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EXECUTIVE SUMMARY

Governance in Health

Minimum Service Standards (MSS)

at District & City Level

USAID-KINERJA Learning Series

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INTRODUCTION

Public service improvements at service units managed by local governments are mandated by various laws, including the Law No. 25 of 2009 on Public Service and the Executive Decision of the Minister of State for Administrative Reform No. 63/KEP/M.PAN/7/2003 on General Guidelines for the Implementation of Public Services.

With the supports from USAID, Kinerja has provided technical assistance to improve quality of public services in 20 partner districts/cities in four provinces in Indonesia (Aceh, East Java, West Kalimantan and South Sulawesi). The program focuses on enhancing capacity of the service providers (supply side) and the service users (demand side) in basic education, basic health, and business enabling environment. In its third year, KINERJA adapted its approach to address health issues in four districts/cities in Papua.

In the health sector, Kinerja encourages local governments to improve and to increase services for mothers and children, particularly with regards to Safe Delivery, and Immediate & Exclusive Breastfeeding (I&EB). The service improvements enable the service units to undertake its activities in achieving Public Service Standards (PSS), Minimum Service Standards (MSS), National Standards, and the Millennium Development Goals (MDGs).

KINERJA also encourages the districts/cities to issue policies which support the replication and dissemination of the maternal and child health services to other regions. In order to assist the local governments and stakeholders improving their services, this module has been developed as a reference material for training, mentoring, and implementation. The module is expected to help local governments in applying good governance and assessing the level of resources needed to achieve the targets of MSS in health (MSS costing). The module also contains list of Kinerja’s partner organizations and consultants who can help local governments implement the program.

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INTRODUCTION 1

TABLE OF CONTENTS 2

CHAPTER 1 EXECUTIVE SUMMARY 3

Kinerja’s Objectives and Achievements 3

Recommendations for Local Government Managers 6

Recommendations for Candidates of Implementing Organizations 6

Recommendations for Education and Training Institutions 7

CHAPTER 2 KINERJA’S APPROACH 8

Kinerja’s General Approach 8

Principles of Health Governance 9

Elements and Stages in MSS Costing for Health 10

CHAPTER 3 KINERJA’s EXPERIENCE IN MINIMUM SERVICE STANDARDS FOR

HEALTH 12

MSS Conditions in the Field 12

How Kinerja Began Working 13

Work Process 15

CHAPTER 4 ADDRESSING CHALLENGES AND ACHIEVING SUCCESS 18

Challenges 18

Program Success 19

CHAPTER 5 RECOMMENDATIONS FOR REPLICATION 22

Recommendations for Governments Interested in Replicating Kinerja’s

Approach 22

Recommendations for Consultants and Implementing Organisations 23

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CHAPTER 1 EXECUTIVE SUMMARY

Kinerja’s O

bjectives and Achievements

1. Objectives

Kinerja is a good governance program focusing on improving public service delivery in the sectors of basic education, maternal and children health, and business enabling environment. The project is funded by USAID and implemented by a consortium consisting of RTI International as the lead firm, The Asia Foundation (TAF), Kemitraan-Partnership, Social Impact (SI), SMERU Research Institute, and Gadjah Mada University (UGM). The program implementation period is five years from September 30, 2010 until February 28, 2015.

Kinerja’s programs are carried out in 24 districts and cities in five provinces – Aceh, West Kalimantan, East Java, South Sulawesi, and Papua. KINERJA works with district/city, provincial, and central governments, and implements the program through civil society organisations (CSOs) to improve participation, transparency, and accountability. The program strengthens local governments to become more responsive towards the public demand for better-managed public services.

Kinerja applies a double-sided approach, working with both service providers (the ‘supply side’) and service users (the ‘demand side’). The project encourages both sides to improve good governance. On the supply side, Kinerja supports district technical offices (eg, the health office), service units (such as community health centers), local governments, and local parliaments to implement effective and efficient management that leads to improved public services and the achievement of service standards. On the demand side, Kinerja facilitates activities aiming at raising public awareness and increasing public participation and oversight of public service quality. The program supports multi-stakeholder forums (MSFs), citizen journalists and alternative media, and other community forums who share the same concerns.

