Sistem Kesehatan Nasiol 2009

Penerapan pelayanan kedokteran keluarga

di masa kini (era JKN)
 SISTEM KESEHATAN NASIONAL

SKN pada hakekatnya adalah bentuk dan cara

penyelenggaraan pembangunan kesehatan
• Sistem Kesehatan Nasional 1982
(KEPMENKES No. 9a/Men.Kes/SK/III/1982)
• Sistem Kesehatan Nasional 2004
(KEPMENKES R I No. 131/Men.Kes/SK/II/2004)
• Sistem Kesehatan Nasional 2009
(KEPMENKES No…/Men.Kes/SK/II/2009
• Sistem Kesehatan Nasional 2012
(Peraturan Presiden RI No. 72/2012)
 PENGERTIAN SKN

• SKN adalah pengelolaan kesehatan yang diselenggarakan oleh

semua komponen Bangsa Indonesia secara terpadu dan saling
mendukung guna menjamin derajat kesehatan masyarakat
yang setinggi-tingginya.
• SKN DISUSUN DENGAN MEMPERHATIKAN PENDEKATAN
PRIMARY HEALTH CARE yang meliputi:
– Cakupan pelayanan kesehatan yang adil dan merata
– Pemberian pelayanan kesehatan yang berpihak kepada kepentingan
dan harapan rakyat
– Kebijakan kesehatan masyarakat untuk meningkatkan dan melindungi
kesehatan masyarakat
– Kepemimpinan dan profesionalisme dalam pembangunan kesehatan
 ALMA ATA DECLARATION 1978 (1)

1. Health is a fundamental human right.

2. The existing gross inequality in the health status of the
people is politically, socially and economically unacceptable.
3. Economic and social development is of basic importance to
the fullest attainment of health for all and to the reduction of
the gap between the health status of the developing and
developed countries.
4. The people have the right and duty to participate individually
and collectively in the planning and implementation of their
health care.
 ALMA ATA DECLARATION 1978 (2)

5. Governments have a responsibility for the health of their people

which can be fulfilled only by the provision of adequate health
and social measures.
6. Primary health care is essential health care based on practical,
scientifically sound and socially acceptable methods and
technology made universally accessible to individuals and
families in the community through their full participation and at
a cost that the community and country can afford to maintain at
every stage of their development in the spirit of self-reliance and
self-determination.
 BASIC ELEMENTS OF PHC

1. Provision of safe water and basic sanitation

2. Food supply and proper nutrition
3. Maternal & child health care, including family planning
4. Immunization
5. Prevention and control of endemic disease
6. Appropriate treatment of common diseases & injuries
7. Health education
8. Provision of essential drugs
 ALMA ATA DECLARATION (3)

8. All governments should formulate national policies, strategies and

plans of action to launch and sustain primary health care as part of a
comprehensive national health system and in coordination with other
sectors. To this end, it will be necessary to exercise political will, to
mobilize the country's resources and to use available external resources
rationally.
9. All countries should cooperate in a spirit of partnership and service to
ensure primary health care for all people since the attainment of health
by people in any one country directly concerns and benefits every other
country. In this context the joint WHO/UNICEF report on primary health
care constitutes a solid basis for the further development and operation
of primary health care throughout the world.
 ALMA ATA DECLARATION (4)

10. An acceptable level of health for all the people of the world
by the year 2000 can be attained through a fuller and better
use of the world's resources, a considerable part of which is
now spent on armaments and military conflicts.
DIMENSION OF PRIMARY HEALTH CARE

1. As a set of activities
• Basic eight, essencial package
2. As a level of care
• First contact
3. As an attribute
• People-centered, comprehensive, continuity, coordination, family
and community oriented
4. As serives provided by general phycisian
5. As a philosophy
• Social justice and equity
• Solidarity
• Self-responsibility
6. As a strategy of organizing health care
 ALMA ATA & PRIMARY HEALTH CARE
UKW UKM
• Pembangunan nasional UKP
berwawasan kesehatan Tersier • Air bersih & Sanitasi
(pertanian, transportasi, (Sub-Sp) • Gizi masyarakat
industri, makanan, dll) • Pendidikan Kesehatan
• Tata ruang alam – Sekunder • Surveilans penyakit
manusia & kegiatannya (Pelayanan • Pencegahan primer &
• Pencegahan primer Spesialistis) sekunder

