Introduction

Severe Acute Respiratory Syndrome Coronavirus 2 (SARSrep-CoV-2) was found to be the cause of Coronavirus Disease 2019 (COVID-19). It is a new variant of the virus that was not known to cause human disease [1].

WHO reports that as of June 4, 2021, there have been 171,782,908 confirmed cases with 3,698,621 deaths worldwide (Case Fatality Rate/CFR: 2.1%) [2].

Indonesia also reported its first case on March 2, 2020, with a swift spread throughout the archipelago. One month later, on June 4, 2021, 1,843,163 confirmed cases were reported, with 51,296 deaths (CFR 2.7%) [3].

Indonesia also reported its first case on March 2, 2020, with a swift spread throughout the archipelago. One month later, on June 4, 2021, 1,843,163 confirmed cases were reported, with 51,296 deaths (CFR 2.7%) [4].

Due to the wide spread of the COVID-19 pandemic, healthcare providers have had to put off some routines, elective care, and outpatient services. This is so that medical resources can be used to care for COVID-19 patients and reduce the risk of the virus spreading [5].

Face-to-face consultations are disrupted due to the patient’s hesitation to consult a doctor at a health facility. According to a WHO survey conducted in 155 countries, the majority of countries have reported a reduction in non- COVID-19 cases such as hypertension (53%), diabetes and its complications (49%), cancer treatment (42%), cardiovascular emergencies (31%), and rehabilitation. (63%) [6].

Telemedicine includes synchronous modes (e.g., video visits, audio visits), asynchronous modes (e.g., email), and remote patient monitoring [7]. Telemedicine is very important in emergencies because it helps patients get the care they need from a distance, streamlines healthcare services, saves medical resources [8] and puts those resources where they are needed most [9].

Globally, 58% of countries experiencing service disruptions have extensively turned to telemedicine during the pandemic to meet healthcare needs [10]. Based on findings in 12 countries through a survey, it was found Forty-eight thousand one hundred forty-four patients surveyed by 146 healthcare providers expressed high satisfaction with telemedicine across the disease spectrum. The most common advantage is time savings due to shorter travel and waiting times, better accessibility, convenience, and cost efficiency [11], Patients have found that telemedicine is an effective way to talk to doctors [12].

MarkPlus Inc., a survey institution in Indonesia, also conducted a quick survey, which was attended by 110 respondents throughout Indonesia. The result of the survey was that, since the coronavirus pandemic, Indonesian people are increasingly afraid to visit hospitals, so digital health consultations are an alternative to health care that people like. Before the coronavirus pandemic, 31.8% of participants admitted to visiting a health service institution at least once a year, and 29.1% admitted to seeing one once every six months; however, with the presence of COVID-19 in Indonesia, 71.8% of participants admitted to never revisiting a health care facility, and 64.5% admitted to preferring to take care of their health independently by resting and consuming healthy food. People are hesitant to visit hospitals or clinics because they believe they will be breeding grounds for the coronavirus. So, 65.5% of the people who took part said they used digital consultations more often because they could still learn about their illnesses without having to go to a clinic or hospital [13].

In 2020, the Ministry of Health issued a Circular Letter of the Minister of Health, Number Hk.02.01/Menkes/303/2020, Concerning the Implementation of Health Services Through the Utilization of Information and Communication Technology in the Context of Preventing the Spread of Corona Virus Disease 2019 (COVID-19) [14], concerning: Based on this, social security agency of health issued a policy in the form of a circular letter from the Director of Health Service Guarantee of social security agency of health Number 16 of 2020 concerning Health Service Policy at First Level Health Facilities During the Corona Virus Disease 2019 Prevention Period, which states that in the framework of efforts to prevent transmission and implement social distancing, FKTP can provide indirect contact services through Tinnitus Teleconsulting media carried out by FKTP (First Level Health Facilities) in providing medical consultations to patients [15].

