Discrepancy evaluation model for human resources health placement evaluation at the puskesmas

Journal of Environmental Treatment Techniques

2019, Volume 7, Issue 4, Pages: 588-594

J. Environ. Treat. Tech.

ISSN: 2309-1185

Journal web link: http://www.jett.dormaj.com

Discrepancy Evaluation Model For Human

Resources Health Placement Evaluation At The

Puskesmas

Meldasari Said , R. Madhakomala , Fahmi Idris

Universitas Negeri Jakarta, Indonesia, meldasaid75@gmail.com

Universitas Negeri Jakarta, Indonesia, madhakomala@live.com

Universitas Negeri Jakarta, Indonesia, fahmiidris.20@gmail.com

Received: 12/05/2019

Accepted: 27/08/2019

Published: 31/08/2019

Abstract

This study aims to evaluate the implementation of the Regulation of Minister of Health (RMH) of Indonesia Number 75 the year

014, as the basis to recruit health care worker of Puskesmas (Community Health Center). The method of study used the Discrepancy

Evaluation Model by Malcolm Provus. The informants are the official of the Office of Health at Banjarbaru City, the official of

Puskesmas, and the community. The research focused on planning, recruitment, selection, placement, and empowerment. The

conclusions of the research is 1) planning, there was no gap or discrepancy between the S (Standard) of the ministerial health policy

and the P (Performance); 2) recruitment, there was a gap or positive discrepancy; 3) selection, there was a gap or positive

discrepancy; 4) placement, there was a gap or positive discrepancy; 5) empowerment, there was no gap or discrepancy, which means

adequacy occurred between standard and performance.

Keywords: Discrepancy Evaluation Model, Human Resources Health, Placement Evaluation, Puskesmas.

financing, recruitment, training, development, benefits and

Introduction

remuneration scheme for health workers in countries -

including Indonesia- SDGs program implementers (17).

The entire implementation of the program activities

should be carried out by health workers who have relevant

skills and competencies. When the organization’s strategic

plan drawn up, the human resources development plan should

be compiled together from the initial stages of strategic

planning development of the organization. The need to

complete human resource planning in conjunction with the

strategic planning of the organization, including the plan of

the SDG’s implementation (17).

The Indonesia Act No. 36 of the year 2009 about Health,

article number 3 mentions the goal of health development is

the increased health awareness, willingness, and ability to

live in a healthy life for everyone in order to increase the

degree of community health can be achieved. Sustainable

Development Goals (SDGs) initiated by the States members

of the United Nations (UN) in September 2015, in the field of

health which determined common goal i.e. "ensure healthy

lives and promote wellbeing for all at all ages "in the year

2030 (29).

Following up the SDGs consensus for every United

The Ministry of Health of the Republic of Indonesia, in

collaboration with the Global Health Worker Alliance and

Deutsche fur Internationale Zusammenarbeit Gesselschaft

GmbH, developed health worker plan Year 2011–2025 (19),

studies show that the health worker is a major key in the

successful achievement of the goal of health development.

Health workers contribute up to 80% of the success of health

development. In the year 2006 the WHO report, Indonesia is

one of the 57 countries who are facing a crisis of human

resources for health in both perspectives the number of health

worker and its distribution. Health workers in the health

center mandated to focus not only to implement the

individual health efforts which focused on the curative

function. But also the efforts to promote the community

health function or preventive approach in a balanced way.

educational and community-based programs are most likely

Nation (UN) the Member States are to determine the target's

healthy development of each country as well as the drafting

process of the achievement of the target which specified in

the time up to the year 2030. From the aspect of preparation

of human resources for health in order to achieve the target of

the SDGs, many general human resources issues and

questions arise, include the size, composition and distribution

of the health care workforce, workforce training issues, the

migration of health workers, the level of economic

development in a particular country and socio-demographic,

geographical and cultural factors (18). After the assessment

process was conducted, composed also of planning aspects of

Corresponding author: Meldasari Said, Universitas Negeri

Jakarta, Indonesia, E-mail: meldasaid75@gmail.com.

