PUSKESMAS Management Autonomy Model, Its Effect PUSKESMAS Performance (Measured by Balance Score Card)
Presenter: Atikah Adyas, Ministry of Health Republic Indonesia
Background: Insufficient resources and lack of management autonomy are problems affecting Puskesmas operation in Indonesia. This problems constraint Puskesmas to meet community expectation and led to dissatisfaction of the users. Despite intensive support from the central and provincial government to improve the Puskesmas facility as well as its management and technical capability, the improvement of Puskesmas performance still far from satisfactory. On possibility that constraint the Puskesmas to perform well has been lack of authority to response adequately to community demand as well as to capture potential opportunity derived from the demand. Therefore it is assumed that a certain degree of autonomy is necessary to improve the Puskesmas performance. It is also assumed that important element in the autonomy include (a) resource management (financial, human and facility/equipment resources), (b) authority to diversify health services rendered by the Puskesmas and (c) authority to improve its organization. With respect to measuring performance, experience in business organization demonstrated that balance scorecard is an effective method to measure the organizations performance. The use of balance scorecard in measuring health facility performance has not been recognized as far as government health facility is concern. This study also assumed that balance scorecard can also be used in measuring Puskesmas performance. To summarize, this research tried to explore the effect of specific autonomy given to Puskemas on its performance, as measured by balance scorecard performance elements.
Methodology: The research has been done in two steps. The first step is to develop autonomy model through a qualitative study participated by 34 respondents from provincial health office, district health office, district local government, local parliament members, public figure and Puskesmas staffs. This process has produced a model of Puskesmas Management Autonomy. In order to implement the model in this research, the the Head (Bupati) of the Tangerang district issued a special letter to legalized the implementation of the model. Based on this legal letter, a set of technical guideline and training were prepared and performed. It take one year to complete the first step. Subsequently, the second step is to implement the management autonomy in a quasi-experimental design, involving 2 Puskesmas (Pamulang and Serpong) as experimental grups and 2 other Puskesmas (Balaraja and Ciputat) as the control group. The selection of these Puskesmas was done purposively, based on the result of earlier assessment that the four Puskesmas are located in areas with high PDRB/capita and high Human Development Index (HDI). With this characteristic, these Puskesmas is assumed as having potential market (need and demand).
The measurement of Puskesmas performance using balance scorecard was done by interviewing 120 employees of whom 40 employees represent health service unit in the respective Puskesmas. In addition, 200 patients were also interviewed to assess their perception with respect to services given by Puskesmas. A dependent t-test has been done to find out the difference of performance before and after autonomy. An independent t-test has been done to prove experimental effect; and 4 rank likert scale was used categorized the 4 aspects of balance scorecard. Finally a linear regression analysis was performed to describe the relationship between the management autonomy and the performance change.
Research result: The participative and bottom up process has formulized a management autonomy model that consists of 3 components: (a) financial, human resources, facility, (b) organizational structure and (c) service diversification. The implementation of management autonomy in the two Puskesmas demonstrated improvement in planning, budgeting, service quality, service diversification as well as staff job description. Improvement also observed in human resources skill and overall system performance.
Evaluation after 6 months showed a significant improvement of puskesmas overall performance before and after autonomy, with a score improvement of 3.54 and SD 1,93 (alpha 5%, P = 0,021). The largest changed is in the aspect of learning and organizational growth (66, 48%). Both employee’s satisfaction and wage has been increased. Operational internal process (medical and non medical equipments and inventory) also significantly increased (alpha 5%, P 0,05). Predisposing factor of delivery services was decreased (-0,38 ,SD 0,16), however the decrease was not significant (alpha 5%, P = 0,091). The predisposing factors include training opportunity and duration of training. In contrast, there was a significant decreasing performance in the control Puskesmas ( 5,31, alpha 5%, and P = 0,00), followed by learning and organization growth aspect (-5,36) and delivery services (-0,42) (significant with alpha 5% and P = 0,026). Even though the internal operational element was increasing (0,08) it is not as much as in the experimental group.
There is no significant different in patient’s satisfaction before and after the experiment both in the experimental group and control group (alpha 5%, P 0,900 and P 0,286). However the visit rate in experimental group was increased by 2,69 during the six month period (alpha 5%, P 0,016). Visit rate in the control group was decreased by -2,58 (alpha 5%, P = 0,106). Basic six program coverage was increasing in the experimental group except for environmental sanitation program. Employee movement between facilities, imbalanced distribution and over target may the reason for this situation. In term of revenue, there is increase revenue in the experimental group (123,62 %), as well as in the control group (37,70%). The increase may also be caused by good accounting management.
T test independent showed the effect of intervention in form of significant increase of Puskesmas performance (alpha 5%, P = 0,000). The level of performance in the experimental group increased from moderate to good performance. In contrast, in control group the performance decreased from good to the moderate performance.
The study concluded that the management autonomy model that formulated through a participative and bottom up approach and legalized by the district government, is an important and necessary process in the implementation of the model. The result showed that there is an improvement in the management aspect of Puskesmas. The six month period to evaluate the effectiveness of the model is not long enough to see the impact in the community. A longer period is needed to evaluate the impact of the autonomy model comprehensively. Balanced scorecard method can be used as a tool to evaluate the performance of Puskesmas. This model can be replicated in other places but need to be adjusted.
Finally it is also concluded that the autonomy model can be used to improve puskesmas management, but firstly it has to be adjusted to the specific region potencies. Technical guidance, training and coaching is one package, they can not be separated from post test formula if the model is going to be implemented. In order to sustain the impact of the model, the legalization of puskesmas management autonomy needs to be harmonized with the other supported authorization.
Authors: Atikah Adyas
Room: No.3 Hall