The Role of Stakeholders in the Provision of Minimum Service Health Care in Wonosobo Regency

Introduction: Wonosobo regency is one of the districts with the lowest achievement of minimum service standards in the health sector in Central Java. In 2022, Wonosobo District could only achieve 16.67%. The implementation of a policy requires the cooperation of all stakeholders. The low achievement of Wonosobo District shows the lack of commitment of the local government and other stakeholders in efforts to provide health services according to minimum service standards. Objective: This study aims to identify the stakeholders involved and how their roles in the fulfilment of health services according to minimum service standards in Wonosobo district so that it can be an evaluation material for stakeholders in optimising efforts to fulfil minimum service standards. Method: This research uses a descriptive method with a qualitative approach. The research informants were identified using a purposive mechanism based on stakeholder involvement. Primary data collection in this research was conducted through in-depth interviews using tools such as interview guidelines, recording and note-taking equipment. Secondary data was obtained through legislative documents and derivative products issued by the Wonosobo District Government and its subordinate organisations, as well as literature reviews. Result: The results of the stakeholder identification show that there are 9 stakeholders involved, representing policy-making groups (Wonosobo District Parliament, Wonosobo District Secretariat, Wonosobo District Development Planning Agency, Wonosobo District Health Office), policy-implementing groups (District Health Office, PHC and health cadres) and support groups outside the system (sub-district government, village government and PKK cadres). Conclusion: Based on the mapping conducted, there are two categories of stakeholders in this study, namely key players and subjects. Wonosobo District Parliament, Wonosobo District Secretariat, Wonosobo District Development Planning Agency, Wonosobo District Health Office, and PHC are in the key player position. Health cadres, sub-district governments, village governments and PKK cadres are in the subject position.


INTRODUCTION
The preamble of the 1945 Constitution of the Republic of Indonesia states that one of the objectives of the establishment of the unitary state of the Republic of Indonesia is to promote the general welfare (1).General welfare can be achieved by fulfilling the rights of every citizen and ensuring the availability of basic needs of the entire community without exception.One of the human rights that must be fulfilled by the government is health, as stated in Article 28h of the 1945 Constitution and Law No. 36 of 2009 on Health (2).Health is a fundamental right that must be protected by the state, law and government, and is one of the important elements in achieving the general welfare (3).However, the Indonesian government faces its own challenges in meeting the health needs of the entire population.Indonesia's vast territory, comprising thousands of islands with diverse community characteristics, creates complex demands on public services.The complex geography and demographics limit the government's ability to manage and address all public health issues (4).
The implementation of decentralization allows the government to achieve equity, effectiveness and efficiency of public services (5).In the context of decentralization, the obligation to meet the needs of public health services is carried out by local governments, taking into account the principles of democracy, equity, justice and the specificity of a region.In order to ensure the equitable distribution of these services, the government has established a policy on the minimum standards to be met by local governments, which is regulated by Government Regulation No. 2 of 2018 on Minimum Service Standards, and one of the mandatory affairs regulated therein is the health sector.The policy states that in health affairs, local governments are obliged to ensure the fulfilment of the type and quality of basic health services for all people in their autonomous regions, with an achievement target of 100%.This shows that the achievement of minimum service standard targets is highly dependent on the performance of local governments (6).The Minister of Health's Regulation Number 4 of 2019 on technical standards for the implementation of minimum service standards in the health sector, states that local authorities are required to meet service quality for each type of health service based on minimum service standards (7).In order to achieve these objectives, local government must ensure that the infrastructure, human and financial resources are in place to support the implementation of these policies.
Wonosobo district is one of the districts with the lowest achievement of minimum service standards in the health sector in Central Java.In 2022, Wonosobo District was only able to achieve 16.67%, with only two out of twelve types of health services meeting the minimum service standard target (8).Limited infrastructure, funding and human resources are obstacles to the delivery of health services in Wonosobo District.The number of human resources is still not adequate to provide services to the target groups, which affects the quality of services (9).Therefore, in order to meet the needs of public health services, it is expected that local governments, with the support of all stakeholders, can improve their performance through good management, supportive human resources and reliable leadership (10).
The low achievement of Wonosobo District shows the lack of commitment of the local government in providing the type and quality of health services according to the minimum service standards.Achieving the type and quality of health services according to minimum service standards requires the involvement and commitment of various stakeholders.Each stakeholder has a role and position that affects the implementation of the policy (11).However, the number of government departments involved in the implementation of a policy can be an obstacle in itself, linked to a lack of integration and coordination in the management of programme planning (12).This is in line with Kurniawati's (2019) study, which found that one of the challenges faced by the Wonosobo district government in implementing the health programme included in the minimum service standard indicators is the lack of cooperation among stakeholders (9).Nisa, et al (2020) also indicates that weak coordination between stakeholders is the reason for the sub-optimal role of stakeholders in one of the health programmers included in the minimum service standards (13).Rohana's (2020) research on neonatal care as a type of minimum standard health service notes that not all parties are well engaged in achieving the goals of the minimum standard health service (14).Zudi (2021) states that one of the barriers to implementing minimum service standards in health is the lack of a shared commitment built into the team to move services forward to provide the best service to the community.
The implementation of a policy in the context of development requires the cooperation of all stakeholders.In essence, a stakeholder is a group of individuals or organizations that have an interest in an issue or a policy (15).Based on this, researchers feel the need to conduct research to identify who the stakeholders are and how their respective roles are in providing health services according to minimum service standards in Wonosobo District, so that it can be an evaluation material for stakeholders in optimizing efforts to meet minimum service standards.

