Abstract: Background: According to the mandate of Indonesian Constitution 1945 and decentralization law, one of the obligatory affairs of the district government is health sector. To ensure that all people are covered with health services then the policy about Minimum Standard Service (MSS) in health affairs was issued. Objective: This study aimed to investigate the implementation of MSS in health affairs of Enrekang from 2013-2015. Materials and Methods: This study was cross sectional by using quantitative and qualitative approach. Implementation measured was determined by analysis of budget supporting, the achievement of indicators and public satisfaction. The primary data, constraints of implementation, was observed in this study, while the secondary data collected were district characteristics and 22 indicators of MSS. A total of 8 key informants were interviewed including the head of the health office, divisions in health office and Puskesmas as well as patients in Puskesmas and the local hospital. Selection of informants used snowball sampling. Results: This study indicated that the budget allocation is still low (less than 10%). Achievements in implementation of MSS policy decreased from 40.9% (2013) to 31.8% (2015). In 2015, the lowest achievement was referral health services, while the highest was health promotion (32 vs. 100%). There are several constraints experienced, particularly the difficulties to understand the guidelines and incompatibility of data management with the guidelines. However, people are satisfied with the services obtained. Conclusion: It is concluded that the implementation of MSS in health affairs might be influenced comprehensively such as, different perception of health workers in understanding the indicators, budget supporting and the number of human resources. The public satisfaction was independent and it is strongly related to the cost of services.
INTRODUCTION
Based on the government regulation of Republic Indonesia, the Minimum Service Standard (MSS) is a provision of the type and quality of basic services. It is a minimal obligatory function provided by government to all citizens1. In addition, to achieve the concept of good governance, Indonesia has been implementing a system of regional autonomy so that all the obligatory functions and authority to carry out that function has been delegated to the local governments. Therefore, to minimize variations in the implementation process of these affairs and to ensure all people get the minimum service, then the application of minimum service standards need to be considered at once to increase the target of universal health coverages targeted by Indonesian government2. The health sector is one of the obligatory functions of local government that gets a large proportion in budgeting. The legal basis for the implementation of MSS is the Regulation of Health Minister of Republic Indonesia number 741 year 2008 and the Decree of Health Minister number 828 year 2008. These regulations are concerning the Minimum Service Standards in health affairs for the regency/city and the Technical Guidelines of Minimum Service Standards in health affairs of the regency/city, respectively. The successful implementation of MSS in the health sector can be an assessment of the public service performance in the health sector2.
Public Health Development Index (PHDI) in 2013 reported that South Sulawesi was ranked 20 out of 34 of provinces in Indonesia3. It means that the achievement in the health sector of this province still needs to be optimized. One area contributing enough to PHDI for South Sulawesi Province was Enrekang Regency in which this regency is ranked 113 out of the 497 regency/cities in Indonesia. However, these achievements need to be maintained or even improved due to Enrekang Regency was the top 5 regency/cities in South Sulawesi with the highest number of poor population (15.11%)4. According to WHO recommendation, the health service utilization for poor people is included as the primary healthcare concept. Therefore, the healthcare should be universally available and accessible without any constraint in delivery. Thus, it is very important to do mature planning in order to ensure they receive good quality service based on the guidelines5,6.
Basically, the implementation of every single policy should be encouraged in order to implement the good governance. But, the differences of the situation in each regency can be an enabling factor influencing the policy implementation7. However, in every public policy implementation, the government should follow properly the set instruction or technical guideline which available so that the inhibiting factor could be minimized8. Rationalization of MSS in health affairs implementation is a guarantee of health care for all people in community and as a measuring tool to assess the public services performance of Health Office. Furthermore, to measure the performance, it is necessary to evaluate the implementation of MSS in health sector periodically. Performance measurement is intended to achieve the goals and provide the relevant information for the policy makers. Furthermore, the performance measurement is indeed a necessity in order to improve the quality of the health services in the future9. The construction of some performance indicators in the public sector is a difficult task because not all goals are measurable. Therefore, the government sets the standards that measurable to assess the performance of the public sector10.
Measuring the performance of health services periodically signifies that health services are very dynamic. It is no longer sufficient to put the outcome alone as the representative of the performance. The patient satisfaction is becoming important aspect in health services11. Therefore, in evaluation of the policy implementation, multidimensional aspect such as policy inputs, performance outcomes and people satisfactions should be measured. The objective of the study was to evaluate the achievement of the health services performance and to analyze the implementation of MSS in health affairs of Enrekang Regency within 3 years from 2013-2015.