Working with the supply side, Kinerja builds capacity of service providers to adopt innovations in service management and good practices of public service improvements in order to achieve minimum service standard (MSS) targets. MSS is a list of the types and qualities of basic services that must be provided by district governments, and that each citizen should receive to a minimum level. Incorporating MSS into programs is mandated by the government regulations. For example, MSS in health is stipulated by the Health Ministerial Decree No. 741/Menkes/Per VII/2008 on Implementation of MSS in Health at the District Level. The standards are made up of

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Kinerja’s objectives can be identified as follows:

1. Creating incentives for local governments to improve services

Incentives encourage district governments and service units to perform better, through improved accountability and stronger citizen participation, rewards (or sanctions) for good (or bad) performance, and pride (or shame) when local government achievements are made public. Kinerja’s technical assistance aims at creating strong incentive mechanisms. For example, Kinerja assists with training citizens to have a more effective voice in advocating for public service delivery improvements, supporting local

governments’ performance management systems, increasing competition through benchmarking, and developing various award programs.

2. Encouraging local governments to adopt innovations in public services

Kinerja offers choices of targeted and well-designed technical interventions in three sectors; education, health, and business enabling environment. The program focuses on a limited number of critical elements that will have positive impact, rather than implementing diverse activities.

3. Replicating improved public service management systems to other regions with

assistance from implementing organizations and consultants. Kinerja hopes that replication will help expand its impact nationwide.

4. Applying a rigorous impact evaluation scheme using carefully selected control

districts and in-depth studies. The evaluation measures the program results to reveal the most effective intervention, why, and how.

2. Kinerja’s

Sites

Kinerja works in 24 districts/cities in 5 provinces:

1. Aceh: Aceh Singkil, Aceh Tenggara, Bener Meriah, Simeulue, and Kota Banda Aceh 2. East Java: Bondowoso, Jember, Probolinggo Tulungagung, and Kota Probolinggo 3. South Sulawesi: Barru, Bulukumba, Luwu dan Luwu Utara, and Kota Makassar 4. West Kalimantan: Bengkayang, Melawi, Sambas, Sekadau and Kota Singkawang

5. Papua: Jayapura, Mimika, Jayawijaya, and Kota Jayapura.

Of the 24 districts, Kinerja assisted 13 districts in round one and 17 districts in round 2 on MSS in health.

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3. Kinerja’s

Achievements in MSS Planning and Budgeting for

Health

Kinerja’s non-MSS health programs at the district level focus on maternal and child health, with a focus on safe delivery and immediate & exclusive breastfeeding.

In MSS for health, Kinerja’s assistance with planning and budgeting has resulted a number of key achievements along the length of the cycle:

Some examples of achievements at the drafting stage:

a) More districts are able to complete MSS planning and budgeting after being supported

for just six months. The planning and budgeting process includes revamping data

collection system for health MSS baseline calculation, analyzing MSS achievement gaps and their causes, identifying and prioritizing programs, and calculating resources needed to achieve MSS targets (MSS costing).

b) Some district governments have successfully integrated MSS costing results into the regional planning and budgeting. This achievement means that the district administration uses MSS to develop their plans and budgets.

Some examples of achievements at the implementation stage:

a) Some Kinerja-supported districts, such as Bener Meriah, Aceh Singkil, Jember, Singkawang and Bulukumba, have integrated MSS costing results into the district planning and budgeting. Singkawang incorporated the MSS costing results into the strategic plan of the District Health Office’s Regional Medium Term Development Plan

(RPJMD) 2013-2018. Jember used the MSS costing results to allocate more than 79

billion Rupiah (US$5.7 million) in the Public Financing Policies and Ceiling for Temporary Priority Funding (KUA-PPAS) 2014. The budget was used to finance health programs that aimed to meet key MSS targets.

b) Makassar City issued a Mayoral Regulation on the Implementation of Minimum Service Standards (MSS) for Health. The regulation includes sections on annual targets and program priorities which support the achievements of indicators and deadlines of health MSS for 2015. The targets and programs were established by the district health office, MSF, and Kinerja through referring to the MSS costing results.

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Recommendations for Local Government

Managers

Kinerja-supported MSS planning and budgeting programs have brought concrete results and changes to a number of districts throughout Indonesia.

