INTRODUCTION
The main duty of the nation in performing governance as mandated in the constitution is serving people fairly and equally (Denhardt and Denhardt, 2003). One service performed by the government of the many services available is in public health.
Although the task of public services is the main function of the government, in its development, not all of these tasks can be performed by the government, thus allowing some functions of public service be performed by private institutions in accordance with the effective regulations (Osborne and Plastrik, 2004). Such policy of service-performing is to allow public participation in providing public service so that the in need can have easier access to available services (Simatupang and Bake, 2011 ; Lanin, 2010).
One public service whose performance is still dominated by the government, particularly the service for the underprivileged is in health sector. There is already private sector participation in the performance of this
service, but the regulation for operating its activities is still made and controlled by the government (Mahsyar, 2011). Government’s involvement in health service is fully required since the majority of public cannot access the available health services.
Some policies with populist tendency have been made for providing health service for the underprivileged, such as free health service policy through Jamkesmas program (Public Health Security) provided by the Central Government and Jamkesda provided by the Local Governments. Such service for the public is provided at the level of Puskesmas and for further treatment the patient can be transferred to referral hospital (Mahlil, 2011).
Concerning health service provision, referring to the existing policy, there are some aspects preventing the optimization of service performance, due to the lack of adequate resources. This situation often confronts the bureaucrat especially the street-level bureaucrats with dilemma in performing their duties (Widaningrum, 2006).
This dilemma emerges since on one hand bureaucrats are demanded to give their best effort in serving public as
The Interaction Model Between Street-Level Bureaucrats and the Public in Health Service Provision at Puskesmas
ABDUL MAHSYAR
Faculty of Social and Political Sciences, Magister of Public Administration Postgraduate Program, Universitas Muhammadiyah, Makassar, Indonesia
Abstract. This research aims at studying and explaining forms of coping behaviors and public respond to coping behaviors as shown by health service officers at street-level bureaucrats in Puskesmas (Public Health Center). The research was conducted in six Public Health Centers in Makassar, employing qualitative approach and naturalistic method. The data were gained from informants, i.e. Puskesmas officers and public patients visiting the Puskesmas as the primary data source, and the secondary data were gathered from documents available in the concerned institutions. Research data were collected through in-depth interviews, direct and participative observations. The research data were then analyzed qualitatively through data reduction, data presentation, deduction and data verification. The results of the research show variety of interactive models as a form of coping behaviors performed by bureaucrats in providing health service, namely the behavior of limiting services, rationing services, giving special treatment, ignoring, and prioritizing. The performed coping behaviors benefit the officers since their obligations were accomplished, though at minimum level. Public responds to coping behaviors quite vary but in general shows positive responds.
Keywords: behavior, coping behaviors, street-level bureaucrats
Abstrak. Penelitian bertujuan mengetahui dan menjelaskan bentuk-bentuk coping behaviors dan respon warga terhadap coping behaviors yang ditampilkan petugas pelayanan kesehatan pada tataran street-level bureaucratsdi Puskesmas. Penelitian dilaksanakan pada enam Puskesmas di Kota Makassar menggunakan pendekatan kualitatif dengan metode naturalistik, sumber data diperoleh dari informan petugas layanan kesehatan dan warga masyarakat yang berkunjung ke Puskesmas sebagai sumber data primer, dan sumber data sekunder diperoleh dari dokumen yang tersedia pada instansi terkait. Data penelitian diperoleh melalui wawancara mendalam, observasi langsung dan partisipatif.Data penelitian dianalisis secara kualitatif melalui tahapan reduksi data, penyajian data, pengambilan kesimpulan dan verifikasi data.Hasil penelitian menunjukkan keragaman model interaksi yang merupakan bentuk coping behaviors yang ditampilkan oleh birokratdalam memberikan pelayanan kesehatan yaitu bentuk perilaku membatasi layanan, menjatah layanan, memberi perlakuan khusus, mengabaikan, dan perilaku memberi prioritas.Coping behaviors yang dilakukan memberi keuntungan bagi petugas karena tujuan pekerjaannya tercapai secara minimal, dan respon warga terhadap coping behaviors cukup beragam tetapi pada umumnya memberi respon positif.
