AN ANALYSIS OF THE HEALTHCARE CENTER SYSTEM AS A GATEKEEPER IN 2018 *Septiana Maharanti, **Puput Oktamianti

In managed care, primary healthcarecare facilities acts as the gatekeepers, and its success is judged from the number of visits. In the year 2016, the Healthcare Centers in Tangerang was unable to meet the targets set by BPJS healthcare, ideally the visit rate should reach >150‰ and the referral ratio <10%. However, the visit rate only reachd 41‰ and the referral ratio was 29%. In addition, most healthcare centers the nonspecialised referral ratio was above 5%. The purpose of this research is to analyze the healthcare service system as the gatekeepers in managed care. This research is a descriptive analytical study with a qualitative approach. The data was collected through in-depth interviews, examination of documents and observations. Research conducted at healthcare centers and clinics Pedurenan Pabuaran Tumpeng from May-June 2018. From this research we discovered that the low contact lrate was caused be the low first contact levels, continuity, and comprehensiveness. The registering process was also complicated. We also discovered that the lack of human resources also influences the low contact rate.


INTRODUCTION
In the National Healthcare Coverage (JKN) era, healthcare services are no longer centered at the hospital or referred healthcare services, referrals would be provided only when necessary. 1 The managed care system integrates financing and healthcare.Managed care is applied to improve the quality of healthcare services and maintain cost efficiency. 2The application of this principle means that the primary healthcare facilities is the hub of healthcare services.The health center provides holistic healthcare services, however the mainstay is disease prevention and health promotion.In addition the Health Centers are also responsible for providing referrals to more advanced facilities when necessary. 3 a gatekeeper, the Health Centers acts as the controller and the main guard in containing healthcare costs, which means that the patient can only access more advanced healthcare facilities after obtaining the approval from the primary healthcare facility.However, when the quality of the primary healthcare facilities are not reinforced, the hospital would become a 'Giant

METHOD
The approach used in this research was the qualitative approach with the descriptive-analytic method to obtain in-depth information about the implementation of the healthcare system at the Puskesmas as the gatekeepers in Tangerang.As a comparison two centers was used, the Pabuaran Tumpeng and the Pedurenan Health Centers.The instruments used in this research was indepth interviews guidelines, observation guidelines and documentary research.
With the Donabedian-Azwar systems approach, the types and numbers of input used can be customized as needed, therefore the output generated is more optimal, accurate, and objective.Feedback is also obtainable at any stage of the program.This research lasted for 2 months, from May to June 2018, all the research phases was completed during this period (the preparation, data collection, data processing, data analysis and evaluation of research activities).Primary and secondary data was used in this research.The primary data was obtained directly from the field through in-depth interviews and observation.The secondary data was from literature and documents from the two Health Centers.The informants were selected based on appropiateness and adequacy, they included JKN patients, registration desk officer, general practitioners, dentists, the Head of the Health Center, the Head of Finance and Health Assurance of the Health Office of Tangerang City, the Head of the Primary Healthcare Services Management Unit (MPKP) of the Health BPJS of Tangerang City.
To maintain data validity, the data was triangulated based on its sources and methods.The data was processed and grouped in a matrix based on the questions and then the findings were conceptualized.

RESULT AND DISCUSSION
RESULT 12 people were selected as the informants for this study.Pedurenan Health Center provides healthcare services for 2 villages, covering a total 32,124 people, and Pabuaran Tumpeng Health Center provides healthcare for 5 villages, covering a total 43,579 people.

Contact Rate
During the study, the Health BPJS stated that the contact rate at both Health Centers was less than 150‰.In January, the Pedurenan Health Clinic reached 109‰, in February it reached 117‰, and in March it reached 111‰.And it was even lower at the Pabuaran Tumpeng Health Center', because most people prefer to visit a hospital, which would result in inflated healthcare costs.
According to the BPJS, there was over 14,5 million visits to the primary healthcare facility in the first trimester of 2015.2,2 million of it was referrals from the primary facility to the secondary facility and 214,706 of it was for nonspecialistic referrals, which shouldn't be referred.Ideally, only 10% should be referred to the secondary healthcare facility, however at the moment the number reached 15.3%. 4 The visit contact rate to Health Centers in Indonesia is far from ideal, of 1000 people registered at the Puskesmas, only around 40 visited it (40.3‰).Ideally, according to the BPJS, the contact rate should reach ≥150‰ (safe zone) or ≥ 250‰ (accomplished zone).The low contact rate and high referral rate indicates that the primary healthcare facilities have not provided optimal services. 4e JKN participant coverage in Tangerang was 66%.Such high numbers should be complemented with good-quality health services.Based on the annual report of the Tangerang BPJS, the average ratio of reference between January to December of 2016 reached 29%.In addition, the nonspecialistik referral ratio indicated that there were still health centers that have a ratio above 5% (unsafe zone).The average visit rate to the Puskesmas at Tangerang city was less than 150‰, it only totaled 41‰. 5 Therefore we would like discover how has the Health Centers in Tangerang has fared as the gatekeepers of managed care in 2018.

