Learning about Kaltim

• 4 Cities, 5 Kabupaten
• 12 Puskesmas
• 2 Pusban, 1 Puskam, 1 Polindes
• 3 hospitals

• Kira kira 4000 Km by road

 Terima Kasih
• Secretary for Population Welfare, Kaltim
• Head, Provincial Department of Health
• Heads, District Departments of Health
• Doctors, Nurses, Bidan and other medical staff
• Kepala puskesmas and other Puskesmas staff
• Patients, Community member, Posyandu Staff, dukuns, pregnant
• Staff at hospitals
• Mayor/Wakil Bupati
• Colleagues from Trisakti University
• Patients at puskesmas
• Mothers and Pregnant women
• Community members
• Special thanks to Ibu Ita & to the staff at all cities and puskesmas
who helped me with English-Bahasa Indonesia translation
 Family Doctor Program Objective

• to provide holistic care focusing on environmental,

behavioral, socioeconomic and biological determinants of
diseases.
• to improve access to primary care
• To allow Puskesmas to focus on prevention and promotion
 Family Doctor - Clinics

• 8 clinics, 20 Dokter Umum, 13 dr gigi, 12 bidans, 20 perawat,

13 dental health nurses/assistants, 16 apotek assistants, 2 lab
technicians and 35 admin staff.
• Each clinic has about 3-4 doctors, 2 dentists, 2 nurses, and 1
to 2 midwives.
• In theory, each doctor responsible for 3000-4000 people
(about 600 to 800 families)
 Review TOR

– Utilization of curative primary care services

– Comprehensiveness (curative, preventive, promotive)
– Quality: effectiveness, referrals, follow ups
– Contribution to disease prevention through Health
education and health promotion
– improved community based and population wide
preventive and promotive services through puskesmas
and posyandu resulting in decrease morbidity and
mortality and improved health status
•
 Method
• Review of documents: Family Doctor Program plan, Jamkesda report and
profile of the Program, Family Doctor training manual, Dinkes annual
reports , Puskesmas and Family Doctor program data and report,
Literature on the concept of ‘Family Doctor’

• Meetings: Bontang City Department of Health Head and other Officials,

staff of Dinkes Bontang, Jamkesda staff, staff of Puskesmas Selatan and
Puskesmas Utara, Family Doctor program doctors and clinic coordinators,
community representatives, Bontang Hospital Staff

• Exit Interviews with 80 patients attending Family Doctor clinics

• Visits to Family Doctors clinics and Puskesmas
 Strengths

• Commitment by the city government

• Access to curative care for Jamkesmas & Jamkesda patients
• Being a CITY provided an opportunity to place clinics across
the city in addition to having puskesmas (This may not be
possible in Kabupaten.
• Location of clinics across the city
• 138000 consultations !
 Comparison - Before & After DK
2006 2010
• Population of Bontang 125817 174000
• Consultations at puskesmas 131547 7200
• Consultations at FD ............ 138000
• ANC K4 (2885/3124)90% (3482/3730)93%
• Number of births in Bontang 2851 (22/1000) 3415
• Immunisations rate Bayi <1 100% 100%
• Child (<5) malnutrition reported 1.35% 2%
• Neonatal deaths reported 4.2/1000 5.6/1000
• Maternal deaths reported 3 /2851 2/3415
• Exclusive Breast Feeding 35.2% (4 months) 22.4% (6 months)
• Contraception Prevalence Rate ???? ????
• Dengue fever reported 200 189
• Malaria Incidence (puskesmas data) 4.9/1000 0.03/1000 ?
 Puskesmas Effectiveness
• Currently progress is not visible with regard to behaviour change,
decrease in infectious diseases, maternal health.

• Data flow and data accuracy issues causing difficulties to initiate

appropriate and timely preventive actions.

• Fewer patients at puskesmas mean fewer opportunities to work

with patients for prevention and promotion.

