SOCIAL EXCLUSION IN INDONESIA MILITARY HOSPITAL

Background: In the era of the COVID-19 pandemic, one of the social protections in Indonesia that still requires special attention is the protection of public health. Aims: This study aims to analyze the principles of social protection in the Social Security Agency for Health (BPJS Kesehatan) and the implementation of inclusive health services in Indonesia Military Hospital. Methods: This study used a qualitative approach by conducting in-depth interviews and made direct observations for one month by observing the processes and phenomena that occurred at the dr. Esnawan Antariksa Air Force Hospital as a case study. Results: The root cause of social exclusion in health services in military institutions was an aspect of the inherent hierarchy that caused exclusion in the income dimension triggered by socioeconomic level, status, and background of patients so that patients did not get the same rights in obtaining health services. Conclusion: Implementing social protection through BPJS Kesehatan in military-based hospitals caused patients with specific groups to experience layered exclusion. Patients who wanted to receive healthcare at military hospitals had differences in the stages of receiving them. However, the quality of medical services doctors and other health workers provided were not discriminatory.


Introduction
In the era of the COVID-19 pandemic, one of the social protections in Indonesia that still requires special attention is the protection of public health. The National Health Insurance (JKN) regulates health protection in Indonesia through Social Security Agency for Health (BPJS Kesehatan). BPJS Kesehatan has a task mandated by the government to administer the National Health Insurance program for all levels of Indonesian society under the mandate of the 1945 constitution. BPJS Kesehatan has been operating since January 1st, 2014. BPJS Kesehatan is a form of the state's effort to ensure the health of its people by providing social protection forms of healthcare. In addition, BPJS Kesehatan aims to protect communities having difficulties accessing healthcare and reduce social inequality. Theoretically, BPJS Kesehatan guarantees equal access and healthcare to the entire community. However, in actual practice, it is closely related to social inequality, especially among certain social groups such as the poor society.
All qualified government hospitals in Indonesia must cooperate with BPJS Kesehatan to provide healthcare to the community. In accordance with the Regulation of the President of the Republic of Indonesia Number 12, 2013, Government hospitals that refuse to cooperate with BPJS Kesehatan in healthcare for BPJS Kesehatan participants are violating the obligations specified in the Presidential Regulation of Health Insurance and will be sanctioned. Studies on Health Insurance related to the BPJS Kesehatan Program have been done widely (see: Arpey, Gaglioti, and Rosenbaum, 2017;Garza, 2019;Putri and Murdi, 2019;Boro, 2020;Purwalaksana et al., 2021). The present study aimed to discuss the phenomenon from the sociological perspective focusing on healthcare in military hospitals managed by the Ministry of Defense. Military patients, civil servants from the Ministry of Defense, and their families were more satisfied with healthcare before the existence of BPJS Kesehatan (Ernawati, 2016). In addition, other studies explained that members of the Indonesian national armed forces, civil servants of the Ministry of Defense, and their families who wished to seek treatment could not go directly to their selected hospital (Purwalaksana et al., 2021). They had to go through the First-Level Health Facilities, known as FKTP, to get the treatment. Before the implementation of BPJS Kesehatan, Indonesian national armed forces, civil servants of the Ministry of Defense, and their families could seek treatment directly at their selected hospital using health insurance from the military institution (Purwalaksana et al., 2021).
Currently, hospitals managed by the Ministry of Defense not only focus on military patients, civil servants of the Ministry of Defense, and their families but must also be inclusive by providing services to the general public or civilians. This policy shift is certainly not easy and has become a challenge. The government's implementation of the BPJS Kesehatan program still needs to be strengthened, including strengthening the leadership role in the various institutions and agencies involved, improving accountability, and increasing collaboration between stakeholders (Pusat Kebijakan dan Manajemen Kesehatan, 2020). The Ministry of Defense, one of the stakeholders in this program, should have been involved. Unfortunately, as a civilian institution, they are also dominated by the military. The form of military presence in the post-reform government in Indonesia could be seen by the military domination within the Ministry of Defense. Although the Ministry of Defense is a civilian institution, the intervention carried out by the military is too strong that it significantly impacts the functions of the Ministry of Defense itself (Djuyandi and Ghazian, 2019). This condition aligns with regulations regarding healthcare made by the Ministry of Defense at military hospitals.
On the contrary, the culture within the military, such as the inherent hierarchy and chain of command, makes achieving inclusiveness in healthcare in military hospitals challenging. This situation makes BPJS Kesehatan's effort to include nonmilitary patients not run optimally because Suar Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p-ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v11i1.2023 Original Research social inclusion is not well-implemented. Fundamentally, social inclusion is an effort to achieve an ideal quality of life for the dignity and independence of individuals or groups. Social inclusion includes social relations and respect for individuals or groups, so those marginalized and people who experience prejudice can fully participate in decision-making, economic, social, political, and cultural life and also have equal access and control over resources to meet their needs according to welfare standards that are considered appropriate within the community group concerned (Hart, 2020). Babajanian and Hagen-Zanker (2012) stated that the social exclusion framework could help the author to analyze social protection interventions. Therefore, the author decided to use this framework to identify the extent of the intervention regarding the factors which restricted individuals' access to healthcare in military hospitals.

Method
This study used a qualitative approach with a case study. The author analyzed the healthcare at dr. Esnawan Antariksa Air Force Hospital, located in Jakarta, under the supervision of the Ministry of Defense, as a case study. The data collection process was carried out by interviewing six informants and determining the informants by using purposive sampling. The selected informants were considered based on their military rank, background, and type of BPJS Kesehatan they had so each informant could represent their respective classes. The author made direct observations for one month by observing the processes and phenomena that occurred at the hospital. The author afterward utilized other supporting data from the Ministry of Defense Regulation, the Regulation of the Commander of the Indonesian National Armed Forces, BPJS Kesehatan Regulation, dr. Esnawan Antariksa Air Force Hospital regulation and other government regulations, as well as articles and online news portals regarding health insurance through BPJS Kesehatan in military-based hospitals. Furthermore, the data obtained were analyzed using three dimensions of social exclusion belonging to Babajanan and Hagen-Zanker (2012). The three dimensions were the income exclusion, participation exclusion, and service exclusion dimensions, using the descriptive analysis method.

Conceptual Framework of Social Exclusion for Analysis Tools
The author used the social exclusion theoretical framework of Babajanian and Hagen-Zanker (2012) to analyze existing interventions in healthcare at military hospitals. The social exclusion framework emphasized the relationship between welfare and more extensive factors, including policies, social relations, norms, and values that shape and change various types of social deprivatization. Social exclusion ultimately helped to capture the natural deprivatization phenomenon that occurred with various interrelated and mutually reinforcing dimensions. service, income, and participation. In connection with this study, the author focused on seeing indications of social exclusion in healthcare provided by BPJS Kesehatan in dr. Esnawan Antariksa Air Force Hospital. Forms of exclusion in the services were socioeconomic level, Suar Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia)

Health Services in the Era of BPJS Kesehatan
The result from previous research related to the BPJS Kesehatan outpatient registration service procedure at a hospital belonging to the Air Force had gone quite well. However, the result showed that as many as 63.43% belonged to a reasonably good qualification but not ideal. The dimension that had the lowest percentage was the empathy dimension, with a percentage of 58.93%. Obstacles to outpatient services for BPJS patients include (1) low level of discipline and communication, (2) insufficient implementation of 3S (smile, greet, peace) to patients, (3) Problems with the digitalbased registration system (Rahayu and Antika, 2022). Ernawati (2016) explained that the satisfaction level of military patients in the BPJS Kesehatan era was entirely satisfactory, but compared to health services before the BPJS Kesehatan era, military patients' satisfaction level was higher. This is caused by the complexity of the registration process, sub-optimal supporting examinations, and the allocation of different drugs. Likewise, Purwalaksana et al. (2021) research explained that implementing BPJS Kesehatan in military institutions did not show effective results and tended to decline. This was explained in Purwalaksana's research, which focused on analyzing Law Number 24 of 2011 concerning Health services for the Indonesian National Armed Forces and their families used in a qualitative descriptive method.
Furthermore, Firdaus and Dewi (2015) explained that many patients were still confused about the referral system established by BPJS Kesehatan. Things that became obstacles to patient satisfaction using BPJS Kesehatan at Panembahan Senopati Hospital Bantul were the registration staff tended to be late and slow, waiting times for treatment tended to be long, staff voices tended to be high, officers were not friendly, rooms were not spacious, waiting rooms were lacking and no loudspeaker. Moreover, Hasrillah et al. (2021), Suprianto and Mutiarin (2016), and Gusnita (2017) explained that the implementation of programs organized by BPJS Kesehatan had yet to be effective.
In a study on social security through the Sistem Jaminan Sosial Nasional Law, Zain et al. (2017) explained that the law was inconsistent in manifesting the concept of the Indonesian welfare state. However, the government was responsible for ensuring the presence of qualified access for every citizen to get ideal and proper health services in fulfilling the fundamental rights of the community, especially in the health sector. The implementation of health based on the International Covenant on Economic, Social, and Cultural Rights in Indonesia was considered to have not materialized in a tangible way (Ardinata, 2020). BPJS Kesehatan is a legal entity that carries out social security programs to ensure that all people, without exception, are met with proper living needs (Solechan, 2019).  Health services at the dr. Esnawan Antariksa Air Force Hospital, a hierarchy in the form of rank was also implemented. This was contained in regulations made by the Ministry of Defense and other informal regulations in the chain of command in military organizations, which were then applied to health services at the dr. Esnawan Antariksa Air Force Hospital. The application of a hierarchy in the form of rank created differences in the health services received by patients, which resulted in the exclusion of working in the service dimension.

Analysis of the Social Exclusion Framework for Healthcare Income Exclusion Dimension
From the interview, the Indonesian National Armed Forces hierarchy greatly influenced the healthcare at the dr. Esnawan Antariksa Air Force Hospital. Military patients with lower ranks felt that their superiors were prioritized in getting services compared to them. In addition, patients with military backgrounds perceived they had service priority and prioritized receiving treatment from healthcare workers.
"I once had an experience where I went to the dentist. While waiting in line, someone with a higher rank bypassed the queue and went straight in. Actually, if my condition were more severe, I could have protested. However, since it was in the clinic and we were accustomed to such situations, we understood and accepted it, because individuals with higher ranks have priority." -(YDK, interview with the author, May 11, 2022) In the interview, YDK explained to the author about her experience during a dental visit, where they were cut in line by a patient with a higher rank. However, YDK understood and accepted this situation due to their lower rank. Nevertheless, YDK expressed that despite having to yield in the queue due to her lower rank, she felt prioritized and given certain conveniences compared to non-military patients.
Similar views were also expressed by WAP and S during their interviews. WAP holds a position as a lower-ranked officer in the Indonesian National Armed Forces, while S is a non-military patient. According to both informants, the ease of healthcare services they receive when seeking treatment at the dr. Esnawan Antariksa Air Force Hospital is attributed to their respective occupational backgrounds. Patients with a military background are given priority and are prioritized when receiving medical treatment from healthcare professionals. As stated by WAP and S during the interviews: Suar Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia)  From the interviews, it can be concluded that the background of patients has an influence on the healthcare service process at dr. Esnawan Antariksa Air Force Hospital. Patients with military background are prioritized in the treatment process compared to non-military patients. Moreover, the healthcare service system based on the administrative rank system also applies among military patients. This is evidenced by flag officer patients being given priority over patients with lower ranks in the healthcare service at the dr. Esnawan Antariksa Air Force Hospital. This statement is supported by the interview results with SH, who is the spouse of a flag officer in the military: "The intended meaning is as follows: Let me explain. We never have to queue, but even when we do, our queue is not as long as theirs. You know. However, for flag officers and colonels, there is a separate room exclusively for them. Have you ever heard of the room below? That one is specifically for colonels and flag officers. In that case, the nurse accompanies us. If there are many patients, we usually wait for our turn Suar Privileges for military patients were not only observable from the priority of healthcare obtained. It was also from the facilities provided by the hospital. In terms of services, the hospital provided an exclusive waiting room for patients with high military ranks and was acknowledged by non-military patients. The difference in waiting room conditions between highranking military patients and other patients was considered exclusive by one of the informants classified as a non-military patient with BPJS Kesehatan Contribution Assistance Recipient, known as PBI. BPJS Kesehatan PBI patients are people classified as poor and underprivileged if according to data from the Social Service, and the funding is funded by the government.

Indonesian Journal of Health Administration
The military hierarchy operating in healthcare institutions means that patients do not have equal rights to access healthcare. The author concluded that the primary factor that triggered social exclusion in healthcare at the hospital was the patient's different rank and background. Therefore, BPJS Kesehatan, as social protection, could not properly function when interacting with military-based healthcare. Hence, the military hospitals, as healthcare institutions and one of the facilitators to improve the welfare of its citizens in obtaining equal healthcare, had not run optimally. It was because the hospital could not provide universal and comprehensive healthcare.