Literature Review
Gatekeepers are the first healthcare facilities that provides standard basic healthcare services.Here is where the screening for referrals to the next facility is performed. 6However, the development of medical science and technology has changed the nature of healthcare and compartmentalized it.According to Azwar, those changes can be overcome by introducing comprehensive and integrated healthcare services through the two approaches, the institutional and the systematic approach. 7e systems approach is a strategy which uses analysis, design and management to achieve the goals effectively and efficiently.Systems approach in health services are divided into three components, they are input, process and output or outcome.Dr. Avendis Donabedian introduced the theory.The input element consists of people, infrastructure, material, information, technology; the processes element consist of what is done and how it is done; and the element output or outcomes consist of healthcare services delivered, change in behavior, change in healthcare healthcare status, and satisfaction. 8ealth Center, in January it reached 62‰, in February it reached 60‰ and in March reached 66%.

Nonspecialistic Referral Ratio
There were no nonspecialistic referral cases at the Pedurenan Health Center (0%) for three consequtive months.However, there were nonspecialistic referral cases at Pabuaran Tumpeng Health Center, but the rate was less than 5%, therefore in compliance with the targets set by the Health BPJS and it was relatively stable in all three months (0% in January, 3.47% in February, and 0.63% in March).

Patient Registration Process
Pedurenan Health Center only has one station that for all the patients, therefore the private, BPJS, and other categories would be handled at that station.However Pabuaran Tumpeng Health Center has three stations at the registration, one for death certificates, geriatry, Haj, and emergency; one for private and BPJS patients; and one for referrals.10 patients at different arrival times were randomly selected, and we observed that 3 people had to wait forf 2 hours, 3 for 1,5 hours, and 4 for 1 hour.Therefore, the average waiting time was 87 minutes.While the waiting time at Pabuaran Tumpeng Health Center, the average waiting time was 32 minutes.

First Contact
There were 12,419 people registered at Pedurenan Health Center and 15,281 participants registered at Pabuaran Tumpeng Health Center, which means 1 doctor has to handle more than 2 patients.An important factor in the selection of healthcare facilities for JKN participants is easy access.The Pabuaran Tumpeng Health Center is not accessible with public transportation and the Pedurenan Health Center is located in the middle of a neighborhood.
Both Health Centers are accessible 24 hours.However, Pedurenan Health Center has provided some efforts to remain accessible outside office hours by providing online access through whatsapp, promotion, suggestion boxes, and the doctor's personal phone numbers.But this was not provided by the other Health Center.

Continuity
At Pedurenan Health Center, each patient is assigned a personal folder, no family folders were used.While at Pabuaran Tumpeng Health Center about 20% of patients were assigned family folders and the rest was provided personal folders.

Comprehensiveness
Both Health Centers provides rather comprehensive services, in addition to two general practitioners (GP), there is a dentist, a laboratory, an apothecary or pharmacy in one environment.However, the GP also acts as the manager for patient education, health promotion, and chronic diseases program.

The Chronic Diseases Management Program or
Program Pengelolaan Penyakit Kronis (Prolanis) was available at both centers and was provided once a month.The activities include exercises; measurements for abdominal circumference, weight, blood sugar, and blood pressure; health promotion and distribution of medication.However, less than 50% of the targets routinely visit the Centers, as evident in the following table.

Referrals
Both Health Centers provided referrals when the patient really should be referred and when the patient demanded to be referred (APS).However, no patients were referred on demand.

Coordination
Pedurenan Health Center cooperates with private midwife practices (BPS) and private doctor practices.At this Health Center, the BPS also provides immunizations for school children.however, this was not found at Pabuaran Tumpeng Health Center.There is communication forum for the area at health Health Center that coveys the interests of each party, through this forum, information is distributed faster.The heads of the Health Centers are members of the forum.

Human Resources
Each Health Center have 2 GPs and 1 dentist.And to improve the quality of the available resource, the local Health Office provides trainings for the doctors on the programs that they must perform, these trainings are done several times a year.While the Health BPJS provides trainings on the management of chronic diseases once a year.

Facilities and Infrastructure
The facilities and infrastructure available at both Health Centers was sufficient according to PMK no.75/2014 on Health Centers, from the ventilation, sanitation, electricity, communication, lightning protection, fire protection, stairs, and ambulance.The Tangerang City Health Office provides free ambulance for referrals.