Kinerja encourages district administration managers, particularly those from areas with limited budgets and big gaps in health care, to learn from the project’s experiences. Kinerja hopes these leaders will learn about health MSS costing and integration of the MSS costing results into planning and budgeting documents. Learning from the project’s experiences, Kinerja would like to make the following recommendations:

a) Strong commitment from local government leaders (district head/mayor, district parliament, district secretary, and head of district health office) is essential for the implementation of MSS in health.

b) Policies on public service provision should refer to MSS indicators in order for clear and easy measurement of achievements and outputs.

c) Civil society organizations/CSOs and community multi-stakeholder forums (MSFs) must be involved in health governance programs.

d) Existing staff, organizational structures, and local resources, such as Health Committees and universities should be empowered and used. It is not necessary to create new working groups.

e) Coordination among the district technical offices (such as the district health office) and other relevant local government agencies should be improved.

f) Performance indicators should be developed and program success should be measured.

g) Local government agencies can adopt Kinerja’s approaches and tools as supporting

instruments to improve public services.

Recommendations for Implementing

Organisations

Kinerja’s implementing organisations (IOs) and consultants are experienced in assisting district governments and community represenattives with MSS planning and budgeting for health. They are invaluable local assets. With this in mind, the project makes the following recommendations for IOs and consultants who will continue working on MSS in health:

a) To integrate good governance principles and involve the community in all activities and programs.

b) To focus on achieving results, rather than fulfilling activity schedules and meeting the required number of participants.

c) To provide stimulating advice and assistance, rather than acting as an employee.

d) To use Kinerja’s modules to improve capacities of IOs, local governments, and the community.

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Recommendations for Education and Training

Institutions

Government owned-education and training institutions are strategically positioned to build the skills of government staff. They have significant influence on government staff’s capacities because they provide them with regular trainings. Therefore, Kinerja recommends that training intuitions to adopt the project’s approach and good practices in their curriculum and trainings.

Kinerja particularly recommends:

a) involving citizens in the implementation of good governance, as citizens are the users of public services.

b) focusing more on improving skills rather than increasing knowledge.

c) adopting the modules, innovations, and good practices developed by Kinerja, other donors, relevant technical ministries, and the Ministry of State for Administrative Reform.

d) conducting regular trainings on public service provision, and exercising possibilities to work with other organizations (IOs, consultants, and local government agencies) that have been innovative in public service improvements.

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CHAPTER 2 KINERJA

’s

APPROACH

Kinerja’s

Approach

Kinerja takes a two-pronged approach, working with both supply and demand sides, in its efforts to assist local governments in improving public services in health, basic education, and business enabling environment. To achieve improvements, the project works through three types of intervention: incentives, greater innovation, and replication. Through this intervention, local governments in Indonesia are expected to provide better quality services, and to be more responsive to the needs and requests of citizens.

One of the key aspects to Kinerja’s approaches is the participation of citizens, civil society organizations (CSOs), and local media, including alternative media and citizen journalists. These community members are encouraged to advocate for better public services. At the same time, the project works with service provides to improve their capacity to meet the

citizens’ demands.

With regards to MSS planning and budgeting, local parliamentarians play a strategic role since they are responsible for approving and overseeing the budget. In addition, the regional planning and development agencies (Bappeda) have an important role as the regional planning coordinator. Most of Kinerja’s activities are implemented by IOs and short-term consultants. Both receive training on governance and public service provision from the project.

Kinerja’s core strategies to improve local government and community capacity are:

1. Supporting the development of evidence and research-based policies, plans, and budgets, such as Regional Budget Analysis and MSS costing.

2. Establishing multi-stakeholder forums (MSFs) as part of an effort to stimulate participatory planning and budgeting. Through the forums, governments and citizens are expected to create a strong partnership and work together.

3. Involving citizens in public service oversight through implementing complaint-handling

mechanisms, and developing service charters and technical recommendations.

4. Supporting public information officials to provide the public with access to information, as well as encouraging local media and citizens journalists to advocate for better public service delivery.

5. Establishing a team to draft MSS plans at the district level, whose membership consists

of government staff and community members. The mixed background of this team leads to better participatory planning and budgeting.

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Kinerja has three intervention focuses:

1. Improving capacity of service users (the ‘demand side’).

2. Promoting good practices and supporting local authorities to test and to adopt standard-based health services.

3. Replicating good practices at the national level and supporting organizations in Indonesia to disseminate good practices to local governments and assist with their implementation.