Journal of Environmental Treatment Techniques

2019, Volume 7, Issue 4, Pages: 588-594

to succeed in improving health and wellness when they

address influences at all levels and in a variety of

environments or settings (27)

Dunn stated that policy analysis is a term that refers to

value judgments about what ought to be, in contrast to

descriptive statements about what is (13). Policy analysis is

an approach to social problem solving starting at a historical

milestone when knowledge is consciously explored to enable

explicit and reflective testing of the possibility of linking

knowledge and action (32). Evaluation plays a number of key

functions in policy analysis (34,35). Policy analysis and

evaluation are two continuous supplementary functions.

Policy analysis is described as the dissection, isolation and

systematic examining and explaining policy phenomena or

components to determine the effectiveness and efficiency of

each part or action (9). Evaluation is an appraisal of

something of value, according to a specific yardstick which

also serves as a standard (22). The word evaluation is used

loosely to encompass many different activities and purposes

(23).

The curative approach is providing good treatment of

physical, psychological, mental, and social events to patients

in need (33). While the preventive approach tends to do

disease prevention efforts and improve health (promotion of)

before the onset of the disease through community organizing

efforts devoted to environmental sanitation. Human resources

for health (HRH) are the cornerstone of health systems,

enabling the improvement of health service coverage (28).

The year 2017, Indonesia was struck with an outbreak of

Diphtheria in 142 districts or cities in 28 provinces (36). This

outbreak claimed as the largest in the world. Recorded from

January to November 2017 there were 593 cases of

Diphtheria mortality with 32 cases. The need to look out for

is the tendency of the number of cases of the disease

increased since 2007 (183 cases) and its peak in 2012 (1.192

cases). After that decreased but the number still hundreds of

cases. When Diphtheria immunization has been running for

the past 5 decades and must be given to infants under 1 year.

Then there is also an advanced vaccine or booster given at 18

months of age, the age of the child grade 1, grade 2, and

grade 5 elementary school (25).

This working paper contributes to the improvement of

knowledge in the human resources domain in health by the

synthesis of certain general information of interest in the

health system (10). The question will be laid down to the

effectiveness of government policy, the skill of health worker

and the knowledge and know-how of community in

responding to the annual outbreak of that communicable

disease. The first step (component of HR Planning or Design)

is the determination of the standard (S) for comparison with

the second step up to fifth (Recruitment, selection,

placement, and empowerment), namely through the

collection of information and data from related parties in

Puskesmas, as well as from the health workers themselves.

The research focused on planning, recruitment, selection,

placement, and empowerment.

In evaluating policies there are 22 approaches (32). The

Discrepancy Evaluation Model (DEM) offers a pragmatic,

systematic approach to a wide variety of evaluation needs

(31). The DEM uses an approach oriented to decisions made

on programs or policies. The model described here deals with

explicit methods for using evaluation as

a program

improvement tool as well as a means of program assessment

(26). Therefore, the picture below explains the application of

DEM based on research into the framework of the

development of the model Quality Health Outcomes

developed (30). There is a discrepancy between the health

HR candidates to the requirements (number and

qualifications), especially with the preventive function in

Puskesmas. The application of DEM in the framework of

research can be seen in Figure 1.

Literature Review

The term policy is often used widely, for example,

Indonesian Economic Policy, National Education Policy,

Health Policy and so on. Etymologically, the term policy

comes from Greek, Sanskrit, and Latin. The roots of words in

Greek and Sanskrit policies (city-states) and pur (cities) were

developed in Latin into politia (state), and finally in medieval

English became policie, which meant dealing with public

problems or government administration (12). According to

Parson (11), the policy can be interpreted as written rule and

the formal decision of an organization which regulates all

aspects of human life, whether in the private or the public

sphere.

