Opinion

Lessons from the Jakarta
Health Card program

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.

The writer is a health management researcher at Airlangga University, Surabaya.

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