Working with both service providers (the ‘supply side’) and service users ( the’demand side’), Kinerja is able to successfully promote the key good governance principles of transparency, accountability, public participation, and responsiveness

Principles Governing the Health Sector

Kinerha’s health programs focus on safe delivery and immediate & exclusive breastfeeding (I&EBF), which are implemented in Indonesia by referring to MSS targets. Kinerja uses the following principles in providing technical assistance in the health sector:

• Encouraging coordination between health offices and other government bodies.

Maternal and child health (MCH) is not the sole responsibility of district health offices and community health centers (puskesmas). It requires the support of a number of other local government agencies, including district planning office (Bappeda), organisational bureau, finance office, district labor office, sub-district governments, village governments, and the district parliament. Therefore, cooperation among the local government agencies is crucial for good implementation of MCH programs.

• Community participation. Community participation through groups such as

multi-stakeholder forums (MSFs) is important. It is important not only because citizens are legally obliged to assist with monitoring public services, but because public participation helps service providers and district health offices to deliver programs in a more transparent and accountable manner. It also enables service providers to continuously improve their services.

• Sustainability. MCH programs should obviously be sustainable. Sustainability can be

achieved when governments and communities monitor the program implementation together, and when the community members perceive that said programs benefit them.

• Meeting service standards. Service standards (MSS, SOPs, Public Service Standards,

and ISO), when implemented properly, can be of great assistance in helping service providers to better measure their performances. Referring to standards also helps service providers to compare the quality of their services to those of other districts and provinces, or even at the national level.

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Elements and Stages in MSS Costing for

Health

Kinerja identifies the major elements of MSS planning and costing as:

1. Application of MSS and/or other service standards will promote continuous and sustainable improvement of public services.

2. Government regulations on MSS and other standards ensure that public services are not only of better quality, bur are more equal and focused.

3. MSS costing is only useful if using valid and up-to-date data. Good data collection by district health offices, community health centers, and hospitals is thus a major pre-requisite for MSS costing.

4. MSS costing is conducted based on government guidelines. It addresses the gaps between current achievements and the targets set at the provincial/national level. In other words, the MSS costing is not decided by the head ofhealth centers, community groups, or the head of districts.

5. Local governments are responsible for MSS costing. This task is carried out by an MSS team, whose membership consists of local government agencies, parliamentarians, and community members. 6. MSS indicators include achievements so that health budgets can be used for public service

improvements, MSS compliance, and MCH quality improvements.

7. Local regulations such as Executive Decisions and District Regulations are essential to ensure that

MSS implementation is sustainable.

8. Regular monitoring and evaluation is important to ensure that MSS implementation meets identified targets and to address any issues that emerge.

9. Transparent complaint handling helps service providers to provide services that meet people’s needs

and demands.

The process of MSS planning and costing at the district level is:

1. Making an agreement with the head of district, the head of puskesmas, and the head of Bappeda on MSS costing activities.

2. Establishing the MSS team, which consists of divisions in the district health office, such as program development, health services, and family health, puskesmas, socio-culture division in Bappeda, finance office, organization secretary, health commission of the local House of Representatives, sub-district officials, and MSFs at sub-sub-district and sub-district level. Then, the head of sub-district health office formalizes the team.

3. Assigning facilitators/trainers to assist the MSS team in the planning and costing process.

4. Organizing workshops to improve stakeholders’ understanding of MSS. Local governments may

conduct a comparative study on how MSS is implemented in other districts, if necessary.

5. After completing the previous steps, the MSS team is responsible for integrating MSS costing results

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CHAPTER 3 KINERJA’S EXPERIENCE IN

MINIMUM SERVICE STANDARDS

FOR HEALTH

MSS conditions in the field

Kinerja conducted pre-implementation research that examined how health MSS is

understood in the field. The results show that many of Kinerja’s partner districts and cities do

not have a strong or in-depth understanding of MSS as it relates to the health sector. MSS targets also do not generally appear in local planning and budgeting documents.

The challenges identified include:

(1) Lack of special teams to assist districts/cities in the application of health MSS.

(2) The technical planning teams at both the district level and the health center level do not have a good understanding of how to plan and budget based on MSS targets.

(3) Inadequate practice-based support for incorporating MSS into the management of health services.

(4) Political commitment and support for MSS in the health sector is insufficient. Health MSS is not generally a priority for either district governments or parliaments.