Primer
(Pelayanan Dasar mencakup 90%
kebutuhan kesehatan individu &
keluarga)

Kontak pertama ke sistem pelayanan

Individu & Keluarga

Upaya Kesehatan Perorangan (UKP)
Upaya Kesehatan Masyarakat (UKM)
Upaya Kesehatan Wilayah (UKW)

Kebijakan publik
 ALMA ATA DECLARATION (5)

Alma Ata ~ Primary Health Care (PHC)

Alma Ata ~ Health For All By The Year 2000 (HFA2000)
Failed to achieve HFA2000 ~ failed of PHC

WRONG PERCEPTION
EVIDENCES IN 3 DECADES SHOWED THAT PHC HAS PROVEN
AND STILL REVELANCE AS A STRATEGY TO IMPROVE HEALTH
 ESSENCE OF PHC

Value: dignity, equity, solidarity and ethics

Protects and promotes health
Centered on people
Universal coverage and equitable access
Focus in quality including cost effectiveness &
appropriate technology
Sustainable finances
 MEDICAL CARE WITHIN PHC

1. To serve as a first contact care

2. To provide continuous and comprehensive care
3. To refer to specialists and/or hospital services
4. To coordinate health services for the patient
5. To provide the best possible health in the light of
economic considerations.
 PHC TO PRIMARY CARE

– Primary health care is primary care applied on a

population level
– As a population strategy, it requires the commitment
of governments to develop a population-oriented set
of primary care services in the context of other levels
and types of services.
 PRIMARY CARE (1)

First Contact • Accessibility. Entry point into the health care system
• Decision to use specialist care is determined by
primary care physician
Person-focused • Better knowledge of patient and better recognition of
problems
Longitudinal • Relationship between a facility and its population
• Use by people over time regardless of the type of
problem; person-focused character of provider/
patient relationship
Comprehensive • Broad range of services
• Recognition of situations where services are needed
Coordination • Mechanism for achieving continuity
• Recognition of problems that require follow-up
Starfield
 PRIMARY CARE (2)

– First contact avoids unnecessary specialist visits.

– Person-focus over time avoids disease-focused care
(makes care more effective).
– Comprehensiveness avoids referrals for common
needs (makes care more efficient).
– Coordination avoids duplication and conflicting
interventions (makes care less dangerous).
WHY IS PRIMARY CARE IMPORTANT?

• Better health outcomes

• Lower costs
• Greater equity in health
 EVIDENCE-BASED SUMMARY(1)

• Countries with strong primary care

– have lower overall costs
– generally have healthier populations
• Within countries
– areas with higher primary care physician availability
(but NOT specialist availability) have healthier
populations
– more primary care physician availability reduces the
adverse effects of social inequality

Starfield
 EVIDENCE-BASED SUMMARY(2)

Primary health care oriented countries

• Have more equitable resource distributions
• Have health insurance or services that are provided by the
government
• Have little or no private health insurance
• Have no or low co-payments for health services
• Are rated as better by their populations
• Have primary care that includes a wider range of services
and is family oriented
• Have better health at lower costs
Sources: Starfield and Shi, Health Policy 2002; 60:201-18. van Doorslaer et
al, Health Econ 2004; 13:629-47. Schoen et al, Health Aff 2005; W5: 509-25.
 EVIDENCE-BASED SUMMARY(3)

Primary care vs Specialist care

• Many other studies done within countries, both industrialized
and developing, show that areas with better primary care have
better health outcomes, including total mortality rates, heart
disease mortality rates, and infant mortality, and earlier
detection of cancers such as colorectal cancer, breast cancer,
uterine/cervical cancer, and melanoma.
• The opposite is the case for higher specialist supply, which is
associated with worse outcomes.

Sources: Starfield et al, Milbank Q 2005;83:457-502. Macinko et al, J Ambul Care

Manage 2009;32:150-71.
 POLARIZATION OF HEALTH CARE SYSTEM

Primary care oriented Specialist oriented

(adopted PHC values & principles)

(Sub Specialist care)

Tertiary care

(Specialist care)
Secondary care

Primary care
Ter
tiary

Secondary

Primary care

Defined population
Population
 GOOD PRIMARY CARE REQUIRES

• Health system POLICIES conducive to primary care

practice
• Health services delivery that achieves the important
FUNCTIONS of primary care
• UNIVERSAL FINANCIAL COVERAGE, under
governmental control or regulation
• Efforts to DISTRIBUTE RESOURCES EQUITABLY
(according to degree of need)
• HEALTH WORKFORCES that suit to PHC
 NEED A REORIENTATION
OF MEDICAL EDUCATION (1)