Figure 1: Application of DEM in the framework of the research

The government has provided first-rate health care

facilities or health services that are directly faced with the

public primarily through public health centers (Puskesmas).

The term "public health" is used in a variety of ways – for

example, as a condition, an activity,

a discipline, a

Public policy forms, according to Baron and Amstrong

can be distinguished as follows: 1) rules or conditions

governing the life of the Community (Regulation); 2)

Distribution or allocation of resources.; 3) Redistribution or

reallocation; and 4) Supply or empowerment. Intended as a

modal or supplementing the community with the means that

need to be independent. The purpose of this policy is also to

equalization, but in this case more on equitable distribution of

capabilities (2).

profession, an infrastructure, a philosophy, or even as a

movement (3). According to Minister of Health Regulation

Number 75 of 2014, Puskesmas is a health service facility

that organizes public health efforts and first-rate individual

health efforts, prioritizing promotive and preventive efforts,

to achieve the highest degree of public health in the region it

works. To provide quality services, resources or health

workers are needed that can move them, even though the

adequacy of resources is insufficient to ensure that an activity

Journal of Environmental Treatment Techniques

2019, Volume 7, Issue 4, Pages: 588-594

or program can run properly, it is necessary to properly place

individuals in carrying out certain tasks according to their

abilities and of course qualifications education (20). The

World Health Organization (WHO) defining health workers

or health workers as "... all people engaged in actions whose

primary intent is to enhance health" (15,16). Based on this

definition, the International Standard Classification of

Occupation (ISCO) classify all workers engaged in the field

of health as health workers, the classification of ISCO can be

seen in Figure 2.

workforce in Puskesmas Banjarbaru city. As evaluative

research, it would like to know the benefits (worth) and

quality (merit) from the placement of health workforce

policies in the Puskesmas Banjarbaru city (35). The method

of study used the Discrepancy Evaluation Model by Malcolm

Provus. The informants are the official of the Office of

Health at Banjarbaru City, the official of Puskesmas, and the

community. The research focused on planning, recruitment,

selection, placement, and empowerment.

In this study, the researcher prefers to use the

Discrepancy Evaluation Model – DEM used to be a model

for the policy evaluation of the implementation of the health

workers placement in Puskesmas in the city of Banjarbaru,

South Kalimantan. The model chosen due to Malcolm

Provus, who created the model and introduced the concept of

evaluation can indicate whether

a policy has been

implemented in accordance with the standards that have been

set or not (26). In the DEM model, the evaluation conducted

by comparing the P (performance) on the field and S

(

standard). Provus mentions five stages of evaluation in

comparing P and S. The Discrepancy Evaluation Model

DEM) (13), developed in 1966 by Malcolm Provus, provides

(

information for program assessment and program

improvement. Under the DEM, evaluation defined as the

comparison of actual performance to the desired standard.

The DEM embodies five stages of evaluation based upon a

program's natural development: program design, installation,

process, product, and cost-benefit analysis (6,8). The

evaluation model stage (Difference Evaluation Model -

DEM), based on Input-Process-Output components and

subcomponents used during the study can be seen in Table 1.

The study used qualitative research and ADDIE model for

instructional design involved 34 subjects including 13

officials from the Office of Health of Banjarbaru city, the 6

head of Puskesmas, 12 officials from the administration sub-

division of Puskesmas who in charge to prepare a proposal of

health worker need which regularly prepared and submitted

to the Head Office of Banjarbaru city. From the community

level, 13 informants are selected from the outpatient who got

health services from Puskesmas.

Figure 2: Classification of health worker based on ISCO-88.

Resources: Working Together for Health: The World Health Report

006 (7)

So as not to cause confusion towards the definition of

health care worker mentioned in ISCO, the Legislation of the

Republic of Indonesia Number 36 the year 2014 on health

workers confirmed the definition of professionals in the

health field as a health worker in article 1 mentions; "Health

workers are any persons who are devoted in the health field

as well as having the knowledge and/or skills through

education in the field of health to a certain kind requires the

authority to make the health effort." Based on the RMH

number 75 the year 2014 about Puskesmas which become the

main government policy target to be evaluated.