Mini-survey results conducted in five districts/cities in South Sulawesi in mid-2011, prior to

Kinerja’s program beginning, shows that many government administrators were not yet familiar with MSS and had little or no experience in incorporating MSS into planning and budgeting.

Kinerja’s experience has shown that despite the efforts of some districts/cities to implement

MSS, the processes have not progressed beyond costing. Most areas do not meet MSS targets, which according to the Regulation of the Minister of Health No. 741/Menkes/PER/VII/2008 were to be achieved by 2015. This shows that MSS is not properly being integrated into health planning and budgeting.

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How Kinerja began working

Kinerja provides technical assistance to improve local health governance from two sides – supply (service providers) and demand (service users). This requires the support and commitment of a range of different regional stakeholders.

1. Commitment of District Head, parliament, and other

stakeholders

Kinerja began providing assistance on MSS in the health sector by holding awareness raising workshops. These workshops aimed to increase the understanding of key local stakeholders on the importance of MSS. Participants included the district head/mayor and members of the local parliament. Comparative study trips were then held for government staff – staff were invited to visit another district/city that was already effectively implementing MSS in the field of maternal and child health. These visits often included the district head, the regional secretary, members of parliament, and the head of the district health office, as well as community representatives. Some districts that were visited were Probolinggo City, East Java; Sragen, Central Java; and Klaten, Central Java.

Following the workshops and comparative study trips, the participating stakeholders demonstrated improved awareness and understanding on MSS and other service standards.

The participants were then better able to advocate to the district’s decision makers on health MSS.

The next step was the establishment of the district health MSS team.

2. Structure

At the district/city level, Kinerja began the program by recruiting staff with experience in public service, called LPSS (Local Public Service Specialist). One LPSS is located in each of

Kinerja’s partner districts/cities. Their main task is to coordinate the program with the district government, MSFs, Kinerja’s consultants, and implementing organisations. LPSS are also responsible for overseeing program implementation quality.

LPSS and Kinerja’s consultants provided assistance to district governments at all stages of

MSS planning and implementation. Kinerja recruited MSS consultants in each province, all of whom received extra training.

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Periodically, specialists from the Kinerja National Office in Jakarta also support MSS activities, especially during large and important events such as workshops on integrating MSS into district planning and budgeting documents.

LPSS always coordinate with the district health offices and the MSS team. The MSS team is made up of the head of the district health office or a senior district health office

staffmember, the heads of Kinerja’s partner health centers, the district planning body, the

organisation division, the finance division, and non-governmental institutions.

3. Work plan development

Once the MSS team is established, the team works together with the district health office and LPSS to draft the work plan and implementation time table for each stage of activities. Work plans and time tables are developed both for the health center level and the district/city level. The work plan should ideally align with the district planning and budgeting cycle so that when MSS costings are finalised, they can be directly integrated into district planning and budgeting.

Kinerja’s MSS assistance process is as follows. Activities are implemented within a one

year period, in alignment with the district government budget schedule.

4. Workshop held on the topic of improving MSS understanding and awareness. Comparative study trip to a district with MSS programs carried out.

5. Regulations and laws relating to health MSS reviewed at the provincial and district/city levels.

6. MSS targets and achievement statuses identified.

7. Gaps between targets and actual achievements analysed. Gaps are given priority status based on how large they are. Strategies to close the gaps are developed.

8. Costs calculated for the funds needed to close the gaps between targets and actual achievements.

9. MSS targets and costs incorporated into both district and health center planning and budget documents.

10. Monitoring of outcomes during implementation, and evaluation at the end of each financial year.

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Work Process

1. Roles of each Stakeholder

All stakeholders work together in planning and implementing MSS, but each stakeholder nonetheless plays a specific role.

• Consultants and/or implementing organizations (IOs) are responsible for conducting workshops and training that increases knowledge and develops skills relating to calculating needs (costing) to achieve MSS targets. Consultants and IOs also assist the government teams with developing the costing itself.

• The MSS Team, made up of government staff, calculates MSS costing needs and prepares technical recommendations to be submitted to government decision makers. The team also advocates for incorporating MSS into regional planning documents.

• Head of Departments and District Heads/Mayors are responsible for following up on technical recommendations that advocate for the integration of MSS costing calculations into official regional planning documents. They also should allocate budgetary funds to finance activities that will lead to the meeting of MSS targets.