– Edinburgh Declaration 1988 (World Federation of

Medical Education)
 12 principles to reorientate medical education
 Link & match between health care system and medical
education
 Trilogy of medical education: basic medical education –
postgraduate - CPD
– Resolution World Health Assambly 1989
 Mandate to reform medical education to make it relevance
with PHC values and principles
 NEED A REORIENTATION
OF MEDICAL EDUCATION (2)

– WHO-WONCA Conference 1994

 Making medical practice and education more relevant to
people’s need: The contribution of the family doctor
 Educational reform – develop specialisation in Family
Medicine
 5 star doctor
WHAT IS THE ORIENTATION OF OUR HEALTH
CARE SYSTEM? (1)

 Oriented to primary care, or

 Oriented to specialist care

See the polarization by assessment of its

characteristics:
 Health system characteristics
 Practice characteristics
WHAT IS THE ORIENTATION OF OUR HEALTH
CARE SYSTEM? (2)

Health System Characteristics

1. Regulation (condusive to primary care?)
2. Health financing
3. Type of primary care practitioner
4. Percent active physicians who are specialists
5. Ratio primary care physician (PCP) to population
6. Type of practice and status of PCP
7. Equal distribution of PCP in a small geographic area
8. Patient lists
9. Specialist allowed practice only in hospital
10. Payment method to physician
11. Professional earnings of PCP relative to specialists
12. Requirements for 24-hour coverage
13. Strength of medical education of PCP
WHAT IS THE ORIENTATION OF OUR HEALTH
CARE SYSTEM? (3)

Practice Characteristics
1. First-contact
2. Person-focus over time
3. Comprehensiveness
4. Coordination
5. Family-centeredness
6. Community orientation
 OVERVIEW
INDONESIA HEALTH CARE SYSTEM (1)

PUBLIC PUBLIC PRIVATE HEALTH

PRIMARY CARE HOSPITAL CARE
755
Dominated by:
District Curative care
Health
Officer
Hospital Type Episodic care
A Private
Fee for service Hospital 768
PHC implementation Hospital Type Self-referral
B
Health Center
8.737 Multi jobs Private Clinic Private Clinic
Multi Specialist Mono
Hospital Type Specialist
C
Sub Mobil Village
Health Health Health
Hospital Type Doctor Nurse Midwive
Center Center Pos
D Practice Practice Practice
22.651 51.996

Posyandu
266.827 COMMUNITY
 OVERVIEW
INDONESIA HEALTH CARE SYSTEM (2)

1. Regulation
 Public policies are not condusive to primary care

2. Health financing
 45% have health insurance
• 76 million social health insurance (Jamkesmas)
• 16 million government employee health insurance (Askes)
• 4 million private employee health insurance (Jamsostek)
• 8 million commercial insurance
• 2 million district health insurance (Jamkesda)
 55% is using FFS and out of pocket

3. Type of primary care practitioner

 Both GP and Specialist, and also nurse and midwive are allowed to practice in
primary level
 Practice individually, not as a team
 OVERVIEW
INDONESIA HEALTH CARE SYSTEM (3)

4. Percent active physicians who are specialists

 21% physicians are specialist
 GP + Specialist = 93.613 physicians

5. Ratio primary care physician (PCP) to population

 1 GP for 3180 (Target 1:2500)
 Uneven distribution

6. Type of practice and status of PCP

 Health centre, Solo practice, Clinic, 24 hour clinic
 Goverment employee in working hours, and private practice after office hour
(Multi jobs)
 More and more PCP working fulltime in private practice
 OVERVIEW
INDONESIA HEALTH CARE SYSTEM (4)

7. Equal distribution of PCP in a small geographic area

 No restriction
 PCP allowed to practice in maximum 3 locations

8. Patient lists
 No patient list
 Self-referral is common

9. Specialist allowed practice only in hospital

 No restriction
 Specialist is allowed to practice in the first level of care
 Multi jobs
 OVERVIEW
INDONESIA HEALTH CARE SYSTEM (5)

10. Payment methods to physician

 Multi sources of income (Gov salary + private practices in 1-3
locations/institutions)
 70-80% income from private practice based on FFS
 Capitation only paid by some health insurance and manage care

