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As the elderly population in Khyber Pakhtunkhwa continues to grow and faces significant healthcare cost burdens, the provincial government introduced the Sehat Insaf Card (SIC), a health insurance program aimed at expanding access to hospital care. This study examines the factors influencing hospital utilization among the elderly in Khyber Pakhtunkhwa before and after the implementation of the SIC, with a particular focus on changes in utilization patterns and disparities by gender, income, and region, as well as stakeholder perspectives. Quantitative findings indicate that overall hospital use increased following SIC implementation, and the previous gender gap narrowed, with no statistically significant male–female differences observed by 2020. However, disparities persisted: elderly individuals in rural areas remained less likely than their urban counterparts to access hospital services, and although hospital use among low-income seniors improved due to reduced financial barriers, income-based inequalities remained. Stakeholder interviews revealed persistent challenges, including limited awareness of SIC benefits among the elderly and continued difficulties in remote areas due to transportation constraints and shortages in healthcare facilities, staff, and infrastructure etc. In conclusion, while the SIC has successfully expanded coverage and improved hospital utilization among the elderly, entrenched access barriers remain, highlighting the need for complementary efforts in outreach and health system strengthening to ensure that all elderly individuals can benefit equitably from the program.
In addition to morbidity and mortality are high, financing catastrophic diseases(kidney failure, cardiovascular disease, cancer, thalassemia and hemophilia) thatabsorb very high cost should be a serious concern. The study aims to analyze thecost of catastrophic diseases based on the characteristics of participants.Quantitative research analytical uses claims data in the form of data BPJSparticipants and costs in 2014 amounted to 309 301 claims. The analysis showedsignificant difference in the average cost of catastrophic illness according tolength of stay, classes and class hospital care. Promotive, preventive and diseasemanagement of patients need to be improved to achieve cost effectiveness andefficiency of health care in ensuring the sustainability of national health insuranceprogram.Key words:Catastrophic diseases, hospital expenses, characteristic of participant, promotive,preventive and disease management.
Latar belakang: Program Jaminan Kesehatan Nasional (JKN) meningkatkan utilisasi dan pendapatan pasien dari prosedur operasi rawat inap di RS Jakarta. Namun, peningkatan ini justru menurunkan laba rumah sakit akibat tarif JKN yang relatif rendah. Prosedur operasi bedah umum merupakan prosedur terbanyak yang dilakukan, tetapi memiliki utilitas kamar operasi terendah. Untuk itu, perlu dilakukan analisis efisiensi biaya prosedur ini sebagai dasar strategi pengembangan layanan untuk kesinambungan bisnis rumah sakit ke depan. Tujuan: Diketahui perbandingan tingkat efisiensi biaya prosedur operasi agar dapat memberikan rekomendasi strategi efisiensi dan pengembangan prosedur operasi bedah umum JKN di RS Jakarta agar tercapai kesinambungan bisnis rumah sakit yang baik. Metode: Penelitian menggunakan data prosedur operasi bedah umum pasien JKN tahun 2023. Biaya satuan dihitung menggunakan metode activity-based costing, mencakup biaya langsung dan tidak langsung. Efisiensi dinilai dengan membandingkan biaya aktual dengan biaya normatif berdasarkan clinical pathway. Total biaya diperoleh dari penjumlahan biaya prosedur dan akomodasi rawat inap. Skor efisiensi teknis dan skala dihitung dengan pendekatan Data Envelopment Analysis (DEA). Hasil: Rata-rata biaya satuan prosedur aktual di kamar operasi sebesar Rp3.515.894,65 dengan skor efisiensi 103,0%, yang idealnya ada di bawah 100%. Komponen biaya jasa medis dan obat serta bahan medis habis pakai (BMHP), menjadi pemicu utama inefisiensi. Rata-rata biaya total aktual, yaitu biaya satuan prosedur aktual di kamar operasi ditambah biaya akomodasi adalah Rp4.678.032,01 dengan skor efisiensi 108,4%. Biaya akomodasi menyumbang 24,8% dari biaya total dan berkontribusi besar pada inefisiensi. Prosedur paling efisien adalah hemoroidektomi kelas 3 dan insisi abses perianal (satu kelas). Kesimpulan: Biaya satuan prosedur operasi bedah umum di kamar operasi untuk pasien JKN tahun 2023 belum efisien karena penggunaan obat, BMHP, dan lama rawat inap yang tidak sesuai clinical pathway. Diperlukan penerapan clinical pathway yang ketat, perubahan sistem pembayaran jasa medis berbasis kinerja, serta optimalisasi metode dan jenis anestesi. Rumah sakit juga perlu meningkatkan kompetensi, khususnya di bidang bedah digestif, untuk menghadapi kebijakan kelas standar dan klasifikasi rumah sakit berbasis kompetensi.
Background: The National Health Insurance (JKN) program has led to increased inpatient utilization and revenue at RS Jakarta, particularly through surgical procedures. However, this increase has paradoxically reduced hospital profit margins due to the relatively low reimbursement rates under JKN. General surgery accounts for the highest number of procedures but demonstrates the lowest operating room utilization. Therefore, a cost-efficiency analysis of these procedures is essential to inform service development strategies that ensure long-term hospital sustainability. Objective: This study aims to compare the cost efficiency of general surgical procedures for JKN patients, providing strategic recommendations to improve efficiency and develop general surgery services to support sustainable hospital operations. Methods: The study used data on general surgical procedures performed on JKN patients in 2023. Unit costs were calculated using an activity-based costing method, incorporating both direct and indirect costs. Efficiency was assessed by comparing actual costs to normative costs based on clinical pathways. Total costs included both procedural and inpatient accommodation expenses. Technical and scale efficiency scores were calculated using the Data Envelopment Analysis (DEA) approach. Results: The average unit cost for actual surgical procedures in the operating room was IDR 3,515,894.65, with an efficiency score of 103.0%, indicating inefficiency as ideal scores should be below 100%. Direct operating costs—particularly medical services, medications, and consumables—were the main contributors to inefficiency. The average total actual cost, including accommodation, was IDR 4,678,032.01, with an efficiency score of 108.4%. Accommodation costs accounted for 24.8% of the total and were a significant source of inefficiency. The most efficient procedures were Grade 3 hemorrhoidectomy and perianal abscess incision (single class). Conclusion: The unit costs for general surgical procedures under JKN in 2023 remain inefficient relative to clinical pathway standards, primarily due to inappropriate use of medications, consumables, and extended length of stay. Improvements are needed through stricter clinical pathway implementation, performance-based physician remuneration, and optimization of anesthetic techniques. The hospital must also enhance competencies, particularly in digestive surgery, in anticipation of standard class policies and competency-based hospital classifications.