• As Bidan, Doctors, Dentists at Puskesmas cannot provide curative

care this has lead to some decrease in provider-community
relationship.
 Organisational Issues

• limited interaction between family doctor program and

community based preventive and promotive program of
puskesmas
• Lack of clarity of roles in terms of prevention and promotion
(? targets
• Salary disparities causing further gulf
• Curative care for national priorities communicable diseases
such as TB, Malaria, and Leprosy still with Puskesmas.
 Family Doctor Effectiveness

• About 97575 eligible members.

• About 138000 visits
• most of the illnesses for which majority of people use these
clinics are minor illnesses.
• The focus is on curative care – holistic care focus not visile yet
 Whether patient was informed about the diagnosis
40

35

30

25

20
Whether patient was informed
about the diagnosis
15

10

0
Cause of the Not Informed Diagnosis Info about
symptoms progress
 Information/Education about the disease
40

35

30

25

20

15
Information/Education about
the disease
10

0
 Suggestions by patients
30

25

20

15

10

Suggestions by patients
5

0
 FD – holistic care

• Curative workload: Each doctor sees about 20 patients in a

shift and generally consultations last only 5 to 7 minutes, the
scope of preventive work & education is quite limited

• Limited outreach two or a few visits by each doctors in a

month. Doctors are paid incentive payments for making two
visits. Effectiveness of visits is limited because of lack of clarity
about what is the objective of these visits and how they
contribute towards improving the health status of the family.
 Dokter Keluarga - integrated care

• Referrals from and to family doctors. So far there is little

interaction between FD program and hospital to improve the
referral system.

• If a patient on Jamkesmas is seen by FD clinic, he/she needs to

get the document stamped by the puskesmas before he/she
would be admitted to the hospital.
 Recommendation - Organisation

– Primary care clinics should report to the Regional Health

Services Coordinator, who should be head of regional
puskesmas as well (community based prevention and
promotion and population wide public health initiatives).
– A finance department at DINKES should be responsible for
all budgeting related management including funding from
Jamkesda, Jamkesmas and other funding sources.
– The finance department and/or Jamkesda staff should not
be responsible for managing the health services (which is
the responsibility of Health Services section).
 Kepala Dinkes

Admin & Human Med Equipment, Finance Health Services & Health Management
Resource pharmacy Information System
& Insurance Health Development

Regional Health Services Regional Health Services Regional Health Services

Bontang Utara Bontang Barat Bontang Selatan

Public Health Primary Health Care

Communicable Medical Services

Good quality holistic care
Disease Control (Family Doctors) including prevention and
health promotion focus
Mass Media

Health Promoting Policies Centre-based

Environmental preventive services National CD Priorities

Health Nutrition

Immunization

Contraception

Med Ser Haji

Community-based

Prevention & Promotion Gizi

MCH

Elderly Hlth

School Hlth

Posyandu
 Recommendation - Organisation

– Remove the disparity between salary/remuneration. (At

present the difference is not justified considering the input
and quality of output. The additional benefits, beyond equal
base salary, should be tied to clear targets in terms of
service quantity and quality of care of providers who are not
permanent staff of Dinkes.
– In order to serve the purpose of achieving the goal of
establishing a ‘health maintenance organisation’ and
purchaser provider separation, Dinkes may like to consider
establishing a planning section directly under Kepala Dinkes.
 REKOMENDASI UNT ORGANISASI
 Menghilangkan kesenjangan antara insentif dan gaji.
(saat ini Sebenarnya perbedaan itu tidak dibenarkan
dalam input dan kualitas output. manfaat
tambahan, gaji dasar harus diikat dengan tujuan
yang jelas dalam hal jumlah dan kualitas pelayanan
khususnya bagi staf honorer Dinkes