11. Professional earnings of PCP relative to specialists

 A wide income gap between GP and Specialist, around 8 – 244 times
 GP average annual income USD.16.000 – 24.000

12. Requirements for 24-hour coverage

 Apply only for health insurance patients
 OVERVIEW
INDONESIA HEALTH CARE SYSTEM (6)

13. Strength of medical education of PCP

 Indicate a weaknesses in PCP education
 GP education is below Specialist

UNDER GRADUATE POST GRADUATE CPD

GP Basic medical education X CPD

Specialist program + 3-
SPECIALIST Basic medical education CPD
4 years internship
 OVERVIEW
INDONESIA HEALTH CARE SYSTEM (7)
Primary Care and Infant Mortality Rates,
Indonesia, 1996-2000
1997- 1998-
1996-1997 1998 1999 1999-2000
Primary care 10.3 9.6 8.5 8.2
spending Reduced
per capita*
Hospital 4.1 4.4 4.6 5.3
spending Increased
per capita*
Infant 20% improvement 14% worsening
mortality (all provinces) (22 of 26 provinces)
(1990-96)
*constant Indonesian rupiah, in billions
Source: Simms & Rowson, Lancet 2003; 361:1382-5.
 OVERVIEW
INDONESIA HEALTH CARE SYSTEM (8)

Primary Care and Infant Mortality Rates,

Indonesia, 1996-2000
• Well designed primary care services have been demonstrated to improve health, even in
developing and middle income countries that have pursued their development.
• In Indonesia, spending on primary care increased in the early 1990s, reaching 10.3 billion
Indonesian rupiah in 1996 and accomplishing a 20% improvement over five years in infant
mortality  improvement in every province in the country. Hospital spending at this time was 4.1
billion rupiah.
• In the subsequent five years, primary care spending per capita was progressively reduced,
reaching 8.2 billion rupiah, concomitant with a rise in hospital spending per capita from 4.1 to 5.3
billion rupiah. During this period, infant mortality rose in 22 of the 26 provinces, with a 14% rise in
the country as a whole.
• Source: Simms C, Rowson M. Lancet 2003; 361(9366):1382-1385.
 OVERVIEW
INDONESIA HEALTH CARE SYSTEM (9)

• Indonesia Health Care System tend to

specialist care orientation
• To improve population health, the health care
system have to be restructurized becomes
primary care orientation
 NATIONAL GOAL
UNIVERSAL COVERAGE IN 2014

Specialist Orientation of Primary Care Orientation of

Health Care System Health Care System
(Sub Specialist care)
Tertiary care

(Specialist care)
Secondary care

Primary care
Ter
tiary

RESTRUCTURIZA Secondary
TION
Primary care

Defined population
Population
 Pelayanan Primer ?
Primary Health Care, Primary Medical Care,
Primary Care
1. As a philosophy
• Social justice and equity
• Solidarity
• Self-responsibility
2. As a strategy in organizing health care
3. As a set of activities
• Basic eight/essencial package
4. As a level of care
• First contact
5. As an attribute
• People-centered, comprehensive, continuity, coordination, family
and community oriented
6. As services provided by general phycisian
 MAKSUD DAN KEGUNAAN SKN

• Sebagai pedoman dalam pengelolaan kesehatan baik

oleh Pemerintah, Pemerintah Daerah, dan/atau
masyarakat termasuk badan hukum, badan usaha,
dan lembaga swasta.
• Merupakan dokumen kebijakan pengelolaan
kesehatan sebagai acuan dalam penyelenggaraan
pembangunan kesehatan
 LANDASAN SKN

 Landasan idiil, yaitu Pancasila

 Landasan konstitusional, yaitu Undang-undang Dasar
1945
Pasal 28 a
Pasal 28 b ayat (2)
Pasal 28 c ayat (1)
Pasal 28 h ayat (1) dan (3)
Pasal 34 ayat (2) dan (3)
 Landasan operasional:
• UU No 36 tahun 2009 tentang Kesehatan
• Peraturan perundangan lainnya
 DASAR PEMBANGUNAN KESEHATAN (1)

