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IMPLEMENTATION OF PROGRAM EVALUATION MANAGEMENT HEALTH CENTER AND THE TISSUE JAMKESMAS IN SORONG REGENCY YEAR 2009
Thesis Summary

Submitted by : ALI DAENG PRATTY Reg. No.: 09/293492/PKU/11003

To POSTGRADUATE PROGRAM FACULTY OF MEDICINE GADJAH MADA UNIVERSITY

YOGYAKARTA 2011

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IMPLEMENTATION OF PROGRAM EVALUATION MANAGEMENT HEALTH CENTER AND THE TISSUE JAMKESMAS IN SORONG REGENCY YEAR 2009 EVALUASI PELAKSANAAN MANAJEMEN PROGRAM JAMKESMAS PADA PUSKESMAS DAN JARINGANNYA DI KABUPATEN SORONG TAHUN 2009 Ali Daeng Pratty1, Laksono Trisnantoro2, Retna Siwi Padmawati2 ABSTRACT Background: Social health insurance (Jamkesmas) was one program for the poor to access healthcare services. The implementation of the Jamkesmas program in Sorong District has still been facing many obstacles, especially in the field and its operational management. It was clearly observed that in some areas of the healthcare services, the indicators of successes have not been met. Objective: The study aimed at evaluating the management of the Jamkesmas program from the aspects of the beneficiaries and the finance of the public health center (Puskesmas) and their network in Sorong District in 2009. Method: The study was qualitative and descriptive with case study design. The subjects were all of the implementers of the Jamkesmas program of PT. Askes (Persero), district management team and the head of public health centers and their networks. The informants were recruited using purposive sampling technique. Results: The study showed that the determination of the poor did not meet the criteria of BPS. The local government did not collect their own data of those in poverty as the beneficiaries of the Jamkesmas, hence the cards has distributed to the wrong target. Of the 6,742 Jamkesmas cards, 20,34%, did not meet the criteria and should be resent to the office of PT. Askes (Persero) of Sorong Branch. Conclusion: Local governments should establish a special team for the completion of public complaints, the validation of a new beneficaries database, as well as put some budget for Jamkesda if funds are insufficient in Jamkesmas. Key words: valuation, jamkesmas, people determination, beneficiaries
1 Sorong Regency Health Office 2 Graduate Program Policy and Health Services Management, Faculty of

Medicine, University of Gadjah Mada University, Yogyakarta

INTRODUCTION Everyone has right to get health service as stated in 2009 Health Act no. 38, section 5 article 2. It is stated that everyone has right to get safe, quality and affordable health service. An awareness on the importance of social protection assurance continue to develop appropriately to the mandate of the change of 1945 Constitution, Section 34 article 2. It is stated that the state develops social inssurance system for all Indonesian people. By entering Social Assurance System into the changing of 1945 Constitution, and the issue of 2004 Act No. 40 on National Social Assurance System, it is a valid prove that the government and stakeholders have really commited to embodying the social welfare for all people. The implementation of health service insurance for people is using social health insurance principle. The implementation of Jamkesmas Program (Public Health Assurance) according to the implementation principles at national wide was non profit, portability, transparence, efficient and effective. The implementation of Jamkesmas program is an effort to maintain the sustainability of health service for the poor and disadvantage, which at this time, is a transition period until it could be transferred to the social assurance administration board. Jamkesmas program in 2009 was implemented by several improvements at participation (membership) aspect, services, funding and organizing. Determination of the poor at Sorong Regency was rather different compared to the other region, wherein the determination of the poor was based on several considerations such as the district with radius 20 km, people without regular occupation and community at remote area. This policy was taken by the regional government based on consideration that the public can not finance yet their health because generally the public lived at village with employment as peasant, fisherman, daily labor, and many of them had no regular employment.

Several obstacles that faced by Public Health Center in implementing jamkesmas program among other was the membership (participation). The database of jamkesmas member until now still referred to 2005 macro data and was determined without by name by address. In Sorong Regency, the health service available was still insufficient. Out of 17 public health centers, only two which have inpatient rooms, whereas transportation vehicle for patient referral was also limited, even many public health center had no transportation vehicle for patients referral such as automobile and, motorcycle, and ambulatory public health center. In other hand the fund for public health center to implement the activities was oftenly received late. To increase the quality and affordable health services, the support of infrastructure and human resources are needed. The ratio of health workers that worked in the local government has been lacking, especially the number of technical workers both medical and non medical persons, such as physician, nurse, midwife, and other health workers.

METHODS This research was descriptive qualitative and using case study design. This study described situation or phenomenon comprehensively in the actual context (Dahigreen et al., 2004). To achieve the objectives, the author used purposive sampling method and in depth interview and observation or direct observation to collect data. The subject of the study was all subjects who involved in implementation of jamkesmas program at Sorong Regency both the administration team at regency level and administration team at public health center and their network. Considering that the subject of the study was too many, therefore the author obtained the sample by purposive sampling method based on the knowledge of the respondents on desired information (Sugiono, 2010).

