Strengthening the District Referral System


The need for a district referral system has been recognized for a long time but even so since the national health insurance (JKN) was implemented in early 2014. Within the JKN system, the referral mechanisms are essential to ensure quality of service and efficiency in financing. However, the referral system, especially for individual health care (UKP) has not been conducted properly. Many patients immediately seek care at the hospital without accessing FKTP – which leads to a heavy load at the hospital. In addition, hospitals are supposed to do back referral but this is also not functioning well because patients refuse to comply when they see striking differences between services in hospitals and FKTP especially in health centers. Based on this issue, AIPHSS has supported the development of a referral system in eight (8) districts.

Referral in health care is a delegated authority and responsibility to provide care for a patient from one health provider to another, either horizontally (between providers at the same level, such as from one health center to another health center, etc.) or vertically (from primary care to secondary care, or vice versa). Delegation of authority and responsibility should be formally regulated.

Accordingly, the referral system must be viewed holistically and comprehensively because it relates to several aspects, such as cultural values, geographical condition, and communications/transportation, as well as the financing aspect, and most importantly the capacity of each health facility.

Therefore, the development of the referral system in eight (8) districts is preceded by in-depth assessment of the following aspects:

  1. Assessment of cultural values that are expected to affect the implementation of the referral system
  2. Assessment of the capacity of existing health facilities in the district, particularly the capacity of health centers and hospitals. This is important to adjust the horizontal and vertical referral network.
  3. Assessment of the transportation infrastructure in the district to set up a referral network.
  4. Assessment of geographical condition, to set up the referral linkages between health facilities.
  5. Review the criteria for referral, for example one that is established by BPJS.

The results of the assessment are used as the basis for formulating the referral system at the district level and were subsequently legitimised through regulations in the district, for example the Regent Regulation (Perbup) on Individual Health Referral System in Ngada No. 44/2014, Perbup in East Flores on Individual Health Referral System No. 22/2015, Perbup on Standard Operating Procedure (SOP) for Individual Health Referral System in South West Sumba No. 25/2015, Perbup on SOP for Individual Health Referral System in North Central Timor No. 16/2014, Perbup on the Health Care Referral System in Situbondo No. 38 in 2015, Perbup on District Health Referral System in Sampang and Bondowoso.

The development of the referral system in these eight (8) districts is undertaken in the following steps:

  1. Assessing the five dimensions as mentioned above. The result serves as evidence for the second step
  2. Drafting the initial document of procedures (Protap) for a referral system
  3. Organising workshops to discuss the standard operating procedure (SOP), attended by representatives of all health centers and hospitals
  4. Formulating the final SOP for the referral system, based on the inputs from the abovementioned workshop
  5. Drafting the decree for Regent regulation (Perbup) concerning the procedures (Protap) of referral system
  6. Conducting training for staff of the health services related to the referral system (health centers and hospitals)
  7. Conducting workshops to disseminate the referral system policy.

The final result is a district referral system that contains a referral linkage between puskesmas (horizontal referral) and referrals between health centers and hospitals (vertical referral). SOPs are then legitimised by Perbup. Now, with a functioning referral system, the local government will be able to identify capacity development needs of each health facility that will enable them to provide good referral services, ensure quality of care for the patient, as well as maintaining effective and efficient health financing.


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