Readiness of Policy Implementation of Indonesian Health Workers in Facing the Services Liberalization Within the Framework of ASEAN Framework Agreement on Services (Review on Mode 4 AFAS: Movement of Natural Persons)

This thesis reviewed of the Provisions of AFAS (ASEAN Framework Agreement on Service) Mode 4 by looking at the overview of Readiness of the Policy Implementation of Indonesian Health Workers in facing the Services Liberalization within AFAS Framework by analyzing how MNP prepared the quality and qualification of Indonesian health workers, and by describing, identifying, and knowing the efforts performed by the government in preparing the Implementation of Indonesian Health Workers Policy. Based on the research results, it is concluded that the implementation of Mode 4 within AFAS framework was one of the strategic issues. However, preparation policy was not optimally implemented optimally due to the lack of coordination among the stakeholders. 


INTRODUCTION
The Article 28H paragraph (1) of the 1945 Constitution of the Republic of Indonesia, stated that "Everyone has the right to live in physical and spiritual prosperity, reside, and obtain good and healthy environment and receive medical care." Therefore, Health Sector Development is aimed so that the Indonesian as an nation can live in prosperity. One of the welfare indicators in line with Indonesian's vision in 2020, is the achievement of the right to a healthy life for the whole society through health systems that ensures the protection of the society from the risks that can affect the health and availability of the quality, affordable and equitable health services.
Considering the Indonesian climate, access difficulties and uneven development across the regions in Indonesia, health development often faces a variety of important issues, such as the unequal distribution and affordability of the health care, and the fulfillment of the number and distribution of the health workers (MoH, 2010). 1 The number of health workers in Indonesia utilized in Health Care Facilities (fasyankes) in 2013 was equal to 894,095 (BPPSDMK, 2013), with the ratio of the strategic health workers per 100,000 population still not met the target. 2 For example, until 2013, the ratio of the general practitioners were 23.99 per 100,000 population (target 40 per 100,000), dentists were 5.7 per 100,000 population (target 12 per 100,000 population), nurses were 174.1 per 100,000 population (target 158 per 100,000 population) (Ministry of Health, Coordinating Ministry for People Welfare, 2013, p. 21). 3 Another problem was the scarcity of the trained health care professionals. Overall in Indonesia the number of health workers was inadequate (Ministry of Health, Coordinating Ministry for People's Welfare, 2013, p. 30). 3 Similar problem was found in other ASEAN countries, with a regional average of 2.7 doctors, nurses, and midwives (combined) per 1000 population. At the national level, however, five countries (Cambodia, Indonesia, Laos, Myanmar, and Vietnam) were below the critical level with an average of 2.28 doctors, nurses, and midwives per 1000 population (Kanchanacitra, et al., 2011). So, it is clear that health worker is one of the issues that needs a special attention because health workers are essential for of the provision of the quality health care, particularly related to quantity, type, and distribution. 4 The development of health services liberalization in ASEAN grows more complex as supplies increases in many countries, scarcity in health workers in developed countries and the presence of the ASEAN Economic Community (AEC), in which one of the target is to achieve a production-based single market in the service field based on the ASEAN Framework Agreement on Services (AFAS)* (ASEAN, 2008). In one of the movement of natural persons (MNP) mode, Indonesia is one of the countries sending the biggest health workers in the world after Filipina. 5 By looking at the problems, we have to prepare and improve our health workers quality so that they can complete in the flow of services liberalization. Indonesia need to participate actively and take a part in the liberalization of trade in health service, especially for MNP, given a target of achieving MEA is accelerated into 2015. However, the year 2020 is the time limit of the imposition of MNP on 3 (three) MRA that have been agreed by ASEAN countries is in 2020.
This time limit is a momentum opportunity to prepare our health workers so that they have qualifications and qualities that are able to provide health care in the global competition. The quality increase as stipulated by the Government Regulation No. 32 of 1996 on Health Workers is conducted through education and training of health workers. Quality control of the health workers is conducted through competency test and registration process of the health workers as stipulated in Article 23 paragraph (3)  Therefore, facing the opportunities, we need to prepare our health workers in order to have the qualifications and qualities meet the standards, or even exceed than the health workers in other ASEAN regions so that later our health workers can compete in the global arena, not only in Indonesia.
Health Services liberalization is a unstoppable, considering the target of achieving MEA, we will find more competition services. In addition, Indonesia itself also facing a health crisis as has been described above. The presence of the health services liberalization will cause a tremendous impacts on the health care in Indonesia, as we cannot solve the health problems ourselves, the health workers from other countries in the ASEAN region will go to Indonesia to help overcome the health crisis in Indonesia. Related to these things, the author tried to examine the Readiness of Policy A review on MNP, as well as to know the efforts that have been made by the Government in preparing the Policy Implementation of Indonesian Health Workers in Facing the Services Liberalization within AFAS Framework by conducting a review on MNP. This research is focused on the Indonesian health workers going to work abroad in order to face the services liberalization within AFAS framework by conducting a review on MNP.

