Pelayanan Pasien pada

Puskesmas Rawat Jalan di Kabupaten Sukoharjo, thesis, Universitas
Muhammadiyah Surakarta.
Toto Tohir Suriatmadja, 2015, Minimalisasi Sengketa Medik Pasien dan Tenaga
KesehatanDihubungkan dengan Undang-Undang Perlindungan Konsumen, Jurnal
LITIGASI Vol.16, No.2 Oktober 2015.

Satjipto Rahardjo, 2005, Ilmu Hukum, Bandung: PT. Citra Aditya Bakti.

Undang Undang Praktik Kedokteran No.29 / Tahun 2004 BAB VII Penyelenggaraan
Praktik Kedokteran.
Aksi Damai IDI Angkat Isu Pendidikan Kedokteran dan JKN - Kompas, Selasa 25
Oktober, 2016.

Kemal Imam Santoso, Direktur Keuangan dan Investasi Badan Penyelenggara Jaminan
Sosial (BPJS) Kesehatan menyatakan, lembaga jaminan sosial itu masih harus
menghadapi defisit pada tahun 2016 (JAKARTA, KOMPAS.com. Rabu, 13 April
2016), diakses 23 Desember 2016.

https://economy .okezone.com/read... BPJS Kesehatan Kolaps 2016. 12:48 WIB, Jurnalis-

Dedy Afrianto, diakses 18 Oktober 2017

http://www.kompasiana.com/egharap/apakah-indonesia
butuhtambahandokter_56b74491a2afbd9314b. Anugrapaksi, Egha. 2015.