Analysis on Policy Implementation of Community Health CENTER as Report Obligation Recipient Institution for Narcotic Addicts in Jakarta Province in 2014

This paper analyzed the Policy Implementation of Community Health Center (CHC) as Report Obligation Recipient Institution for Narcotic Addicts in Jakarta Province in 2014. The design of the study employed a mixed methods approach of Sequential Explanatory. The implementation analysis employed the model developed by Donald Van Meter and Carl Van Horn. Within the model, policy implementation was associated with performance. The relationship was influenced by six variables: standards and targets, resources, communication among implementing agencies, implementing agency characteristics, attitudes of the implementers, as well as social, economic, and political factors. We found that variations of those six variables influenced policy performance linearly.    


INTRODUCTION
Narcotics have long been known in human civilization since more than five thousand years BC. However, the new synthetic narcotics were known to man approximately one to two centuries ago since the discovery of barbiturates in 1903 and benzodiazepines in 1957 (UNODC, 2012). 1 During the 1970s, the use of narcotics and other psychoactive substances became a major problem for the world, including Indonesia, as in addition to the growing number of users most of the users are at productive age.
In addition to the problem of big supply and demand, the handling of drug addicts also appears problematic. For instance, drug addicts sentenced to jail until May 2012, according to the data of the Ministry of Health of the Republic of Indonesia, have been as many as 24,237 people not to mention the high incidence of HIV AIDS among addicts (Nelwan, 2010). 2 In the Act No. 35 of 2009 on Narcotics, it has been stated that drug addicts have to file a report. The Ministry of Health issued a Ministerial Decree No. 1305 of 2011 on Report Obligation Recipient Institution (IPWL) to receive the report.
This study aims to analyze the implementation of policies in health centers acting as Report Obligation Recipient Institution (IPWL) for drug addicts in Jakarta. In addition, this study also aims to provide inputs for future planning in the implementation of the policy for those health centers.
This study employed a combination of Sequential Explanatory models of in policy implementation of Community Health Centers (CHCs) as Report Obligation Recipient Institution for narcotic addicts, with a case study analysis. The research was conducted in Jakarta from May to June 2014.

THEORETICAL REVIEW
Public policy is a very broad field of study and involves many disciplines (Winarno, 2012). 3 It is often defined as a number of decisions made by the government, referring to the responsible actors in certain policy areas (Buse, 2013). 4 Policy analysis can be defined as a multidisciplinary approach to policies that aims to explain the interaction between institutions, interests, and ideas in the policymaking process (Dwiyanto, 2009). This is useful both retrospectively and prospectively to understand the failure and success of a past policy to plan the implementation of policies in the future . 6 Many theoretical models are available to study the implementation of a policy. One of them is the theory by Donald S. Van Meter & Carl E. Van Horn (Nugroho, 2012). 7 According to this theory, there are six variables that affect the performance of policy implementation, namely: a. Standards and targets; b. Resources; c. Communication among implementing agencies; d. Characteristics of implementing agencies; e. Attitudes of implementer; and f. Social, economic, and political factors.
To choose the best implementation model means to consider the type of policy. Matland (1995) divides the implementation model into a matrix based on ambiguity-conflict (Nugroho, 2012). 7

RESEARCH METHODS
The method used was descriptive analytic within the approach of mixed methods of Sequential Explanatory model, namely the collection of quantitative data in the form of questionnaires, followed by collection of qualitative information by conducting in-depth review of documents and interview results.
Quantitative method was used to see the policy implementation of Report Obligation Recipient Institution (IPWL) for drug addicts in Jakarta. Qualitative method was used to examine the phenomenon occurring in the six variables of the implementation.
The population study was those 12 Community Health Centers listed as Report Obligation Recipient Institution (IPWL) in the area of Jakarta. Informants in this study consisted of IPWL officers, the Head of Subdistrict Community Health Centers, officers in charge of mental health of the Department of Health.
The instrument used was a structured questionnaire containing of six questions for both the independent variables as previously mentioned and the dependent variable of policy performance.
Validity and reliability testing was done altogether with the testing on respondents. Reliability test on the research instruments was performed using Cronbach Alpha formula. As for the qualitative data, validation test was performed using triangulation.
Univariate analysis was conducted to see the frequency distribution of each independent variable and frequency distribution of the policy performance of Community Health Centers designated as Report Obligation Recipient Institution (IPWL). Qualitative data analysis was done by organizing data into a theme to be interpreted (data reduction), followed by data presentation and conclusion drawing.

RESULTS § The Results of Reliability Test
Reliability test on the seven variables studied performed altogether with the distribution of the questionnaire on May 22, 2014 to 30 IPWL officers, with Cronbach alpha technique.
Questions on standards and targets consisted of two (2) questions, on resource consisted of four (4) questions, on communication among implementing agencies consisted of two (2) questions, on characteristics of implementing agencies consisted of five (5) questions, on attitude of implementers consisted of four (4) questions, on economic, social, and political factors consisted of two (2) questions, on performance consisted of four (4) questions, and all resulted in rvalue > 0.361. Thus, it could be concluded that all the questions in the questionnaire for both the independent variables and the dependent variable passed the reliability test and were eligible to be used in the study. § Informant Profiles Most of the informants were employees who had been working for more than five (5) years (80%), and most of them were doctors (60%). The highest education background was postgraduate (40%). The key informants in this study were coordinators of mental health in the Community Health Centers. § Characteristics of IPWL Officers Half of the IPWL officers were doctors aged 24 to 34 years old. As many as 43.3% of the officers had been working for 5 to 10 years, and thirty of them (60%) had been handling drug addiction cases for 5 to 10 years. § Policy Performance From Table 5, we can see that CHC in each area shows variations in terms of performance, yet the biggest gap is to be found in Central Jakarta in which the highest performance was found in Gambir as many as 114, while lowest performance was found in Senen as many as 14. The lowest gap was found in North Jakarta.
Seen from the overall performance, CHC Gambir had such good performance (> of the median); however, seen from individual performance, there had been such big gap. Only three (3) respondents did not comprehensively utilize the available guidance in helping drug addict filing the Report. Two of them were working in Central Jakarta, while one was working in North Jakarta. They had been doing their job from more than 7 years. They hold a bachelor degree, SMF, and a general practitioner as HR coordinator.
From the qualitative data, almost all informants stated that standards were available but not all of them were practiced. All the patients with Report Obligation were PTRM patients. All informants confirmed they did not know about the indicators. § Resources The number of staff for each CHC was different. The CHC Senen, