Decentralization of Health Service at Darussalam Public Health Center Medan

The problem with health decentralization in Indonesia is that health decentralization is still half-hearted. The policy direction in the health sector initially rested on efforts to treat disease and restore health. And next, policy direction has also shifted towards implementing comprehensive health efforts with an emphasis on disease prevention and health promotion. The shift also occurred in the focus of policy direction in the health sector, which initially focused on individual health, which then shifted to public health. This study aims to determine how the decentralization of health service delivery at the Darussalam Public Health Center, Medan City. type of research in this study is a qualitative research with a descriptive approach in the form of written or spoken words from people and observable behavior.

Konfrontasi Journal: Culture,Economy and Social Changes,9 (3) , 449-455 ISSN: 1410, 2716-2095 DOI: https://doi.org/10.33258/konfrontasi2.v9i3.238 http://www.konfrontasi.net/index.php/konfrontasi2 450 health center (internal) and the external environment that affect the basic guidelines applied by the center (Department of Health Strategy). Katarina, et.al (2007), "Decentralization is a major strength of health sector reform. On the one hand, the understanding of many countries about the benefits of decentralization is increasing, but on the other hand the knowledge of what factors influence the implementation of decentralization is still weak."

Fildza Hafart, Muhammad Husni Thamrin Nasution: Decentralization of Health Service at Darussalam Public Health Center Medan
Reflecting on the research of Suwarlan et al (2019), it shows that the low capacity of the regions is indicated by the small amount of local revenue (PAD); Not spurring regional innovation and creativity in elaborating regional potential; Dependence on the center, especially in the budget and regional independence has not yet been achieved, especially in financing the health sector. The word decentralization implementation in many countries has a large and positive influence on regional progress, for example on aspects of health services, provision of health facilities, health development, and increasing public participation in the formulation of health policies in the regions. Laksmiarti and Pranata (in yuniza, 2012) state that the existing health services in Indonesia are not evenly distributed and have not resulted in an increase in health development work as measured by improvements in public health status. There are some areas where the health services are adequate, but in other areas there are also areas where the health services are quite apprehensive. Whereas decentralization in the health sector aims to realize national development in the health sector based on community initiatives and aspirations by empowering, collecting, and optimizing regional potential for the benefit of the region.
The government tries to provide health services starting from the sub-district level, namely the public health center. Regulation of the Minister of Health of the Republic of Indonesia number 75 of 2014 concerning public health centers is a health service facility that organizes public health efforts and first-level individual health efforts, with priority to promotive and preventive efforts, to achieve the highest public health status in working area. Public health center is a functional organization that organizes health efforts that are comprehensive, integrated, equitable, acceptable and affordable by the community, with active community participation and using the results of the development of appropriate science and technology, with costs that can be borne by the government and the community.
In general, health services provided by public health center include curative (treatment), preventive (prevention efforts), promotive (health improvement) and rehabilitation (health restoration) services. The main activities carried out at the Darussalam Public Health Center Medan include maternal and child health (KIA), family planning (KB), efforts to improve nutrition, environmental health, prevention and eradication of infectious diseases, treatment including emergency services due to accidents, public health education, business school health, public health care, dental and oral health, mental health, eye health, simple laboratories, recording and reporting in the framework of health information systems. However, in health service activities at the Darussalam Public Health Center Medan there is still the possibility of patient dissatisfaction with services that are not in accordance with the wishes of the community. Public health service efforts in general are still not perceived as an individual need but have a broad influence on the health status of the community. Therefore, this effort must still get the budget from the government, both central and local. So that flexibility (autonomy) can be given to the form and type of individual health services only. The release of individual health services to the market mechanism is important so that public health center can be more creative and competitive with similar services according to the needs of the community in their working areas.
The implementation of health decentralization policies that have not been optimal has resulted in the emergence of regions that are getting poorer, while others are getting richer. If the decentralization policy is carried out wholeheartedly, there should be coordination between the center and the regions, agreed and mutually willing, and there is a spirit of togetherness (ugm.ac.id, 2009). The policy direction for the regulation of the health sector is defined as the extent to which laws and regulations give authority to local governments to regulate health affairs. Meanwhile, broad autonomy in question is the granting of authority by the central government to regional governments to regulate and manage their interests according to regional conditions and not to violate higher legislation (ugm.ac.id, 2016). Therefore, research on the implementation decentralization of health services at the Darussalam Public Health Center Medan needs to be carried out, so that services that are less than optimal can be improved and services with the best quality values can be maintained. The success of decentralization can be seen from the decentralization indicators, namely; authority, resources, and public access.