 Khusus Untuk mencapai tujuan “pemeliharaan

organisasi kesehatan” dan pembeli mungkin seperti
pemasok terpisah, Dinkes mempertimbangkan untuk
menjadikan suatu bagian Perencanaanlangsung dibawah
Kadinkes
 Recommendation – Quality of Care
– SOP & Disease management protocols for endemic
infectious diseases, maternal and child health services, and
emerging chronic diseases such as HTN and DM.
– The SOPs and protocols should include elements of health
education, prevention, health of the family members of
the patients, referral, and follow up.
– Implement rigorous monitoring and supervisory support,
and regularly review the quality of care, and take
measures to address poor quality service provision,
including decisions about training, staffing, incentive,
supplies, and facilities’ improvement.
– Incentives for outreach visits by doctors should be tied to
working closely with the puskesmas outreach care
providers for community-based work rather than visit to
individual families.
 SOP & protokol manajemen untuk endemik penyakit menular,
pelayanan kesehatan ibu dan anak dan penyakit kronis seperti
hipertensi dan DM.

 SOP dan protokol harus mencakup unsur-unsur pendidikan kesehatan,

pencegahan, kesehatan anggota keluarga pasien, rujukan dan tindak
lanjut.

 Menerapkan pengawasan yang ketat dan dukungan pengawasan dan

secara teratur meninjau kualitas pelayanan dan mengambil langkah-
langkah untuk mengukur rendahnya kualitas manajemen, termasuk
keputusan pada pelatihan, kepegawaian, insentif, pasokan dan
perbaikan fasilitas.

 Insentif untuk kunjungan penjangkauan oleh dokter harus berkoordinasi

dengan baik dengan puskesmas penyedia layanan kesehatan untuk
pelayanan masyarakat, bukanmengunjungi. Keluarga secara individu
 Documents Reviewed
• Examples:
– Kaltim Provincial Maternal Health Profile
– 2010 Kukar Department of Health Report
– Evaluation Report (Presentation) Program Kesehetan Keluarga, 2009
– Kukar Laporan PWS KIA, December 2010
– Kutai Kertenegara Health Profile 2009
– Kukar Data Maternal Deaths 2009, 2010
– Kukar Maternal Death case study from one puskesmas catchment
area
– Kukar Infant Mortality Data
– Data dasar kesehatan ibu, Paser
– Paser Data Maternal Deaths 2009, 2010, Neonatal death case study
from one puskesmas
– Paser Maternal and Infant Mortality Data
– Paser Presentation and data provided by four puskesmas (Tanah
Grogot, Muara Komam, Paser Belengkongaser, Long Kali)
– Kutai Barat ..................................................
 Interviews &
Discussions
– Puskesmas & Community based government
– Private Midwifes from across the district,
– Hospital based midwifes and dotors,
– Head of Puskesmas, Dinkes, Provincial Department of Health
– Puskesmas & Community based government and private
midwifes from across the district
– Hospital based midwifes and doctors
– Head of Puskesmas
– Dinkes, Provincial Department of Health, and Academy of
Midwifery Training Kukar staff
 Visits & Situation Analysis
– Urban & Rural puskesmas, review of information and
discussions with staff
– Visits to Hospital: maternity care information review,
discussion about links between Dinkes & Hospital
 Maternal Health Context: Kaltim
• Provincial and districts’ Maternal and Child Health Program, under the vision
Indonesia Sehat 2010, prioritise maternal and infant mortality reduction, provision
of safe and high quality antenatal, intrapartum and postnatal care.
• Major strategies include actions that each delivery is assisted by appropriately
skilled health personnel, the capacity to provide adequate care for obstetrics and
neonatal complications, management of complications of miscarriage, and
reduction in unwanted pregnancies.
• Indicators to assess the success include the number of antenatal visits, proportion
of deliveries by skilled personnel, effective management of obstetrics
complications, contraceptive prevalence rate.
• The focus is on the improvement of services at the primary care level, increasing
the number of skilled personnel, placement of midwives in rural and remote areas,
provision of incentives for provision of care to pregnant women and mothers,
training of traditional birth attendants, working with the skilled birth attendant in
the private sector and with the traditional birth attendants, and efforts to improve
the referral system.
 Current situation
• Success in terms of improved access, high rate of ANC (92% K1 and 80% K4
in Kaltim in 2009).
• Overall, 80% deliveries conducted by the skilled attendants.
• The overall rate of deliveries by dukun in Kaltim has decreased to only
8.7% by 2009 (except in Nunukan and Kukar where dukuns still conduct
about 18 and 19%).
• In Paser and Kubar only 6% and 8% deliveries were conducted by dukuns
in 2009.