METHOD
This research uses a descriptive method with a qualitative approach.The researchers chose this method in relation to the research objectives, namely to describe the condition of the research object through primary and secondary data collection.The data collection was conducted in September-November 2023 in Wonosobo Regency.
Publisher: Fakultas Kesehatan Masyarakat, Universitas Muhammadiyah Palu The determination of research informants was carried out using a purposive mechanism based on stakeholder involvement.Primary data is a source of data obtained directly from informants by researchers.Secondary data is a data source obtained through a literature review of written documents related to the research topic.Primary data collection in this study was conducted through in-depth interviews using tools such as interview guidelines, recording equipment and recordings.Secondary data was obtained through legislative documents and derivative products issued by the Wonosobo District Government and its subordinate organizations as well as literature studies.
The data analysis technique used in this research is qualitative data analysis, where the data obtained through data collection and processing activities are then interpreted by describing and explaining the problems studied in the form of sentence explanations.The stages carried out in data analysis are 1) data reduction, namely the stages of selection, focusing and simplification, abstraction and transformation of data in the form of transcripts, 2) systematic presentation of data based on the results obtained from the data reduction process.The selected data is then presented in the form of textual descriptions in the form of narratives.Furthermore, 3) drawing conclusions, where at this stage the researcher interprets the data that has been collected so that the right conclusion can be drawn.Based on the results of the interview, the stakeholders in this study will be grouped according to their influence and interests in order to find out the role played by each stakeholder.