II. Research Methods
The method used in this study is a qualitative research method. According to Bodgan and Taylor (in Moleong, 2006) qualitative research methods are research procedures that produce descriptive data in the form of written or spoken words from people and observable behavior. In their opinion, this approach is directed at the background and the individual holistically (whole). The data collected is in the form of words, pictures, and not numbers. The researcher will determine the informants in his research by using purposive sampling. Purposive Sampling (Sugiyono, 2011) is a sampling technique based on certain considerations based on meeting information needs. Without knowing the data collection techniques, the researcher will not get the expected data (Sugiyono, 2016). Data collection techniques used in this study include; interviews, observations, and documentation. Moleong (2006:247), a qualitative analysis technique is carried out by presenting data starting with examining all available data, examining, compiling them in one unit, which is then categorized in the next stage and checking the validity of the data and interpreting it with analysis according to the ability of research reasoning to make research conclusions.
To ensure complete data/information and high validity and reliability, qualitative research uses triangulation techniques. Wirawan (2011:156-158) states that triangulation is a research approach that uses a combination of more than one strategy in one study to collect data/information.

III. Results and Discussion
The Darrusalam Public Health Center is located in Medan Petisah District which consists of 2 (two) sub-districts, namely Sei Sikambing D and Sei Putih Barat. The Darussalam Health Center is located at Jalan Darussalam No. 40 Kelurahan Sei Sikambing D is a public health center with the category of Urban Health Center with the type of firstrate outpatient service in Medan City. The Darussalam Public Health Center has the responsibility to provide health services to the 2 urban villages with an environmental area of 176.98 hectares and a population of 25,748 people. The implementation of decentralization of health services at the Darussalam Public Health Center Medan can be seen from the decentralization indicators, namely; authority, resources, and public access.

Authority
Authority as stated by Deliarnoor, et al (2017) and draws relevance according to Rondinelli's (1999) opinion is the ability of local governments to carry out planning, budgeting, and management to meet their own household needs. Of all the powers that have been given or decentralized, which specifically is how the Medan City government through the Health Office and Darussalam Public Health Center prepares planning, budgeting, and managing health affairs as one of the affairs related to basic services. The authority given to the Darussalam Public Health Center in planning, budgeting and managing runs as it should. This means that the Public Health Center is given the authority which includes planning, making a budget for the needs of the Public Health Center and managing the Public Health Center. However, these processes must go through the Medan City Health Office and still receive supervision and approval from the Medan City Health Office.
Planning, the authority given to the Darussalam Public Health Center in planning in general in the form of preparing health service needs, for procurement carried out based on a proposal from the public health center in coordination with the Health Office. Furthermore, the Department of Health has the authority to approve or not. Planning in carrying out health services as a whole is carried out by the Darussalam Health Center, all matters relating to health service procedures are the authority of the public health center. However, public health center which are the Implementing Units of the Medan City Health Office must still seek approval from the Medan City Health Office to comply with the policies issued by the Regional Government. This is because the Medan City Health Office is then responsible for all services carried out by health centers throughout the city of Medan, including the Darussalam Health Center.
Budgeting, the source of the budget at the Darussalam Public Health Center comes from the Health Operational Costs (BOK) and the Health Social Security Administering Body (BPJS). The BOK is planned by the Darussalam Public Health Center to meet the needs of health services for a period of one year, then the BOK is submitted to the Medan City Health Office. The BOK comes from the APBD, so the fulfillment of the needs that come from the BOK is adjusted to the available APBD. So it can be said that the Health Service determines how much budget can be allocated for the BOK Darussalam Public Health Center. Then BPJS Health funds go directly to the Darussalam Public Health Center account, but any budget planning made by the Darussalam Health Center must still get approval from the Medan City Health Office. The authority in budgeting the need for health services at Darussalam Public Health Center still relies on the Medan City Health Office. This of course can be an obstacle in the budgeting process in meeting the needs of health services. All the needs needed by the Darussalam Public Health Center cannot be done quickly and precisely, so if there is a sudden need it cannot be met quickly because it must obtain prior approval from the Medan City Health Office.
Management, Darussalam Public Health Center has the authority to manage BOK and BPJS Health funds which have been approved by the Medan City Health Office. The operational management of the Darussalam Public Health Center is under the authority of the Darussalam Public Health Center as long as it has been approved by the Medan City Health Office. So BOK and BPJS Health funds can be allocated according to the plans that have been made previously. The management of health services at the Darussalam Public Health Center can run smoothly according to the plans that have been made previously.

