Reinforcement of human resources in implementing healthy indonesian program with family approach.

Background: The Healthy Indonesia Program is a government program implemented with the Family Approach (HIP-FA) through a survey on healthy families. However, the quality of the program depend on the performance of the Human Resources (HR). This study aims to examine various aspects of HR in implementing the program at health centers. Design and methods: Data were collected through in-depth interviews, Focus Group Discussions, and document review on eight informants at the Health Office center.
Results: Four themes revealed from the study: being burdened, feeling overwhelmed, feeling incompetent, and confused managing technology. The results showed that the implementation of the HIP-FA survey is an additional burden for health center staff. Conclusions: It is necessary to strengthen the implementation of all programs through continuous training and education, positive affirmation, recalculating employee workload and remunerations. ©Copyright: the Author(s).

Introduction

The Healthy Indonesia Program is one of the 5th agendas of Nawa Cita (nine-point development program), aimed at improving the quality of life of the Indonesian people by upholding three main pillars, namely, application of the health paradigm, strengthening health services, and the implementation of the National Health Insurance (JKN). The government launched the Healthy Indonesia Program in accordance with the Family Approach (HIPFA). [1] This program needs to be implemented and actualized by all levels of stakeholders, especially the Ministry of Health that spearheads this policy in all provinces as well as Technical Implementation Unit (UPT) of all health centers. Madiun is one of the cities located in East Java, consisting of three districts, namely Kartoharjo, Manguharjo, and Taman. The city has a population of 209,809 people with 6 main health centers and 18 sub-health centers.

HIP-FA was initiated in 2016, with implementation in 9 Provinces. It aims at being implemented in all regions of the country by 2018.[1] A certain aspect that describes the quality of a program is reflected in the performance of Human Resources (HR). However, some problems are encountered due to the sub-optimal performance of human resources, such as health center employees. Therefore, this research aims to study the roles of HR in implementing HIP-FA in health centers.

Design and methods

This is a qualitative research, with data descriptively obtained through in-depth interviews with the stakeholders. It was conducted at the Technical Implementation Unit of the Health Office located in Madiun city, which was appointed the Pilot UPT by the Ministry of Health. The data were collected through in-depth interviews with 2 policy holders of the HIP-FA and 6 employees of the UPT during Focus Group Discussion (FGD).

Results and Discussions

This study describes the aspects of HR in the implementation of the HIP-FA program by conducting a survey of healthy families in each community. It also explored the experiences encountered by the program implementers and policymakers. Subsequently, it is expected to describe the actual conditions and experiences of HR.

However, there are weaknesses associated with implementing HIP-FA by the HR. Four themes revealed from the study (Table 1): being burdened, feeling overwhelmed, feeling incompetent, and confused managing technology.

Table 1.

Themes and sub-themes.

Themes	Sub-themes
Being burdened	Needs to conduct further surveys It must be carried out by all employees
Feeling overwhelmed	Working after hours Takes up a lot of time and energy
Feeling incompetent	Lack of intense training Lack of understanding of job description
Confused managing technology	Difficulties managing data processing system Lack of training about the data processing system

Being burdened: Employees feel they have additional workload besides their main job, they ‘needs to conduct further surveys’ and ‘it must be carried out by all employees’. The survey obtained from many communities by a third party was considered invalid, therefore, all health center employees were requested to carry out field surveys. This is an additional workload, which makes them carry out their duties even at odd hours, such as at night and even on holidays. The staff felt they had a double job in addition to the main task at the health center, which was laborious, time-consuming, and without additional pay. Secondly, the health center employees lacked an understanding of the operational definition of the questionnaires, and they were incapable of operating the HIPFA data processing system, thereby running the process less optimally. This is due to the lack of socialization and training that needs to be carried out on prospective surveyors.