In the Regulation of the Minister of Health of the Republic of Indonesia, Number 20 of 2019, Concerning the Implementation of Telemedicine Services Between Health Service Facilities, Article 3 Paragraph 1d, it is stated that Telemedicine Services consist of one of them being Clinical Teleconsulting, so the focus of discussion in this research is related to Tinnitus Teleconsulting. As of August 2021, it is known that the percentage of FKTPs that have used social security agency of health Teleconsulting is 40.73% (8,713 of the total 21,391 FKTPs nationally); this figure has not yet reached the target of 100% nationally, with utilisation only getting 2.07% (8,343,257 indirect contacts out of 402,099,198 total FKTP contacts with patients).

The distribution of FKTPs and the low percentage of FKTPs using Teleconsulting indicate potential problems in implementing hearing Teleconsulting policies. In addition, when viewed from a policy perspective, the Social security agency of health Head Office has the same approach, but its performance in the regions has different results. So it is necessary to study the factors influencing the implementation of FKTP Tinnitus Teleconsulting policies in these areas. It is essential to analyse the performance of the policy implementation to provide an evaluation and generate feedback for the subsequent policy development process.

It was determined that the research would be carried out in South Jakarta City. The city was chosen because it had the highest percentage of FKTPs that used Teleconsulting nationally: 83 (94.3%) of 88 FKTPs used Tinnitus Teleconsulting. Nationally, a lot of FKTPs use Teleconsulting, and a lot of patients use it as well. 453,271 (17.1%) of the 2,657,688 patients who visit FKTPs use audiology Teleconsulting, but not all FKTPs do.

The research was conducted using the Focus Group Discussion (FGD) method on the South Jakarta City FKTP and in-depth interviews as source triangulation for the South Jakarta City Health Service, the South Jakarta Branch social security agency of health, and the social security agency of health JPKP Head Office. Participants that recruited are 10 persons and the process of recruitment is based on recommendations from primary health care centers.

Methods

The research design is a qualitative study using the Rapid Assessment Procedure (RAP) method. This method is used to find problems, find ways to improve, and understand the successes and issues that come up when doing Audiology Teleconsulting. Focus Group Discussions (FGD) and in-depth interviews (WM) were used to collect data.

This research was conducted at FKTPs in South Jakarta City that had or had not implemented Audiology Teleconsulting. In addition, analysis was carried out at the South Jakarta City Health Office, the South Jakarta Branch Office of the Social Security Agency of Health, and the Social Security Agency of Health’s Head Office. The data collection time was November 2022–June 2023.

This study used primary data collected through informants using the FGD method and indept interviews which were guided by a list of questions prepared by the researcher. interview answers were recorded by recorder and then we made the interview transcript. Secondary data was obtained from the social security agencies dealing with health, legislation, documents, and literature related to research.

Before conducting this research, a written request was made to the Department of Public Health Science, Ethical Committee of the Public Health Faculty, University of Indonesia. After reviewing our request, the project was approved by the Ethical Committee on April 2023. Participants were given the purpose of the research and asked to participate in the study; they welcomed it. Written consent was obtained from all participants, and they were informed that their anonymized data would be published.

Results

The FKTP Teleconsulting Policy has been in effect since April 2020, based on SE Director of social security agency of Health Service Guarantee Number 16 of 2020 Concerning Health Service Policy at First Level Health Facilities During the Coronavirus Disease 2019 (COVID-19) Prevention Period. This was also known to FKTP, according to what FKTP informants, both those who have implemented it and those who haven’t, said : “We had communicated with patients via WhatsApp for a long time before the pandemic. Still, it has been increasing since the pandemic, in conjunction with the already existing policies from social security agency of health and making performance achievements, which makes us... appreciate you.” (FKTP A2)

Based on what was conveyed by the informant above, the FKTP already knew information about implementing the FKTP Teleconsulting policy during the COVID-19 pandemic. As for how the Teleconsulting process was, it can be seen from the following informants, namely : “Yes, there is a JKN. Doctors and patients also download the application, and then there is a schedule, for example, Monday through Thursday. I saw that I answered, for the PCare, “..this will go straight into the PCAE data later.” What is usually input to PCare? If the consultation is delayed, another public health centre officer will be assigned to input the information, usually tomorrow. Because of the talk, there are even some in the afternoon, so they are collected first.” (FKTP A1)

They can’t clearly explain the process to FKTPs that still need to put it into place because they’ve never done it before.