Kata kunci: coping behaviors, perilaku, street-level bureaucrats
mandated in the effective regulations, on the other hand they are not supported by organizational resources in performing their duties (Winter, 2002). Should they fail to finish their duties or accomplish the target as planned, the consequences are sanction or bad assessment from their superiors.
To cope with the problems, street-level bureaucrats, like officers at Puskesmas, make various efforts to manage or handle the lack of resources so they can fulfill the responsibility in serving public health effectively. These efforts are what Lipsky (1980) called as coping behaviors, kinds of behavior conducted by individuals to overcome, handle or control particular situation as outcomes of the lack of resources. This research is focused on the types of coping behaviors conducted by bureaucrats, as well as public responds to the coping behaviors conducted by the health service officers at Puskesmas in Makassar.
Individual behaviors in a bureaucracy are always guided by the regulation in effect inside the organization, therefore, this study, analyzing the behaviors of street- level bureaucrats in giving public health service at Puskesmas, is expected to generate results that can be useful and provide solutions for similar officers to cope with or control the limited resources in health service provision for public; thus the positive coping behaviors can be taken as a model.
RESEARCH METHODS
This study employs a qualitative approach with naturalistic method; it is a case study (Yin, 2003). The research object is the interaction between the bureaucrats providing the health service and the public using the health service at six Puskesmas in Makassar. Informants for this research include the officers providing health service, the public using health service in Puskesmas, and higher officials related to the implementation of health service in Makassar.
Research data were gathered through interviews, field and participative observation, and secondary data were collected through public service documents. The data gathered from the field were then scrutinized to ensure their validity, through four techniques according to Denzin and Lincoln (2009) namely by noticing their credibility, transferability, dependability, and conformability.
RESULT AND DISCUSSION
Street-level bureaucrats are the foremost apparatus having routine direct interaction with public in the implementation of government programs or policies (Lipsky, 1980). Particularly in the government implementation of public health program at health service institutions, they work at the organization or working unit of Puskesmas. These street-level bureaucrats are key actors in the policy implementation process (Lipsky, 1980).
There is a dilemma faced by street-level bureaucrats in providing routine service duties for public: they are confronted by uncertainties (Lipsky, 1980). Organizational resources are sometime inadequate while public demands are sometime unpredictable; therefore, these street-
level bureaucrats often take their own initiative to manage or overcome the inadequacies through coping mechanism (Winter, 2002). The study on these street- level bureaucrats finds a symptom of similar behavior in the implementation of policies whether conducted by doctors, social workers, teachers, police, or others. These similar behaviors are caused by similarities in working structures and conditions. One of the most fundamental problems encountered by street-level bureaucracy is inadequacies of resources they have to fulfill the demands of clients (Lipsky, 1980).
Specifically, in cases of implementing public health service, just like in Makassar, Puskesmas is still the public’s main choice to access health service (to cure or get treatment for their diseases), particularly for the underprivileged. They select Puskesmas mainly for its non-paid service programs, or its low cost payment even if they should pay. In Makassar, there are about 43 units of Puskesmas in 2012, a rapid growth compare to just 16 units (year 2008) dispersed in 14 sub-districts (BPS Makassar, 2013). This amount of Puskesmas is actually insufficient compared to ratio of Makassar inhabitants. Below is the data of public visits to Puskesmas in Makassar based on the type of visit in the last three years (2010-2012).
The data above depict that from the total amount of visitors to Puskesmas there were more ill visitors than healthy visitors. It means that some Puskesmas programs such as counseling and disease preventing programs are still not optimally implemented. The considerable numbers of visitors show that the public has become more aware of the importance of health. On the other hand, Puskesmas service unit is overburdened and lacking the ability to perform programs integrally in providing premium service for public as the result of the lack of resources possessed, such as inadequate medical and non- medical facilities and infrastructures of service, lack of human resources both quantitatively and qualitatively, and limited budget. Therefore, the method taken by Puskesmas Management to minimally perform some programs is by conducting coping behaviors, particularly for medical service activities (medication and treatment).