RESEARCH METHOD
This was a qualitative research by looking at the Readiness of the Policy Implementation of Indonesian Health Workers in Facing the Services Liberalization within AFAS Framework by conducting a review on MNP, subsequentky called as the policy readiness. We would describe and explain the qualification and quality standards of the Indonesian health workers in facing the services liberalization within AFAS framework. We collected information through in-depth interviews, as well as literature studies of the secondary data through normative approach. Using the combined theory of Easton and Edward III, it was expected to help the researchers to get deeper results on the Readiness of the In addition, we also used archives or documents related to the research subjects by using literature investigation through books, journals, and data obtained from the institution.
The results obtained from the in-depth interviews with the informants were described in the form of a detailed and complete writing of what was seen and heard either directly or from the recording, while the secondary data in the form of official documents and reports would be read, studied, and analyzed, and further the data reduction would be done through abstraction process by making a core summary, and then conducting the data category and data classification having the same characteristics and presenting it in the form of a matrix where possible.
From the various sources, Sugiyono summarizes the definition of data analysis as the process of systematically looking for and arranging the data obtained from the interviews by organizing the data into a category and laying it into units, by synthesizing and arranging it into a polo by choosing which is important and which will be studied, then drawing a conclusion so that it can be easily understood by oneself or others (Sugiyono, 2012). 7 We conducted content analysis through coding the term or the use of relevant and most frequently appearing words in the communication, classifying the categoris found then relating one another to find the significance, meaning and purpose of the interview.
To validate the result, we triangulate information gathered by checking the data through a variety of sources, methods, theories and different ways, in different time (Bungin, 2007) 6 , (Sugiyono, 2012) 7 .

RESULTS AND DISCUSSION
Policy implementation plays an important role in the process of public policy; because it is the only way the policy can achieve the goal. George C. Edwards defined implementation as one of the public policy stages, between the establishment of the policies and the consequences of the public policy, between the establishment of the policies and the consequences affecting society (Winarno, 2011) 8 . A policy to resolve or reduce the problems but incorrectly detailed in accordance with the objectives of a policy, then the policy will likely to fail even if the policy implementation is run well, so the readiness of the implementation of these policies will determine the effectiveness and success of a policy. Therefore, the presence of the policy makers and implementers are essential in providing input from the results of the research (Ayuningtyas, 2014). 9 The Readiness of the Policy Implementation is one of the strategic issues that will be faced by our nation, especially with the impending agreement of ASEAN Economic Community (AEC) in 2015, in which there will be a free flow of goods, services, investment, skilled labor and freer flow of capital. Liberalization in the field of services is carried out through ASEAN Framework Agreement on Services (AFAS) negotiations mechanism, one of them is through Movement of Natural Persons (MNP) mode. With the presence MNP, it will be a challenge to the stakeholders to take the policy direction to prepare for the Quality and Qualification of the Indonesian Health Workers in facing the services liberalization within AFAS framework.
By looking at the System Theory of Easton and the Policy Implementation of George C. Edward III, the variables used are Environmental Policy, Communications, Resources, Disposition and Bureaucratic Structure and its Readiness by looking at the quality and qualification of the health workers.