• However, despite these effort the maternal mortality is still high

• Need for much improvement in other pregnancy outcomes as well.
• Many women suffer from complications during pregnancy and delivery for
which they often find it difficult to access services.
• One major challenge is to provide adequate and high quality care in rural
and remotes areas.
 Strengths
POPULATION
• Relatively small population size
• Relatively less absolute poverty due to population size,
mining, infrastructure development with opportunities for
jobs and businesses
HEALTH SYSTEM
• A network of services which are strategically located for
universal coverage and ease of access
• Motivated senior managers and program coordinators at
Dinkes level, with good understanding of local issues
• A large number of staff (nurses, bidan, doctors, admin staff)
• Young, motivate able workforce
• Existing links with a large number of community volunteers
 Strengths
POLITICAL DECISION MAKING
• Good interaction between district government and district
health departments
• Approachable politicians
• Provincial government and Provincial Department of Health
keen to support districts for policy and regulation changes, as
well as for technical assistance to improve maternal health
• MATERNAL AND CHILD HEALTH
• Maternal mortality on the decline
• High coverage of ANC, PNC, TT, deliveries by the trained staff
• Many women approaching district hospitals for ANC/deliveries
 Current Approach

• The current approach to promote mothers and children is

about access to skilled birth attendants for all pregnant
women in the district.
• The strategies within this approach include recruitment of
trained midwives,
• on the job training for the midwives,
• improving puskesmas services for EmOC, and
• improving referrals for pregnancy and delivery complications.
 Findings
• Reported deliveries by Trained birth attendants in the three districts
– about 80%
• K1 78% to 85%, K4 60% to 80%
• High KN1 and KN2 rates (60-80%)
• There are however issues with the targets provided by the Bureau
of Statistics
• Nakes reported 20% women as having one or more risks for
pregnancy or delivery
• Majority of the reported maternal deaths in hospitals (for example
out of 9 deaths in Paser 7 in hospital, and out of 27 in Kubar 17 in
hospitals)
• Many deaths among 30-39 years of age
• Many deaths in those areas that are only two/three hour distance
from hospitals
 Findings
• So far no review conducted to explore reasons and circumstances
beyond the immediate cause (such as haemorrhage, hypertension
etc),
– other serious illnesses,
– too many pregnancies
– too short period between the consecutive pregnancies,
– complications during previous pregnancies
– how those complications were managed.

• Information about other pregnancy outcomes such as intrauterine

growth retardation, early rupture of membranes is not available.

• Similarly, the information on complications, complications during

postnatal period, interval between pregnancies, contraceptive use
by those who have delivered babies in the last year is not available.
 Findings: Planning and Management Capacity