The results of study on coping behaviors by street- level bureaucrats in public health service in Makassar shows some forms of coping mechanism performed by Puskesmas officers, namely:
The first one is the behavior of limiting service. This behavior emerges since the many health service programs to be offered at Puskesmas are incomparable to the number
Table 1. Data of Public Visit to Puskesmas in Makassar
Year Type of Visit
Total
healthy ill
2012 548,544 1,438,802 1,987,346
2011 506,089 1,370,599 1,876,688
2010 460,706 1,561,199 2,021,905
Total 1,515,339 4,370,600 5,885,939
Source: Health Service Management Sector of Makassar Health Agency , January 2013
of available resources; the officers cannot perform some programs simultaneously. This happens particularly in the implementation of medication and treatment service for patients visiting Puskesmas, since the number of patients who come for medication every day is quite numerous;
hence the service officers become rather overburdened in giving services to all incoming patients. Patient registration record in one of the Puskesmas shows that the number of incoming visitors every working day is about 90 to 150 patients registered in large Puskesmas, while in small Puskesmas, the number of registered visitors is no less than 60 every day (Makassar Health Office, 2013).
These numbers could grow higher if there is no restriction activity. The increasing number of Puskesmas visitors usually happens after holiday, for example on Mondays or other days right after the celebration days. This condition is not accompanied by adequate numbers of officers. Besides, not all Public Health Service programs are indoor, such as medication and treatment services, but there are also outdoor services of Puskesmas.
Coping behaviors mechanism conducted by officers to manage the service for patients is by restricting the number of patients registering at registration window.
Restriction of the number of patients is conducted by closing registration window early so that the flow of service stopped from reaching medical act namely examination and treatment by doctor. Regulation states that registration window should be opened from 8 a.m. to 2 p.m. proper to working hour. However, restriction of the number of patients permits officers to close the window at 11.00 a.m. or even earlier when there are so many visitors.
This service restriction behavior conducted by officers particularly in medication and treatment service is conducted to manage the number of patients served every day particularly when not many doctors can conduct examination or when some officers do not come to work.
Without restriction, there will be too many patients so that service time or working hour will increase; in addition, the performance of other programs such as health promotion, information and patient administration arrangement can be hampered.
The second behavior is service rationing. This kind of behavior is opted by health service officers in Puskesmas since they prioritize the urgency of a program or accommodate public needs. The health service programs conducted at Puskesmas, in fact, give a bigger ration on patient medication and treatment services, although it should be given to the health promotion or information program. So, in reality the opposite happens, thus Puskesmas is only known as a medical clinic curing illness, instead of preventing it.
The coping behavior conducted by officers is giving more ration to the service for patients, coming for medication, treatment, or asking referral for further treatment in hospital. This behavior occurs since other service-programs at the Puskesmas cannot routinely or periodically be performed, while medication and treatment service program is the main function that should be performed every day and is the main indicator for public in assessing the performance of a Puskesmas.
The third one is special treatment. This kind of behavior is shown at the action conducted by service officers by giving special treatment to certain patients, particularly in the programs of medication and treatment.
Special treatment in serving patient can be observed in the arrangement of patients at the registration window and waiting room, in the medication and treatment action, and in the implementation of other outdoor main programs.
Special treatment is intended to provide convenience for special patient such as those with certain contagious diseases that potentially infect other patients. This kind of patient is served in special medication room separated from service room for general patient. In addition to that, Puskesmas also provides special treatment for old aged patients and children. Particularly for old aged patients, they are provided with special treatment such as being prioritized at registration window so that they do not have to queue, as well as during medication and treatment.
This special treatment behavior shows that street- level bureaucrats in performing their duties possess the authority to modify their works which they perceive appropriate to give convenience or contentment to service user. Furthermore, this behavior is not free from the interests of the apparatus (bureaucrat), i.e. to ease them in performing their duties.
