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The impact of National Health Insurance online referral system on the access and quality of health services in Gianyar District, Bali, Indonesia


Background and purpose: The introduction of an online referral system aims to improve the quality and costs control of the National Health Insurance (NHI) or Jaminan Kesehatan Nasional. This study aims to determine the impact of the NHI online referral system implementation on access and quality of health services in Gianyar District.

Methods: This is an explorative qualitative study conducted in Gianyar, Bali, Indonesia. Data was collected through semi-structured in-depth interviews to a total of 26 informants recruited purposively. They were including policy makers in the health office and the NHI implementing organization (BPJS), heads of public health centres (puskesmas), private health facilities and referral healthcare facilities; and 13 NHI participants. Data collection was undertaken from May to August 2019. The interview results were thematically analysed based on the Health Care Reform Control Knobs Framework.

Results: The study identifies several positive impacts of the online referral system, which include: the closer distance of patients accessing services, the easier it is to obtain information on services at referral health facilities, and the easier the hospital to promote its service products, the higher assurance of patients being accepted by the referral hospitals, patients with special conditions are better accommodated, the easier the administrative procedure, improved time, cost and working procedure efficiencies, increased punctuality of the services, and guaranteed data security that reduces the risk of lost or damaged referral documents. On the other hand, the online referral system has also resulted in negative impacts, some of them were system inconsistencies, information and communication technology (ICT) constraints, service discontinuity, service injustices and loss of patients’ loyalty.  

Conclusion: NHI online referral system generally have positive impacts on access and quality of health services, however, it is necessary to improve several aspects of the online referral system to better accommodate user needs and to optimize service.