All problems encountered are further explained in the following analysis. According to the 2017 survey, the health office in Madiun made an agreement with third parties to conduct a survey of healthy families in all the communities. However, it was discovered from the results obtained that some communities were not surveyed even though it is the pilot health center in the city and needs the achievement of HIP-FA total coverage, as stated in the following interview excerpts

“The third-party failed to survey all residents, therefore, there was no total coverage. The Ministry of Health also made the Tawangrejo clinic a pilot health center for the program.” (S2)

The results obtained by the third party were invalid because some people were not surveyed. However, the data was sent to the health center, as quoted in the following interview

“At the time they visited Oro-oro Ombo village, I was not around. They met only my assistant, and after that, they never visited again. Where did the data come from?” (W1)

This requires all health center employees to carry out a followup survey to complete the exercise, as quoted in the following interview

“Whenever the data obtained is inaccurate, the health center staff visits the community immediately.” (W1)

The survey target is all members of the community in the Public health center working area without exception, this requires hard work from the Public Health Center, so that the policy holders in the Public Health Center make health policies involving all employees both medical and non-medical, as stated below:

“Because there are a lot of targets, only health workers are sorry. So we are for each team that is certain that one team is the only non-health worker. One is non-health workers, like the counter is real, if the midwife, nurse, doctor is right. “ (W1)

Feeling overwhelmed: This situation makes the Public health center staff feel they have to ‘working after hours’ and ‘takes up a lot of time and energy’, as testified below:

“Yesterday, we have to work twice in the afternoon, we have to go there again or maybe during the weekend Saturday, on weekends, we go there again.” (S2)

“... my time and energy is so much wasted, we have to do our main job... but later in the afternoon we have to do a survey. The worst thing is….when we come to the house, the person to whom it is addressed does not exist, and we must ask everyone and neighbors whether they know the person lives”. (S2)

This situation made the health center employees feel they had a double job. They have to complete their main tasks and also conduct surveys after hours even some informants stated that they work at night and during the holidays. However, this additional load does not appear to be compensated with rewards, especially for civil servant employees because there are rules for remuneration as explained in the following interview:

“Civil servants are not rewarded during extra work hours, while remunerations are offered to non-civil servants.” (W1)

Feeling incompetent: This happened because of the ‘lack of intense training’ and ‘lack of understanding of job description’. Initially the training was only managed by 5 employees per Public Health Center who were trained by the Center:

“... I feel like I am not capable in doing this. “ (S1)

It shows that HR failed to understand how to socializing the HIP-FA data processing system. This resulted in inaccurate information and a lack of in-depth understanding of the implementation of the HIP-FA. Some surveyors ‘lacked knowledge of the operational definitions’ of the questionnaires prepared by the Ministry of Health. An informant stated that the operational definition of HIP-FA was difficult to understand without optimal training and lack of field practice.

“Therefore, in my opinion, a lot of difficulties tend to be encountered when they are not maximally trained with practices. When we understand that, the results tend to be different.” (W4)

Confused managing technology: Further problem arises as some employees experience ‘difficulties managing data processing system’ because ‘lack of training about the data processing system’. Lack of human resources who have capabilities in operating the HIP-FA data processing system make HIP-FA runs less optimally and affects the quality of the data produced:

“... but I don’t know how to input the data (confused operating), maybe because of the I am not familiar using technology.” (W3)

There were a few employees who were able to operate the data processing system. In fact, based on a decree made internally the Public Health Center shows that all surveyors are data processors, meaning that all employees should be familiar with it, but the reality is different:

“If I’m not mistaken 19 people, they are still active until now, they can manage this program” (S2).

The incapability of the HR to operate the HIP-FA data processing system affects the quality of data produced by all surveyors and employees. There are only few employees that are able to operate the existing data processing system, thereby leading to an efficient and effective process.

“... finally it is still part of the health promotion and subordinates in charge of data input.” (W3)

Examining the various sources of information from several informants, the conditions experienced by employees in health centers can be summarized as follows: the job was time-consuming, tasks were completed both inside and outside the facility every working day including evenings and holidays, difficulty in understanding the questionnaire due to lack of socialization and incapable HR. The results from the surveys conducted by a third-party were invalid, and this made the policyholders decide to involve all existing health center staff, both the medical and non-medical department, to carry out a survey of healthy families in their respective areas. This led to an additional workload on the part of the employees.