Adjustment conducted by street-level bureaucrats in performing their duties is basically very helpful in the performance of their duties, and what they do is considered legal since available service procedures have been standardized in a standard operational procedures (SOP) as reference for all service activities. Therefore, despite the special treatment, other members of public do not question it for being unfair. On the contrary, it gains positive respond from Puskesmas service users since it is considered quite helpful and can also protect them from the threat of certain contagious diseases.
The fourth one is the behavior of ignorance. Ignorance behavior is a coping mechanism, shown from the action of letting the patient to wait for a long time without any treatment, paying no attention to the patient’s needs, becoming ignorant, controlling the work, acting know all, refusing patient, and various other forms of ignorance that encumber patient with psychological burden.
Ignorance behavior usually emerges when the officers face unsympathetic people or patient who tends to think that they know the duties of Puskesmas, cannot be organized, or demanding too much from the organization.
Moreover, ignorance behavior is also shown by service officers, whether doctors or paramedics or service administration officers, when they face patients, deemed unqualified for service procedures determined by Puskesmas. For example, when the patients come late or exceed patient registration window open hours, or when the patient does not come equipped with required administrative documents for free health service. As publicly known, free health services are given to people with administrative identity such as Public Health Security (Jamkesmas or Jamkesda) card, Health Insurance card for civil servants, and Citizen Identity card proper to service area of the Puskesmas.
Ignorance Behavior is also shown consciously or unconsciously by the officers when simultaneously they (medics and paramedics) have other necessity in connection to their agencies, for example when the officers are invited to a meeting at Health Agency Office or other agencies. These officers will prioritize such agency business compared to serving patient; they often let the patients to wait. Other behavior of ignoring certain patient is when the service officers are about to perform other Puskesmas programs, for example outdoor programs such as information pro/gram, house visit, and environment sanitation program. Such programs limits the time for medication service program so that patient needing medication or treatment will not be served and will be advised to come on other working day instead.
The fifth one is prioritizing behavior. Coping behavior conducted by street-level bureaucrats often evokes prioritizing behavior to certain program over other programs of the Puskesmas. Puskesmas programs are comprised of indoor and outdoor programs. Moreover, some programs are principal necessities of public while other programs are deemed unnecessary by public, although all Puskesmas programs are actually synergetic to each other with equal urgency levels.
Prioritizing behavior is conducted by Puskesmas apparatus in order to perform certain service program considered by the apparatus as necessary for public. In this matter, Puskesmas apparatus have identified which program is probably necessary for public. Service program prioritized as seen in general is medication and treatment service program. In addition, usually when there is a special case, drawing public attention and highlighted by media, it will be given sudden priority by the officers, for example cases like malnutrition, dengue fever plague, and avian influenza. When such incident occurs, usually the officers prioritize the settlement of these cases.
The kinds of coping behaviors shown by street-level bureaucrat emerge or are conducted consciously or unconsciously. In other words, whether they are planned or not, these behaviors have goals namely to overcome or manage the lack of resources possessed by the organization to perform its services. This management effort is intended to accomplish the goal of service for Puskesmas users although minimally. To be clear, coping behaviors conducted by the service officers (street-level bureaucrats) benefit them in their performance assessment since the service duties as their responsibilities can be performed although minimally.
The responds from public concerning coping behaviors as shown by street-level bureaucrats in giving public health service at Puskesmas in Makassar quite vary.
There is no extreme respond, meaning that the public shows both positive and negative responds. However, negative responds from public do not mean their refusal or antipathy towards coping behaviors conducted by the service officers. They just show their discontentment of the coping behaviors shown by street-level bureaucrats.
Public responds to coping behaviors conducted by health service officers at Puskesmas are as follow: First, towards service restriction behavior. The majority of
public rates this kind of behavior in general as negative.
As explained by some members of society, they have the rights for health services, so when officers show service restriction behavior, it can be seen as a kind of violation of regulation, since it limits public rights to accept maximum service. As can be seen in the service implementation at Puskesmas, particularly medication, examination and treatment of patient. Whereas the Puskesmas management confines service hour (registration window open time) only until 11.00 a.m. every working day from Monday to Saturday. This is conducted to prevent long queue (waiting time) of patients, which later will prolong working hours of the officers even exceeds office hour.