1. Perikemanusiaan
• Pembangunan kesehatan harus berlandaskan perikemanusiaan yang
dijiwai, digerakkan, dan dikendalikan oleh keimanan dan ketaqwaan
terhadap Tuhan Yang Maha Esa
• Nakes harus berbudi luhur, etika profesi, menerapkan prinsip
kemanusiaan, memiliki kepedulian sosial terhadap lingkungan sekitar.
2. Pemberdayaan dan kemandirian masyarakat
• Setiap orang dan masyarakat bersama Pemerintah berperan,
berkewajiban dan bertanggungjawab untuk memelihara dan
meningkatkan derajat kesehatan perorangan, keluarga, masyarakt dan
lingkungannya.
• Pembangunan kesehatan dilaksanakan dengan berlandaskan pada
kepercayaan atas kemampuan dan kekuatan sendiri, semangat
solidaritas sosial, gotong royong, dan penguatan kesehatan sebagai
ketahanan nasional.
 DASAR PEMBANGUNAN KESEHATAN (2)

3. Adil dan merata

• Setiap orang mempunyai hak yang sama dalam memperoleh derajat
kesehatan yang setinggi-tingginya tanpa memandang suku, agama,
golongan dan status sosial ekonominya.
• Setiap orang berhak memperoleh pelayanan kesehatan.

4. Pengutamaan & manfaat

• Mengutamakan kepentingan umum ketimbang kepentingan perorangan
atau golongan
• Mengutamakan peningkatan derajat kesehatan dan pencegahan penyakit
• Mengutamakan tata penyelenggaraan yang baik dan berhasil guna dan
memberi manfaat yang sebesar-besarnya untuk masyarakat
• Memberi perhatian khusus pada penduduk rentan, a.l. ibu, bayi, anak,
manusia usia lanjut, dan masyarakat miskin.
• Mengintegrasikan pusat dan daerah dengan mengedepankan nilai-nilai:
berpihak pada rakyat, bertindak cepat dan tepat, kerja sama tim,
integritas tinggi, dan transparansi serta akuntabilitas.
 PRINSIP DASAR SKN
1. Perikemanusiaan
2. Keseimbangan
3. Manfaat
4. Perlindungan
5. Keadilan
6. Penghormatan hak asasi manusia
7. Sinergisme dan kemitraan yang dinamis
8. Komitmen dan tata pemerintahan yang baik
9. Legalitas
10.Antisipatif dan proaktif
11.Gender dan nondiskriminatif, dan
12.Kearifan lokal
 SUBSISTEM SKN
1. Subsistem Upaya Kesehatan
2. Subsistem penelitian dan pengembangan kesehatan
3. Subsistem pembiayaan Kesehatan
4. Subsistem sumber daya Manusia kesehatan
5. Subsistem sediaan farmasi, alat kesehatan, dan
makanan
6. Subsistem manajemen, informasi, dan regulasi
kesehatan
7. Subsistem pemberdayaan masyarakat
 SISTEM KESEHATAN NASIONAL
Hubungan antara UKP & upaya lainnya dalam SKN

Upaya yang dilaksanakan sistem kesehatan Objektif sistem

kesehatan
Stewardship

Responsiveness

Sumber Daya Manusia Kes

Farmasi, Alkes & Makanan

UKP Sehat
Manajemen & Informasi Kes
UKM
Pemberdayaan Masyarakat
UKW
Fairness
Financing
(Collecting, Pooling &
Purchasing) WHO 2000, modifikasi

UKP = Sistem Kesehatan Perorangan; UKM = Sistem Kesehatan Masyarakat

 SUBSISTEM UPAYA KESEHATAN

• Pengertian
Subsistem Upaya Kesehatan adalah pengelolaan upaya
kesehatan yang terpadu, berkesinambungan, paripurna, dan
berkualitas, meliputi upaya peningkatan, pencegahan,
pengobatan, dan pemulihan, yang diselenggarakan guna
menjamin tercapainya derajat kesehatan masyarakat yang
setinggi-tingginya

• Tujuan
Terselenggaranya upaya kesehatan yang adil, merata,
terjangkau, dan bermutu untuk menjamin terselenggaranya
pembangunan kesehatan guna meningkatkan derajat
kesehatan yang setinggi-tingginya
 SUBSISTEM UPAYA KESEHATAN

