National Health Architecture
Primary healthcare-service transformation is a must. The health and resilience of the nation is at stake.
The COVID-19 pandemic has brought awareness about the need for a strong national-health architecture as part of the policy to create national-health resilience.
It has also become a global issue as the recent Group of 20 Summit in Bali showed.
In fact, Indonesia has a strong foundation for building a health financing and service system as mandated in the 1945 Constitution. See Article 28H that stipulates that everyone has the right to receive healthcare services and social security.
Article 34 also contains a statement that the state is responsible for the provision of healthcare-service facilities. This constitutional mandate should be used as a reference for the national-health architecture.
The following three things deserve scrutiny to see whether the mandate on "healthcare services" and "social security" is implemented.
First is whether mandatory-health insurance is in place for citizens to make healthcare services everyone’s right, instead of a commodity accessible only to financially abled citizens. Second is who is the first-level service provider. Third is how citizens are given the access to healthcare-service facilities (fasyankes), with financial cost being no longer a barrier.
Eight years of JKN
Ratified in 2004 and enforced on January 1, 2014, the Law on the National Social Security System (UU SJSN) administers that every citizen be a participant of the National Health Insurance (JKN) program by paying a monthly premium. Those who cannot afford the premiums are entitled to government subsidy.
Entering its ninth year, the JKN program registers 244,600,449 participants (as of September 2022) or 89 percent of Indonesia's population. As many as 110 million of them are the beneficiaries of premium assistance (PBI).
What an achievement. In a relatively short time, the Healthcare and Social Security Agency (BPJS Kesehatan) had managed to collect funds amounting to Rp 143 trillion (2021) and personal-data verification of 245 million citizens across 6,000 islands, 34 provinces, 544 regencies/municipalities and 74,000 villages.
Where do these 245 million people go for healthcare services? BPJS (2022) provides 22,393 primary-healthcare facilities, consisting of 46 percent community-healthcare centers (puskesmas), 32 percent first-level (pratama) clinics and 22 percent private-medical services. About 80 percent of these 245 million people are registered at puskesmas although 529 of them do not have doctors, and there is a puskesmas with healthcare services covering 145,000 participants.
Also read:
> Turbulence of the 2023 Health Program
On the other hand, there are quite a number of private primary-healthcare facilities with only 600-800 participants.
Given Indonesia's geographical conditions, the number of primary-healthcare facilities above is evidently neither sufficient nor evenly distributed. The growth and distribution of primary-healthcare facilities is hampered because puskesmas, with its role both as public health unit (UKM) and individual health efforts (UKP), is still seen as part of government-administered JKN.
In fact, in the era of social health insurance, primary-healthcare services should be left to the private sector and the community, except in certain areas. This policy will open room for 140,000 medical practitioners and 12,000 new doctors per year to participate in supporting JKN.
Accessibility is said to be good if citizens visit the healthcare facility at least once a year and the facility can be reached in about 30 minutes.
What is the current level of accessibility? Accessibility is said to be good if citizens visit the healthcare facility at least once a year and the facility can be reached in about 30 minutes.
The frequency of visit varies according to age, gender, disease epidemiology, behavior and available facility and infrastructure. As a comparison, 90 percent of the citizens of Organization for Economic Co-operation and Development (OECD) countries see a doctor at least once a year with an average of 6.5 visits per person per year.
Referring to the definition above, it turns out that the accessibility of 245 million JKN participants is very low, even though they do not have to pay for healthcare services.
Look at the following BPJS Kesehatan data: 10 percent (2014), 17 percent (2015), 20 percent (2016), 25 percent (2017), 26 percent (2018), 27 percent (2021). Out of the 245 million participants (2021), only around 60 million (27 percent) visit healthcare facilities with the frequency of 0.75 visits per person per year. In several healthcare facilities, access has only reached 6 percent.
What does this lack of accessibility imply? What is certain, first, is that the amount is insufficient and the distribution is uneven. Second, it is about injustice and discrimination. The benefits of JKN are only enjoyed by citizens who live in areas that have good health facilities.
Third, healthcare services are specialist-oriented and expensive. This is illustrated by the dominant proportion of referral service costs that has triggered deficits from year to year: 79 percent (2014), 80 percent (2015), 81 percent (2016) and 84 percent (2017).
Fourth, there are 73 percent or around 172 million participants who have never visited healthcare facilities. It is a huge number. Their health conditions are unknown. The potential deficit for BPJS Kesehatan will continue if this group of people is not catered to properly.