• Insufficient management capacity: for example reporting delays,

misallocation of resources (for example availability of 19 bidans at one
puskesmas covering a population of about 6000),
• lack of planning to proactively serve those pregnant women who are at
high risk of complications,
• lack of attention to factors such as contraception,
• inadequate attention to resolve the referral delay issues,
• Lack of capacity at puskesmas and dinkes level to plan and improve
condition of facilities/ambulances/labour room/supplies for emergency
obstetrics care.
• Inadequate capacity to use local data for local puskesmas based planning
• . Need for capacity to review the current situation/trends and plan for the
needed change.
• Kepala puskesmas and bidan coordinators require skills for local planning,
and effective management of resources (human resources and facilities)
for which they are responsible.
 Temuan perencanaan dan kapasitas
manajemen
 Kapasitas manajemen yang tidak memadai: keterlambatan laporan , penempatan
sumber daya yang kurang tepat (misalnya ketersediaan bidan puskesmas 19
orang menngcover populasi sekitar 6000),
 Kurangnya perencanaan untuk proaktif melayani perempuan hamil yang beresiko
tinggi /dengan komplikasi,
 kurangnya perhatian terhadap faktor-faktor seperti kontrasepsi
 Tidak adekuatnya dalam penyelesaikan masalah keterlambatan rujukan
 Kurangnya kapasitas di puskesmas dan DinKes t untuk merencanakan dan
memperbaiki kondisi fasilitas / ambulans / kamar bersalin / peralatan untuk
perawatan obstetrik darurat.
 Kapasitas yang tidak memadai untuk menggunakan data lokal untuk perencanaan
berbasis puskesmas
 Perlu kemampuan untuk meninjau situasi dan tren dan merencanakan perubahan
yang diperlukan.
 Kepala puskesmas dan bidan koordinator perlu keterampilan untuk perencanaan
lokal, dan manajemen yang efektif untuk sumber daya (sumber daya manusia
dan fasilitas) sebagai tanggung jawab mereka
 Findings: Planning and Management Capacity

• Focus on achieving the input and process targets (ANC visits,

number of postnatal visits, delivery by skilled attendants).
• As the focus is on extending the coverage the focus on quality of
care of these human resource is less the optimum.
• Dinkes, at present, does not have sufficiently trained enough
number of staff who could provide planning and management
support to kepala puskesmas or bidan coordinators.
• Generally, the quality improvement efforts are limited to training of
the staff at a hospital or university
• The capacity is also limited because of lack of delegation of
authority to Dinkes about resource planning and allocation
decision; for example the decisions about the number of staff
needed, appointments, placement, type and place of training etc.
 Temuan perencanaan dan
kapasitas manajemen
Fokus pada pencapaian target input dan proses (ANC, jumlah kunjungan pascakelahiran,
persalinan dengan tenaga terampil).

Tujuannya adalah untuk memperluas cakupan dalam kualitas perawatan bagi sumber
daya manusia yang kurang optimal

Dinas Kesehatan, saat ini, kekurangan staf yang terlatih untuk dapat memberikan
dukungan perencanaan dan manajemen untuk pimpus atau bidan koordinator.

Umumnya, kualitas upaya perbaikan terbatas pada pelatihan staf di rumah sakit atau
universitas

Kapasitas ini juga terbatas karena kurangnya pendelegasian wewenang ke Dinkes tentang
perencanaan alokasi sumber daya dan keputusan penempatan sarana, seperti keputusan
mengenai jumlah staf yang diperlukan , pengangkatan, penempatan, jenis dan tempat
pelatihan, dll
 Findings: Data quality and use
• The review found little evidence of the use of data for
management purposes. At present the data is mainly used for
projecting targets for the next year. For example, the coverage of
various services vary across different regions within the district.
However, the data at present is not reviewed to highlight this and
then to work with the concerned puskesmas teams to improve the
performance.

• Kajian ini menemukan sedikit bukti penggunaan data untuk tujuan

manajemen. Saat ini data yang digunakan terutama untuk tujuan
diproyeksikan untuk tahun mendatang. Sebagai contoh, cakupan
layanan yang bervariasi antara daerah yang berbeda di dalam
kabupaten. Namun, data ini sekarang direvisi untuk menyorotnya
dan kemudian bekerja dengan tim yang tertarik untuk
meningkatkan kinerja puskesmas.
 Findings Data quality & Use
• Issues with the targets supplied by the Bureau: The projected targets received
from the Bureau are not confirmed through home visits, nor do all pregnant
women visit the centres. In fact utilisation of centre-based services by the
pregnant women is very low. The staff also relies on private midwifes to report
data; however, puskesmas midwifes mentioned that not all high risk
pregnancies, deliveries or complications are reported.