A. Environmental Policy
Environmental policy is the most dominant variable to influence a public policy (Ali, Natural & Wantu, 2012) 10 , enable policy demanded transformed into a political system (Ayuningtyas, 2014) 9 . Related to the policy readiness, it is also considered important to check readiness for the international level of health care, tourism health care, medical rehabilitation of patients with drug dependence, education, professional education of the health workers, and other related cooperation.
The Secretary-General of the Ministry of Health, has predicted Indonesia to become one of the countries for centre of economic development and industrial in Asia. This is what makes Indonesia targetted by the international community for the development of trade and investment, including the health field. In the AEC 2015, not only the health industry investment, but also the flow of foreign professional workers will enter and work in Indonesia (Ministry of Health, 2014). 11 In addition, there are factors that will inhibit the policy readiness.
Therefore, we found that many policy holders still did not really know the AFAS policies, eventhough AFAS has existed since 1995. Nowadays, health is one of the main priorities in the services liberalization stages. On the other hand, we still have opportunities to improve the existing situation. As many actors who should be able to take the policy have not understood the policy issues and its impact in the future, it is needed to have an understanding or a wise strategy and innovation that cannot be self-centered thinking in deciding a policy goal, because if it is not conducted then Indonesia cannot take advantage of the existing opportunities as best as possible.

B. Communications
Communication is one of the factors determining the success in achieving the objectives and goals of Public Policy Implementation. In the policy communication, the policy makers need to know and understand what must be conducted and done clearly because a policy will work well and effectively if there is an effective communication among the policy makers and the policy implementers.
The first factor influenceing the policy communication is the transmission because before the policy makers can implement a decision, he must be aware that a decision that has been made and will be implemented by the policy implementers and the policy target groups must be understood correctly by the policy implementers, for what objectives the policy was made, so that what becomes the objectives and target of the policy must be transmitted properly and correctly so it will reduce the distortion of a policy and program implementation.
The results of the research conducted showed that the transmission of communication was considered as running well because the policy direction taken by the actors related to the Policy Readiness had been presented in the meetings held by the policy makers in both the closed and open forum. Some excerpts of the interviews were presented as follows: The second most influential factor is the knowledge of the concept of the Readiness of the Policy implementation of Indonesian Health Workers in Facing the Services Liberalization within AFAS Framework by conducting a review on MNP so that the information can be clearly and easily understood and implemented by the policy implementers.
Based on the extracted information on the informants, most of them understand the purpose, goals and target in the Readiness of the Policy implementation of Indonesian Health Workers in Facing the Services Liberalization within AFAS Framework by conducting a review on MNP. The MRA roadmap that has been made and agreed by ASEAN countries makes it easier to the actors to take the policy direction to prepare Indonesian health workers in facing the health services liberalization within AFAS framework. Nowadays, there is some discretion that still occur from the policy makers to understand the policy direction that will be taken, but it is in the good meaning.
The third most influential factor in a policy communication is the consistency which is the perception similarity of the existing information related to the Readiness of the Policy implementation of Indonesian Health Workers in Facing the Services Liberalization within AFAS Framework by conducting a review on MNP, so it does not cause confusion from the policy implementers, the target groups and the related parties. From the results of the interviews conducted for the Readiness of the Policy implementation of Indonesian Health Workers in Facing the Services Liberalization within AFAS Framework by conducting a review on MNP, the informants agreed that policies that should have been prepared were Quality and Qualification of Health Workers and strengthening the existing regulations in the country related to it.
Considering the results of the research conducted on the research topic, it can be seen that the response to this issue is still not implemented because the existing agreement in the ASEAN region itself has not been the same. Related to the quality and qualification standards of the health workers, it is necessary to develop into a global direction, but because this issue has not been considered as a major issue in Indonesia, so this constraint leads to the purpose obscurity of the policy implementation, so the innovation of the new programs development that are considered to facilitate the policy implementation of the health workers in facing services liberalization in MNP supply mode is less initiated by the policy makers and the policy implementers.