Participation Exclusion Dimension
The exclusionary dimension of participation at dr. Esnawan Antariksa Air Force Hospital could be seen in the different access to healthcare that patients receive, which was between military and non-military patients. Inequality in access to healthcare reflected the limitations on patients to fully participate in receiving primary social services in the health sector. Restrictions on patient participation in healthcare at the hospital could lead to social exclusion. According to United Nations Development Program (2019), Social exclusion is the systematic process of marginalizing individuals or groups by denying them access to resources, opportunities, and services that are available to others in society. In the concept of the welfare state, equality of opportunity, equitable distribution of wealth, and public responsibility are the basic principles used when dealing with people who cannot provide for their personal needs for a decent life (Alfitri, 2012). From the concept, the principle of equality in opportunity related to access to healthcare in hospitals must be optimally realized and implemented. However, the difference in access to healthcare between military and non-military patients in the hospital reflected the fulfillment of the principle of equal opportunity that had not been fully implemented. It could trigger social exclusion in the participation dimension, which caused the concept of a welfare state not to run optimally.
Based on the interview results, informants with military backgrounds explained that the hospital prioritized patients with higher ranks if they were to seek treatment simultaneously with military patients with lower rankings.
"In my experience, when I seek treatment and there are flag officers and colonels present, they are always prioritized." -(WAP, interview with the author, April 10, 2022) "It does have a difference, sis. There is a difference. Like, there were many queues, but we were prioritized. Well, not exactly prioritized, but they were more helpful to us, you know. But if there are higher-ranking officers than us, they will be prioritized" -(YDK, Suar Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p-ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v11i1.2023 Original Research interview with the author, May 11, 2022) Meanwhile, a widow whose husband retired as a non-commissioned officer explained that she could not get the same hospitalization services when compared to when her husband was still serving in the military.
"Nowadays, the process becomes longer for non-military patients, and the conveniences are reduced. Regardless, being in the military still provides a much more pleasant experience, especially for military personnel. The healthcare service is significantly different." -(S, interview with the author, April 28, 2022) On the contrary, retired colonels, flag officers, and their family members still had the same hospitalization services as when they were still in the service. Moreover, flag officer patients received health service priority. There were priority queues and exclusive waiting rooms for flag officer patients. Priority queues for flag officer patients resulted in relatively shorter waiting times, which was inversely proportional to non-military patients who experienced longer waiting times for treatment. As stated by the informants: "Indeed, it is considerable, depending on the patients. If there are numerous patients, it may take hours, consuming an entire day to visit the hospital. Currently, they are prioritizing those wearing camouflage uniforms and blue uniforms." -(RS, interview with the author, April 28, 2022) "Indeed, there is a difference. You know, sis, it's written on the wall, read it. It says that the military is prioritized because they have to go back to work..." -(RS, interview with the author, April 28, 2022) "In general, when going to the hospital, we have to be there from early morning until the whole day. As non-military patients, we understand that we receive free healthcare here, so we can't complain or get angry about it. We just have to accept and follow the rules." -(RS, interview with the author, April 28, 2022) "Yes, there's definitely a difference. We don't use the regular waiting area, there's a separate place for us. And the regular waiting area is managed by the staff there. So, everything is arranged, and we wait in the VIP waiting room. The doctors are not always available on standby, so we wait there. But the waiting time is not usually long unless there's a surgery going on. We will be informed when the doctor arrives, and then we can go to the examination room." -(SH, interview with the author, May 12, 2022) "Hmm, but don't say it's easier, otherwise, those who are not flag officers will say they are not served, hahaha. So, since flag officers receive more attention, that's the point. Basically, flag officers receive better service. The bottom line is, colonels and above are definitely different, but in terms of healthcare service, the doctors are the same." -(SH, interview with the author, May 12, 2022) In light of this explanation, the exclusion dimension of participation worked in the healthcare process. Social exclusion occurred in the healthcare provided and the process of obtaining healthcare from healthcare workers provided by the hospital. This condition leaves patients with specific backgrounds unable to receive quality healthcare services. Therefore, these patients did not have equal opportunities to participate in the process of fulfilling basic needs in the form of healthcare.

Service Exclusion Dimensions
In practice, the healthcare provided by military hospitals was regulated through various policies and regulations issued by the government and health institutions. In a regulation issued by the Commander of the Suar Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p-ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v11i1.2023  If viewed from the service dimension, the differentiation in patients legalized through various policies and regulations would trigger social exclusion. The division in the administrative system, the division of service space between military and nonmilitary patients, and the priority of healthcare for military members showed the dimensions of service in military hospitals. Referring to the concept of a welfare state, the Republic of Indonesia must provide universal social protection. Providing social protection that is particularistic and selective makes the state deny the philosophy, function, and identity agreed upon by the founding fathers (Sukmana et al., 2015).