Medical Equipment
Based on what we observed and PMK no.75/2014 on Health Centers, the availability rate at Pedurenan Health Center was 56% and at Pabuaran Tumpeng Health Center was 68%.In the documents from the Health Office, the availability of medical equipment at the Pedurenan Health Center was the lowest in Tangerang City, which was 9.89%.While the availability of medical equipment at Pabuaran Tumpeng was 32.54%.There were also necessary equipment that was not available, such as Ear-Nose-and Throat equipment for cleaning ears, etc.

Medication
The availability rate at both Health Centers were similar, it was 37%.

DISCUSSION
The contact rate at both Health centers was less than 150‰, which is in the low category.The community has not made the Health Center as their main first contact location.While there were no problems in nonspecialistic referral ratio, because it was less than 5% at both areas.
According to Fuanasari et al., more stations at the registration desk equals shorter waiting time. 9Because there was only one station at the Pedurenan Health Center and 3 stations at the Pabuaran Tumpeng Health Center, the waiting time at the second Health Center was shorter.Although both Health Centers has problems with unstable internet connection.Pabuaran Tumpeng also has no direcrt access to public transportation, therefore was harder to access.The combination of all these factors, according to Mcmurchy, would suppress the contact rate, as experienced at both Health Centers. 10 In addition to those problems, both Health Centers do not have 24 hours service.Pedurenan Health Center, though has endeavored to solve it by providing other modes of access to the doctors through the telephone and whatsapp.
Just as what Rahmi discovered in her research, the community has not made the Health Center as their first contact access to healthcare, which is most probably caused by the limited human resources and the large number of participants, which equals to not optimal services. 13To improve the contact rate, Fitriani,11 improvement in the quality would also increase the loyality of the patient, since they would be more satisfied.When patients are loyal, then they would routinely access the Health Center and use the services provided in continuity, not only when they are ill.They will also recommend it to their closest relations.Consequently, the contact rate would rise.
The number of prolanis participants that routinely visit the puskesmas was influenced by the visit rate, the participation rate in activities, communication rate, resources involved (which included location and funding), disposition for the program, SOP, level of education, and support from the health officer and family. 12,13,14High risk prolanis participants that do not routinely visit the Health Center are vulnerable to complications.Therefore, the health goal was not achieved and the patient must be referred to a higher health facility.This program has been performed, but it was not optimal.
The primary healthcare facility is responsible for transferring information for the accurate planning of healthcare management and disease prevention.According to Starfield, coordination is the activity that connects each element of the service. 15At the Health Center this was evident in a communication forum between Health Centers and the cooperation of the BPS at the Pedurenan Health Center.
Meanwhile, human resources are evaluated based on the scheduling of the doctors, diagnosing, trainings, and the competence of the doctors.Both Health Centers' ratio of doctor to patient was not ideal.1 doctor should only serve 5,000 patients, 6 but the ratio of BPJS participant to doctor at Pedurenan Health Center was 1:6.209 and at Pabuaran Tumpeng it was 1:7640,5.To avoid not having any doctors during service hours, when a doctor could not be present, either because of meetings, field service, or any other reasons, the schedule was adjusted.
There were not enough medical equipment at both health centers, at Pedurenan the rate only reached 56% and Pabuaran Tumpeng it was 68%.Pedurenan also had the lowest availability rate in Tangerang City, which was 9.89%.While the availability of medical equipment at Pabuaran Tumpeng was 32.54%.One example was the lack to ENT equipment, while cerumen prop is one of the highest diagnosis to be referred to a higher healthcare facility.
Diabetes mellitus and cough are among the 10 most common ailments suffered by the JKN patients at the Health Centers.However, Pedurenan Health Center does not have any Glimepiride and there were not black or white cough syrups.Pabuaran Tumpeng also did not have nay black or white cough syrup.This Health Center also did not have a complete array of life saving medication, such as diazepam i.v./i.m. and diphenhydramine i.v./i.m.Stockouts on certain medicines, such as amlodipine also has occurred in the past.Whenever that happens, the Health Center would give the patient a prescription to the patient, when they agree, so that they would buy it themselves.This problem was caused by inaccurate planning, and if it is not addressed, would threaten the continuity. 16,17

CONCLUSION
In this research we discovered that the contact rate at both Health Centers did not reach the coverage indicators, this was caused by the length of the waiting time and the lack of human resources.And the lack of medical equipment and medication can also increase the number of nonspecialistic referrals to higher healthcare facilities.

Table 1 .
The ration of Prolanis participants that routinely visit the Health Centers between January-March