• The Budget Team and the Regional Parliament are required to approve the proposed MSS budget allocation after ensuring it aligns with the results of the analysis and calculation process. The Budget Team and Regional Parliament should also play a role in overseeing the implementation of the MSS program and its use of funds.

• The MSS Team, together with multi-stakeholder forums and CSOs, carry out policy advocacy and monitor MSS implementation and achievements to ensure the sustainable improvement and development of public services.

• Multi-stakeholder forums (MSFs) should engage the MSS Team and work with them during both the costing calculation phase and the implementation monitoring phase to ensure that MSS targets are met.

• At the health centre level and the district government level, staff are responsible for implementing MSS programs, monitoring implementation, and ensuring complaints and feedback are passed on and acted on by decision-makers.

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2. Work Plan Implementation

KINERJA MSS planning activities are carried out through the following stages:

1. Workshop on Improving MSS Understanding, and comparative study trip on the application of service standards in health: Workshops are held at the district/city level, and are attended by all relevant stakeholders from all levels of government, health centers, and the community in order to increase understanding and awareness of the importance of MSS and other service standards. Where possible, local government staff also conduct a comparative study trip to other districts/cities that are already effectively implementing MSS.

2. Review of MSS regulations at the district/city level: The MSS team and District Health Office conduct a broad review of all MSS-related regulations in order to assess regulations that support or that hinder MSS implementation and target achievement. 4. Identification of MSS target achievements: The status of MSS targets and whether they

are being achieved or not must be identified, both at health centers and at the district/city levels.

5. Gap analysis and strategy development: The gaps between achievements and MSS targets are identified, analysed, and prioritised for action. Largest gaps are to be

addressed first. Analysis is carried out through using ‘problem tree’ or ‘fishbone’

methods. An MSS strategy is then developed, complete with program activities, in order to address the problems and gaps identified.

6. Calculation of costs needed to achieve MSS targets: Following the development of priority targets and an MSS strategy, the funds needed to achieve MSS targets must be

calculated. This process is referred to as ‘costing’. Costing is generally calculated in stages, generally in the medium-term of around three to five years.

7. Workshop on MSS costing integration: A workshop is held to disseminate the results of MSS costing calculations and to integrate the costing results into official regional planning and budgeting documents, including the Conducting a workshop of MSS costing calculation results by inviting various parties (public examination) and integrate the MSS costing results into Official and Regional planning and budgeting documents, such as the taskforce work plan and budget (RKA), Public Financing Policies and Ceiling for Temporary Priority Funding (KUA-PPAS), and general work plan (Renja). These documents are then to be used as references for the drafting of the Health Department’s Strategic Plan (Renstra) and the district’s Regional Medium Term Development Plan

(RPJMD).

8. Monitoring and evaluation of MSS achievement: The MSS team and district health offices monitor the implementation of MSS program activities, periodically evaluate MSS achievements, and conduct reviews if implementation plans need altering.

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district heads/mayors can develop regulations on MSS application; district health offices can expand MSS costing from pilot health centers to all health centers in the district; other district offices can adopt MSS costing and implementation methods; MSS

indicators can be referred to as the basis for drafting the district’s Regional Medium Term

Development Plan (RPJMD); and public service standards can be adopted to support MSS target achievement.

3. Benefits of Developing an MSS Work Plan

The benefits of developing and implementing an MSS work plan quickly become evident to governments undertaking such efforts. They include:

• Local government capacity is significantly increased. Government staff now have improved understanding on maternal and child health service standards and financing needs, how to calculate financing gaps, and how implement MSS programs.

• Increased community participation in MSS implementation and monitoring.

Multi-stakeholder forums in Kinerja’s partner districts have been very keen participants in each

stage of MSS costing and implementation.

• Health sector staff have increased skills in determining budget allocation needs to achieve MSS targets.

• The development of regional regulations on MSS increases the likelihood of MSS targets being achieved.

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CHAPTER 4 ADDRESSING CHALLENGES AND

ACHIEVE SUCCESS

Challenges

Kinerja’s experience working on assisting local governments to plan and implement minimum service standards in the health sector shows that a number of challenges can arise. These include:

• Building the understanding and capacity of district health office staff on MSS is not sufficient. It is also crucial to ensure that other key stakeholders also recognise and understand the importance of MSS in the health sector. These stakeholders include the district parliaments, district heads and their deputies, and the district planning body.

