Mengapa Masih Ada RSUD Yang Belum Menjalankan PPPK-BLUD ?

Pasal 12 Ayat (1) UU Nomor 23 Tahun 2014 tentang Pemerintahan Daerah telah secara tegas menyatakan bahwa KESEHATAN merupakan urusan pemerintahan KONGRUEN yang bersifat Wajib dalam kategori berkaitan dengan Pelayanan Dasar. Urusan Pemerintah KONGRUEN artinya urusan pemerintah yang DIBAGI antara PEMERINTAH PUSAT dan PEMERINTAH DAERAH (Provinsi dan Kabupaten/Kota). Sekali lagi ini merupakan penegasan bahwa urusan KESEHATAN tetap menjadi DESENTRALISASI berdasarkan prinsip OTONOMI DAERAH.

Ketika kesehatan di-desentralisasikan tentu akan terjadi deviasi atau perbedaan “aroma” dunia kesehatan antar tiap daerah. Meskipun Norma Standar Prosedur dan Kriteria (NSPK) tetap harus mengacu kepada kementerian teknis terkait, namun tetap akan terjadi kendala ketika berhadapan dengan kepentingan politis “raja kecil” penguasa daerah yang dipayungi oleh prinsip OTONOMI DAERAH. Contoh paling nyata dan terbaru adalah terkait dengan RSUD yang BELUM menerapkan Pola Pengelolaan Keuangan secara Badan Layanan Umum Daerah (PPK-BLUD).

Sebuah RSUD yang menjadi PPK-BLUD bukan berarti berubah status badan hukum dan kepemilikan. Hal ini masih sering dikacaukan dengan salah pemahaman dan penterjemahan banyak pihak. Perubahan RSUD yang menjalankan PPK-BLUD sama sekali TIDAK MERUBAH badan hukum dan status kepemilikan. Badan Hukum nya jelas yaitu merupakan sebuah Lembaga Teknis Daerah (LTD) dan status kepemilikan tetap oleh Pemerintah Daerah. Yang berubah adalah POLA pengelolaan keuangan nya menggunakan prinsip-prinsip Badan Layanan Umum Daerah sebagaimana diatur dalam PP Nomor 23 Tahun 2005 dan Permendagri Nomor 61 Tahun 2007.

Benarkah RSUD menjadi sumber PAD ? Jika sebuah RSUD BELUM menjalankan PPK-BLUD dimana pendapatan RSUD harus tetap “disatukan” dalam pendapatan daerah memang sangat mungkin terjadi demikian. Namun ketika RSUD telah menjalankan prinsip PPK-BLUD maka secara teori TIDAK MUNGKIN pendapatan RSUD akan menjadi PAD. Secara laporan memang masih menjadi PAD, namun real uang nya tidak lagi masuk ke dalam kas daerah namun masuk dalam kas BLUD sebuah RSUD. Secara jumlah pendapatan memang menjadi salah satu kontributor (penyumbang) PAD, namun pemanfaatan pendapatan tersebut menjad kewenangan penuh RSUD karena sejatinya pendapatan tersebut tersimpan dalam kas RSUD tersendiri.

Pemanfaatan pendapatan RSUD telah diatur dengan tegas dalam UU Nomor 44 tahun 2009 tentang Rumah Sakit pada Pasal Pasal 51 yang berbunyi : “Pendapatan Rumah Sakit publik yang dikelola Pemerintah dan Pemerintah Daerah digunakan seluruhnya secara LANGSUNG untuk biaya operasional Rumah Sakit dan TIDAK DAPAT dijadikan pendapatan negara atau Pemerintah Daerah”. Bukankah ketentuan ini sudah sangat gamblang dan tegas ?

Kembali kepada persoalan awal terkait PPK-BLUD rumah sakit. Penegasan bahwa RS yang didirikan oleh pemerintah dan pemerintah daerah WAJIB menjalankan PPK-BLU atau PPK-BLUD berawal dari terbitnya PP Nomor 23 Tahun 2005 yang kemudian khusus untuk RS milik Pemerintah Daerah diatur dalam Permendagri Nomor 61 Tahun 2007. Didalam kedua produk hukum tersebut telah secara jelas menyatakan bahwa rumah sakit HARUS menerapkan prinsip-prinsip PPK-BLU atau PPK-BLUD.