Quantitatively, strategic health personnel (doctors,

dentists, nurses, and midwives) have been distributed, except

for dentist health workers who are still very lacking, giving

rise to inequity in health service use (4). The lack of a

number of health workers compared to the existing

Puskesmas makes the health workload of the health center

staff higher and not in accordance with the task, function, and

educational background. So that in the end, it has an impact

on decreasing the quality of services in the Puskesmas (21).

The planned promotive and preventive activities are not

scheduled on a regular basis, even some programs have not

been carried out at all due to lack of costs, lack of health

workers, lack of cooperation between health workers, cadres

and the community and there is no good management system

in carrying out these activities (37). The low quality of

Puskemas, caused because so far the activities or activities of

health human resources in the Puskesmas have never been

evaluated, (24).

4 Result and Discussion

4.1 Planning of Health Worker

The results of the interview with the Head of the

Department of HR Planning and HR Planning Section-Head

of Health Office Banjarbaru City, Head of Puskesmas, Head

of Administrative Section of Puskesmas, as well as

Surveillance Officer of Puskesmas, from the 6 Puskesmas’s

chosen, about the health worker planning. From the

perspective of evaluation by using the DEM method, the

policy or standard subject to be evaluated is the RMH

number 75 the year 2014. For the Health HR Plan, in the

article 33 paragraph 4 of the RMH 75/2014 mentioned that

the Head of Puskesmas requested to develop HR plan and to

submit the plan to the Health Office of Banjarbaru City. The

conclusion obtained is; 1) The needs of Health HR according

to the planning process is in compliance between S (standard)

and/with P (performance). In the implementation, all the

Puskesmas’s Heads drafting HR planning based on workload

analysis, then presented to the City Health Office and Office

Research Method

In general, this research aims to clarify the

Regional

Staffing

Agency

Banjarbaru.

implementation of the placement policy of the health

Journal of Environmental Treatment Techniques

2019, Volume 7, Issue 4, Pages: 588-594

Table 1: Design Criteria DEM Standard

Stages

Component

Input

Process

Output

Planning

HRD

Basic Policy Manpower Planning

Health issue at the health center

(1) Goal, (2)Target,

(3)Strategy

The need for permanent and

temporary staff determined.

The need for staff

. Permanent staff

a. Government

b. Contract

9 types of health staff recruited

1. The number of each type of

health staff, especially those

carrying out the preventive

function.

2. Permanent staff

a. Type of health function

position

. Temporary staff

a. Central hired

b. The district

hired

Criteria: (number, type,

qualification)

Recruitment

c. Local hired

d. Others:

b. Qualifications/ level of health

function position

Mobile team

Individual

Selection process:

. Administrative reviews.

. Academic test

. Competency /skill &

knowledge test

Candidate of 9 types of health

staff as many as needed selected.

Selections

9 types of health staff

. Personality test

. Medical test

. Interview

. Practical test

Conformity with the

requirements of the

recruitment (1)Number,

2)Type, (3)Qualification

Placement of 9 types of health staff

as needed and required by the

health center.

Appropriate (adequate), or Not

appropriate (discrepant) to the

policy

Placement

(

. Patient satisfaction. 2.

The development of skills

and capabilities

Empowerment

Appropriate or Not appropriate

Incompatible with the use of the

budget

In the aspect of the planning process, there is adequacy or

suitability between the S and the P. 2) The type and quantity

of the positions planned, in most Puskesmas, the type, and

the positions planned still dominated by the types and

positions which support the curative functions.Some other

Puskesmas already planning additional health workers by the

number and types of positions which support the preventive

function.

entirely as the national government. So the process of

recruitment will be carried out by the Central Government. b)

The whole recruitment process of local hired has already

been done in the Puskesmas. Health workers who locally

recruited by Puskesmas were included: medical doctor,

midwives, and nurses.