Prinsip-prinsip upaya kesehatan

1. Terpadu, berkesinambungan, dan paripurna
2. Bermutu, aman, dan sesuai kebutuhan
3. Adil dan merata
• Pemerintah wajib menyediakan fasyankes yang merata untuk memnuhi
kebutuhan masyarakat di seluruh wilayah NKRI
4. Nondiskriminatif
• Sesuai kebutuhan medis, bukan status sosial ekonomi dan tidak
membeda-bedakan suku/ras, budaya, agama, dan kesetaraan gender.
5. Terjangkau
6. Teknologi tepat guna, dan
• Teknologi tepat guna yang berbasis bukti, sesuai kebutuhan, dan tidak
bertentangan dengan etika dan agama
7. Bekerja dalam tim secara cepat dan tepat
 SUBSISTEM UPAYA KESEHATAN
Penyelenggaraan
1. Upaya kesehatan dibedakan atas dua:
• Upaya Kesehatan Masyarakat (UKM) terutama diselenggara-
kan oleh pemerintah dgn peran aktif masyarakat
• Upaya Kesehatan Perorangan (UKP) diselenggarakan baik
oleh pemerintah maupun masyarakat dan dunia usaha
2. Terbagi 3 tingkatan
• Tingkat pertama / primer
• Tingkat kedua / sekunder
• Tingkat ketiga / tersier
3. Secara terpadu, berkesinambungan, dan paripurna
melalui sistem rujukan
4. Dilaksanakan sesuai dengan ketentuan peraturan
perundangan yang berlaku
 LOGICAL FRAMEWORK
SISTEM PELAYANAN KESEHATAN BERBASIS PELAYANAN PRIMER
DALAM ERA JAMINAN KESEHATAN NASIONAL
Pola Pencarian Layanan Kesehatan Strata Fasilitas Kesehatan Peran dan Fungsi
0,1% ke TERSIER • PUSAT RUJUKAN untuk mengatasi masalah
strata Sub Sp khusus, juga sebagai pusat penelitian &
tersier
pengembangan ilmu kedokteran
Kendali 50% Kendali
• BACK-UP untuk mengatasi masalah
3-5% ke Biaya Mutu
strata SEKUNDER kesehatan yang tidak dapat diselesaikan
sekunder RS, Klinik Sp Dokter Pelayanan Primer (DPP)
PRIMER • GATEKEEPER untuk memenuhi sebagian
besar kebutuhan kesehatan warga
25-33% ke 50% (promotif, preventif, kuratif, rehabilitatif)
strata primer Klinik/Praktik Mandiri • 1 DPP mengayomi + 2500 warga
Dokter Pelayanan Primer • Rerata kontak per orang per tahun + 4 kali
di tengah masyarakat • Sekitar 10-12% dirujuk ke strata sekunder
SETIAP WARGA diajak berpola hidup sehat,
75-80% punya gejala Fasilitas pendukung Self-Care mampu mengobati diri sendiri (SELF-CARE)
dan faktor risiko & tahu saat yang tepat berkunjung ke dokter

Gambaran peristiwa kesakitan Integrasi dan rayonisasi fasilitas kesehatan SETIAP WARGA wajib mendaftarkan diri ke 1
per 1000 orang dalam sebulan untuk menjamin ketersediaan, keadilan, mutu, klinik/praktik mandiri strata primer yang
keterjangkauan, kesinambungan & keamanan berada di wilayahnya
Source: Lord Dawson's Report on Future Provision of Medical and Allied Services 1920. Green, The Ecology of medical care revisited 2001. Starfield, Primary Care, Balancing
Health Needs, Service, and Technology 1998. Modified by Gatot Soetono
 JKN UNTUK SELURUH PENDUDUK
• Disparitas antar dan dalam
Melihat Indonesia wilayah
• Transisi demografi
secara komprehnsif
• Transisi epidemiologi
integral • Pembangunan &
pertumbuhan ekonomi
• Geografi & infrastruktur
• Desentralisasi & globalisasi
• Booming teknologi
• Dalam dunia yang berubah
cepat dan tidak pasti

INDONESIA BUKAN JAKARTA

Implementasi JKN harus dapat menjamin akses & mutu pelayanan
kesehatan bagi +240 juta penduduk yang tersebar di + 7000 dari 13.466
pulau

MODEL TANGGUNG JAWAB

Perkotaan Swasta/Masyarakat
Pedesaan Pemerintah Daerah/Swasta/Masyarakat
Daerah terpencil Pemerintah Pusat
 REKOMENDASI IDI

2. Menata ulang sistem pelayanan kesehatan agar

sejalan dengan JKN
Center of exellence
TOP REFERRAL NATIONAL
Tipe I Tertiary care

