The conceptual article was published in 2026 in the Indonesian Journal of Interdisciplinary Research in Science and Technology (MARCOPOLO). It examines how rehabilitation services funded through Indonesia’s Jaminan Kesehatan Nasional (JKN) and administered by BPJS Kesehatan can be governed as one interconnected health-service pathway rather than as a series of isolated clinical encounters.
Hernayati and Iwan Kusnawirawan are affiliated with the College of Litigation Law, Jakarta. Dwi Ratna Sari Handayani is affiliated with the Physiotherapy Study Program at Binawan University, Jakarta. Imam Waluyo is affiliated with Manual Manipulative Indonesia, while Muhammad Arsyad Subu is affiliated with the Nursing Department, College of Health Sciences, University of Sharjah.
The article was received on February 20, revised on March 24, and accepted on April 28, 2026. Its findings matter because having health insurance does not necessarily mean that a patient can obtain appropriate physiotherapy at the right time, in the right place, and with adequate continuity.
Financial Coverage Does Not Always Mean Effective Access
Rehabilitation has become an increasingly important part of modern health systems as populations age and the burden of chronic diseases, injuries, neurological conditions, and long-term disabilities grows.
The World Health Organization has estimated that around 2.4 billion people worldwide live with a health condition that could benefit from rehabilitation. The need is particularly significant in low- and middle-income countries.
Physiotherapy plays a central role in rehabilitation by helping manage movement limitations, injuries, musculoskeletal and neurological conditions, post-operative dysfunction, and chronic disabilities. However, the quality of physiotherapy depends on more than the skills of individual practitioners.
Patients also need functioning referral systems, available providers, adequate staffing, appropriate equipment, manageable waiting times, effective administration, and continuity of treatment.
The authors therefore distinguish financial coverage from effective rehabilitation access. A patient may be eligible for physiotherapy through JKN but still face difficulties completing a referral, finding an available provider, obtaining an appointment, travelling to a facility, or continuing treatment.
Five Domains Form the Proposed Governance Model
Hernayati and colleagues propose five interconnected domains for governing BPJS-funded physiotherapy rehabilitation.
1. Effective access and coverage.
This domain examines whether JKN entitlement is translated into actual access. Relevant indicators include referral completion, waiting times, service availability, geographical accessibility, appointment availability, cancellations, and continuity of authorised treatment.
2. Service organisation.
Facilities need adequate personnel, professional qualifications, equipment, infrastructure, supervision, documentation systems, and referral coordination. These organisational conditions can directly influence the quality and safety of physiotherapy.
3. Clinical quality.
The model considers assessment, clinical reasoning, treatment planning, intervention, monitoring, evaluation, documentation, communication, referral, and follow-up. The authors emphasise that quality standards should still allow appropriate clinical judgement because patients do not necessarily require identical treatments or treatment schedules.
4. Patient safety and continuity.
A safe rehabilitation service extends beyond an individual treatment session. It requires risk identification, incident reporting, communication, information transfer, follow-up, and coordination throughout the patient's rehabilitation pathway.
5. Proportional accountability.
Responsibility should be assessed according to authority, risk exposure, control capacity, preventability, and evidence of contribution. This prevents responsibility from being assigned simply to the person or institution most visible at the point of care.
Responsibility Should Follow Risk and Control
One of the article's central arguments is that an undesirable health outcome does not automatically establish professional negligence.
The authors distinguish between an undesirable outcome, an adverse event, a preventable event, and professional or institutional failure. A problem may arise from clinical decisions, inadequate staffing, equipment shortages, weak supervision, referral delays, poor communication, or other organisational conditions.
The proposed framework therefore asks five key questions: Who had authority over the relevant decision? What risk occurred? Who had the capacity to control that risk? Could the problem reasonably have been prevented? What evidence demonstrates each actor's contribution?