MATERIALS AND METHODS
In this study cross sectional design with concurrent embedded mixed method was used12. Quantitative approach aimed to collect primary and secondary data. Primary data such as indicator of MSS achievement while secondary data is budget allocation. These data were collected using interviews and document observation. Interviews to collect primary data were performed on 12 heads of Puskesmas in Enrekang Regency or representative officials. The method to get the sample was purposive sampling. Document observation is conducted by requesting permission from the head of finance at Enrekang Regency Health Office to collect secondary data. Total of 22 indicators of MSS in health affairs, based on the Regulation of Minister of Health Number 741 year 2008, was evaluated. Coverage of evaluation includes the financial, management and facilities aspects as well as the achievement of all MSS indicators from year 2013-2015.
The qualitative approach was to collect also the primary and secondary data. Primary data include the constraints and level of public satisfaction of MSS policy implementation, while secondary data includes the flow/pathway of data management. Primary data were obtained through in-depth interviews to the Health Office division for implementation barrier. Furthermore, the people satisfaction, the indicators of impact measurement of the policy implementation, was obtained qualitatively by interview to the patients from Puskesmas and local government hospital. Secondary data was obtained through document observation in planning department of Health Office. The informants is selected by purposive sampling to measure the level of public satisfaction. The analysis of policy implementation in health affairs MSS of Enrekang conducted from May-August, 2016.
Interview: An interview to the key informant aimed to explore and investigate the context of the process and the output of policy implementation of MSS. A total of 8 key informants was interviewed in depth for this study. Sample size of key informants selected to be interviewed are at least 6-12 for the data to be reliable13. The key informants were the head of HO, the chief of division in HO and the head of Puskesmas. In addition, society as informants is to gauge the level of satisfaction for health services delivered by Enrekang Regency government. Selection of key informants was conducted by the snowball sampling technique that starts from the chief of Health Office of Enrekang District as the primary informant.
Document review: The document review was conducted to evaluate the budget allocation for health service performance in the last 3 years. In addition, the primary data and the data based on documents from Health Office are compared to confirm the indicator achievement. The head of HO was asked in related to the sources of document. Some documents collected include health profile of Enrekang Regency year 2013 until 2015 from the Planning Division and budget usage report from Financial Division of HO. The data were obtained from 12 Puskesmas and LGH. Data processing based on such documents was done by comparing to the technical instruction of MSS in health affairs.
Data analysis: The quantitative data were presented using the form of tables and graphs. The percentage was computed for some variables such as budget allocation and the achievement of MSS indicators. The qualitative data were analyzed using a deductive approach.
RESULTS AND DISCUSSION
Characteristics: The profile of Enrekang district can be seen in Table 1. The number of Puskesmas was 13 while 12 of those have been able to serve hospitalization. With regard to increase accessibility, the government of Enrekang Regency has two local hospitals, 55 village health posts (Poskesdes) spread throughout the village and followed by 301 integrated health centers (Posyandu). The proportion of children under 5 compare to population was 8.06% while 23.52% of them are infant (0-11 months).
Resources: The implementation process of MSS in health affairs covers three stages: Planning (preparation and dissemination), implementation, monitoring and evaluation. The important parts of the planning are resources and budget allocation. The number of health workers in Enrekang Regency were still less than expected (Table 2). There are only 31 medical doctors distributed in 129 villages from 12 districts to cover 198.194 inhabitants.
| Table 1: | Characteristic of Enrekang district in 2016 |
| Table 2: | Number of health workers in Enrekang district in 2016 |
It made the ratio of medical doctors per population reached 1:6.393. Health workers is needed to run a public policy related to health. Lack of health workers in both quality and quantity can cause the problem in health service delivery. For instance, the current study found that the ratio of medical doctors per population was not ideal especially if compared to the ratio in Java which was only 1:3,000 inhabitants. Currently, most of the rural or remote areas face the lack health workers crisis such as medical doctors, midwives, nurses, nutritionists and sanitarians. They tend to reject to stay in those areas due to the lack of entertainments and basic need facilities, low salaries and incentives from the local government. The other reason is also due to unsafe conditions in which they are assigned. So, potentially they provide not enough services with a short duration of time14.