C. Resources
Resource is one of the supporting factors having an important role in the Readiness of the Policy implementation of Indonesian Health Workers in Facing the Services Liberalization within AFAS Framework by conducting a review on MNP. It can be seen from the consistency of the provisions and rules. 0 How accurate the delivery of the provisions or rules is, if the policy implementers, who are responsible for implementing the policy, lack for having the resources to implement the policy effectively, the policy implementation will not be effective (Winarno, 2012). 8 Here, the resources are related to any resource that can be used to support the success of the policy implementation. These resources include human resources, budget, facilities, information and authority described as follows:

Human Resources
The results of the research conducted through interviews with the informants in the Readiness of the Policy implementation of Indonesian Health Workers in Facing the Services Liberalization within AFAS Framework by conducting a review on MNP showed that the existing resources to prepare the Indonesian Health Workers in facing the services liberalization within AFAS framework had had the ability to implement it because it had the ability and competence in the field of expertise.
The results of the data collecting conducted by the researchers showed that the number of the doctors and dentists having Letter of Registration (STR) in Indonesia was 149.153 people and the number of the health workers having Letter of Registration (STR) in 2013 was 414 408 people (Health PPSDM Board, 2013). 12

Information
There are so many regulations or guidelines used as a reference for the quality development of the health workers. However, the technical guidelines in the road map framework of the quality and qualification development of the health workers in the direction as the Policy of Indonesian Health Workers in Facing the Services Liberalization have not been compiled. In contrast, the policies related to the health workers utilization both the foreign health workers who will be working in Indonesia and Indonesian health workers who will work abroad have been created and started to run.
From the results of the research, it can be seen that nowadays the existing setup related to the health workers liberalization is still talking about the utilization and the preparation of the quality and qualification standardization of the health workers, but how the policy direction is and how the implementation is still cannot be seen. In order to prepare the quality and qualification of the health workers under the direction of the Minister of Health, the Health PPSDM Board is asked to draw up a road map and National Action Plan on Education and Training Program of the Health Workers in the area of Ministry of Health and Ministry of Education and Culture by following the national standards (Secretary-General of Ministry of Health, 2014). 13

Facilities
From the results of the document review and confirmation through the interviews conducted with the informants, there was interesting thing that had previously been prepared by the Health PPSDM Board, but the evaluation did not run well. Meanwhile, there were some innovations that had been made by some institutions in which the direction and the goal were to improve the quality and qualification of our health workers. The Policy Readiness was presented as follows.

a) Opening International Class for Nursing Studies Program
The International class has been implemented and held since 2009, but until now its implementation has not run optimally. The constraints faced by the policy implementers were the budgetary factor, the lack of teachers, the absence of evaluation and guidance from the center, and the absence of the clear policy direction related to the utilization of the graduates.

b) Making International Cooperation in the form of an
International Memorandum of Understanding (MoU) which aims to improve the knowledge and skills of Health Polytechnic lecturer.

Authority
The results of the research showed that authority granting in preparing the health workers quality so that the Readiness of the Policy implementation of Indonesian Health Workers in Facing the Services Liberalization within AFAS Framework by conducting a review on MNP can run well. This can be seen from the division of responsibility given by the informant 1 based on Regulation of the Minister of Health No. 1144/Menkes/PER/VIII/2010 on the Organization and Working Procedure of the Ministry of Health, and its amendments. On the other hand, there are still many overlapping of authority. The most crucial one of the awarding authority is set up in Act, Presidential Decree, so the policy implementers will not focus on carrying out its responsibility.