• Nearly all districts have problems with health data. Data is often incomplete, inaccurate, or invalid. This means that during the initial stages of MSS programming, it is difficult to obtain accurate data – something that is vital for the accurate calculation of MSS funding needs.

In Kinerja’s experience, this was the case at both the community health centre level and at

the district level.

• The MSS costing calculation process sometimes ran on a different schedule to the district planning and budget cycle. This meant that the results of MSS costing were finalised too late to be incorporated into the district budgeting documents, which ultimately caused levels of funding for health MSS to be inadequate or even non-existant.

• Limited budget availability and the funding needs of other priority sectors can lead to depleted funds for health MSS activities. This means that sometimes MSS targets are unlikely to be realized.

• Time constraints and limited capacity of government staff responsible for MSS can lead to the MSS process (from costing through to implementation) running more slowly than ideal. This challenge is best addressed through continuous learning programs and intensive assistance from start to finish.

• Capacity of consultants and implementing organisations are also often low at the beginning of program implementation. Technical assistance and training needs to be provided.

• Changes in stakeholders within the district government can be problematic and slow down progress. Briefings must be provided to new key stakeholders (especially district heads and heads of district health offices) so that they have a strong understanding of the program and will support it.

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Program Success

1. Success story from Makassar City

Makassar City, the capital city of South Sulawesi province, is a good example of success in health MSS. The city originally faced a problem of large gaps between MSS targets and actual achievements in the health sector.

a) Effort to address gaps in health MSS

In addressing the challenge of health MSS achievement gaps, the district health office and

the city’s health centers collaborated with the Makassar City multi-stakeholder forum (MSF) and Kinerja staff to calculate the gaps between MSS targets and actual achievements in the health sector. The costing was done through a series of workshops involving not only the three Kinerja-supported community health centers, but also the other 20 community health centers in Makassar City. The results of the MSS costing were then incorporated into the city’s planning and budgeting documents (Renja, RKA, Renstra,

RPJMD).

To ensure that the MSS costing needs were funded and that MSS targets were aimed for, the mayor of Makassar City developed a mayoral regulation. The development took place over a series of discussions and advocacy meetings with various government offices, legal bodies, district secretary, multi-stakeholder forums, and representatives of the community. The mayoral regulation was made into law in December 2013, ensuring district government support for MSS in health from not just the district health office but also other bodies such as the district planning body and the office of public work. The implementation of the regulation is monitored by multi-stakeholder forums and all community health centers incorporated the targets into their workplans.

b)

Kinerja’s approach

Kinerja’s approach involves not just the service provider side (the ‘supply side’, i.e. the

local government offices and community health centres), but also the service user side

(the ‘demand side’, represented by the health multi-stakeholder forums).

On the service provider side, Kinerja’s approach strengthens the district government through:

• Increasing understanding of the impact of health MSS gaps in community health centers for health services quality improvement.

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• Improving skills in calculating health MSS needs in order to gradually meet targets.

• Effectively incorporating health MSS into planning and budgeting at the district level. On the service user side, Kinerja’s approach strengthens the community through:

• Improving community understanding of their rights to good-quality health services.

• Ensured community members are actively involved in decision-making and policy-making.

• Allowing community members to take on the responsibility of monitoring MSS implementation and advocating for improved implementation that is transparent, accountable, and participatory.

Kinerja’s approach also utilize the mass media, including alternative media (citizen journalism), to increase opportunities for public participation. This open approach is driven by the awareness of the necessity of urgent action and highlights the fact that the common good is the goal of local government policy.

c) Program Strategy

1) Strengthening Civil Society Organizations

Makassar City Government made room for local civil society organizations by involving them in all stages of MSS programming: analysis, planning, monitoring and evaluation. The government and CSOs are now collaborating more frequently in order to find the best solutions for the challenges Makassar City faces.

2) Establishing and strengthening multi-stakeholder forums (MSFs)

The district government is supported in its health MSS activities by the city-level MSF and the sub-district-level MSFs. The forums advocated strongly for the adoption of MSS in the health sector in Makassar City, and also raise awareness on MSS by engaging community members, health professionals, and journalists.

3) Establishing MSS Team

Makassar City government established an MSS Team that included members from a number of different government bodies – the district health office, the district planning body, the community health centers, and the multi-stakeholder forums. This team was tasked with calculating, analysing and verifying the data for each health MSS indicator. The team was also responsible for drafting the mayoral regulation on health MSS implementation.