In the recruitment process is there any gap between S

(Standard-RMH number 75 the year 2014 with

(

Performance) during the implementation of recruitment by

.2 Recruitment Stage

Recruitment of health worker candidates at the

Puskesmas? S does not mention explicitly Puskesmas has the

authority to recruit health worker. The role of the Puskesmas

according to the S, mainly discussed how the Puskesmas

mandated by the Government to provide health services to

the community, as the front line government health facility

through the function of a curative and promotive function.

The role of Puskesmas Head on the health worker

recruitment according to the policy is to draft the worker

need and to submit it to the City Health Office for follow up.

Thus gap or discrepancy occurs between the S and P, at

the stage of recruitment. Because the S does not provide

authority to the Puskesmas to do recruitment. In P,

Puskesmas can do recruitment at any time when the status of

the Puskesmas has become autonomous. However, despite

Puskesmas has not become autonomous yet, several

Puskesmas recruited new apprentices staff who newly

Puskesmas does not always through the usual stages of the

recruitment process. The recruitment process through the

usual stage, for example by broadcasting information to the

public about position, duties and minimum qualification

required by the prospective employees to fill the vacant

position, yet can be done in the Puskesmas.

From the perspective of evaluation by the DEM method,

the conclusion of the health worker recruitment process is as

follows: a)The recruitment process of health worker,

depending on the position and the status of worker recruited.

For workers with the status as a government employee and

paid by the National Government then the entire process of

recruitment would be done at the central level and at the City

Government. The status of the promotive position will

Journal of Environmental Treatment Techniques

2019, Volume 7, Issue 4, Pages: 588-594

graduated from health and non-health education to work

voluntarily in the Puskesmas.

program. HR competency improvement activities

implemented in the Puskesmas in collaboration with the

Health Office Banjarbaru, colleges, as well as an institution

which has the credibility to issue a certificate of expertise

necessary for a health care worker to perform in more

professional duties. Strengthening the competence of the

existing health worker in Puskesmas implemented in two

aspects. The first aspect is the process of empowering health

workers conducted internally in a Puskesmas and given by

Puskesmas’s officials. The second aspect is the

empowerment process done outside the Puskesmas. The

empowerment process by external carried out by parties

outside the Puskesmas. The other important effort to build

the good teamwork for the Puskesmas’s employees is to keep

giving motivation to them by the Head of Puskesmas, or

providing continuous mentoring by the senior in the field of

certain professions to the employees of the Puskesmas. The

benefit of this motivation is to promote solid teamwork and

to increase their spirit to work well, at the time when the

Puskesmas employees confronted by the limitations of the

number of health workers. These were particularly necessary

for rural areas. Educational preparation was found to be

insufficient for the activities that graduates were engaged in

(14)

4.3 Selection Stage

The selection process as a continuation of the recruitment

process is not an authority of Puskesmas management. The

selection process which currently partly performed by

Banjarbaru Office of Health is a selection process conducted

nationally.

Is there a gap in the selection process between S

(

standard-RMH number 75 the year 2014) and P

performance) during the implementation of the HR selection

process by Puskesmas? In S it does not mention the authority

to process the selection for the health worker by the

Puskesmas. The focus of RMH number 75 the year 2014,

mainly to provide mandates to Puskesmas as the first and

front line government facilities to provide health services to

the community, through the function of curative and

preventive. The gap or discrepancy occurs between the S and

P, at the stage of selection. Because the S does not mention

the authority of Puskesmas to do worker selection process.

However, in P, there is an opportunity to Puskesmas to do

worker selection process for a local contract at the time when

the status of the Puskesmas has become autonomous

Puskesmas.

Whether in the process of empowering health workers

there is a gap between S (standard) and P (performance) the

implementation of empowerment by Puskesmas? At the S,

there is explicitly mentioned regarding the authority of

Puskesmas to facilitate the empowerment process or capacity

building of Puskesmas’s health worker. In the stage of

empowerment Puskesmas’s health worker, there is adequacy

or suitability between the S and P. There is no discrepancy or

gap between S and P.