D. Disposition
Based on the results of the research, the attitude, integrity and professionalism of the policy implementers are very high. This is a good capital in preparing the quality and qualification of the health workers. If we look at the results of the research that is juxtaposed with the Edward theory, the attitude of the quality implementers has been going well and supported each other. Although there is no policy direction for preparing the quality and qualification of the health workers, the template to that direction has already owned by the policy implementers. The policy disposition run by the policy administrators has been in line with item 2 of Article II of AFAS.

E. Bureaucratic Structure
Bureaucratic structure is one of the most fundamental structural aspects in an organization. In the working procedures of an organization, workflow is a guide for the policy-makers or policy implementers in running the day-to-day activities in order to obtain similarity of attitude and perspective of all existing elements in achieving the objectives of an organization because the bureaucratic structure is responsible for implementing policies that have a significant impact on the policy implementation (Subarsono, 2010). 14 Bureaucratic structure seen by the researcher here was the policy implementers in the Policy Readiness.

Mechanism
Program implementation mechanisms had been established by the policy implementers of the target groups and the related parties in preparing Indonesian Health Workers in Facing the Services Liberalization within AFAS Framework by conducting a review on MNP.
The results of the research showed that the targets that needed to be prepared were the quality and qualification of the health workers, how to make the quality and qualification of our health workers could be recognized and equivalent to the foreign health workers. Therefore, a mechanism for quality assurance of the health workers through the competency test system was created so that we could know our health workers quality, while a mechanism for the quality improvement was through education and training of the health workers. Related to that thing, until now the existing policies are limited to the draft of Road map Regulation and Preparation.

Fragmentation
From the results of the research juxtaposed with the Edward theory, it can be seen that there was no strong authority in the policy implementation because of the splitting of certain functions to the different institution or board. The responsibility for a policy area is scattered among several organizations. From the results of the document review in preparing the health workers quality in the Readiness of the Policy Implementation of Indonesian Health Workers in Facing the Services Liberalization within AFAS Framework by conducting a review on MNP, there were many fragmentation that occurred among the institutions resulting in the overlapping of authority because many policy implementers still wanted to run the policies that became the responsibility of their institution as well as to delegate the responsibilities that should be done to other organizations. Moreover, each board/agency has limited jurisdiction over a field, so the important tasks that may be been displaced. Then a narrow view of the board may also inhibit the change.

Inter-Institution Coordination
The results of the research showed that inter-institution 3 coordination has been carried out on an ongoing basis in order to increase Indonesian health workers quality, for example in the curriculum development in Article 36 of Higher Education Act. It is stated that: "Professional education curriculum is formulated together with the Ministry, other Ministries, Non-Ministry Government Institutions (LPNK), and/or a professional organization that is responsible for professional services quality with reference to the National Standards for Higher Education." If we review the article, we know that the compiling of the curriculum development is done by a crossministerial. Therefore, to prepare our quality, health workers curriculum should be developed by looking the service standards, professional standards and educational standards in which the task division in the standard compiling is their own responsibility. Thus, the inter-institution coordination and harmonization are needed in preparing the health workers quality who have global quality.

F. Readiness
The From the results of the research, in general the informants also said that we are less prepared; this is due to various constraints: 1. There is no consensus on standard benchmark for measuring the health workers quality throughout ASEAN; 2. The equation of our nomenclature of Health Workers Qualifications is still different; in addition, the existing quality measurement in Indonesia itself is still using a written administrative standard, not a not direct ability test. It also causes our health workers downgrade; 3. The Administration of the Competency Test of the Health Workers now cannot be used as a benchmark of overview of the health workers quality in Indonesia; 4. In term of regulation, we are ready, but in term of its implementation, there are still many overlapping of authority and confusion from the policy implementers to develop the direction of the health workers quality.