• K1 and K2 Information is also unreliable For example, at Puskesmas XXXXX the

Bureau target for Bumil was 177 and target for deliveries was 166. The
puskesmas staff however was able to record only 98 deliveries, which they
believed is the correct number. The staff in XXX insisted that their data accounts
for all the deliveries in the area. If the 420 number was correct, and if Bureau of
Statistics projects are incorrect by similar margin across the whole district, then
the actual number of births might be quite low compared to the estimates. Such
as situation poses serious challenge for health services and human resource
planning. At present this is difficult to judge if the puskesmas are unable to
record all deliveries in all areas. Regardless, this situation presents challenge for
local service planning.
 Recommendation: Quality of Care
• Continuation of excellent coverage already achieved:
• There is a need to improve the quality of the services provided
by the existing staff, and for which resources are required.
• Follow up care for those who are identified as having high risk
pregnancies: In one area, for example, almost half of the
pregnant women were diagnosed with one or more risks.
However, the bidans did not refer the patients to doctors and did
not involve the puskesmas doctors for needed treatment.
• Support to bidans for better health education and counselling:
Despite a large number of contacts with pregnant women,
perception about hospital use and the role of family towards care
for pregnant women are not influenced.
 Quality of intrapartum care
• Equipment Needs: It was highlighted by the puskesmas staff that rural puskesmas
lack dopplers, oxygen supplies, bidan kits, blood transfusion facilities. All
puskesmas in rural and remote areas should be ready to provide EmOC and that
the midwives placed there should be fully trained to provide basic EmOC. Neonatal
resuscitation, blood transfusion and eclampsia management training is needed for
the midwives.
• Policy and Protocols to Use Bidan Skills: Some Bidans are trained and some of
them have experiences for providing additional needed services during pregnancy
and delivery. Examples of these interventions include blood transfusion,
management of haemorrhage, labor induction, manual removal of placenta, and
IUCD insertion. However, the current regulation does not allow bidan to use these
skills even when these interventions are needed and where referral is difficult or is
refused by the family
• Coordination with Hospital: Dinkes should interact with, and preferably place one
coordinator at the hospital, hospital for data on delivery outcomes, and arrange
for follow up visits for those mothers who have complications during pregnancies
and for babies who are born with low birth weight or other complications/diseases
or congenital problems.
 Recommendations: Improve Resource
Management
• Basic Emergency Obstetrics Care: at puskesmas that are more than 2 hour
drive from the hospital, with both doctor and midwife trained to manage
basic obstetrics complications, with adequate labour room facilities.
• Supervision of Puskesmas: Dinkes mid level managers should visit
puskesmas regularly and work with the Kepala Puskesmas and Bidans to
provide support for planning

• Support & supervise midwives for a focus on prevention of diseases (e.g.

malaria, worm infestation), health education, planned pregnancies with
appropriate duration, identification of risk and referral of neonates.

The responsibility focus should be on pregnancy outcomes rather than only

on ANC visits and delivery by skilled attendant
 Recommendation:
Planning and Management Capacity

• Strengthen Service Planning Capacity at Puskesmas level.

Management training , ongoing support and review (by
Dinkes) for kepala puskesmas and bidan coordinators on how to
utilise local information for targeting management of high risk
pregnancies, follow up and home visits

• Dinkes train existing staff and appoint additional skilled staff

to strengthen its management capacity

• Consider incentives for skilled senior midwives for placements

and continuation of service in rural & remote areas.
 Recommendation:
Coordination with the local hospitals

• Develop SOP and agreements between Dinkes and hospital

about exchange of referral and follow up information
between the hospital and pusban/puskesmas/polindes
• Utilise the local hospital for placement/training of dinkes
bidan and doctors
 Recommendation:
data for local planning
• Need to improve dinkes and puskesmas management
capacity to review, analyse data and use it for planning

• Validate the information by conducting census in

catchment areas of some of the puskesmas and then
identify if the Dinkes information is incorrect or if the
Bureau of Statistics estimates need to be changed.