RESULTS
The identification of stakeholders involved in efforts to provide health services in accordance with minimum service standards in Wonosobo District was carried out by reviewing written documents consisting of legal provisions and regulations derived from them.The results of the review were then matched with key stakeholders responsible for health sector affairs in Wonosobo District.The results of the stakeholder identification showed that there were 9 stakeholders involved, representing policy-making groups (Wonosobo District Parliament, Wonosobo District Regional Secretariat, Wonosobo District Regional Development Planning Agency, Wonosobo District Health Office), policy-implementing groups (Health Office, Puskesmas and health cadres) and support groups outside the system (district government, village government and PKK cadres).The informants in this study are representatives of the identified stakeholders, consisting of different agencies with different characteristics.The majority of the informants were male (6) and female (4).The age of the informants ranged from 32 to 57 years.The lowest level of education is Senior High School and the highest is a Master's degree.One informant is a high school graduate, five informants are undergraduate students, two informants are pursuing professional education, and two informants have postgraduate degrees.
The results showed that all stakeholders have an important role to play in efforts to deliver health services in line with the minimum service standards.However, not all stakeholders have much influence.The greatest influence is held by the policy-making group, where this group can influence the sustainability of the policy and the achievement of the policy's objectives.The Wonosobo Regency DPRD is a stakeholder that has the authority to approve the draft APBD, which will be allocated in an effort to meet minimum service standards in health care.The regional secretariat and Bappeda have an important influence in relation to their roles, namely to coordinate the preparation of policies to monitor all stakeholders involved so that the fulfilment of health service needs can meet the targets of the minimum service standards and in accordance with the predetermined planning.In order to ensure the provision of health services in Wonosobo District in accordance with the provisions of the Minimum Service Standards, the Wonosobo District Health Office participates in the preparation of policies, including the issuance of a decree by the head of the office to be followed by service providers.In addition, the Wonosobo District Health Office strives to ensure that service support needs are met.In order to ensure that health services in Wonosobo District are provided in accordance with minimum service standards, the health office also conducts monitoring of all health centers in Wonosobo District.
The health service is the implementing element in the affairs of the regional government in the health sector, so that the health service has influence not only in the formulation of policy, but also in the implementation of policy in the field.The direct implementer of health services to the community, which is regulated in the provisions of the minimum service standard, is the community health center.PHC is a public health manager who is the spearhead in the implementation of health service programs, so its influence greatly determines the success of fulfilling services and achieving predetermined goals.Health cadres are stakeholders who contribute to the delivery of services in health service activities at the village level and play a role in mobilizing the community to participate in community empowerment in the health sector.In any health effort, cadres help carry out activities and assist health workers in providing services.Although involved in service delivery, health cadres do not have the authority to influence policy.
The sub-district government plays a role in coordinating the implementation of health programs to meet minimum service standards in the sub-district area and in facilitating health activities in the sub-district area.The village government is a partner of the community health center in the implementation of health programs in the village/sub-district area.Meanwhile, PKK cadres contribute to supporting the implementation of health programs at Publisher: Fakultas Kesehatan Masyarakat, Universitas Muhammadiyah Palu the sub-district level.In addition, the PKK also conducts outreach activities and disseminates information about health activities to the community.These three stakeholders are groups outside the system, so they do not have a strong influence on policy.The results of the interview were analyzed based on the stakeholder influence and interest matrix as shown in Figure 1.

Figure 1. Influence and Interest Matrix of Stakeholders
From the results of this analysis, the interests and influence of each stakeholder can be mapped.Based on the mapping carried out, it is known that DPRD, Regional Secretariat, Bappeda, Health Service and Community Health Center are in key player positions where this group is a stakeholder group with high influence and interest.Health cadres, sub-district government, village government and PKK cadres occupy subject positions because they have high importance but low influence.

