Since 2014, the Indonesian government has been implementing the National Health Insurance (JKN). Accordingly, the health referral system is crucial because it concerns the sustainability of health care ranging from primary health care in puskesmas up to the tertiary level of health care in the hospital, but moreover, because a referral system is needed to ensure that individuals receive optimal care at the appropriate level of health care.
The Minister of Health regulation (Permenkes) No. 1 Year 2012 on Individual Health Care Referral System article 11 (1) requires each health care provider to refer patients when necessary, unless there is a legitimate reason not to, and approved by the patient or their family.
The East Java Province, with support of the Australia – Indonesia Partnership for Health Systems Strengthening (AIPHSS), has issued guidelines specific to the region as a follow up to the Governor Decree SK no 188/786 / KPTS / 013/2013 governing the referral system.
The Process of Setting Up and Regionalising the Referral System
The setting up of the referral system in East Java was developed based on the results of a case study in the AIPHSS districts in East Java (Sampang, Bangkalan, Situbondo and Bondowoso).
The commitment of the East Java Regional Government- led by the East Java Provincial Health Office- to produce a basic law governing the referral system in East Java province is driven by:
- The standard quality is not met by service providers. The health centers and hospital service quality achievement is less than 20%;
- Not every district/city has a referral system that regulates the procedures and referral mechanism;
- Although there is a governor decree on the referral system, not all of the procedures, workflow, recording and reporting of referral processes are done properly by district/city;
- The absence of continuous guidance and supervision for implementing the referral system;
- The number of non-compliance cases in the referral system which therefore cannot be financed by BPJS.
The new governor decree is enacted following the seven (7) stages of the improvement process and development of the referral system, namely:
- Development of assessment instruments for health clinics and hospitals, including TOT (training of trainers) for Focus Group Discussions (FGD);
- Assessment of health facilities and FGD, including mapping of health facilities, DKT for health centers, hospitals, community and Provincial and District Health Office, as well as the analysis of assessment results;
- Disseminate the results of the assessment and FGD through workshops at the provincial and district / city;
- Development of the referral system model, including the dissemination and finalisation of the referral system model at the provincial and district / city;
- Disseminate the referral system model through workshops at the provincial and district / city;
- Piloting the referral system including monitoring and evaluation, and drafting guidelines of the referral system in provincial and district / city;
- Finalising guidelines of the referral system, including a workshop on the results of the implementation of the referral system.
The Governor’s Decree No. 118/359 / KPTS / 013/2015 determines that the regionalisation of the referral system in East Java is divided into eight (8) regional and tertiary hospitals as follows: 1). RSU Dr. Saiful Anwar, Malang; 2). RSU Haji, Surabaya; 3). Ibn Sina Hospital, Gresik; 4). Sidoarjo Hospital; 5). Jombang Hospital; 6). Iskak Hospital, Tulung Agung; 7). RSU Dr Soedono, Madiun; 8). Dr Soebandi Hospital, Jember. Each hospital serves as a Center of Referral for the surrounding areas.
Learning from East Java, other areas may follow similar steps to develop a referral system in their region using the Governor decree or regional regulation. The process to establish a legal basis for this regulation should involve as many agencies and other relevant stakeholders as possible, as well as community groups, including the private sector and health professional organisations. This can be done through forums, hearings and other similar events according to the local need. These processes are part of the process of improving the understanding of the Health Office and other regional bodies, as well as the process of grounding legislation according to the real need of the people. When the legislation is drafted, these processes should also be applied to members of the Legislature, which upon having a better understanding of health, will provide legislative support to the Governor.
MAINTAINING SUSTAINABILITY OF REGIONAL REFERRAL SYSTEM
To ensure the sustainable implementation of a regional referral system, the local budget commitment should be allocated and improved for:
- Socialisation to the local leaders, staff at health care facilities, and communities;
- Supporting health care facilities in order to meet quality standards, more so following the reduction in state budget support;
- Provision of technical guidance for health care facilities, including district health care facilities, and monitoring and evaluation in an integrated manner;
- Integration of information systems between basic and referral facilities;
- Effective cooperation and coordination with BPJS.