Development of the Cesarean Section Clinical Pathway Model: Not Examining Cesarean Section Comprehensively [Response to Letter]

Dear editor

We are very pleased and highly appreciative of the criticism of our article entitled “Development of an Efficient and Effective Clinical Pathway for Caesarean Section in West Sumatra (Indonesia).” The criticism is very targeted and sharp with quite rational reasons by opening the issue of cesarean section more broadly and comprehensively associated with cesarean section services within the framework of the JKN /BPJS system. So that it opens our insights related to the problem of cesarean section services.

However, there are several important points that become the focus of discussion that we need to clarify:

First, our study stems from reports of an increasing incidence of cesarean sections in Indonesia and West Sumatra is the fifth province has highest incidence of caesarean section.¹ The increase in the incidence of cesarean section does not necessarily lead to cost efficiency nor does it increase the effectiveness of hospital services. This is due to the change in the financing system in Indonesia from a fee for services system (billing system) to a prospective payment system (package) which for hospital services is called the INA CBG’s system. Several studies found that many hospitals suffered losses due to this system after calculating the unit cost of cesarean section services.^2,3 Clinical pathway (CP) has long been recognized as a very important tool to achieve quality control (good clinical governance) and cost control (good corporate governance) in hospital services.^4–6 Therefore, we focus on developing a Clinical Pathway model for cesarean section services in an integrated manner where elements of cost evaluation (efficiency) and quality evaluation (effectiveness) are important aspects in the model developed within the framework of the INA CBGs system. Thus, geographical aspects are not our concern, let alone associated with Indonesia as a whole.

Second, related to the comparative analysis between government hospitals and private hospitals, we have conducted which is part of this study using BPJS secondary data. We have analyzed the costs and incidence of cesarean sections in government hospitals and private hospitals in West Sumatra and the article has been published in 2021 in the journal Kesehatan Masyarakat Andalas (Sinta 3). Furthermore, it can be accessed at https://doi.org/10.24893/jkma.v15i2.659

Third, as stated above that our research focuses only on developing an integrated Clinical pathway model that is effective (quality control) and efficient (cost control), so our focus is microeconomics, namely calculating unit costs and reviewing procedures/outcomes and not macroeconomics, namely aspects of health service financing policies and programs.

Fourth, sociocultural factors and patient behavior in seeking cesarean section services is an interesting phenomenon to study, but again our study did not aim to analyze this phenomenon.

We appreciate the opinions and suggestions of Mr. M Zaenul Mutaqqin and friends who look at cesarean section services more broadly and comprehensive studies are needed to provide evidence-based input for policymakers to improve maternal health services in Indonesia. We offer to discuss this matter, please feel free to send your ideas and writings to my Email [email protected].