The intersection between Dimensions of Social Exclusion
The dimensions of social exclusion in healthcare in the military were interrelated and had intersections between dimensions. The main factors causing social exclusion in the income dimension were socioeconomic background, status, and level. Furthermore, this was supported by bureaucracy and administration and also legalized through existing regulations in military hospitals. The impact of intersections between dimensions of social exclusion was most felt by patients with non-military status and BPJS Kesehatan PBI patients. In these circumstances, those patients experienced layered social exclusion. The first layer of social exclusion could be seen from the implication of BPJS Kesehatan. The regulations within BPJS Kesehatan restrained BPJS Kesehatan PBI patients from only getting Class 3 healthcare. The patients also could not apply to transfer or upgrade the membership classes. The second layer of social exclusion was the patient's background, resulting in limitations in the health service process. This limitation was supported by regulations made by the government and the dr. Esnawan Antariksa Air Force Hospital.
In addition, other patients with nonmilitary status also encountered social exclusion triggered by their background and status. The non-military backgrounds of these patients had limited access to healthcare, leading to the participation exclusion dimension to work. Furthermore, for non-military patients, social exclusion was from the income and participation dimensions worked because it was supported by the bureaucracy and administration legalized by military hospital institutions and regulations made by the Ministry of Defense. In summary, the three dimensions of exclusion worked were the income exclusion dimension, the participation exclusion dimension, and the service exclusion dimension for non-military patients. Thus, retired military officers and their families with ranks below colonel received the same hospitalization services as non-military patients.
The dr. Esnawan Antariksa Air Force Hospital executed the Ministry of Defense's regulations. The regulations passed by the Ministry of Defense stated that colonels, flag officers, and high-ranking civil servants of the Ministry of Defense received preferential treatment, including VIP rooms. There were also several privileges for these patients, such as having different registration areas, special waiting rooms, and treatment prioritization. Although military patients with ranks below colonel felt more prioritized than non-military Suar Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) (2014) patients, they still faced limitations in inpatient services and room classes as well as facilities provided compared to facilities for colonels, flag officer patients, and highranking civil servants of the Ministry of Defense.
Multi-layered social exclusion occurred in military hospitals because the state could not properly regulate the law passed by the President. The social security ratified by the President should be implemented as a form of social protection to ensure that all Indonesian citizens can fulfill their basic health needs properly with the principle of equity and to meet equality in obtaining healthcare according to their medical needs and not be influenced by the number of contributions paid. However, in military hospitals, equity aspects and universal healthcare could not be fulfilled because military institutions did not comply with the highest regulations in the government. It could be seen from the overlapping regulations made by the Ministry of Defense regarding the privileges received by certain patients. In addition, the membership class made by BPJS Kesehatan through the Presidential Regulation on Health Insurance also created inequality for patients to get classified rooms. It was also one of the causes of the emergence of layered social exclusion when social protection in the form of BPJS Kesehatan intersected. The implementation of BPJS Kesehatan in military-based hospitals caused three dimensions of social exclusion, namely income, participation, and service exclusions. The concept of a welfare state adopted by Indonesia might not function well in dr. Esnawan Antariksa Air Force Hospital, where social exclusion occurred due to poor governance. The social exclusion in dr. Esnawan Antariksa Air Force Hospital happened in the process of receiving treatment from medical personnel. However, the services and care provided by medical personnel to all patients were equal and well-received by patients from all backgrounds.

Conclusion
Social protection in the form of healthcare through BPJS Kesehatan is one of the efforts of the Republic of Indonesia so that all citizens have the same opportunity to access healthcare. Military hospitals participate in realizing a welfare state by providing inclusive healthcare for them. However, in practice, they provide healthcare by incorporating hierarchical aspects. This does not align with the concept of a welfare state in the health sector, where all people should have the right to have equal opportunities to obtain healthcare regardless of their status. Unequal opportunities to get healthcare in Suar Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p-ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v11i1.2023 Original Research military hospitals were caused by the hierarchy inherent in these health institutions. Implementing social protection through BPJS Kesehatan in military-based hospitals caused patients with specific groups to experience layered exclusion. The first layer was caused by the existence of classes in BPJS Kesehatan. Meanwhile, the second layer of social exclusion in military hospitals was rooted in the inherent hierarchy of the healthcare institution itself. This was contrary to the Indonesian government's guarantee to provide fair and non-discriminatory healthcare to its people. Layered social exclusion in military hospitals resulted from the interaction between BPJS Kesehatan as the embodiment of social protection and hierarchical military-based healthcare institutions. Patients who wanted to receive healthcare at military hospitals had differences in the stages of receiving them. However, the quality of medical services doctors and other health workers which are provided was not discriminatory. Suar (Jurnal Administrasi Kesehatan Indonesia) p-ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v11i1.2023