Resources
To be able to carry out the task of autonomy as well as possible, of course, really need the support of good and quality resources. The implementation of decentralization will be difficult to implement without the support of adequate resources. Resources in question such as; human resources, finance, infrastructure, and equipment.
Human resources, there is still limited administrative staff that has not been fulfilled in supporting the successful implementation of health decentralization at the Darussalam Public Health Center. Of course, this condition has had a major impact on health services, especially for reaching services to the community. The existing stakeholders are very aware of this, even though the actual achievements from year to year are not non-existent, but still not optimal. The problem of the availability of health workers cannot simply be said to be regional incompetence, if it is traced in more detail the very close relationship with policies from the center such as the very limited quota of health workers and administrative personnel in the selection of Candidates for Civil Servants. Not all of the existing personnel are civil servants. To overcome the problems of health workers in the city of Medan, more serious and comprehensive steps are a necessity to be carried out, given the very importance of the availability of health workers both in terms of numbers and adequate qualifications in achieving the vision and mission of the city of Medan, especially in the development of the health sector. Of course, the support for additional quotas from the center is very decisive and helps in overcoming the problem of limited health personnel, which is very crucial to be fulfilled as soon.
Finance, there are two main cost components at the Darussalam Public Health Center, namely BOK (Health Operational Assistance) and BPJS (Social Security Administering Body) Health funds. The institutional capacity of a region in managing funds is the ability to explore their own sources of income. One of the goals of implementing decentralization in Indonesia is to make the regions more prosperous economically. Constraints in the process of financial resources between the Darussalam Public Health Center and the Medan City Health Office are quite long. After the Darussalam Public Health Center submits their financial needs, the Darussalam Public Health Center can only wait for an indefinite period of time. This causes many needs at the Darussalam Health Center to be hampered. The the Darussalam Public Health Center does not have a special budget to run operations apart from the BOK and BPJS which must obtain prior approval from the Medan City Health Office. The institutional capacity of a region in managing funds is the ability to explore their own sources of income. This means that the Darussalam Health Center must have the authority and ability to explore its own financial resources, as well as manage and use them to finance the provision of health services.
Infrastructure, the availability of health infrastructure is an important part that supports the implementation of decentralization of health at the Darussalam Health Center. With a working area covering 176.98 hectares, the availability of infrastructure is an absolute must in order to bring services closer to the community to create a better level of public health. The Darussalam Health Center itself already has adequate infrastructure. This infrastructure development itself is inseparable from the decentralization given by the central government to local governments. However, regarding maintenance, there are still obstacles, this is due to the problem of maintenance costs included in the budget planning so that if there is infrastructure that starts to break, it must wait for approval from the Medan City Health Office.
Equipment, the equipment available at the Darussalam Public Health Center is adequate to provide health services, but rejuvenation related to the health equipment must also be carried out to provide consistent and more optimal services. For the equipment itself, it is also adjusted to the budget from the Medan City Health Office. However, the health equipment available at the Darussalam Public Health Center still needs rejuvenation. Because equipment that is no longer suitable for use must be immediately replaced with new ones to optimize health services provided to the community. In contrast to infrastructure, related to equipment financing, BPJS Health funds can use BPJS Health funds, although there is a need for approval from the Medan City Health Office, the allocation can be realized more quickly.

Public Access
The cost of medical treatment is often a serious obstacle in health development in Indonesia, especially for the poor and experiencing severe health problems. In general, public access to health services at the Darussalam Public Health Center can be said to be relatively affordable, especially at the First Level Health Facilities (FKTP). Access related to costs can already use BPJS Health by fulfilling predetermined conditions, so that people do not find it difficult to get health services at relatively affordable costs. However, the procedure for administering BPJS seems to need improvement so that people don't complain about the administration that seems slow.
Distance access to reach health services at the Darussalam Public Health Center is not difficult. Geographical location in urban areas and road access that has been touched by development make the Darussalam Public Health Center very easy to reach by the community. The problem is if people who are outside the working area of the Darussalam Public Health Center do not bring complete administrative files, so that the Darussalam Public Health Center cannot process services. Decentralization of health services provided for equitable distribution of health through public health center is very effective in providing health services to the community without having to go to a public hospital which incidentally does not always reach every ward in Medan City.
In addition, the access to transportation at the Darussalam Public Health Center is quite good. The availability of transportation facilities is already available at all public health center and can be said to be ideal. With a very wide service area and a very large number of people, of course, vehicles such as ambulances really help people access to get maximum health services.

IV. Conclusion
The phenomena analyzed in the field were three indicators that were studied in the implementation of health decentralization at the Darussalam Public Health Center, namely the factors; Authority, Resources, and Access. It was found that the implementation of health decentralization at the Darussalam Public Health Center which was actually aimed at realizing the independence of health institutions was still marked by a number of positive and negative findings. The authority of the Darussalam Public Health Center in planning, budgeting, and managing health services still depends on the Medan City Health Office. The planning, budgeting, and management processes are still relatively slow because they must get approval from the Medan City Health Office. The resources owned by the Darussalam Public Health Center can be said to be sufficient in terms of infrastructure and equipment. However, in terms of resources, there needs to be improvements to cover existing deficiencies such as a shortage of administrative and health personnel and for finance the public health center must also follow the budget from the Health Office not from the APBD, in this case the Darussalam Public Health Center can only submit these deficiencies to the Medan City Health Office because the one who has the authority to make repairs is the Medan City Health Office. Regarding the access provided by the Darussalam Public Health Center in providing health services to the community, it has been very good. Starting from finance, the public can use BPJS Health access. The distance is not far from the residential community is also very easy to access. There are also many available transportation facilities to access the Darussalam Health Center.