POLICY IMPLEMENTATION PERFORMANCE RELATED TO THE PROCUREMENT OF PRB DRUGS IN THE SUBDISTRICT PRIMARY HEALTHCARE CENTER PHARMACY AND PRB PHARMACY IN CENTRAL JAKARTA QUARTER I, II, AND III OF 2019

Back-Referral Program (PRB) is one way to improve the quality of the health services for BPJS participants in conducting quality control and cost control. The unavailability of pharmacies and drugs for PRB causes the PRB program not to run optimally, thus increasing the catastrophic disease sufferers and absorbing big claims in JKN. This study is qualitative research with a descriptive approach using the method of in-depth interviews and document review. The research informants' criteria were: the elements of the leadership and policy management officers in the DKI Jakarta Provincial Health Office, Central Jakarta Health Office, Central Jakarta BPJS Health Center, Central Jakarta District Health Center, and Central Jakarta PRB Pharmacy. The results showed that the implementation performance was not optimal, which was influenced by policy standards and objectives, resources, communication between organizations, the implementers' attitude, the implementing organization's characteristics, and the economic, social, and politics. Coordination, commitment, and evaluation of activities from the Ministry of Health, BPJS Health, Government Service Goods Procurement Policy Institute, and DKI Jakarta Provincial Health Office are needed in terms of the availability of this PRB drug


INTRODUCTION
Referral Program Services (PRB) are health services provided to patients with chronic diseases with stable conditions and still need long-term treatment or nursing care at the First Level Health Care Services (FKTP) on recommendation/referral from the treating Specialist/Sub Specialist. The scope of PRB includes Diabetes Mellitus, Hypertension, Heart, Asthma, Chronic Obstructive Pulmonary Disease (COPD), Epilepsy, Schizophrenia, Stroke, and Systemic Lupus Erythematosus (SLE) . 1 Drug unavailability at PRB Pharmacy is one of the problems of maintaining quality and cost control. Research at BPJS Kesehatan Central Jakarta in June -Six variables that influence public policy are policy standards and objectives, resources, characteristics of the implementing organization, communication between related organizations and implementation activities, dispositions or attitudes of the implementers, and the social, economic, and political environment. 8

METHOD
This research is qualitative research with a descriptive approach using in-depth interviews and document review. The research location is at the DKI Jakarta Health Office, City Health Office, BPJS office, eight district primary health care, and eight PRB Pharmacies in Central Jakarta. This research has received a recommendation letter from the Ethics Commission for research and community health service, Faculty of Public Health, University of Indonesia number: 411 / UN2.F10 / PPM.00.02 / 2019 dated 11 June 2019.
The research informants were the Head of the Food and Beverage Pharmacy Section of the DKI Jakarta Health Office (1 person), the Heads of the District Primary Healthcare (7 people), the chief of Pharmacy at the Health Office (1 person), head pharmacist for the District Primary Healthcare (8 people), the Pharmacist in charge of the PRB Pharmacy (9 people), and the head branch of BPJS Primary Benefit Insurance (1 person) in the Central Jakarta area. Informed consent was given to informants before the researchers took primary and secondary data.
The data analysis procedure steps: informant descriptions, compiling transcript notes, data organization, data categorization/coding, summarizing data into matrices, identifying variables and relationships between variables, and drawing conclusions. The data triangulation approach uses technical triangulation, data retrieval utilizing in-depth interviews, observation, document review, and source triangulation by collecting data from several informants and comparing data obtained from one informant with other informants. August 2014 showed that PRB drug unavailability was found from the unserved drug demand, which was 43.2% participants in June, 15.2% participants in July, and 9.7% participants in August 2014.2 Therefore, many patients buy their own drugs or do not even consume drugs that trigger catastrophic diseases.

RESULT AND DISCUSSION
Catastrophic health spending can lead to impoverishment. The indirect economic impact of chronic disease is reduced income due to lost productivity due to illness or death, reduced opportunities for savings, and loss of employment or education opportunities. Groups of catastrophic diseases such as kidney failure, cardiovascular, cancer, thalassemia, and hemophilia create the most significant spending from the National Health Insurance (JKN), absorbing large claims in JKN and need serious attention Central Jakarta BPJS data shows 8 PRB pharmacies in Central Jakarta out of 293 Pharmacies at the beginning of 2019. The unavailability of PRB Pharmacies drugs at the PRB Pharmacy caused the PRB program not to be optimal. Even though sub-district primary healthcare has an E-catalog system to optimize drug availability, many still cannot run PRB optimally.
The purpose of this study was to determine the performance of policy implementation related to the availability of PRB drugs in the sub-district health center pharmacy room and PRB pharmacy in Central Jakarta for the first, second, and third quarters of 2019 based on the Republic of Indonesia Minister of Health Regulation Number 99 of 2015 concerning health services on JKN article 25. To ensure PRB drugs' availability, BPJS Kesehatan must collaborate with pharmacies or pharmacy installations in FKTPs that are easily accessible to JKN participants. 5 According to Dunn (2004), there are three policy elements: political actors, policy environment, and public policies.6 Policy implementation is the fourth stage after the agenda-setting, policy formulation, and policy adoption stages, followed by the policy evaluation stage in the policy formulation or development cycle. 7 To determine the performance of policy implementation in this study, we use a policy model theory according to Van Meter and Van Horn.
Van Meter and Van Horn's policy model states that policy implementation runs linearly from public policy, implementor, and public policy performance.
Besar District Primary Healthcare and Kemayoran District Primary Healthcare.
The Head of the DKI Jakarta Provincial Health Office did the first socialization of PRB drugs for primary healthcare at the Regional Health Work Meeting in April 2019. DRR drugs, provided for district primary healthcare as a Pilot Project, are for hypertension diagnosis without any complications. The PRB Pharmacist serves 8 Other diagnoses at the primary healthcare pharmacy room. Another primary healthcare provides a pharmacy room for the PRB Pharmacist, while the remaining five Primary healthcare are waiting for instructions and planning preparations.
Obstacles faced in implementing policies were:

