Pengelolaan Obat Instalasi Farmasi Pasca PPK BLUD

obat-obatan

Tujuan diterapkannya PPK BLUD bagi rumah sakit sebagaimana diamanatkan oleh Permendagri 61/2007 sebenarnya untuk meniadakan praktik-praktik bisnis yang tidak sehat sekaligus pada saat yang sama mendukung fleksibilitas penatausahaan keuangan dalam rangka percepatan peningkatan pelayanan kepada masyarakat.  Secara tegas dalam permendagri ini dinyatakan bahwa sebagai langkah nyata dukungan terhadap fleksibilitas penatausahaan keuangan, BLUD rumah sakit diberikan keleluasaan untuk melakukan praktik yang merupakan pengecualian dari ketentuan pengelolaan keuangan daerah pada umumnya.

Terdapat dua kata kunci dalam paragraf di atas, yaitu praktik bisnis yang tidak sehat dan fleksibilitas keuangan.  Benarkah sebelum era PPK BLUD diberlakukan, terdapat praktik bisnis yang tidak sehat?  Benarkah BLUD rumah sakit mengalami hambatan untuk menggunakan pendapatannya dalam rangka layanan kesehatan yang diselenggarakannya?  Kedua tesis ini sangat menarik untuk didalami agar diperoleh gambaran yang sebenarnya mengenai praktik yang dilakukan, kondisi yang memaksa untuk melakukannya dan keterbatasan regulasi yang memayungi aktivitas tersebut.  Untuk mempersempit bahasan, maka kedua tesis tersebut kita fokuskan pada salah satu layanan kesehatan yang terdapat di rumah sakit, yaitu layanan farmasi.

Layanan farmasi sendiri telah disinggung dalam empat pasal yang berbeda  dalam Undang-undang no 44 tahun 2009 tentang rumah sakit yaitu terdapat dalam pasal 7 ayat 1, pasal 10 ayat 2 huruf I, pasal 12 ayat 1, dan secara khusus dalam pasal 15.  Dalam regulasi ini telah dinyatakan dengan tegas mengenai pengertian instalasi farmasi yaitu merupakan bagian dari Rumah Sakit yang bertugas menyelenggarakan, mengkoordinasikan, mengatur dan mengawasi seluruh kegiatan pelayanan farmasi serta melaksanakan pembinaan teknis kefarmasian di Rumah Sakit melalui sistem satu pintu.

Adapun yang dimaksud dengan satu pintu adalah bahwa rumah sakit hanya memiliki satu kebijakan kefarmasian termasuk pembuatan formularium pengadaan, dan pendistribusian alat kesehatan, sediaan farmasi, dan bahan habis pakai yang bertujuan untuk mengutamakan kepentingan pasien.  Praktik bisnis sehat yang dituntut oleh undang-undang ini diantaranya adalah Informasi harga obat (perbekalan farmasi) harus transparan atau dicantumkan di dalam buku daftar harga yang dapat diakses oleh pasien.

Bagaimana dengan praktik kefarmasian sesungguhnya di rumah sakit?

Pada sebagian besar rumah sakit terdapat praktik penerapan dualisme kebijakan dalam farmasi terutama dalam pengadaan obat.

Untuk obat-obat yang berkategori generik dan ditujukan untuk melayani masyarakat miskin dan layanan kesehatan rutin rumah sakit, pengadaan obat berikut penatausahaan keuangannya diselenggarakan dengan mengikuti sepenuhnya regulasi tentang pengadaan barang dan jasa (Keppres 80/2003 jo Perpres 54/2011).  Mekanisme pelelangan diselenggarakan  untuk mendapatkan obat-obatan dan alat kesehatan yang diprediksi menjadi kebutuhan pasien dalam satu tahun anggaran layanan kesehatan.  Jenis pelelangan yang dipilih menyesuaikan dengan nilai pengadaan sesuai regulasi pengadaan barang dan jasa yang berlaku.  Pelelangan dilakukan oleh panitia lelang dan menjadi tanggung jawab kepala instalasi farmasi untukmemastikan bahwa pengadaan obat sesuai dengan kebutuhan yang direncanakan.

Namun untuk pengadaan obat yang bermerk atau paten, pengadaannya diserahkan pada depo farmasi melalui pembelian langsung kepada pedagang besar farmasi.  Alasan yang mendasarinya adalah bahwa kebutuhan obat paten tidak dapat diprediksi.  Tergantung pada kemauan pasien dan jenis penyakit yang dideritanya.  Memasok obat paten melalui sistem pengadaan barang jasa Keppres 80/2003 hanya menimbulkan ketidakefisienan dan pemborosan.  Karena obat paten yang terlanjur dibeli boleh jadi kadaluarsa akibat tidak digunakan pasien.  Dari sisi fleksibilitas, model pengadaan pembelian langsung sangat fleksibel dan merupakan penerapan prinsip-prinsip praktik bisnis yang sehat.  Dimana efisiensi dan layanan prima pada pasien menjadi pilarnya.  Namun dari sudut legal formal menjadi patut dipertanyakan terutama mengenai sumber pendanaannya.