CONCLUSIONS
In general, from the overview of the quality and qualification of Indonesian Health Workers on the Readiness of the Policy Implementation of Indonesian Health Workers in Facing the Services Liberalization within AFAS Framework by conducting a review on MNP, we concluded the following: a) It is needed to have an understanding or a wise strategy and innovation that cannot be self-centered thinking in deciding a policy goal, as we need to take advantage of the existing opportunities as best as possible. c) Resource was one of the important variables in achieving the policy goals and objectives in the policy readiness. More many facilities and infrastructures were still needed that support the preparation of the quality and qualification of our health workers, but we sensed that there was a comittment to provide them. There were still many 5 overlapping of authority in the task execution, in which the most crucial one was of the division of the authority should be set up in Act or, Presidential Decree, so it would legally binded for the implementers. We also did not found any road map or a national action plan on education and training of the health workers.
We found that several educational institution had implemented international classes of Health Workers, that in return will reduce the dependence on the foreign labor (anticipating mode 3 of MNP).
d) The attitude of the policy implementers were good and very supportive to each other. Although there is no policy direction for preparing the quality and qualification of the health workers, we found the template to that direction. The attitude of the policy implementers has been going well and supported each other. Although there is no policy direction for preparing the quality and qualification of the health workers, the template to that direction has already owned by the policy implementers.
e) Bureaucratic structurewas one of the most fundamental structural aspects in an organization. Mechanism, fragmentation and inter-institution coordination were running well, but many policy implementers still want to run the policies of their own institution separately, so the existing resources and resources that have been build cannot be optimally executed. The bureaucratic structure will not run optimally if they still think self centered. Thus, it is expected in the Policy Readiness to have a non-egocentric thinking. We must stick together to pincrease the quality of our health workers in order to become competitive with other health workers outside Indonesia. Quality in order to get the selling power and be competitive with other health workers outside Indonesia.
f) The Policy Readiness was not yet appropriate and meet the quality and qualification standards. Indonesian Health Workers have been recognized by the countries in ASEAN region. Although Indonesia had drafted the Indonesian National Qualifications Framework, however the competency test administration was not appropriately described our health workers quality. In contrast, the educational qualifications of our health workers was often downgraded because the existing competency test systems in our country was only administrative.
Overall, Indonesia was not ready for the Readiness of the Policy Implementation of Indonesian Health Workers in Facing the Services Liberalization within AFAS Framework by conducting a review on MNP because the policy preparation to that direction was unclear. However, resoaurces and regulation for mplementation were there, so that it could be started SUGGESTIONS a) PPSDM requires strong and responsible collaboration from upstream to downstream, to prepare the health workers quality, and provide technical policy proposals on the curriculum development of the health workers in accordance with the Higher Education and Health Care Standards Act.
b) Sooner or later, Health Services liberalization will take place in Indonesia. Thus, to welcome its implementation, it is needed attention and seriousness in the environment of Ministry of Health, especially Health PPSDM to create a policy to prepare the health workers quality in order to be ready in facing the Services Liberalization within AFAS framework mainly to the review of MNP.
c) PPSDM has to create a policy and roadmap of Health Workers Development by putting the national action plan on education and training leading to the related policies on the quality development of the health workers towards global direction.
d) The Center of Education and Training of Health Workers is expected to develop the International Class, and conduct an evaluation of the existing International classes. e) Improving the matching certification system policy with other ASEAN countries, so that the Indonesian health workers working abroad and the foreign health workers coming to Indonesia are tested in terms of their competence and awarded a certification with a compatible method and can be standardized between countries in ASEAN region.
f) Making a matched certification policy with other ASEAN countries, so the Indonesian health workers working abroad and the foreign health workers coming to Indonesia are tested in terms of their competence and awarded a certification with a compatible method. Thus, there will be equality with other countries.
g) The team that has been formed, both internal and external of the ministry, should be more actively participate in doing promotion related to issues on Indonesian Health Workers Policy in Facing the Services Liberalization within AFAS Framework by conducting a review on MNP to the policy makers.
h) It is suggested to conduct further research on the Readiness of Indonesia in Facing the Health Services Liberalization by looking at the mode 1, 2, 3, and 4 of AFAS framework, with the scope of the policy direction that has been taken by Indonesia and its impacts on the supply side of the existing economic chain in Indonesia.