Produk hukum yang makin menegaskan KEWAJIBAN RS milik pemerintah dan pemerintah daerah menjalankan prinsip pengelolan BLU atau BLUD terdapat pada UU Nomor 44 Tahun 2009 tentang Rumah Sakit. Pada Pasal 7 Ayat (3) yang berbunyi : ” Rumah Sakit yang didirikan oleh Pemerintah dan Pemerintah Daerah sebagaimana dimaksud pada ayat (2) harus berbentuk Unit Pelaksana Teknis dari Instansi yang bertugas di bidang kesehatan, Instansi tertentu, atau Lembaga Teknis Daerah dengan pengelolaan BADAN LAYANAN UMUM (BLU) ATAU BADAN LAYANAN UMUM DAERAH (BLUD) sesuai dengan ketentuan peraturan perundang-undangan “.

Dipertegas lagi pada Pasal 20 Ayat (3) yang berbunyi : ” Rumah Sakit publik yang dikelola Pemerintah dan Pemerintah Daerah diselenggarakan berdasarkan pengelolaan BADAN LAYANAN UMUM (BLU) ATAU BADAN LAYANAN UMUM DAERAH (BLUD) sesuai dengan ketentuan peraturan perundang-undangan “. Masihkah ada multi tafsir terhadap bunyi pasal-pasal tersebut ??

Dalam UU Nomor 12 Tahun 2011 tentang Pembentukan Peraturan Perundang-undangan diatur tentang jenis dan hierarki peraturan perundang-undangan Republik Indonesia adalah sebagai berikut : 1). UUD Negara Republik Indonesia Tahun 1945; 2). Ketetapan MPR; 3). UU/Perppu; 4). Peraturan Presiden; 5). Peraturan Daerah Provinsi dan 6). Peraturan Daerah Kabupaten/Kota. Memang kita melihat bahwa baik itu Peraturan Pemerintah (PP) dan Peraturan Menteri (Permen) TIDAK masuk dalam hierarki atau tata urutan peraturan perundang-undangan. Sehingga ketika pemerintah dan pemerintah daerah TIDAK mentaati PP 23 Tahun 2005 tentang PPK-BLU dan Permendagri Nomor 61 Tahun 2007 tentang PPK-BLUD, mungkin secara aspek legal formal masih dapat dipahami dan dimaklumi.

Namun ketika sudah terbit Undang-Undang (UU) dimana menempati urutan ke-3 dalam hierarki tata urutan perundan-undangan, maka TIDAK ada alasan pembenaran untuk TIDAK melaksanakan ketentuan tersebut. UU Nomor 44 Tahun 2009 merupakan produk hukum berbentuk Undang-Undang hasil dari pembahasan bersama antara pemerintah (eksekutif) dengan DPR selaku lembaga legislatif. Jadi kesimpulannya, tidak ada lagi alasan teoritis dan legal untuk TIDAK menerapakan PPK-BLUD pada RSUD.

Bagaimana dengan aturan peralihan ? Karena setiap produk hukum yang secara substansial mengatur atau merubah aturan terdahulu selalu terdapat ketentuan peralihan. UU Nomor 44 Tahun 2009 telah mengatur ketentuan peralihan pada Pasal 64 Ayat (1) yang berbunyi : ” Pada saat Undang-Undang ini berlaku, semua Rumah Sakit yang sudah ada HARUS menyesuaikan dengan ketentuan yang berlaku dalam Undang-Undang ini, PALING LAMBAT dalam jangka waktu 2 (dua) tahun setelah Undang-Undang ini diundangkan “. Pada Ayat (2) berbunyi : ” Pada saat undang-undang ini berlaku, Izin penyelenggaraan Rumah Sakit yang telah ada TETAP berlaku SAMPAI HABIS MASA BERLAKUNYA “.

Dari ketentuan peralihan tersebut dapat disimpulkan bahwa selambat-lambatnya pada tahun 2011 semua Rumah Sakit harus menyesuaikan dengan ketentuan-ketentuan yang diatur dalam UU Nomor 44 Tahun 2009 tentang Rumah Sakit tersebut. Pun demikian andaikata pada tahun 2009 IJIN OPERASIONAL (Ijin Fungsi) sebuah rumah sakit baru diterbitkan sebelaum UU Rumah Sakit ini ditetapkan, maka pada Tahun 2014 pasti ijin operasional tersebut SUDAH HABIS (Ijin Operasional diberikan selama 5 Tahun). Artinya terhitung sejak tahun 2014 sesungguhnya SELURUH rumah sakit harus mengikuti ketentuan dalam UU Rumah Sakit tersebut. Lebih fokus lagi adalah SELURUH rumah sakit milik pemerintah dan pemerintah daerah HARUS menjalankan prinsip PPK-BLU atau PPK-BLUD tanpa terkecuali.