Regarding the implementation of Teleconsulting, FKTPs conducted Teleconsulting; the majority of them stated that they had done so before the COVID-19 pandemic but not as much as during the pandemic; however, there was an increase in the use of FKTP Teleconsulting, as reported by the following FKTPs : “We used this Teleconsulting before the pandemic, but only in Washington, usually only in the Prolanis group. It’s easy to use WA here; we also have our application; yes, WA too; since this pandemic, more and more people are using WA for consultations via our application; COVID patients also have a lot of talks. They are happy...” (FKTP A2).

In consideration of using Teleconsulting by FKTP, most of the FKTP informants answered that it would make it easier for patients, especially during the COVID-19 pandemic, as conveyed by the following informants : “…This pandemic, yes. Patients think that the health facility is a source of transmission, so they are afraid to seek treatment, but when they want to seek treatment, the patient becomes confused. With this Teleconsulting, it makes it easier... Patients can still ask the doctor questions. There is no need to visit a medical facility...” (FKTP A1).

All FKTPs that had been implemented said that there had been an increase, but the amount of growth wasn’t properly recorded by the health facility, so the health facility only looked at the data for an increase based on feedback from the social security agency of health, as told by the following informant : “Yes, we don’t know the exact number, so it’s just growing; the number of patients served is increasing, so they’re busy answering Teleconsultings,... that’s all. We’ll be able to find out how much the nominal visit data is per month, every month, in the feedback we get later from the social security agency of health.” (FKTP A2)

In accordance with the results of source triangulation for the South Jakarta Branch of the Social Security Agency of Health, the informant conveyed the following:: “…This online consultation goes into the KBK assessment on indirect contact, which helps FKTP a lot. ..” (BPJSK 1).

Most of the problems come from the fact that the doctor needs to make a more accurate diagnosis, according to the following source : “.If there are obstacles, for example, we don’t know if what the patient said is true—is it this patient or even his neighbor?—or if the patient didn’t understand what the doctor said. Usually, we ask for a photo or if the patient wants to come or doesn’t want to come. That’s usually the issue. Sometimes, on the way, the patient doesn’t want to write down his number. Yes, we can’t input it on PCare…” (FKTP A6).

For the efforts made to maintain the continuity of implementation, FKTP informants mainly conveyed it through promotions with posters or social media owned by FKTPs. In contrast, the social security agency for health included it as an achievement in the KBK assessment and health facility compliance indicators, according to what the following informants conveyed : “We, from the Head Office, have issued two regulations to strengthen the implementation of FKTP Teleconsulting as part of the form of FKTP service to patients, namely social security agency of health Circular Number 2 of 2020 concerning the performance of KBK Payments during the FKTP Period during the COVID-19 Disaster Period, which was established in October 2020, and Regulation of the Board of Directors of the Health Social Security Administering Body Number 44 of 2021 Concerning Guidelines for Measuring Health Facility Compliance with the Cooperation Agreement...ee...this July 2021 comes into effect, so with these two regulations, we will encourage FKTP in its implementation..” (BPJSK 2).

Discussion

Implementing the FKTP Teleconsulting Policy in South Jakarta is already exemplary. There is still a chance to increase its achievement further, as can be seen in the graphic data presented in the Results Chapter; in both the city of South Jakarta and national data, there has been a significant increase; this is supported by the issuance of two supporting regulations for the implementation of the FKTP Teleconsulting Policy, namely, Social Security Agency of Health Circular Number 2 of 2020 concerning Implementation of KBK Payments during the FKTP Period During the COVID-19 Disaster Period, which was stipulated in September 2020, and Regulation of the Board of Directors of the Health Social Security Organizing Agency Number 44 of 2021 concerning Guidelines for Measuring Health Facility Compliance with Cooperation Agreements.

Most FKTP Teleconsulting implementations in South Jakarta City use the WhatsApp app instead of the JKN mobile app or mobile JKN health facilities. This makes it impossible to monitor Teleconsulting.