Also read:
> Reforming the Health Architecture
> Industry 4.0 and Health Services
The dominant referral services have so far caused panic, distortion and misguidance among the public in understanding the service system. They might see it is about the need for specialist services, hospitals and sophisticated medical equipment, while, in fact, the root of the problem is that the foundation of the service system has not been properly arranged. As a result, primary-healthcare facilities have collapsed, which prompts the patients to turn to referral-healthcare facilities.
In such a situation as described above, the COVID-19 pandemic broke out. The panic caused by the pandemic opened our eyes to the fact that primary-healthcare facilities and referral-healthcare facilities had yet to form an integrated service system.
Thank God, quick action, mutual cooperation and leadership during the pandemic succeeded in overcoming the imbalance in the existing service system.
Healthcare centers
Put aside the puskesmas and hospitals for a while. The design and construction of the health-service architecture in the JKN era should begin with the establishment of an entity that serves as the entry point for the citizens to the healthcare system.
This entity is called healthcare service center (pusyankes), which is the first-level healthcare facility (fasyankes) for “family doctors” (DK) and their team to carry out their profession. DK should be chosen as the core of JKN services. Why so? It is because a DK is a generalist and specialist who is competent to cater to most health needs and solve health problems of individuals throughout their life cycle.
In other words, if 5,000 JKN participants of all ages are registered at a healthcare center, then most (90 percent, Starfield) of an individual's health needs and problems — whether they are infants, toddlers, adults or elderly — will be handled at the healthcare centers.
The remaining (10 percent) that cannot be resolved are admitted to referral-healthcare facilities. With their capacity and role, the healthcare centers can come to the fore as the foundation of the healthcare services in JKN. In this context hospitals act as a back-up with support when problems cannot be resolved at the healthcare centers.
It is the responsibility of the state to organize a network for even distribution of healthcare centers across the country.
If the National Health Architecture stipulates that one healthcare center is filled with one DK with the ideal DK-population ratio being 1: 2500, then to serve 275 million people, at least 110,000 healthcare centers are needed.
The entire population would be completely split into 110,000 healthcare centers and each healthcare center is responsible for taking care of the health of 2500 people as its target community.
This national-health architecture sees the healthcare services for the population in fostered community clusters. In a cluster, community members have a DK. They are encouraged to participate actively in a planned-health program tailored to individual conditions in a more-established doctor-patient relationship. Medical consultations can take place anytime and anywhere, with more well-arranged IT-based medical records. In this case, we deserve to be confident about improved national-healthcare services with a more-balanced budget.
This national-health architecture would see horizontal coordination among the 110,000 healthcare centers that provide healthcare services for 275 million JKN/KIS cardholders, and form a vertically integrated health-service system between healthcare centers and hospitals. The system will encourage the promotion of healthy lifestyle as part of individual-health efforts (UKP).
Primary healthcare-service transformation is a must. The health and resilience of the nation is at stake.
The national network of healthcare centers will make it easier for the government to carry out various public-health efforts that reach proper beneficiaries. It will also eliminate potentially overlapping costs because the targets of government programs — whether they are babies, toddlers, pregnant women, elderly or people with special illnesses — are members of a community within a healthcare center.
Thus, various healthcare programs as part of individual health efforts can be entrusted or carried out by the healthcare centers with a more specifically drafted financing mechanism.
So, what about the relevance of community healthcare centers (puskesmas) in the JKN era? Would their role and function be pushed aside? No. Puskesmas and pusyankes have their respective roles and functions, human resources (HR) competency and funding sources. See the mandate of Article 28H of the 1945 Constitution, stating that every person has the right to a good and healthy environment and has the right to receive healthcare services.
As the name implies, puskesmas focuses on its role as a leading community-healthcare center responsible for the environment and public health in an administrative area. This national-health architecture makes puskesmas more focused on its functions, going hand-in-hand and complementing pusyankes in accordance with the mandate of the 1945 Constitution.
Healthcare transformation
In essence, the transformation of primary-healthcare services aims to rearrange the entities that make up the foundation of the healthcare system in the JKN.
This rearrangement requires both deregulation and reregulation, with objectives including: 1) the healthcare-center entity as the frontrunner and foundation of the healthcare-service system; 2) every JKN participant must have DK; 3) the DK who works at the healthcare center has the status of functional medical-strategic staff regulated by the state; 4) facilitating the development and distribution of healthcare centers with public-private participation approaches; 5) reorienting medical education, shortening the medical-education term; 6) repositioning of puskesmas.
The COVID-19 pandemic only appears to be the trigger and accelerator of this transformation and a reminder about the urgency to prepare for the next challenge in an everchanging and dynamic world. Primary healthcare-service transformation is a must. The health and resilience of the nation is at stake.
Gatot Soetono
Gatot Soetono, Indonesian Doctors Association Board of Experts and Independent Health Consultant
This article was translated byMusthofid.