Meanwhile the public wishes patient registration window to open in accordance to office hour.
The second one is for service rationing behavior.
Public respond to service rationing behavior shows positive ones since the service programs prioritized in Puskesmas are medication, examination and treatment of patients. While other programs, although kept performed, are relatively less in frequency compared to medication service program. Therefore, service rationing behavior gets positive responds from public. Although some informants rate service rationing behavior negative for the difference in priority among service programs available at Puskesmas, public demand for medication and treatment program is relatively high; thus service rationing in Puskesmas programs is rated positive by public, since it is often conducted by the officers with regards to public needs.
The third one is special treatment behavior. The coping behaviors conducted by public health officers by giving special treatment to certain patients gets positive responds from public. Special treatment is given at some Puskesmas possessing special service facility for certain diseases suffered by patients, particularly in certain disease cases highlighted by public or mass media.
Special treatment behavior is also conducted by officers to provide convenience for certain members of public, for example old aged people who come for medication and mothers carrying babies, so that the members of public get faster service in accordance to the condition so that they do not have to wait too long in line.
The fourth one is ignoring behavior. Ignoring behavior is a kind of coping behaviors conducted by street-level bureaucrats when there are activities to be contemporary done by officers, whether doctors or nurses, concerning agency matters or not. Ignoring behavior also usually emerges from the attitude of service officers when they face patients with too many demands or think they know the duties ideally conducted by the health service officers.
Ignoring behavior is also rated by some patients (public) who feels they do not get maximal service, for example when the doctors do not adequately communicate with patients during examination or consultation. As mentioned by one of the patients, ”It seems like the doctor is in a hurry in examining patient, we have not even asked about the cause of the disease, the doctor has already written receipt and told us to go to the medicine teller”. This informant’s explanation shows that ignoring behavior is responded negatively by the public.
The fifth one is prioritizing behavior. This behavior can be seen in cases of service performance at Puskesmas. Some kinds of this behavior are: Puskesmas officers concentrate more on certain services or service programs that draw many attentions from public. All Puskesmas in Makassar region prioritize the program of medication, examination and treatment of patient more than other health service programs that are also their duties. The same thing is applied in almost all Puskesmas in Indonesia. In accordance to this condition, public, in general, see the function of Puskesmas as a clinic for medication and treatment of illness, although the real function of Puskesmas is basically as the place of preventive activities so that public do not get infected by diseases or can live in good health condition.
Public respond to this prioritizing behavior is in general positive, particularly by those often visiting Puskesmas for medication. This is connected to the priority selected by all observed Puskesmas in medication, examination and treatment of patient. The public judges that although other programs do not get their portion of performance, it is not a problem since they are deemed unimportant. What public deem important is indoor service program. If medication service activities are not optimum, as the consequence, the officers are deemed fail to give health service in accordance to public demand.
Based on the responds from the public (patients) receiving services from Puskesmas towards coping behaviors conducted by street-level bureaucrats performing health service, in principles, they can accept the behaviors or generally give positive responds. The reason for this is because some kinds of coping behaviors give convenience to and benefit public. On the part of the officers, coping behaviors conducted by street-level bureaucrats, whether intentionally or unintentionally, actually fulfill the goal of the behaviors namely attempting to overcome, surpass or control the situation of their working condition, when they face client and get in a situation of working uncertainty, due to the lack of organizational resources
CONCLUSION
The results of this research conclude that coping behaviors conducted by street-level bureaucrats in public health service at some Puskesmas in Makassar show some kinds of coping mechanism, i.e. service restriction, service rationing, special treatment, ignorance, and prioritizing behaviors. Varieties of coping behaviors shown by street-level bureaucrats conducting health service at Puskesmas in Makassar are not constant or very situational depending on the condition of patients (service acceptors) since every individual performing service can behave differently when encountering different client (public/patient) in different situation.
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