The size of this Teleconsulting Implementation Policy is determined by the percentage of FKTPs that use Teleconsulting and the rate of utilisation by patients. While the policy goal is to increase indirect contact health services by FKTPs through Teleconsulting to patients, the quality of FKTP services can still be optimal during the COVID-19 pandemic, and patients can receive health services from their FKTP via Teleconsulting [16].

All FKTPs have the means to implement this FKTP Teleconsulting policy because the vast majority of FKTP doctors have electronic devices (smartphones), WhatsApp applications, and open data/internet communication networks.

The South Jakarta City Health Office still needs to support the FKTP Teleconsulting policy optimally, even though this is one of the suggestions from the Ministry of Health through Minister of Health Circular Letter Number Hk.02.01/Menkes/303/2020 Concerning Health Service Delivery Using Information and Communication Technology in the Context of Preventing the Spread of Corona Virus Disease 2019 (COVID-19), namely, faceto- face relationships between doctors as health service providers and patients as recipients of health services are vulnerable to the spread of infectious diseases, including COVID-19, both from patients to doctors and from doctors who were previously infected as asymptomatic carriers.

There are no problems with communication between organisations when putting the FKTP Teleconsultings policy into action. All of the organisations involved have been given clear information about the policy through meetings, online meetings, and letters.

All implementing dispositions already know the performance, measures, and goals of the FKTP Teleconsulting policy and accept or reject it as a whole. What is still missing is the intensity of implementation, because there are still FKTPs that haven’t done the best job of implementing the policy, especially when it comes to filling out the logbook and entering data into the PCare application from the Social Security Agency of Health.

The budgetary support for implementing the Teleconsulting policy still needs to be improved. FKTP has not budgeted explicitly for FKTP Teleconsulting services and data/pulse package costs, so they only use electronic devices for doctors at FKTP or data usage for the WhatsApp application. Meanwhile, the budget for social security agency of health for the South Jakarta Branch and social security agency of health for the JPKP Head Office is already available in the form of a programme budget, which is implemented through offline and online socialisation activities, field supervision, and the promotion of FKTP Teleconsulting services.

Support from the social environment in the form of community acceptance of this FKTP Teleconsulting policy by increasing the use of patient FKTP Teleconsulting via WhatsApp, Telegram, social media, mobile apps, and other applications owned by FKTP [17].

Support from the political environment, from the South Jakarta city health office, and from the South Jakarta city government is not specific. Still, it also prohibits implementing this policy. In principle, the South Jakarta city government supports all policies related to full procedures and health services for the people of South Jakarta, especially during the COVID-19 pandemic.

Economic, environmental, or budgetary support is another research result that needs improvement; all FKTP informants stated that there was no specific budget allocation for implementing the Teleconsulting policy, which only used electronic devices and data packages owned by FKTP doctors. The performance of the implementation of the FKTP Teleconsulting policy in the City of South Jakarta has been good, and there is an opportunity for the achievement to be further improved. As seen in the graphic data in the Discussion Chapter, there has been an increase in the use of Teleconsulting by patients.

Conclusion

For this reason, steps are needed to prevent the spread of COVID-19, one of which is limiting face-to-face health services by utilising information and communication technology in the form of telemedicine. The FKTP Audiology Teleconsulting, which includes this referral program, needs the help of social security agency of health, health service facilities, and the government from the South Jakarta city health office and through the South Jakarta city government as soon as possible.

Grant Information

To all who have been very helpful so that this article can be adequately prepared, to Directorate of Research and Development, Universitas Indonesia under Hibah PUTI 2022 (Grant No. NKB-262/UN2.RST/HKP.05.00/2022), who have provided enthusiasm and support regarding funding. Hopefully, this article can be helpful for all of us and get constructive criticism and suggestions for future improvements.

Data Availability

Underlying data

Figshare: Permatasari, Putri (2023). Evaluation of the Tinnitus Teleconsulting System’s Back-Referral Program for National Health Insurance Patients with Diabetes Mellitus in Primary Care. figshare. Dataset. https://doi. org/10.6084/m9.figshare.23931129.v2

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Declarations

Declarations Confict of interest I declare no confict of interest.