Jakarta. As Indonesia expands its National Health Insurance (JKN) program, one feature remains central to ensuring effective and equitable healthcare: the tiered referral system. Designed to guide patients through the right level of care, the system requires all JKN participants to begin their medical journey at a primary healthcare facility, or FKTP.

This starting point, whether a community health center (puskesmas), primary clinic, or private physician, serves as the foundation of a streamlined healthcare pathway meant to deliver accurate diagnoses, reduce unnecessary hospital visits, and protect the long-term sustainability of the JKN fund.

The First Stop: FKTP as the Gatekeeper

At the FKTP level, patients receive initial examinations, basic treatments, and evaluations to determine whether their condition warrants advanced care. This structure isn’t merely bureaucratic; it reflects medical logic.

“If a patient is in an emergency, the priority is their right to receive care,” said BPJS Health spokesperson Rizzky Anugerah. He stressed that the system never delays life-saving treatment. Patients in critical condition may go directly to a hospital without a referral. Even hospitals that do not partner with BPJS are required to provide initial emergency assistance.

The rules governing this system are outlined in the Ministry of Health Regulation No. 16/2024, which updates Indonesia’s referral framework to match evolving healthcare standards.

Why the System Exists: Efficiency, Accuracy, and Access

Dr. Donald Pardede, who oversees Primary Services at the National Quality and Cost Control Team (TKMKB), describes the tiered referral system as fundamental to ensuring patients receive care that matches their medical needs.

“Not every complaint has to be treated at a hospital,” he said. “There are 144 competencies that primary-care doctors can and should handle at the FKTP level.”

Common issues like coughs, colds, minor aches, or routine check-ups fall squarely within primary-care capacity. Redirecting these cases to FKTPs prevents hospitals from being overloaded with mild conditions and reserves specialists for more complex medical problems.

This approach benefits patients as well: visiting the nearest FKTP shortens travel time and eliminates long hospital queues, making care faster and more accessible.

Hospitals for the Complex, FKTP for the Manageable

Hospitals are designed to treat conditions that require specialized expertise. The tiered system ensures hospitals focus on advanced cases instead of minor illnesses that could be resolved earlier in the chain.

The financial rationale is equally important. Treating mild cases in hospitals significantly increases costs—costs that ultimately strain the national health insurance fund.

“Cost control only works when cases are managed according to their appropriate level of competency,” Donald said.

Regulation 16/2024: What’s New

The introduction of Regulation No. 16/2024 replaces the older 2012 regulation and introduces a more detailed, modern framework. It emphasizes that referrals must consider:

• Medical necessity

• Service capacity at each facility

• Accessibility, including distance and travel time

• Quality of services, rather than financial factors

Hospitals and clinics must also meet specific requirements related to available services, medical personnel, infrastructure, equipment, and capacity.

A Major Shift: From Hospital-Class Referrals to Competency-Based Referrals

Indonesia’s healthcare transformation, driven by the 2023 Health Law and the new Ministerial Regulation, introduces a major overhaul: the shift from hospital-class–based referrals to competency-based referrals.

Under the old system, referrals moved step-by-step through hospital classes D to A. The new model directs patients straight to the facility best equipped to handle their condition, regardless of hospital class.

Donald clarified that FKTPs remain the gatekeepers, handling 144 primary-care diagnoses, but now have greater flexibility in directing patients.

For example, if a class-C hospital has a cath lab and qualified specialists, a patient needing cardiac intervention can be referred directly there instead of being required to visit a class-B or class-A hospital farther away.

This change is expected to motivate hospitals across classes C and B to upgrade their skills and equipment.

Challenges Ahead: Aligning Tariffs and Policy

Despite its benefits, the transition requires significant adjustments. Tariffs in the BPJS payment system still follow hospital classifications, even though referrals will soon be based on competencies.

Donald said successful implementation will require:

• Comprehensive tariff reassessments

• Policy harmonization between the Health Ministry and BPJS

• Clear guidelines to avoid confusion among patients and providers

“The competency-based referral system must be supported by aligned regulations, fair payment structures, and careful implementation,” he noted.

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