RESULTS The data on participant of jamkesmas that owned by Askes Inc was data in the form of list of name, age and address of each participant. Those name list by Askes Inc. was already printed out their member card as much as 34,398 and those card was already distributed by Askes through village office at each Public Health Center. But after observation and in depth interview to several respondents, actually part of that name list did not match to the reality. There were many errors in determining the participant of Jamkesmas, as it was also covering the wealthy people, the high rank officials, migrated people, the deceased, civil servant and so on. From this study, there were several problems related to the determination of criterion for the poor wherein still be problem related to the number of jamkesmas participant that was established by the regional government. In this respect, it was The Decision Letter of the Regent No. 66 in 29 February 2008 on determination of the data on the jamkesmas program targeted poor in Sorong Regency in 2008. The problem was not utilizing the criterion as stated above. Out of 14 determined criterions none was used to determining the poor in Sorong Regency. The result from not implementing the assessment to determining the poor therefore would result in many errors in determining the jamkesmas participant in the field. Data from this study showed that many wealthy people, deceased people or migrated people, name of non local citizen, address error, civil servant, even official, was recorded as participants, and their names were listed at the list of jamkesmas participant chart recipient. The Askes office had also not been performing data logging appropriately to the mechanism, because the Askes office considered the sent data by Pemda (Regional Government) as data that had already being selected through data logging mechanism as determined in implementation guideline of jamkesmas. The intended mechanism was data logging mechanism begin from RT/RW (household union level/

citizenship union), village, and district to regional government. The administration of the health service in Jamkesmas Program at Public Health Center and their network covering all age group, all kind of basic health service and referral service as well as complaint management from the public about Jamkesmas. The management of health service that was intended in this study was how the form of health service that was already rendered by health service provider especially Public Health Center and their network to the poor as jamkesmas participant in 2009. The intended health service was health service related to the provided service package, how the implementation of referral system at advance level, how much the utilization of health service by the poor provided by Public Health Center and their network, and how the handling of complaint from jamkesmas participant to the provided health service. The data that was obtained from this study showed that the providing of health service package by Public Health Center and their network in order to provide a service to the poor as jamkesmas participant at Sorong Regency in 2009, actually implemented all form of basic services such as first level outpatient service, advanced level of inpatient service, provide medicine (drug), labor management, preventive service such as immunization, malaria examination, maternal and child health, family planning, ambulatory services from Public Health Center, even the Public Health Center also performing prime service that was service for 24 hours. The basic health service and labor management provided by Public Health Center was also provided by their network under their work area such as pustu (auxiliary Public Health Center), polindes (Village maternity clinic and posmaldes even can be performed simultaneously with the activity. Health service utilization by the poor was very high at each Public Health Center, and the highest was at Kalfdalim Public Health Center

(290%) and the least was at Aimas Public Health Center (97%). In general, the utilization of Public Health Center by the public had achieved 112%. This showed that the public awareness of health service provided by Public Health Center was high and those services had fulfill their need. The fund for Jamkesmas program for Public Health Center and their network in Sorong Regency in 2009 originated from Central Government budget from Ditjen Bina Kesehatan Masyarakat (General Director of Public Health Building) for 2009 No. 0675.0/024-03.0/-/2008. The fund allocation for Jamkesmas program in 2009 for Sorong Regency was Rp 739,260,000,-. This fund was sent through Sorong Branch Post Office. The head of health office of Sorong Regency issued Decision Letter No. 848/0462 in 25 May 2009 on fund allocation for jamkesmas program for Public Health Center trough Sorong Regency. The used fund must be accounted by Public Health Center appropriate to the fund utilization for each activity and it will be liquefied the fund for second stage.

DISCUSSION Evaluation of Jamkesmas program was one of the management activities which has been performed to evaluate the health maintenance assurance program in this respect of jamkesmas (public health assurance). Evaluation on Jamkesmas program at Public Health Center and their network was an evaluation that was performed to know the success achieved by the program in any period and what barrier or obstacles that were faced during program implementation. In this evaluation, the evaluation on several variables that had influenced the success of jamkesmas program among others, as well as evaluation on participation (membership) management, service management and administrative and financial management were found. The government of Sorong Regency, from 2009 tuntil now had not performed yet on the up-dating the data of jamkesmas participants. The problem emerged because the implementation of management of

jamkesmas participants at Public Health Center and their network did not match or miss target. These had become main problem in this study. Based on interview and obtained quantitative data, there was 6,742 (20.34%) participant which was miss target or in other words was not the condition that must be assured by Jamkesmas. Study at 4 Public Health Center showed that the number of Jamkesmas participant which was listed and had a card that was printed by Askes Inc. and was distributed through village office at each work area of Public Health Center was 36,708 people. Whereas many of a member card that was distributed was not target appropriate or not appropriate to the criterion of the poor and not matched of name and address. The member card that was not target appropriate or miss target will be returned by the village head to the Askes Inc. The returning with the hope that card can be replaced by the poor who were not registered and had jamkesmas card yet. But until now this was not performed yet. The determination of the poor at Sorong Regency can not be assessed by 14 criterions set by Badan Pusat Statistic (Statistic Central Board). The data of participant from the poor that was used by Askes Inc. in 2009 was data that was obtained from the result of population census in 2007 by regional government, that data was not checked again appropriate to the prevailing regulation. Data on the poor which owned by regional government and Askes Inc. was data that was established by Regent by Decision Letter no. 66 at 29 February 2008. This study showed that the data logging mechanism of the poor at Sorong Regency was not performed both by the regional government and Askes Inc as a caretaker of the management of jamkesmas. The government never performing data logging to determine the poor appropriate to the regulation from Statistic Center Board that is to determine the poor household should be listed by established team to be used as a jamkesmas participant data. Data on the poor that was owned by regional government and Askes office was data in the form of by name