  1. World Health Organization. The World Health Report 2008: Primary Health Care. Now More Than Ever. Geneva; 2008.
  2. President of The Republic of Indonesia. Undang-Undang Republik Indonesia Nomor 40 Tahun 2004 Tentang Sistem Jaminan Sosial Nasional [The Republic of Indonesia Law No. 40 Year 2004 on National Social Insurance System]. Jakarta; 2004.
  3. Ministry of Health of The Republic of Indonesia. Pedoman Umum Program Indonesia Sehat Dengan Pendekatan Keluarga [Guidelines for the Program of Healthy Indonesia with Family Approach]. Jakarta; 2016.
  4. President of The Republic of Indonesia. Peraturan Presiden Republik Indonesia Nomor 82 Tahun 2018 [Indonesia Presidential Regulation No 82 Year 2018]. Jakarta; 2018:1-74.
  5. Primasari KL. Analisis sistem rujukan Jaminan Kesehatan Nasional RSUD. Dr. Adjidarmo Kabupaten Lebak [Analysis of National Health Insurance referral system at Dr. Adjidarmo Hospital in Lebak District]. J Adm Kebijak Kesehat. 2015;1(2):78-86.
  6. Faudzan M, Karim A, Paselle E. Studi tentang sistem informasi pendaftaran rujukan rawat jalan online (SIPULAN) di RSUD A.M Parikesit Tenggarong [Study on the online outpatient referral information system at A.M Parikesit Hospital, Tenggarong]. eJournal Adm Reform. 2017;5(3):622-632.
  7. Indrianingrum I, Handayani OWK. Input sistem rujukan Badan Penyelanggara Jaminan Sosial (BPJS) Kesehatan di fasilitas kesehatan tingkat pertama (FKTP) Kabupaten Jepara [Input on referral system of the BPJS Kesehatan at the primary health facilities]. Public Heal Perspect J. 2017;2(2):140-147.
  8. Widhiastuti IAP, Januraga PP, Wirawan DN. Hubungan persepsi manfaat dengan kepesertaan JKN secara mandiri di Puskesmas I Denpasar Timur [Association between perceived benefits with independent participation of National Health Insurance at Puskesmas I Denpasar Timur]. Public Heal Prev Med Arch Univ Udayana Bali. 2015;3(2):203-210.
  9. Naseriasl M, Adham D, Janati A. E-referral solutions: Successful experiences, key features and challenges-a Systematic review. Mater Socio Medica. 2015;27(3):195-199.
  10. Bello AK, Molzahn AE, Girard LP, et al. Patient and provider perspectives on the design and implementation of an electronic consultation system for kidney care delivery in Canada: a Focus group study. BMJ Open. 2017;7:e014784.
  11. Augestad KM, Revhaug A, Johnsen R, Skrøvseth S-O, Lindsetmo R-O. Implementation of an electronic surgical referral service. Collaboration, consensus and cost of the surgeon–general practitioner Delphi Approach. J Multidiscip Healthc. 2014;4(7):371-380.
  12. Antara News. IDI Surabaya tolak aturan baru rujukan berobat [Indonesia Medical Doctor Association Surabaya branch refuses the new regulation on treatment referral]. Available from:
  13. Media Indonesia. Persi: Perlu aturan lebih tinggi untuk rujukan berjenjang daring BPJS [Indonesia Hospital Association: Need a higher regulation for BPJS online tiered referral]. Available from:
  14. Perhimpunan Rumah Sakit Seluruh Indonesia (PERSI). Masukan PERSI soal sistem rujukan berjenjang telah disampaikan pada kemenkes dan dinkes [PERSI recommendations on the tiered referral system have been provided to the Ministry of Health and health offices]. Available from:
  15. Roberts MJ, Hsiao W, Berman P, Reich MR. Getting health reform right: A guide to improving performance and equity. New York; 2004.
  16. Gianyar District Health Office. Profil Kesehatan Kabupaten Gianyar [Gianyar District Health Profile]. Gianyar; 2019.
  17. Sawitri IAAD. Studi pendahuluan permasalahan dalam penerapan sistem rujukan online BPJS Kesehatan di fasilitas kesehatan penyelenggara JKN di Kabupaten Gianyar [A preliminary study on problems in the implementation of BPJS Kesehatan online referral system at the health facility implementing National Health Insurance at Gianyar District]. Gianyar; 2018.
  18. Toyabe S, Kouhei A. Referral from secondary care and to aftercare in a Tertiary Care University Hospital in Japan. BMC Health Serv Res. 2006;6(11):1-9.
  19. Patel MP, Schettini P, Leary CPO, Bosworth HB, Anderson JB, Shah KP. Closing the referral loop : an analysis of primary care referrals to specialists in a large health system. J Gen Intern Med. 2018;33(5):715-721.
  20. Goldthorpe J, Sanders C, Macey R, Gough L, Rogers J, Tickle M. Exploring implementation of an electronic referral management system and enhanced primary care service for oral surgery: Perspectives of patients, providers and practitioners. MBC Heatlh Serv Res. 2018;18(646):1-14.
  21. Tuot DS, Leeds K, Murphy EJ, et al. Facilitators and barriers to implementing electronic referral and/or consultation systems: A qualitative study of 16 health organizations. BMC Health Serv Res. 2015;15(568):1-10.
  22. Scheibe MM, Imboden JB, Schmajuk G, Margaretten M. Efficiency gains for rheumatology consultation using a novel electronic referral system in a safety net health setting. HHS Public Access. 2016;67(8):612-624.
  23. Petruik CR, Drobot A. The e-referral evaluation final report. Alberta Health Service. Calgary; 2015.
  24. Warren J, White S, Day KJ, Gu Y, Pollock M. Introduction of electronic referral from community associated with more timely review by secondary services. Appl Clin Inform. 2011;2(4):546-564.
  25. Naseriasl M, Janati A, Amini A, Adham D. Referral system in rural Iran: Improvement proposals. Cad Saude Publica. 2018;34(3):1-12.
  26. Zhou L, Nunes MB. Barriers to knowledge sharing in Chinese healthcare referral services: An Emergent Theoretical Model. Glob Health Action. 2016;9(1):1-13.
  27. Maarop N, Singh SSH, Win KT. Teleconsultation technology and its benefits: in the case of public hospitals in Malaysia. AIS eLibrary. 2011:1-12.
  28. Chen SJ, Lai KC, Shih FY, et al. Electronic referral system for transferred patients with acute myocardial infarction. J Med Sci. 2015;35(6):248-253.
  29. Boykan R, Milana C, Propper G, Bax P, Celestino P. Implementation of an inpatient electronic referral system (Opt-to-Quit ) from the electronic health record to the New York State smokers’ quitline: First steps. Hosp Pediatr. 2018;6(9).
  30. Muchsam Y, Mareta F. Analisis pengaruh kepahaman sistem rujukan online peserta BPJS terhadap kepuasan pelayanan BPJS [Analysis on the influence of BPJS participants' awareness regarding online referral system towards satisfaction on BPJS services]. Portal J Univ Islam Indones. 2019:34-39.
  31. Lestari WRS, Rahmayanti F, Noor VMM. Observasi terhadap rendahnya kunjungan pasien rawat jalan pelayanan medik spesialistik lain [Observation towards the low number of outpatients visit at other specialistic medical services]. Akademika. 2018;16(2):87-96.
  32. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Heal. 2003;57:254-258.
  33. Bouamrane M, Mair FS. A qualitative evaluation of general practitioners’ views on protocol-driven ereferral in Scotland. BMC Medical Informatics Decis Mak. 2014;14(30):1-14.
  34. Jaya I, Sidi F, Ishak I, Affendey LS. A review of data quality research in achieving high data quality within organization. J Theor Appl Inf Technol. 2017;95(12):2647-2657.
  35. Setiawati ME, Nurrizka RH. Evaluasi pelaksanaan sistem rujukan berjenjang dalam Program Jaminan Kesehatan Nasional [Evaluation on the implementation of tiered referral system in the National Health Insurance Program]. J Kebijak Kesehat Indones. 2019;08(01):35-40.
  36. Hermiyanty, Wandira BA, Nelianti F. Implementasi rujukan pasien Jaminan Kesehatan Nasional (JKN) Badan Penyelenggara Jaminan Sosial (BPJS) di Puskesmas Singgani Kecamatan Palu Timur Kota Palu [Implementation of National Health Insurance BPJS patients referral at Puskesmas Singgani, Palu Timur Sub-District, Palu City]. J Kesehat Tadulako. 2019;5(1):32-38.

How to Cite

Sawitri, I. A. A. D., Januraga, P. P., & Nopiyani, N. M. S. (2020). The impact of National Health Insurance online referral system on the access and quality of health services in Gianyar District, Bali, Indonesia. Public Health and Preventive Medicine Archive, 8(1), 32–40.




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