Piloting Puskesmas Accreditation Instrument: Efforts to Advance Health Care Quality

Accreditation of Puskesmas (primary health center) as first-level health facility is one way to ensure that primary health care (PHC) facilities are equipped to carry out their functions and roles. The Ministry of Health through the Directorate of Primary Health (BUK) has carried out the accreditation of health centers since 2011 as a form of implementing the fifth point of the Nawa Cita (vision) “Improving the quality of life of Indonesian people” which has also been adopted as an indicator for RPJMN and Strategic Planning.

Since 2011, The Ministry of Health has undertaken a number of activities in this regard, for instance: developing the primary health care accreditation concept; collecting instruments of accreditation in several provinces and conducting cross sector and cross program meetings to review the accreditation concept. These series of events have resulted in a number of outputs, such as: initial draft for standards and accreditation instruments for health centers and pratama clinics; the initial draft of the accreditation process; and piloting the initial draft of the accreditation instrument in several test sites in Central Java (Semarang District, Jepara, Magelang and Tegal).

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Continuing the development from previous years, several activities have been carried out in 2014, namely: preparing the Norms, Standards, Procedures and Criteria (NSPK) using the state budget funding and funding from the Australia Indonesia Partnership for Health Systems Strengthening (AIPHSS); conducting workshop and training sessions 2015; socialisation and advocacy, and preparing the facilities, infrastructure and tools using the Special Allocation (DAK) funds and Assisting Task (TP) funds; and trialling accreditation in eight (8) districts in the East Java province and East Nusa Tenggara (NTT) province with the support of AIPHSS Program funding.

The above activities have produced the following outputs: the piloting of the PHC accreditation in AIPHSS pilot areas, and also the drafting of PHC accreditation standards and instruments; Guidelines for PHC accreditation surveys; Guidelines for PHC accreditation assistance; Guidelines for the preparation of PHC documents; the Curriculum and Teaching Program Outline (GBPP); Training of Trainers (TOT) for surveyors and TOT for assistance; and the Roadmap of puskesmas accreditation.

The purposes of piloting the PHC accreditation are to get input related to the implementation of the accreditation module and technical standard materials as well as the accreditation instruments, and to revise the NSPK for puskesmas accreditation.

There are some valuable lessons learned from the piloting process, namely: (1) standards and accreditation instruments can be applied by health centers; there are 6 out of 16 health centers that passed the accreditation assessment, while the health centers that did not pass the assessment show improved process performance when compared between pre- and post-accreditation; (2) During the trial process from preparation, assistance, up to the assessment, there are observable improved performance of individual health effort (UKP) and community health effort (UKM) in all health centers; (3) Before the health center is ready to be surveyed, the accreditation assistance process must take place for seven to eight months; (4) Financing the accreditation process, starting from mentoring and survey, is estimated at Rp. 80 million up to Rp. 120 million  per health center; (5) The commitment and the role of the District Health Office /City Health Office are crucial for health centers to enable them to pass the accreditation assessment; and (6) Improvement of NSPK is required for the health centers.

In 2015, the Ministry of Health implemented a number of activities: Implementing First Level Health Facilities Accreditation (FKTP) where there are 110 health centers that have been accredited; trials for surveyors training and accreditation assistance training in eight (8) districts, financed by AIPHSS; Piloting the puskesmas accreditation (operational assistance team and surveyor) in eight (8) districts financed by AIPHSS; Technical assistance for piloting puskesmas accreditation; Meetings for reviewing the NSPK for puskesmas accreditation; and; Dissemination of pilot results.

POLICY & SUSTAINABILITY STRATEGY OF PUSKESMAS ACCREDITATION

Revitalising the role of puskesmas as mandated by the Minister of Health Decree (Kepmenkes) No. 128/2004, and the need to strengthen the health systems, requires a hard work and cooperation between stakeholders at all levels and across sectors. The Ministry of Health has been and is making efforts to sustain accreditation processes, particularly as the AIPHSS program is ending. Some programs or activities being implemented to ensure the sustainability are as follow:

  1. Accreditation of FKTP is established as a standard that must be met and assessed by an Independent Agency to ensure the provision of services according to standards and enforced regulation.
  2. Accreditation of health center serves as one of the Program Performance Indicators (IKP) of the Ministry of Health in 2015-2019.
  3. The Minister of Health Regulation (Permenkes) No. 46/2015 serves as a reference for the accreditation of health centers and other FKTP.
  4. The existence of technical guidelines related to the implementation of accreditation that have been tested in the field. The technical guidelines consist of several stages as follow:
  • Pre-Accreditation Assistance: conducted in six (6) months on average. The type of activities includes: workshop, assistance during document preparation, assistance during implementation, assistance during pre-survey assessment, and proposing a survey.
  • Survey, which consists of two (2) phases. The first phase is survey implementation, conducted in: a). Puskesmas (3 days) concerning administration, UKM and UKP; b). Clinic (2 days) concerning administration and UKP; c). Individual Practice of GP /Dentist (2 days) concerning administration and UKP. The second phase is determining the accreditation status by the FKTP Accreditation Committee (3 days).
  • Post-Accreditation Assistance (once every 6 months), includes: Recommendations according to the results of the survey; technical assistance; Pre Assessment Survey.

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