.4 Placement Stage

a health worker who recently passed the selection process

is crucial. The condition of each Puskesmas from the

perspective of the number of health workers, almost the

same. Each Puskesmas has a problem of lack number of both

health workers and non-health worker. The head of sub-

division or Admin Head of Puskesmas Guntung Payung

illustrates the magnitude of the needs for a health care worker

to achieve good performance. Because the activities of

providing health services by Puskesmas is indoor (in the

Puskesmas care unit) and outdoor (at the community). If

measuring the number of the worker against workload,

following the standard of RMH 75/2014 with workload

analysis, then the current number of health workers in each

Puskesmas as the locus of study is sufficient. But when

looking at the activities of the Puskesmas both indoor and

outdoor, the existing number of health worker is insufficient.

objectively evaluated four different placement algorithms,

4.6 The Public Perception Towards Quality of Puskesmas

Service

In the DEM method, health worker empowerment

perspective is at stage five, the cost and benefit analysis.

According to Buttram (5), the DEM embodies the five stages

of evaluation, based upon a program's natural development:

program design, installation, process, product, and cost-

benefit analysis. The meaning of the cost and benefit

implications (benefit) is the social and political economy of

what is expected to be achieved from the implementation of

the health worker empowerment efforts in Puskesmas

Banjarbaru. The benefits of empowering health workers can

be seen from the perception of citizens as the end-user

against the quality of medical services by the Puskesmas.

The community perception obtained in the research gives

an indication of the level of community satisfaction over

Puskesmas services. Given this level of satisfaction while

providing an assessment of preventive and curative function

conducted by Puskesmas. The preventive function which

presented from the perspective of positive perception is a) the

officers of the Puskesmas often come to the village for the

integrated services post or Posyandu & extension, b) there

are Puskesmas’s officers to the school to do ORI program.

From the perspective of negative perception, have never seen

Puskesmas’s officers come to the village.

including

a novel algorithm for placement based on

identifying existing clusters (1).

Whether in the process of placing the health workers

there is a gap between S (standard-RMH number 75 the year

2014) and P (performance) in implementing worker

placement by Puskesmas? In S it does not mention explicitly

the authority of the placement process of the health worker in

the Puskesmas. Thus gap or discrepancy occurs between the

S and P, in the placement of health worker. However, in P,

health office and Puskesmas can do the placement of local

hired or apprentice worker at the time the Puskesmas’s status

is not yet autonomous, nor has become the autonomous

Puskesmas.

4.5 The Empowerment Stage

In the RMH number 75 the year 2014, article 6 paragraph

f, the stage to empower Puskesmas’s health staffs is

implementing human resource competence improvement

Journal of Environmental Treatment Techniques

2019, Volume 7, Issue 4, Pages: 588-594

Chowdhury, M., … Michael, S. Human resources for healthꢀ:

overcoming the crisis. The Lancet Journal. 2004; 364(figure 1),

Conclusion

The Stage of Planning. There is conformity or adequacy

984–1990.

Dessler, G. Human Resource Management. (E. Svendsen, Ed.)

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between S and P. While the stages of recruitment, selection,

and placement, the discrepancy are still happening. But the

value of discrepancy that happened will give opportunities to

improve the program. Because when in S, recruitment,

selection, and placement does not mention, but in P

recruitment, selection and placement have been done. So the

process of placing health care worker can be implemented.

The Stages of Recruitment. In the process of recruitment,

there is a gap between S with P. In S there is not mentioning

explicitly the health worker recruitment processes in the

Puskesmas. Thus gap or discrepancy occurs between S and

P, at the stage of recruitment. Because the S does not mention

the Puskesmas’s authority to do recruitment. However, in P,

Puskesmas can do recruitment at a time when the status of

the Puskesmas has become autonomous Puskesmas.

(

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