Beyond REGIONAL REFERRAL

Tipe II (20 -40 LOCAL REFERRAL)
district
Secondary care
LOCAL REFERRAL
Tipe III District (6 -8 POLYCLINICS)

• Primary care services

POLYCLINIC • Education & training
Tipe IV SubDistrict (10 -20 BASIC UNITS)
• Research
POINT OF CARE POINT OF CARE POINT OF CARE POINT OF CARE
(2500 people) (2500 people) (2500 people) (2500 people)

1 people served by 1 basic unit

 POKJA PERSIAPAN IMPLEMENTASI SJSN

1. Prof Dr. Zubairi D, Sp.PD(K) 5. Prof Dr. Errol UH, Sp.B.SP.OT (K)
2. Prof Dr. Ilham OM, Sp.OG(K) 6. DR.Dr. Fachmi Idris, M.Kes
3. Prof Dr. Hasbullah T, MPH, DR(PH) 7. Dr. Pranawa, Sp.PD, KGH
4. Prof Dr. Amal CS, MPH, DR(PH) 8. Dr. Prijo Sidipratomo, Sp.Rad
1. Dr. Gatot Soetono, MPH 11. Dr. Moh Adib K., Sp.OT
2. Dr. Abraham AP. Patarai, Mkes 12. Dr. H.N. Nazar, Sp.B. MH Kes
3. Dr. Andi Alfian Z., M.KM 13. Dr. Kadarsyah, MS
4. Dr. E. Sutarto, SKM 14. Dr. Mahesa Paranadipa, MH
5. Dr. Darwis Hartono, MHA 15. Dr. Yuyun Grahnawati
6. Dr. Dya A. Waluyo 16. Dr. Dien Kurtanty, M.KM
7. Dr. Ari Fahrial Syam, Sp.PD 17. Dr. Abdul Halik Malik
8. Dr. Daeng M. Faqih, MH 18. Dr. Suyuti Symsul
9. Dr. Djoni Darmadjaja, Sp.B 19. Dr. Pimprim B Yanuarso, Sp.A
10. Dr. Zulkifli Amin, Sp.PD 20. Dr. Akmal Taher, Sp.U

gsoetono@yahoo.co.id
 SUBSISTEM UPAYA KESEHATAN

• Untuk menjamin terpenuhinya persyaratan mutu

ditetapkan beberapa persyaratan pokok:
• bersifat menyeluruh, terpadu, berkelanjutan,
terjangkau, bermutu dan berjenjang
• mengikuti prinsip profesional, ekonomis, kaidah
sosial serta sesuai dengan moral dan etika
bangsa
• didasarkan atas perkembangan mutakhir Iptek
kedokteran dan kesehatan
 UPAYA
KES

UKM UKP

Swasta/
Pem Pem Swasta
ukbm

•Puskesmas
•Puskesmas •Praktik-2 Nakes, Klinik
Strata-1
•Pos-2 Kesehatan •Apotek, Lab, toko
obat, Optik, dll

•Praktik Nakes Spes Kons

•Dinkes Kab/Kota •RS C & B
Strata-2
•UPT-2 •Apotek, Lab, Optik, T Obt
•Balai-2 Kes, dll

•Dinkes Prov •Praktik Nakes Spes Kons

•RS B & A
Strata-3 •Depkes •Apotek, Lab, Optik, T Obt
•Institut-2 Kes •Pst-2 Unggulan Nas,
 Sistem Kesehatan Nasiol 2009

Penerapan pelayanan kedokteran keluarga

di masa kini (era JKN)
 LOGICAL FRAMEWORK
SISTEM PELAYANAN KESEHATAN BERBASIS PELAYANAN PRIMER
DALAM ERA JAMINAN KESEHATAN NASIONAL
Pola Pencarian Layanan Kesehatan Strata Fasilitas Kesehatan Peran dan Fungsi
0,1% ke TERSIER • PUSAT RUJUKAN untuk mengatasi masalah
strata Sub Sp khusus, juga sebagai pusat penelitian &
tersier
pengembangan ilmu kedokteran
Kendali 50% Kendali
• BACK-UP untuk mengatasi masalah
3-5% ke Biaya Mutu
strata SEKUNDER kesehatan yang tidak dapat diselesaikan
sekunder RS, Klinik Sp Dokter Pelayanan Primer (DPP)
PRIMER • GATEKEEPER untuk memenuhi sebagian
besar kebutuhan kesehatan warga
25-33% ke 50% (promotif, preventif, kuratif, rehabilitatif)
strata primer Klinik/Praktik Mandiri • 1 DPP mengayomi + 2500 warga
Dokter Pelayanan Primer • Rerata kontak per orang per tahun + 4 kali
di tengah masyarakat • Sekitar 10-12% dirujuk ke strata sekunder
SETIAP WARGA diajak berpola hidup sehat,
75-80% punya gejala Fasilitas pendukung Self-Care mampu mengobati diri sendiri (SELF-CARE)
dan faktor risiko & tahu saat yang tepat berkunjung ke dokter

