RATIONING SEBAGAI UPAYA PENYESUAIAN DALAM IMPLEMENTASI KEBIJAKAN PELAYANAN OBAT BAGI PESERTA JAMINAN KESEHATAN NASIONAL DI RUMAH SAKIT

ENDANG YUNIARTI, Prof. Dr. Dra. Sri Suryawati, Apt.; Prof. Dra. RA Yayi Suryo Prabandari, M.Si., Ph.D.; Dr. Dra. Erna Kristin, M.Si., Apt

2019 | Disertasi | DOKTOR ILMU KEDOKTERAN DAN KESEHATAN

Latar Belakang: Kebijakan pelayanan obat bagi peserta Jaminan Kesehatan Nasional mengacu pada Formularium Nasional (Fornas). Adanya isu keterbatasan sumber daya finansial dari paket pembayaran prospektif INA CBGs membuat rumah sakit melakukan strategi rationing pemberian obat. Tujuan penelitian: Mengungkap proses implementasi Fornas dan praktik rationing yang dilakukan oleh manajemen dan pemberi pelayanan di rumah sakit untuk mengetahui dampaknya terhadap terimplementasikannya Fornas dan terpenuhinya prinsip etika medik. Metode: Desain mixed method concurrent. Data kualitatif diperoleh dari wawancara terhadap 56 responden yang dipilih secara purposive, yaitu perwakilan manajemen rumah sakit dan pemberi pelayanan (dokter, apoteker dan perawat) dan dianalisis menggunakan analisis konten tematik. Data kuantitatif diperoleh dari hasil sampling resep dan dianalisis secara deskriptif. Model implementasi kebijakan Mazmanian dan Sabatier digunakan untuk mengidentifikasi faktor- faktor yang memengaruhi proses implementasi Fornas, praktik rationing dianalisis menggunakan klasifikasi yang dikembangkan oleh Maybin dan Klein (denial, selection, delay, deterrence, deflection, dan dilution), sedangkan kontradiksi terhadap proses transparansi dari rationing dievaluasi menggunakan empat kondisi accountability for reasonableness dari Daniel dan Sabin (relevance, publicity, appeal, dan enforcement). Hasil penelitian: Faktor yang memengaruhi implementasi Fornas berasal dari faktor teknis, faktor intrinsik serta faktor ekstrinsik Fornas. Praktik rationing yang banyak dilakukan adalah dilution (penggantian obat dan pengurangan jumlah obat), denial (tidak memberikan obat), deterrence (memfasilitasi pasien untuk membeli obat secara out of pocket) dan belum sepenuhnya transparan. Tidak ada perbedaan antara rumah sakit pemerintah dan swasta. Rationing yang dilakukan sebagai bentuk pnyesuaian terhadap keterbatasan paket INA CBGs dalam proses internalisasi Fornas dapat memberikan dampak positif maupun negatif terhadap proses implementasi Fornas dan pemenuhan prinsip etika medik. Kesimpulan: Rationing dapat memfasilitasi implementasi Fornas, namun berpotensi menimbulkan masalah etika medis. Jika dilakukan melalui proses yang lebih terstandar, rationing akan sangat bermanfaat bagi pasien dan sistem. Panduan untuk praktik rationing yang lebih eksplisit, adil dan transparan harus dikembangkan di tingkat rumah sakit.

Background: Medicine policy for participants of the National Health Insurance refers to the National Formulary (Fornas). The issue of limited financial resources from the INA CBGs prospective payment system has led hospitals to implement rationing strategies for medicines. Objectives: To analyze the implementation process of Fornas and the rationing performed by management and health care providers in hospitals, and to determine the impact on the implementation of Fornas and to evaluate its fairness. Method: Concurrent mixed method design. Qualitative data was obtained from interviews with 56 respondents selected purposively, namely representatives of hospital management and service providers (physicians, pharmacists and nurses) and analyzed using thematic content analysis. Quantitative data were obtained from the results of prescription sampling and analyzed descriptively. Mazmanian and Sabatiers policy implementation model is used to identify the factors that influence the implementation process, strategies for rationing were categorized using the matrix developed by Maybin and Klein (denial, selection, delay, deterrence, deflection, and dilution), while contradictions in fairness were evaluated using the four conditions of accountability for reasonableness of Daniel and Sabin (relevance, publicity, appeals, and enforcement). Results: The implementation of Fornas was influenced by technical factors, intrinsic and extrinsic factors of Fornas. The most frequent rationing performed was dilution (to replace medicines with others which were perceived by physicians as less effective or less safe and to reduce the amount of medicines), denial (not to provide medicines), deterrence (to encourage patients to pay for medicines) and the rationing was not yet fully transparent. There is no difference between government and private hospitals. Rationing which is performed as an adjustment to the limitations of the INA CBGs in the Fornas internalization process has a positive or negative impact on the implementation of Fornas and the medical ethical principles. Conclusion: Although rationing strategies were facilitating the implementation of National Formulary, they potentially raise problems related to the principles of medical ethics. If performed in the more standardized decision-making process, rationing would be of great benefits to patients and the system. Guidance for more explicit, fair and transparent of rationing should be developed at the hospital level.

Kata Kunci : rationing, implementasi kebijakan, Fornas, INA-CBGs