• Interact with the Bureau of Statistics to discuss the

situation
 Recommendation: Quality of ANC
• Plan regular home visits particularly for those at high risk, and plan for
regular support visits by bidan coordinators. Train Kepala puskesmas for
such management skills
• Develop and monitor the implementation of specific protocols on how to
manage high risk pregnancies. Involve Kepala puskesmas and doctors at
the puskesmas
• Assign responsibility and train puskesmas doctors to work with
bidans/perawat For example, puskesmas doctors should be involved in the
care of those women who have HTN or past history of eclampsia,
eclampsia or other complications in the past.
• Improve quality of communication and health education. Home visits will
contribute to this process if home visit are planned carefully.
 Ref System
• Dinkes should make sure that the ambulances are functional
(equipment, staff, driver, petrol) and available 24 hours a day
and are available at no more than two hour distance for a
comprehensive EmOC centre
• Where needed, Puskesmas should be provided with an
appropriate vehicle for staff movement.
• Communities, Posyandu volunteers, Pustus, Polinkams staff
should have access to the phone number of nearby functional
ambulance.
• Dinkes staff should visit the puskesmas when a death is
reported, review the information regarding ref & delays and
plan to avoid future occurrence of such reasons.
 Recommendation:
Quality of Intrapartum Care
• Puskesmas: Plan and implement a system of following up
(phone, and home visits) high risk women during the last
week of pregnancy
• Doctors at puskesmas that have Basic/Comprehensive EmOC
should be trained to provide clinical care to those who suffer
from delivery complications.
• Dinkes to review the condition at Puskesmas on a regular
basis (availability of equipment, maintenance of equipment
and ambulances, building).
• Regularly collect and review information on pregnancy
outcomes
 Recommendation: Dukuns

• Puskesmas should identify the families that still use dukun,

and analyse the reasons for such reliance on dukuns

• Dinkes should compare the complication rate and poor

pregnancy outcomes for those cared by the midwives and
those cared by dukuns
Quality of Care: Right Person for Right Job
• Specific job descriptions needs to be developed for
clinical staff in particular. SOP alone are not helpful.
• Need for clarification and communication about tasks to
inpatient ward doctors and nurses.
• Discuss performance (quality/quantity) situation with the
concerned unit heads and plan for needed actions.
• Develop and implement work performance reviews,
linked to incentives – and with a clearly defined process
about actions if the work is not performed as planned.
• Carefully assess the need for any further increase in the
number of nurses at the hospital, Interact with Pemda for
placement of public contract full time nurses rather than
only the contract nurse.
 Hospital/Unit Performance
• The review suggests that hospital performance since BLUD has not
improved..

• BLUD is to improve efficiency & quality. Incentives are not an end but
a way to reach efficiency and quality objectives. Need for rigorous
monitoring and change If efficiency and quality not improving.

• Information on quantity is already collected. Indicators about quality

should be defined and data should be collected and analysed regularly.

• Need for overall hospital performance review and performance

review of each unit – at least once a year. Poorly performing units
should be supervised and monitored more closely and solutions
(including incentives, disincentive, reward and disciplinary actions).
 Hospital/Unit Performance
• Keep a check on the use of pharmaceutical drugs. Apotek
makes 15% profit from the sale of drugs. That may counter the
effect of insurance system (jamkesmas).
• Inadequacy of equipment for daily patient care needs. Need to
Perform audit and develop a system of regular identification of
equipment and procurement of the needed equipment.
• As the owner of the hospital, Pemda should be provided with
detailed analysis of hospital performance and performance of its
units – quantity indicators and quality indicators.
 Human Resource Planning
• Invest in the training (conditional to stay at hospital) and support
for nursing quality and management staff as quality depends to
a large extent on nursing care and managerial processes.