Keppres 80/2003 menyatakan bahwa sepanjang dana untuk belanja suatu kegiatan berasal dari sumber APBN dan atau APBD, maka pengadaan barang dan jasa tersebut harus tunduk dan patuh pada klausul pengadaan barang dan jasa tersebut.  Bagaimana dengan dana untuk melakukan pembelian langsung oleh depo farmasi tersebut?

Banyak rumah sakit yang mensiasati kondisi ini dengan membentuk satu instalasi sendiri yang meskipun masih dibawah koordinasi instalasi farmasi namun pada hakikatnya terpisah, yaitu Depo farmasi.  Dimana alur tanggung jawab dan komando berada langsung di bawah direktur rumah sakit atau wakil direktur pelayanan.  Dana operasional awal depo farmasi berasal dari sumbangan pihak ketiga atau melakukan kerja sama dengan pedagang besar farmasi dalam bentuk konsinyasi.  Pembayaran baru dilakukan jika obat terjual.  Dengan metode ini, praktis depo farmasi tidak perlu modal yang banyak.  Keuntungan dari penjualan obat, diputar kembali untuk melakukan pembelian dan investasi.  Kalangan rumah sakit menyebut sistem ini sebagai Revolving Fund (dana bergulir).  Meskipun ditengarai sebagai salah satu bentuk praktik penumpukan dana non budgeter, namun pihak rumah sakit berkilah bahwa apa yang dilakukan oleh depo farmasi dalam tataran operasional mirip koperasi karyawan yang terdapat di sebuah perusahaan.

Bagaimana dualisme kebijakan ini bila dipandang dari sudut PPK BLUD?

Praktik pengadaan obat generik melalui mekanisme pengadaan barang jasa sesuai dengan Keppres 80/2003 jo Perpres 54/2011, meskipun telah sesuai dengan regulasi namun mengandung kelemahan bila dilihat dari sisi efisiensi, efektivitas dan fleksibilitas.  Nilai pengadaan obat yang di atas satu milyar, membuat panitia tidak punya pilihan lain selain menggunakan metode pelelangan umum/terbatas dalam pelaksanaannya.  Hal ini sudah merupakan kerugian tersendiri.  Bagaimanapun juga proses pelelangan tersebut  perlu durasi cukup lama untuk pelaksanaannya, mulai dari pengumuman hingga penetapan pemenang.  Penggunaan metode penunjukan langsung pun mustahil untuk diterapkan mengingat Perpres 54/2011 sendiri menetapkan batasan penunjukan langsung maksimal senilai Rp.100 juta.  Selain kerugian waktu, rumah sakit juga mengalami penurunan daya beli.  Hal ini diakibatkan karena adanya larangan bagi pedagang besar farmasi untuk menjadi rekanan pelelangan.  Otomatis birokrasi pengadaan menjadi lebih panjang.  Rekanan yang menjadi pemenang membeli obat dari pedagang besar farmasi.  Itu berarti rumah sakit membeli barang dengan harga yang jauh lebih mahal bila dibandingkan membeli langsung pada PBF.  Dampak lanjutannya adalah rumah sakit mengalami penurunan kualitas bersaing dengan rumah sakit swasta yang membeli langsung dari PBF.

Adapun praktik pengelolaan depo farmasi dengan sistem Revolving Fund , meskipun memiliki keunggulan dari sisi fleksibilitas dan efisiensi, namun bertentangan dengan regulasi yang berkaitan dengan pola pengelolaan keuangan BLUD yaitu Permendagri 61/2007 terutama pasal mengenai penyusunan anggaran BLUD dan UU 44/2009 tentang rumah sakit terutama pasal yang menyatakan bahwa satu-satunya instalasi yang berhak menangani tata kelola farmasi adalah instalasi farmasi.  Terlepas dari aturan yang dilanggarnya, praktik revolving fund cenderung tanpa kontrol dan sering disalahgunakan peruntukannya sebagai dana taktis rumah sakit.

Lantas apa kewajiban pemerintah/regulator menyikapi hal ini?  Meskipun BLUD rumah sakit diberi wewenang penuh untuk mengusulkan aturan main pengadaan barang jasa dengan perkecualian khusus dari yang diharuskan Perpres 54/2011, namun masih terdapat keengganan kepala daerah untuk melegalkannya dalam suatu peraturan kepala daerah.  Keengganan yang dapat dimengerti mengingat adanya kekhawatiran bahwa kebijakannya selaku kepala daerah akan dianggap sebagai kebijakan yang melindungi dan memicu praktik tindak korupsi di lingkungan rumah sakit.

Sunggguh mengenaskan, fleksibilitas yang menjadi substansi BLUD ternyata hanya beredar di wilayah penganggaran melalui fleksibel budget, tapi belum menyentuh substansi pengelolaan manajemen BLUD dalam rangka peningkatan layanan kepada masyarakat.

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