by address but the data was not obtained by any data logging procedure appropriate to the regulation that was determined by the government in national wide. The health service package that was provided by the Public Health Center to the poor almost even at all Public Health Center. Generally the service package delivered by the Public Health Center and their network was outpatient basic health service such as general medicine, health examination and health consultation, dental health service include teeth withdrawal, emergency management, pregnancy examination, basic and complete immunization, blood examination for malaria, family planning service, and labor service by health workers. Analysis in this study showed that utilization of health service at Public Health Center and their network by the poor was very high as shown by visiting number by the public to get health service at 4 Public Health Center was very high in 2009. Quantitative data showed that the average of visiting number for outpatient was above 100% even in one Public Health Center. Klafdalim Public Health Center the visiting number achieved 290% for outpatient service. The implementation of referral at advance service at Sorong Regency has not showed significant increase as shown by tabulation of referral service to Class C general hospital at Sorong Regency in 2009 was 0.35%. This because the average of the sufferer that attended the Public Health Center was the patient with mild illness such as malaria, upper respiratory infection and other annual disease. Therefore the case management was not too heavy and can be handled by Public Health Center without referral, except for severe incident that need to be referred to the higher health service facilities or hospital. Each patient that was referred would immediately be transported by ambulance automobile owned by Public Health Center because all four Public Health Center therefore facilitate the mechanism and procedure of referral.

The number of Jamkesmas fund in 2009 for Sorong Regency was Rp 739,260,000,- whereas the fund for 4 Public Health Center was 384,216,000,with detail for Airmas Public Health Center was

180,000,000,-; for Klafdalim Public Health Center was 52,639,000,-; for Majaran Public Health Center was Rp 96,493,000,- and for Mayamuk Public Health Center was Rp 55,084,000,- and these fund was liquefied by Public Health Center through PT Pos Indonesia from each Public Health Center in two stages, in the first stage was liquefied at early program implementation and second stages at the mid of program implementation that was showed by the accountable prove of the fund utilization at first stage. Whereas the fund allocation for health assurance for the poor at Sorong Regency only sourced from APBN (State Expenditure and Revenue Budget) with DIPA from Secretariat of General Director of Public Health Development for 2009 budget year No. 0675.0/024-03.0/-/2008. The amount of fund that was allocated for 4 Public Health Center, based on interview to the respondent, all of them stated that the fund that was owned not sufficient to cover the activity at Public Health Center, because the 2009 budget for all Public Health Center sourced from one source that was the fund for Jamkesmas program and from other source was not provided.

CONCLUSION The conclusion can be drawn from three aspects as follow: Membership (participation) aspect 1. Implementation of determination of jamkesmas participant in 2009 at Sorong Regency was not met the target that was about 6,742 poor people was not ascertained as jamkesmas participant. 2. The determination of Jamkesmas participant at Sorong Regency in 2009 was not performed through data logging mechanism and did not match the criterion that was established by Health Ministry and Central Statistic Center Bureau.

Service aspect 1. Utilization of health service by the poor at Public Health Center and their network in 2009 at Sorong Regency was 112%. 2. Health service package from jamkesmas program that was provided by Public Health Center had already appropriated to the standard and guideline which attached in technical guidelines of jamkesmas program implementation at Public Health Center and their network. 3. Implementation of referral service from Public Health Center to the higher level appropriated to the prevailed mechanism and procedure. 4. The mechanism and procedure of management of community complaint on jamkesmas program implementation did not follow the procedure and not transparence.

Financing aspect 1. The amount and allocation of Jamkesmas fund for Public Health Center and their network in 2009 at Sorong Regency was 42.69%. This fund not covered yet the need to financing all jamkesmas program. 2. The payment mechanism and claim procedure of Jamkesmas fund at Public Health Center and their network not appropriated yet to the regulation, based on the guidance from the head of Public Health Center is provided as service payment.

RECOMMENDATION 1. Regional government and Askes Inc. was expected to performing validation of data on membership (participant) by establishing a cross agency office coordination team (coordinated with village office and Public Health Center) to establish the criterion and performing data logging on the poor appropriate to the procedure, to obtained database of the new jamkesmas participant in 2011. Therefore the poor which not have yet jamkesmas card can immediately be listed and printed their jamkesmas participation card.

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2. It was advisable that the regional government quickly prepares the infrastructure for payment tariff of jamkesmas fund at each program, take form as regional fee. 3. Regional government, Askes Inc., and Health Office need to quickly set a special team to tackling the problem related to the management implementation of jamkesmas program and tackling the communitys complaint.

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