Maka sungguh sangat mengherankan ketika pada hari ini, pada tahun 2016 kita masih mendengar ada RSUD yang BELUM menjalankan prinsip PPK-BLUD sehingga tidak memiliki fleksibiltas dan kewenangan mengelola pendapatan serta menyusun anggaran belanja sendiri sampai-sampai kehabisan obat karena tidak mampu membayar obat. Miris lagi sampai para dokter dan perawat melakukan penggalangan dana untuk membeli obat-obatan. Sungguh fenomena tersebut merupakan SINDIRAN tajam dari para pegawai yang nampaknya LEBIH PAHAM undang-undang ketimbang para pengampu kebijakan di daerah.

Beberapa sejawat masih ada yang menulis bahwa selama ini RSUD menjadi SAPI PERAH untuk menyumbang PAD sebuah daerah. Ada juga yang menyatakan bahwa pembayaran klaim BPJS Kesehatan tidak berarti apa-apa karena pendapatan disetor ke kas daerah, sehingga para dokter, perawat dan semua yang memberikan pelayanan tidak mendapatkan yang sesuai sebagaimana yang diharapkan. Bagi telinga dan mata saya, sungguh rasanya tidak enak dan sangat mengganggu sekali ketika masih ada kalimat “SAPI PERAHAN PEMDA” atau kata-kata “SETOR KE PEMDA”. Namun ketika memang fakta di lapangan memang masih ada RSUD yang belum menjalankan pengelolan PPK-BLUD maka anggapan seperti itu masih wajar.

Lantas salah siapa kalau begitu ? Pemerintah sudah menerbitkan peraturan perundang-undangan terkait hal ini. Namun pelaksanaan di lapangan masih sangat bervariasi antar daerah karena sangat tergantung pada kepentingan politis sang penguasa daerah dengan senjata Otonomi Daerah. Sadarkah raja-raja lokal tersebut bahwa dampaknya akan sangat panjang ? RSUD TIDAK melayanai peserta JKN dan hanya melayani pasien umum karena tidak tersedia obat-obatan. Dampaknya RSUD jadi sepi karena ketika program JKN sudah bergulir, maka hanya sebagian kecil saja masyarakat Indonesia yang BELUM memanfaatkan JKN dan pasien umum (out of pocket) semakin sedikit.

Kenapa tidak ada sangsi bagi pemerintah daerah yang TIDAK mentaati Undang-Undang ? Dalam UU 44 Tahun 2009 tentang Rumah Sakit memang ada pasal tentang Ketentuan PIDANA, namun itu hanya berlaku bagi rumah sakit yang tidak memiliki ijin operasional. Tidak ada sanksi administratif atau sanksi secara perdata bagi pihak-pihak yang tidak mentaati ketentuan dalam undang-undang tersebut.

Itulah Indonesia…. begitu banyak orang pintar menyusun peraturan perundang-undangan, begita banyak peraturan perundang-undangan yang dibuat sampai banyak yang bertentangan dan bertabrakan.

Namun manakala memasuki area penegakan aturan (law enforcement) tiba-tiba menjadi ambigu dan gagap seolah-olah tidak tahu. Standar ganda penegakan hukum di Indonesia, ironis ketika seorang nenek karena kelaparan mencuri makanan harus dihukum namun ketika para pemangku jabatan tidak melaksanakan ketentuan undang-undang tiba-tiba hukum menjadi tumpul.

Terakhir…. inilah salah satu sisi gelap DESENTRALISASI KESEHATAN. Berulangkali saya menyatakan bahwa urusan kesehatan adalah urusan dasar manusia sehingga seharusnya TIDAK ADA perbedaan di setiap daerah, maka menurut saya pribadi seharusnya kesehatan menjadi urusan pemerintah yang bersifat ABSOLUTE, artinya TIDAK di-otonomikan (DESENTRALISASI). Selamat menikmati desentralisasi kesehatan.

Salam

Tri Muhammad Hani
RSUD Bayu Asih Purwakarta
Jl. Veteran No. 39 Kabupaten Purwakarta – Jawa Barat

 

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    and from now on whenever a comment is added I receive four emails with the exact same comment.
    There has to be a way you can remove me from that service?
    Thanks!

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