Interaction helps to strengthen the leader’s confidence in dealing with complex programs.[2] According to the Health Office, which is the highest policy holder in an area, all stakeholders, especially all heads of Health Center need to carry out as follow-up surveys in collecting HIP-FA data. According to the HIP-FA training module,[1] the family/regional coach plays a role in data collection. This shows that the person that carries out a healthy family survey is assigned to every health center. However, with the small number of family coaches compared to the huge number of people surveyed and the responsibility of carrying out their personal job descriptions, policymakers decided to empower all employees as surveyors of the HIP-FA Program. Therefore, it became necessary for employees to possess numerous skills.[3]

Workload is defined as the ability of employees to carry out their task appropriately. Additionally, in most occupations, physical, and mental demands which have an impact on human performance are also needed.[4] Leaders burdened with the number of staff, morale, workload, ability to provide high-quality, safe and effective services[5] because surveys carried out to determine healthy families using the HIP-FA program is an additional workload both physically and mentally. The formal guidance program positively impact on the development of personal skills and selfevaluation. [6] Employees willingness to work helps to mediate the negative relationship between vulnerability and eligibility[7] This is because they tend to work extra hours by providing services and making reports. Therefore, proper time management is required for optimal performance and to maintain the physical and mental state of the human body.

Fatigue, in facts, leads to a decrease in job satisfaction, control over workload, prolonged documentation time, poor leadership and inefficiency during teamwork.[8] The implementation of the HIP-FA program is an extra burden on the health center staff. The increase in workload does not appear to be accompanied by adequate rewards. The rewards or compensations are what employees receive in return for the contributions made to the organization The offering of rewards tends to motivate employees and increase their productivity in implementing the program..[9]

Every employee needs adequately mapped out strategies in order to properly muti-task with improved performance.[10] Subsequently, the health center needs to pay attention to the physical and mental conditions of all employees, which greatly influences the implementation of the HIP-FA survey in the field.

HR Management needs to be properly carried out by the policymakers to ensure adequate workforce. The limited number of existing HRs does not rule out the possibility of policymakers carrying out a skill mix on some of their employees. This is also applied to the implementation of the HIP-FA survey because of the limited number of human health resources that play such roles as family advisors in the community or spearheads the data collection. This requires the head of the clinic to leave all medical and non-medical employees for the exercise because of the large number of survey targets.

Furthermore, the skill mix is not just technical training. It is a method of organizational change that requires careful planning, communication, implementation, and evaluation that is needed to achieve its objectives.[11] Therefore, policymakers need to be aware of the decisions that have been taken, always pay attention, and evaluate their performance in order always to achieve good and maximum results. Formal guidance programs play a positive impact in developing personal skills.[6] Therefore, improved training and provision of adequate information at work helps in the prevention and reduction of work-related errors.[12] The operation of the HIP-FA data processing system is unlikely to be separated from the demand that employees need to master computer operations. Technological advancements has the ability to improve the efficiency and accuracy of reports, thereby making it reliable.[13]

In accordance with the problems encountered in the field relating to the HR aspects in the implementation of the HIP-FA program, it was discovered that the goal determination and reinforcement theories, were used for analysis.[14] Health center staff needs to have specific targets derived from within one another to increase their motivation in carrying out their main tasks and functions, especially in the implementation of the HIP-FA program. In addition, employees also need to get reinforcements from external factors, for example, the head of the hospital, health office, and HIPFA project leader or from community leaders, thereby causing the implementation of the program to be properly run. Strengthening the motivation of HR as the main implementer of the HIP-FA program at the health center has become very important in the successful implementation of the exercise. This is achieved through positive affirmation (self-talk) and the development of a long-term perspective on the importance of the HIP-FA program.[15]

Conclusions

In conclusion, human resources tend to encounter some weaknesses in implementing the HIP-FA, and this affected the quality of data collected and processed. Therefore, it is necessary to strengthen the implementation of all programs through continuous training and education, positive affirmation, recalculating employee workload and remunerations.