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There
was something interesting in one of the lectures on Healthcare Policy
Reform and Initiatives at Columbia University, New York City, which I
attended recently. Ranu Dhillon lauded Jakarta’s new leadership regarding
implementation of Jakarta Health Card (KJS), saying one of the key factors
in healthcare system reform was strong leadership.
Dhillon is affiliated to the Earth Institute, Columbia University, and a
faculty member at Harvard Medical School. He was assessing the
effectiveness of Jakarta Governor Joko “Jokowi” Widodo’s leadership, which
he said was a prototype for health sector reform.
So is Jokowi’s KJS a permanent solution for people in other parts of
Indonesia? His action is undoubtedly worthy of appreciation, but there will
always be room for improvement that needs to be considered by the other
health policymakers.
Healthcare is a series of long and complex supply chains, which does not
just involve medical and nursing staff, but medical equipment, support
equipment, pharmaceuticals, transportation, catering, laundry, IT and waste
management. All these components affect the capacity of healthcare
facilities.
KJS is a very good policy on the downstream side of healthcare, opening
access to healthcare. The poor who have always been reluctant to seek
health treatment are now encouraged to go to healthcare centers. Of course
this is a positive step and will play an important role in improving the
human development index.
The impact on the upstream side’s unpreparedness is starting to show. Four
months into the policy hospitals are overwhelmed by patients due to
imbalance in supply and demand. The surge in the patient numbers outweighs
the increase in pharmaceutical supplies, the number of medical personnel
and other healthcare factors. As a result, the quality of health services
has been disrupted.
One example of the lack of synchronicity between upstream and downstream is
in Budhi Asih Hospital in Cawang, East Jakarta. The average number of
outpatients after KJS implementation is 900 people per day, up 50 percent.
Doctors in Jakarta are experiencing an excessive workload. Per day, each
doctor handles an average of 60-70 patients. The figure is far above the
ideal of 20-30 patients per day.
The lesson from these empirical facts is that healthcare policymakers in
other regions must anticipate this imbalance. Prior to any campaign to
stimulate people to seek healthcare, it is necessary for policy makers to
restructure the upstream supply chain.
A sudden increase in the number of patients at any particular facility can
be avoided by a better referral system. It is well known that there are
three grads of healthcare, i.e. primary, secondary and tertiary. The first
level of service is intended for people with mild illness and those who
seek improvement in their health. This group represents approximately 85
percent of the population. Services needed by this group are nothing more
than basic healthcare and can be fulfilled by the community health centers
(puskesmas), sub-health centers, mobile clinics and community health
centers (balkesmas).
The secondary level of care means patients who require hospitalization and
can no longer be covered by primary healthcare. The examples of this form
of service are Type C and D Hospitals.
Last, tertiary health services are required by patients with complex and
severe illnesses who require the attention of specialists. Services
categorized in this level are provided at type A and type B hospitals.
Most people have not been properly educated about this health service
classification, and it is this that has triggered the hoard of patients
swarming at the outpatients department of any given hospitals. Many
patients with conditions that could easily be treated at puskesmas or
balkesmas go to type A or B hospitals. To deal with this phenomenon, the
public need to be educated regarding healthcare classification while the
healthcare policy makers can apply a two-way referral system.
Two-way referral system allows referrals from tertiary or secondary
healthcare to lower services (primary). While the existing referral system
is based more on medical reasons, two-way referral system allows
operational and capacity reasons as considerations to refer patients to
certain types of hospitals. Therefore, patients with less severe conditions
such as casual diarrhea, for example, who come to a Type A hospital, may be
referred to a more appropriate healthcare provider.
To implement this system, it is an indispensable requirement is to have a
reliable information system, connect one service with another. The health
information system needs to be accessed by all government hospitals, health
centers, as well as balkesmas. In the information system, there will be
information on the availability of medical personnel, beds, pharmaceuticals
and other relevant matters.
The system will definitely help physicians and medical personnel make
referral decisions. They will be informed of the medical team’s
availability, as well as space and facilities required by patients
elsewhere. Currently, information is obtained manually (e.g. by phone).
Theoretically, a reliable information system could improve healthcare
delivery speed and improve patient safety. ●
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