DISCUSSION
Stakeholders have a role and position in the success of a policy/program.The stakeholder role provides an overview of a manager's task management for the benefit of the organization with the goal of mutual benefit.Without the stakeholder role, an organization cannot make unilateral decisions (16).A person who has a particular role is expected to be able to perform a set of tasks and make decisions in accordance with that role.Roles can be defined as actions performed by a party or stakeholder based on their function and position in a position or program (17,18).Stakeholder role will be challenged in a program/policy that requires multi-stakeholder involvement due to potential.Stakeholder management often creates its own conflicts, besides that stakeholders often do not provide direct or indirect support for the success of a program.
Key Player Stakeholders have a high level of influence and interest.The Key Player group is the stakeholder who is most often involved in decision making activities and has a very big influence on decision making (19).According to Roman Pichler in Surendra (2018), the form of engagement that must be carried out with stakeholders included in the key player category is collaboration (20).The word collaboration is often used to describe the process of getting work done that is cross-industry, cross-relationship, and cross-organizational (21).Collaboration is a cooperation that is carried out by different parties to achieve a common goal (22).In terms of terminology, collaboration is interpreted as a situation of cooperation between two or more groups who have a common understanding of their respective situations and try to solve problems together.Collaboration is a very basic social process, and usually collaboration involves sharing tasks and each person doing their own work, which is a responsibility to achieve a common goal (23).Gray in Ansell and Gash defines three stages of the collaboration process, including problem setting (determining the problem), direction setting (determining the goals), and implementation (24).In order to strengthen the role of all stakeholders in the key player group, it is necessary to strengthen the cooperation between all stakeholders.This is because the fulfillment of health services within the minimum service standards is a common goal of stakeholders in the key player group as elements of local government.This is in accordance with the provisions of Law No. 23  The cooperation and coordination carried out by the various parties is the key to the success of a program/ policy (25).Therefore, good cooperation and increased coordination are very necessary to mobilize all stakeholders to achieve common goals.Synergistic collaboration is the main key to achieving goals.Commitment to collaboration is the most important variable in explaining the success or failure of a collaboration.A sense of ownership and commitment can strengthen the commitment of stakeholders.A sense of ownership of the process has implications for the emergence of a sense of mutual responsibility for the process (26).To increase engagement, all stakeholders must be given equal opportunities to contribute.This is in line with the research on the cooperation between the provincial governments of the Special Region of Yogyakarta and Kalurahan in the use of special funds, which states that increasing the value of any government activity will be realized if actors have the same space and opportunities to participate in any process that is carried out as a result of cooperation between the stakeholders themselves.Actors also have the same space to fight for the interests they carry within a policy framework that is jointly decided (27).
Subjects are stakeholders with high interest but low influence.The presence of health cadres, sub-district government, village government and PKK cadres plays an important role in facilitating health service activities at the village level.Facilitators have an important role in raising and increasing public awareness (28).In order not to shift their important existence due to their limited influence, it is necessary to increase the involvement of subject groups to support the fulfillment of health services in Wonosobo district.Roman Pichler in Surendra (2018) states that the involvement of subject parties is a way of empowerment (20).Empowerment is a continuous, dynamic, and synergistic activity.It involves all existing potentials (29).
Empowerment must be a priority in all development efforts and in the improvement of community wellbeing (30).Empowerment is used to elicit thoughts and ideas from stakeholders so that they feel involved in the development of a program/policy.Empowerment through discussions and lectures can increase stakeholders' knowledge and encourage them to improve their performance in providing optimal services (31).In this research, increasing the empowerment of village health cadres and PKK cadres is very important because these two groups are directly involved in health care activities in the village.This is consistent with the research on the empowerment of cadres and baduta mothers to prevent stunting in Pilangsari Village, Bojonegoro Regency, which states that empowering posyandu cadres has been proven to increase their role as leaders in efforts to optimize posyandu (32).

CONCLUSIONS
Based on the mapping done, there are two categories of stakeholders in this research, namely key players and subjects.DPRD, Regional Secretariat, Bappeda, Health Service and Community Health Center are in key player positions where this group is a stakeholder group that has high influence and interest.Health cadres, sub-district government, village government and PKK cadres occupy positions as subjects because they have high importance but low influence.

SUGGESTION
To optimize the role of each stakeholder involved in the effort to provide health services in accordance with the provisions of the service standard, it is necessary to consider appropriate methods based on their respective roles.For stakeholders in the key player category, role optimization can be achieved by increasing cooperation among stakeholders.Meanwhile, for stakeholders in the subject category, role optimization can be enhanced by empowering them.
of 2014 on Local Government and Government Publisher: Fakultas Kesehatan Masyarakat, Universitas Muhammadiyah Palu Regulation No. 18 of 2016 on Local Organizational Structure, where local governments have broad powers to manage their own internal affairs.