• It is very costly to train the nurse for effective hospital work.

Lobby Pemda for strategies to retain the experienced and
trained nurses who are on contract but may leave the hospital
once they qualify for the permanent government job.

• Overall number of nurses is already sufficient. Do not hire

additional junior nurses without very careful review if any more
nurses are needed. If needed hire only after developing a
detailed plan of job description, placement and training.
 Human Resource Planning
• Review the role of specialists towards hospital performance. A
simple analysis informed that the availability of specialists has not
yet resulted in change in disease pattern with which patients use
the hospital, and for increase in the quality of care.
• Reviews individual performance s(using job description and
agreed performance indicators) on a regular basis.
• Regularly review (6 monthly-1year) unit performance in terms of
trends in number of patients, number of admissions, morbidity
pattern, severity of illness for which the patients utilise the
hospital, and complications. Then plan increase or decrease in the
number of human resources needed for those units.
 BLUD
• Since introducing BLUD, the hospital revenue had increased by
XXXXX %. This is a need to compare pre-BLUD and post BLUD
quantity and quality data. Preliminary assessment suggest that there
is not much change in admission, severity of illness with which
patients get admitted etc. Data on quality of care indicators is not
available but the review suggests that quality has not changed.
• Link BLUD incentives to improved performance indicators rather
than on formula only. Poorly performing units should be identified
and resource/attitude/human resource/contextual information
should be reviewed. Appropriate actions, including lack of incentives
and disciplinary action, should be taken as necessary.
• BLUD savings current formula for incentives heavily leans towards
more incentives for doctors. Such formula should include quantity
and quality of care indicators to achieve the BLUD objective of
Efficiency and Quality improvement.
 BLUD
• Invest in improved management. Investing in technical
resources alone will not achieve the efficiency and quality
goals. Increase incentive proportion for the
structural/management of hospitals and for nurse
managers/unit incharge.

• There is a need to identify the actual cost (excluding Jasa

Pelayanan, Jasa Rumah Sakit because doctors fees and
hospital infrastructure and capital costs are already covered
by Pemda). Micro costing for those diseases with which most
of the patients are admitted to the hospital could easily be
done because such micro costing for this hospital does not
require calculation of overheads and the time of health
personnel. Such micro costing will also help identify the use of
medical utilities and any associated inefficiencies.
 BLUD
• Motivation of staff should not overly be dependent on
financial incentives. It is very much possible that the Tariff
packets will decreased in the future and then there will be a
need to decrease the incentives. The staff will then be de-
motivated and object to any such decrease.
• To improve the quality, a good proportion of BLUD funds
needs to be used for:
– training (better to have in-the -hospital) particularly of nurses, and
management staff,
– procurement of needed EVERY-DAY USE EQUIPMENT (stethoscopes,
suction apparatus, ECG machine etc),
– basic improvements in building (such as ramps for patients)
development
– implementation of flow charts, specific job descriptions.
 Information System (for Jamkesmas and other
hospital management need)
• The process is already quite strong and robust , and calculation
and reporting for reimbursements from Jamkesmas are strong.
• Duplication: There are some duplication. For example,
verification of apotek receipts, aggregation of cost by ward and
medical record system etc
• Retraining Need for doctors and nurse incharges for ICD codes
for those diseases with which most of the patients get admitted
to the hospital
• To improve data entry, filing of documents needs to be better
organised to improve data entry
Information System (for Jamkesmas and other
hospital management need)
• Avoid delays in reporting to Jamkesmas and
reimbursement. For example, Nurses incharge
should be allowed to enter the diagnosis on the
summary sheet once the patient is discharged.
• Patients should not be asked to carry their
files/documents to the lab/apotek . At times
files/documents go missing.
• A unit about HMIS needs to be established for
information for hospital planning, management
and evaluation. HMIS unit could be a functional
unit under Kasubbagian RM