This approach also differentiates responsibilities among BPJS Kesehatan, referral institutions, healthcare facilities, physiotherapists, technology providers, and patients or carers.
BPJS Kesehatan is primarily considered within financing and access administration, while healthcare facilities have responsibilities related to staffing, equipment, scheduling, service organisation, and safety. Physiotherapists retain professional responsibility for clinical assessment and treatment decisions.
The model does not conclude that every failure is the responsibility of BPJS Kesehatan, healthcare facilities, or individual physiotherapists. Legal responsibility must still be determined according to applicable laws, professional standards, contractual arrangements, and evidence.
As Hernayati and her co-authors explain, accountability should follow demonstrable contribution and relevant control capacity rather than institutional visibility or proximity to the patient.
From Retrospective Liability to Risk Prevention
The article proposes a shift from a predominantly retrospective approach, which focuses on assigning responsibility after harm occurs, toward prospective risk governance.
Under this approach, an incident should trigger more than an investigation into who was responsible. It should also generate questions about how the risk developed, whether existing controls were adequate, who could have prevented or reduced the risk, and what changes are needed to prevent recurrence.
The model connects health-service quality management with legal accountability without treating every quality deficiency as a legal violation. Quality indicators can identify weaknesses that require managerial improvement, while specific incidents may still require separate legal or professional assessment.
Implications for Indonesian Health Policy
The proposed framework could help policymakers evaluate rehabilitation beyond the number of services financed.
For JKN, the authors recommend measuring effective rehabilitation coverage through indicators such as waiting times, referral completion, provider availability, geographical access, treatment continuity, appointment cancellations, completion of authorised rehabilitation episodes, and patient experience.
Healthcare facilities could strengthen physiotherapy governance through workforce planning, equipment maintenance, clinical supervision, incident reporting, documentation, referral coordination, and follow-up systems.
The model also addresses digital rehabilitation. Tele-rehabilitation may improve access for patients facing geographical or mobility barriers, but it introduces additional concerns involving platform reliability, patient identification, data privacy, cybersecurity, remote assessment, emergency escalation, and digital exclusion.
The Model Still Requires Empirical Validation
The authors emphasise that their framework is conceptual rather than empirical. It does not measure current BPJS performance, establish the prevalence of adverse events, or determine the legal liability of particular institutions.
Future research could test the model using BPJS claims and utilisation data, referral records, waiting times, provider distribution, staffing and equipment data, clinical indicators, incident reports, patient-reported outcomes, patient experiences, and relevant accountability cases.
The authors also recommend mixed-method research, comparisons between urban and rural facilities, and Delphi studies involving experts from rehabilitation, health-service management, health law, patient safety, health financing, and patient advocacy.
Author Profiles
Hernayati — College of Litigation Law, Jakarta; expertise related to law and governance.
Iwan Kusnawirawan — College of Litigation Law, Jakarta; expertise related to legal and accountability issues.
Dwi Ratna Sari Handayani — Physiotherapy Study Program, Binawan University, Jakarta; expertise in physiotherapy and rehabilitation services.
Imam Waluyo — Manual Manipulative Indonesia; expertise related to physiotherapy and rehabilitation services.
Muhammad Arsyad Subu — Nursing Department, College of Health Sciences, University of Sharjah; expertise in nursing and health services.
Research Source
Article Title: Governing Effective Rehabilitation Coverage: An Integrated Health-Service Accountability Model for BPJS-Funded Physiotherapy in Indonesia
Authors: Hernayati, Iwan Kusnawirawan, Dwi Ratna Sari Handayani, Imam Waluyo, Muhammad Arsyad Subu
Journal: Indonesian Journal of Interdisciplinary Research in Science and Technology (MARCOPOLO)
Publication: Volume 4, No. 4, 2026, pp. 265–282
DOI: 10.55927/marcopolo.v4i4.35
Official Journal: https://journalmarcopolo.my.id/index.php/marcopolo
0 Komentar