The quality and management of health services remain important challenges for Indonesia’s health care system. External assessments of health care quality started with the establishment of the National Accreditation Body, known as KARS, or Committee of Hospital Accreditation, in 1996. This program was reinforced through Law No. 44 of 2009 which required all hospitals to be accredited every three years. Following the accreditation process for hospitals it was soon recognised that there was also a significant need for accreditation at the primary health care or Puskesmas level.
Prior to 2013, the Directorate of Primary Health Care (BUKD) in Ministry of Health (MoH) that is leading the accreditation of the Puskesmas, conducted accreditation trials in 6 provinces: Lampung, North Sumatra, Central Sulawesi, South Sulawesi, West Java and East Nusa Tenggara. This pilot program paved the way for the current accreditation drive. The MoH/BUKD saw an opportunity through the Australia Indonesia Partnership for Health Systems Strengthening (AIPHSS) to continue the next stages of revising and improving the Puskesmas quality standards to improve the quality of primary health care nationwide. This sytem will also provide a credentialing system for Puskemas as a provider of health care under the National Health Insurance System (JKN).
Under the current law accreditation is given to a Puskesmas that meets the accreditation standards of health services established by the MoH. A Puskesmas needs to be accredited once every 3 years through an independent assessment process.
Ms. Masturah was the head of Arusbaya Puskesmas, Bangkalan District, from 1995 to 2015. As a mother of 5 children, and qualifications in nursing as well as a Master’s degree in Public Health, she knows what it is like to work hard to achieve qualifications. In May 2015, through AIPHSS and BUKD, she received accreditation training to become a Puskesmas facilitator. She was motivated by the fact that her Puskesmas had failed to achieve accreditation and she was now determined to make sure it met the required standards.
“When the accreditation assessment was conducted in early 2015 through AIPHSS and BUKD, I led a Puskesmas which was one of the pilot projects in East Java. At the time, I felt that our Puskesmas was not ready for the accreditation, since we didn’t follow the process as it should have been. It turned out to be true. We failed to get an accreditation! I was disappointed, so now I am very motivated to become an accreditation facilitator, there should be no more Puskesmas that fails to obtain accreditation.”
Now Ms Masturah is determined to find any weaknesses in her Puskesmas that might jeopardize being accredited and wants to address them immediately. One critical lesson learnt by Ms Masturah was that solid teamwork is the key to the accreditation success. She knows that each team in the Puskesmas must work together:
“…A Puskesmas will not be successful pass the accreditation if it only copies and pastes from documents of other Puskesmas which have received accreditation. The accreditation instruments and documents require us to do it by ourselves, and not just cover up the weaknesses without the accreditation assessment team knowing…”
BUKD, supported by AIPHSS, conducts accreditation training for facilitators and surveyors, followed by field practice. Sixteen Puskesmas in two AIPHSS provinces have been selected for accreditation trials. Each selected Puskesmas receives assistance which aims to make sure that all accreditation requirements are met properly.
To support the accreditation, BUKD and AIPHSS produced training curricula, modules, accreditation standards and accreditation instruments including a final assessment survey, a total 13 documents were completed by August 2015. The accreditation standards consist of nine components divided into sections covering administration management, public and clinical health. Each component includes a set of minimum performance standards that must be met in order to become accredited.
Ms. Yanti Nurhayati, Head of the Puskesmas and Referral Development Section, in the Bondowoso District Health Office, also emphasized the importance of team work based on her experience. She provides guidance to the Puskesmas and is learning to quickly assess the situation with regard to accreditation standards. She has noted the lack of knowledge about service quality and poor coordination and communication. There is a poor awareness of how each part contributes to maintaining service quality.
“…this accreditation process is just like to wake up call to a “sleeping” Puskesmas. They just wake up and realize that in fact before we determine the type of services to be provided by Puskesmas, we should know first the needs of public, each Puskesmas still has their own ego, eg., my SoP is my part, and others don’t need to know. If they want develop their SoP, they will have to do it by themselves”
Yanti emphasized that the implementation of service quality and achievement of accreditation are not only a matter of meeting the standards of an assessment. Accreditation is about how a team works together through a shared knowledge and understanding of what is needed. It requires collaboration, workflow and organizational structure. Each part needs to know how its role and function works as a whole, and how all of these are intended to improve service quality for the community they serve.
Across the districts involved with AIPHSS, the desire from Puskesmas’ to achieve accreditation continues to grow, and the demand for training and assistance is increasing. This is reinforced by the need to have accredited status as a prerequisite for Puskesmas to receive capitation funds from BPJS.
Currently 6 out of the 16 Puskesmas which attended the accreditation trials which commenced in 2014, have managed to achieve accredited status for basic and intermediate levels. These successes are encouraging for other Puskesmas who are currently striving to improve their systems and achieve accreditation.
Mr. Benedict, the Head of Oelolok Puskesmas in North Central Timor (TTU) District, whose Puskesmas was recently receiving accreditation assistance, wanted to know why some Puskesmas were accredited and others failed. Using his own initiative and expense, he traveled to several Puskesmas which had attended accreditation to find out more about the differences between them:
“…I traveled to several Puskesmas which attended accreditation, the successful and the unsuccessful ones. Now , I can compare why a Puskesmas was successful in gaining accreditation and why others were not. It turned out to be very different in terms of service quality. The accredited Puskesmas had better service quality, more motivation, smiles and clear service procedures. Now I know the principle ‘write what you do and do what your write’ should really be implemented. Otherwise, how long are we going to be an ordinary health care provider?”
The increasing demand for accreditation presents a new challenge to the Ministry of Health. This requires training services, advisers and system development. In response, consideration is being given to focus these activities in a separate directorate specifically for monitoring the quality of Puskesmas services. Drg. Kartini Rustandi, Kes, the Director of Primary Health Care, MoH, emphasized that multi-sector cooperation at every level was very important in realizing the improvement of service quality. Under her leadership, it is expected that the accreditation system continues to grow. The MoH have an ambitious target that an additional 350 Puskesmas will soon receive assistance for accreditation.
“Write what you do and do what your write”, emphasizes the spirit of service quality improvement amongst those involved in the program. This motto has created a sense of shared responsibility to build a better working team which is able to provide improved health care services for the benefit of the community. Accreditation has also encouraged and inspired health care workers such as Ms. Masturah, Ms. Yanti, and Mr. Benedict to dedicate themselves to improving health care and not to just achieve accreditation as a mandated government process.
Finally it is important to note that many districts have begun to visit the successfully accredited Puskesmas in East Java, this is a success story for the BUKD led initiative as it has become learning ground for others in Indonesia.