Gambaran peristiwa kesakitan Integrasi dan rayonisasi fasilitas kesehatan SETIAP WARGA wajib mendaftarkan diri ke 1
per 1000 orang dalam sebulan untuk menjamin ketersediaan, keadilan, mutu, klinik/praktik mandiri strata primer yang
keterjangkauan, kesinambungan & keamanan berada di wilayahnya
Source: Lord Dawson's Report on Future Provision of Medical and Allied Services 1920. Green, The Ecology of medical care revisited 2001. Starfield, Primary Care, Balancing
Health Needs, Service, and Technology 1998. Modified by Gatot Soetono
 DATA & FAKTA TENTANG PUSKESMAS

(Quality, Donabedian)
• Risfaskes Puskesmas (2011)
STANDAR OUTCOME
• Masih banyak yang berada di bawah standar
ST. PELAYANAN
S • Input dan proses yang mendukung
T ST. KINERJA keberhasilan fungsi Puskesmas masih jauh dari
harapan
P PEDOMAN
R PROSEDUR • Terdapat disparitas input dan proses yang
O PERANGKAT KERJA cukup tajam berdasarkan geografi, kota/desa
S dan regional
JOB DISCRIPTION
E
S STANDAR KOMPETENSI
Pasal 44 UUPK:
STANDAR PERILAKU
Dokter wajib mengikuti standar pelayanan
POLICY kedokteran, … dibedakan menurut jenis dan
strata sarana pelayanan kesehatan.
STANDAR STRUKTUR

Aspek jumlah dan mutu:

• Banyak puskesmas yang tidak eligible untuk praktik dokter dan untuk di kontrak
BPJS
• Penambahan jumlah dan peningkatan mutu puskesmas terkendala dengan biaya
 AWAL PENERAPAN JKN JANUARI 2014

• Pasar JKN dan pasar komersial (non JKN) masih berimbang

• Makin baik JKN, pasar komersial akan mengecil
• Tahun 2019 diharapkan pasar JKN mencapai 90%
PASAR JKN + 121 JUTA
PESERTA 2014 PROVIDER
Jamkesmas PNS 17,274,520 BPJS
III
Jamkesmas PBI 86,400,000 Kontrak, pembayaran,
premi, manfaat, lingkup,risiko, otonomi
JPK Jamsostek 5,600,000 II
TNI/Polri 2,200,000
Jamkesda/PJKMU 10,000,000
I
TOTAL 121,474,520 PRIMER
Eligibilitas • Info produk 40-50% POINT OF CARE
• Kartu
Biaya langsung
Yanmed Obat2an Retribusi Copayment

Biaya tidak langsung Sudah dibayar

Peserta JKN
Opp cost Transport Makan Akomodasi
Harus bayar
Individu Biaya tidak langsung Non JKN

PASAR NON-JKN / KOMERSIAL + 131 JUTA

 JAMINAN KESEHATAN NASIONAL (JKN)

Penerapan JKN memadukan 2 sistem:

• Sistem pembiayaan kesehatan
2 sisi dari 1 mata uang
• Sistem pelayanan kesehatan

PROVIDER

BPJS
PAYOR III
• Pemerintah (PBI)  Premi Kontrak, pembayaran,
premi, manfaat, lingkup,risiko, otonomi
• Pemberi Kerja  % income II
• Pekerja  % income
• Informal  Nilai nominal I
PRIMER
Eligibilitas • Info produk 40-50% POINT OF CARE
• Kartu
Biaya langsung
Yanmed Obat2an Retribusi Copayment

Biaya tidak langsung Sudah dibayar

Peserta JKN
Opp cost Transport Makan Akomodasi
Individu Harus bayar
Non JKN