Policy standards and objectives
There are still obstacles in policy implementation performance in the monitored indicators so that it is not optimal according to the target and the number of collaborators. The primary healthcare center drug budget was from the regional public service agencies. PRB pharmacies budget from private and state-owned funds. The drug planning process starts from preparing online planning through the e-monev system, procurement / epurchasing through the e-catalog system, or other programs according to the Presidential Regulation on Procurement of B/J by the Government. All PRB Pharmacies in Central Jakarta in the 1st, 2nd, and 3rd quarter of 2019 have not received an e-monev account. A policy or program will not be able to achieve its goals or objectives without adequate budget support. 13

Resources
The procurement of PRB drugs by the dispensary pharmacy needs to be adjusted to the Republic of

Communication between Organizations
Policy transmissions are delivered through meetings, WA groups, telegrams, and letters addressed to PRB Pharmacies and Primary healthcare centers. Not all of them understand the information provided regarding PRB. The transmission of understanding in forwarding policy messages is not optimal at the executive level. George C. Edwards stated that if we want to make policy implementation effective, then implementation orders must be consistent and clear. 17

The attitude of the implementers
Initially, some primary healthcare centers refused to implement the program. Only pharmacies that can fund the programs accepted the policy implementation. Moreover, the Central Jakarta BPJS Kesehatan has not implemented a reward and punishment system. George C. Edwards argues that one of the techniques suggested high-level policymakers overcome the likelihood of implementers by manipulating incentives such as reward/punishment so that it is likely to influence policy implementers' actions. 17

Characteristics of the Implementing Organization
Fragmentation of the organizational structure subdistrict primary healthcare supports implementing PRB drugs procurement policies because of the accreditation. PRB pharmacies have not implemented optimally Permenkes No. 73 of 2016. Primary healthcare providers of PRB drugs already have their own SOPs, but not all PRB Pharmacies. SOPs uniformity is the officials' actions in complex and widespread organizations and has significant similarity in applying regulations. 17

The Economic, Social, and Political Environment
The social environment inside and outside the Health Office, Primary healthcare, and PRB Pharmacy support the procurement and service of PRB drugs. Implementation in Subdistrict Primary Healthcare is supported by the Head of the Health Office and the Governor of DKI Jakarta Province. The leader of the Pharmacy also supports implementation at the Pharmacy. Because not all primary healthcare has the same amount of BLUD income, it requires a legal umbrella in PRB drug procurement management. There are still PRB participants who prefer to seek treatment and meet specialist doctors at the hospital. Hospitals have an essential role in the successful implementation of PRB policies in line with previous studies. 11, 18

CONCLUSION
The implementation of policies related to the procurement of PRB drugs in the subdistrict primary healthcare pharmacy room and PRB Pharmacy in Central Jakarta for the first, second, and third quarter of 2019 have been carried out by 8 PRB pharmacies from 293 pharmacies and 2 out of 8 subdistricts primary healthcare as pilot projects with not optimal results. The following reasons are: 1. Subdistrict primary healthcare: The attitude, response, and commitment of the implementers are influenced by the support of the economic environment, the availability of SOPs, the absence of a particular legal umbrella, and communication between organizations which includes clarity, method, consistency in delivery, objectives and policy objectives. Not all of the resources involved have a clear understanding of the standards and policy objectives. It is also affected by the fulfillment of resources, including the availability of human resources for pharmaceutical services in several sub-districts primary healthcare, the availability of funds/budgets that affect the PRB drug planning process, the time required for drug fulfillment, and the absence of incentives or rewards and punishments. 2. PRB Pharmacy: The attitude, response, and commitment of the implementer are influenced by the support of the economic environment, the availability of SOPs, and the pharmacy's organizational structure as well as communication between organizations which includes clarity, method, consistency of delivery, policy objectives, and objectives, fulfillment of human resource discipline, availability of funds/budget, the PRB drug planning process, the time needed to fulfill the drugs, the absence of incentives or rewards/punishments, and the lack of easy access to orders through e-catalogs in the process of procuring DRR drugs.