4) Policy advocacy by MSS Team

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held discussions and workshops across the city, involving the heads of community health centers, the district legal office, and the city parliament.

5) Monitoring and evaluating by MSF

To ensure the mayoral regulation on health MSS is implemented, the MSFs, citizen journalists and other community groups monitor activities and achievements.

d) Results of health MSS implementation in Makassar City

The results of implementing health MSS in Makassar City include:

1) An increase in district government initiatives surrounding MSS, such as the development of the Mayoral Regulation on Health MSS Implementation.

2) Costing results have been fully incorporated into Makassar City’s planning and budgeting.

3) Community health centres have improved understanding of health MSS.

2. Leveraging MSS success in health

The health MSS program, introduced by Kinerja and implemented by district governments, has so far demonstrated good results from a governance perspective. MSS programs are now effectively implemented in Kinerja partner districts such as Makassar City, and budgetary allocations are now regularly provided for health MSS.

The program has particularly been a success when considering community participation. Community members, primarily through the development of multi-stakeholder forums, have become very active in the entire MSS cycle – from initiation and planning through to implementation and monitoring. Public participation is one of the major principles of good governance, and assists with transparency and accountability.

The success of properly incorporating MSS into health programs can be used as leverage for other sectors, too. There remain many basic services that must be provided to the community by the government, and MSS is one way of improving such services when the government and the community shares the same concerns and are willing to work together.

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CHAPTER 5 RECOMMENDATIONS FOR

REPLICATION

Kinerja has so far assisted several Indonesian districts with implementing MSS in the health sector. Our work is replicable throughout the country, and indeed, in other countries, too. Kinerja hopes that through this document, the benefit of using MSS as a way of improving public services

is visible, and that other districts will take up Kinerja’s model and replicate it.

Following are a number of recommendations for governments that are interested in replicating

Kinerja’s model for minimum service standards implementation.

Recommendations for governments

interested in replicating Kinerja’

s MSS

approach

Kinerja would like to make several recommendations to governments interested in

replicating Kinerja’s approach to MSS in health or other sectors.

a. A high level of commitment is required from the district head/mayor, the regional parliament, and the district health office in order to effectively implement MSS and achieve targets. This commitment can be demonstrated through the development of official polices, laws, regulations, and technical guidance documents, as well as through the incorporation of MSS targets into local planning and budgeting processes.

b. Policies should prioritise public service. Local governments should provide services for the benefit of the community with the aim of increasing public welfare.

c. Involve the community, such as through multi-stakeholder forums, in all stages of MSS planning and implementation. As programs carried out by local governments are for the public, it is crucial that community members are involved in policy making, planning, implementation, and monitoring.

d. Empower existing staff and organizations without forming new organizations or units. Implementing MSS does not require new structures or new employees; existing staff and structures are generally adequate.

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involved as much as possible, as they are required to approve programs and their budgets.

f. Establish indicators and measurements for program success. It is vital to know how programs are performing in order to continuously improve.

g. Adopt Kinerja’s approaches and utilize the materials made available by Kinerja, such as training modules and good practice books. These materials can help guide program planning and implementation.

Recommendations for consultants and

implementing organisations

Recommendations for consultants and implementing organisations helping local governments in replicating MSS for health or other sectors:

a. Always integrate aspects of good governance (transparency, accountability, responsiveness, and public participation) in all strengthening and assistance activities involving communities and multi-stakeholder forums.

b. Remain results-oriented. Try not to just meet activity schedules and participant quotas. c. Act as advisers who stimulate rather than as employees who implement programs.

d. Use the modules developed by Kinerja to strengthen your own capacity as well as strengthening local governments and multi-stakeholder forums.

Recomendations for training providers

Educational and training institutions at all levels of government play a strategic role in developing the skills of civil servants. Kinerja recommends that these institutions:

a. Include Kinerja’s approaches and governance principles in the education and training curricula, with a focus on involving citizens as public service users.

b. Become more oriented towards skill improvement rather than mere increase of knowledge and understanding. This can be achieved through carrying out follow-up activities after trainings, as providing continuous assistance will allow training participants to develop the best skills possible.

c. Adopt the modules developed by Kinerja. Kinerja recognizes that education and training institutes have their own modules, but would also like to recommend that Kinerja’s models be incorporated.

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Email: info@kinerja.or.id

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