The successful implementation continuously of the policy requires inputs, one of which is the financial aspect7. In fact, the obstacle factor in policy implementation is budget allocation set out from the regional budgetary plan (APBD). Current study found that the budget for health sector was lacking within last 3 years (2013-2015) as indicated in Fig. 1. The budgeting process should be internalized and integrated in planning and budgeting mechanisms. The percentage of budgeting was reduced from 6.83% in 2013 to 6.65% in 2015 although it was increased in from 2014-2015 about 0.32%. According to the informants, which could be seen in Table 3, the budgetary factor causes delay in the implementation of government health programs in Enrekang Regency. However, Health Operational Fund (BOK) greatly helped the implementation of MSS in health affairs. The BOK sourced from the National Budget (APBN) acted as the funding to implement the program tasks from Ministry of Health in regency/regional level, especially for operationalization of Puskesmas (a.2).
| Fig. 1: | Percentage allocation of health sector budgeting in Enrekang district within last 3 years |
| Table 3: | Interview scripts of key informants |
The financial aspect evaluation to support MSS policy implementation shows that the allocation in health affairs has been integrated with Regional Mid Term Development Plan (RPJMD) and therefore it was included in the proposed budget fiscal in each year. Financial aspect is crucial to influence the process of a policy7. In the other words, the integration of MSS into RPJMD, as a basis for strategic planning of Regional Work Unit (SKPD) is supposed to be prioritizing the funding for MSS in health affairs achievement in Enrekang Regency. A financial source as input for policy implementation is derived from the regional budget (APBD), so the budget given each year depends on the financial condition of the regency. According to the Health Ministry's strategic objectives, the budget allocation for the health sector in the district level should be 10% from the total regional budget per year.
Data managements: Data and information management of MSS in health affairs should be like what was described in Fig. 2. According to the technical guideline of MSS in health affairs, the pathway of data management supposes from primary unit of health service provider (Puskesmas, local hospital, private practice and other government units) and to Health Office. However, the data management in health affairs of Enrekang Regency was not fully in accordance with the guideline. Based on the observation, the clinic of treatment and private/individual practice were not covered by the system while public health center (Puskesmas), district hospitals and government (BUMN) health units have already connected. All data collected by Health Office would be forwarded automatically to the online National Health System (SIKNAS). Furthermore, the results are submitted to the head of regency (Bupati) and superior of Health Office (provincial level).
Although technical guideline has been applied but only performed by Puskesmas and hospital. The reports from all Puskesmas in Enrekang Regency were collected by Health Office each 3 months then it was delivered annually to SIKNAS at once in order to make a health profile book every year. In addition, the incoming data is also the subject of evaluation and consideration for the next year planning. Therefore, the accuracy in data management is strongly necessary in supporting health service right on the target and effective15.
Even after the procedure of data management has been justified with technical guideline, the way in data calculation is still be a problem. The main constraint found in this study was inconsistency between the data in Puskesmas, field division of Health Office and planning division of Health Office. Based on the investigation conducted, it was constituted by different perception to calculate the MSS indicators. Even though the technical guideline of MSS has been published since 2008, the health officers still have different perception (b.1, b.2). Different perception in calculation obviously contributes to different results of indicator achievement. Major cause of this problem is the calculation done manually instead of using database or online-based system. A study concludes that healthcare data management using database was very helpful in planning administration in order to improve the quality of health services management of the institution16. The use of information systems should be accompanied by training or mentoring for health workers in the Health Office, Puskesmas, local hospitals and other primary care units. Good human resources will ensure good quality health services also included good in the management of health service system17.
A theory explains that the policy implementation can be driven successfully by the ability to adapt with the prevailing circumstance7.
| Fig. 2: | Data and information management of MSS in health sector |
In the era where the knowledge has been advanced, information and management systems will greatly help to provide data valid and reliable. It was at once made the national database will be able to describe precisely the condition of Indonesian people representatively.
Achievements: In the context of good governance, indicators used as benchmarks for excellent services performance are effectiveness, efficiency, transparency, responsiveness, responsibility and accountability in providing services18. The evaluation of the public services performance is also one attempt to show the value of accountability to the community. In determining the achievement of the public service performance, the synchronization between the goals, resources and outputs including budget planning is required10. In order to measure the success of policy implementation and service delivery performance, quality of services and the achievements (output) as well as the efficiency and effectiveness of the services should be measured.
The current study found that, among 3 years, the achievement in 2015 was the lowest compared to others. Achievement of MSS indicators in health affairs of Enrekang Regency within last 3 years (2013-2015) has decreased from 40.9% to only 31.8% of indicators achieved, as shown in Fig. 3. Accordingly, the achievement in 2013 and 2014 was equally while a decline occurred in 2015 were 40.9, 40.9 and 31.8%, respectively. Furthermore, this study also compared the achievement in last year (2015) to the national level and then the result is presented in Fig. 4. There were only 7 indicators reached the national targets. In general, from 22 indicators, indicator 13b (pneumonia case for toddlers detection) and indicator 15 (referral service for poor patient) had the lowest achievement: 2.95 and 13.13%, respectively.
All of indicators were grouped based on the type of health service (Fig. 5). The lowest achievement occurred in health care referrals domain, even it showed a positive trend from 2013-2015 (1 and 30%, respectively). However, health promotion and community empowerment services has met all targets (100%). Basic health services domain shows fluctuation result, declined for 12% from 2013-2014 and raised up to 14% (2014-2015). The MSS achievement acts as the description of MSS policy process included in either on or off track achievement. The declining result from the current study is suspected because of the financial factor and different perception. The variation on perception may result under or over-estimation of indicator calculation. According to some studies, the factors affecting the health policy implementation are capacity of the leader, effective multi sectorality, cooperation in the overall level of activity, knowledge and awareness as well as conflict19. Motivation of the health workers relating to the capacity to which the policy contribute to their goals affects implementation. Therefore, the motivation is one of the important aspects to be measured to help the leaders put the correct people as implementers. In addition, other factors also play important role in successful policy implementation, such as information, power and interaction20.
| Fig. 3: | Achieved indicators of MSS in Enrekang district within last 3 years |
Fig. 4: |
MSS indicators achievements of Enrekang district in 2015 |
| Fig. 5: | MSS indicator achievements based on type of services in Enrekang district within last 3 years |
The findings of public satisfaction, as shown in Table 3, indicate positive responses. Most people feel satisfied with the health services obtained mainly in terms of the health worker competencies in Puskesmas and hospital. However, few people claimed that the services provided by health workers were less hospitable (c.1, c.2). In addition, there are several respondents who believed that they lacked in quantity, especially for specialist doctors at the hospital (c.3). For the facility and infrastructure, the people confessed of being satisfied with the services by Puskesmas and hospital. They are likely to feel comfortable and safe coming here to receive medical care (c.4, c.5). The cost aspect of health care is also satisfactory, both in Puskesmas and hospital. Most people who receive health services in primary health centers were satisfied with the suitability between the service price and the advantages afforded (c.6, c.7, c.8, c.9).
The implementation goal of MSS in health affairs is to provide the optimal services to the people. The optimal service will result in the satisfaction and give the benefit to the public health. Therefore the health service managers should focus to achieve this targets21. Satisfaction also can be used as good governance indicators. There are several indicators to be used to assess the public satisfaction for health services such as the attitude, hospitality and competency of the health workers, facility and infrastructure and service cost. The interpersonal skill in terms of knowledge, attention of care, emotional condition, attitude of respectfulness and mutual understanding to the patients are influential factors on patient’s satisfaction21,22.
CONCLUSION
Based on the evaluation of the implementation of Minimum Service Standard (MSS) policy in Enrekang Regency, the performance of health services was decreased. This is likely influenced by the input factors provided by the government. The inputs are budget and health personnel resources. To achieve the optimal output, then the input should be well-planned and the implementation process should be monitored properly. Thus, the regional head (Bupati) and program holder must understand and concentrate on the importance of these factors in the implementing process of MSS policy to the community.
SIGNIFICANCE STATEMENTS
The finding of the this study will increase the awareness of the local government, as the policy implementers, to concern about the implementation process of public policy including Minimum Service Standard (MSS). The government should focus on the input constraints such as budget and human resource limitation such as the finding of this study. Thus, the government could increase the public health services by strengthening these inputs of the public policy. For the community, definitely by strengthening the health service in applying the minimum service standard, it did not only increase the public satisfaction but also contributes to the health outcome which can be measured by the index of public health development. Thus, this is an opportunity for researchers to develop capacity building instruments for health workers.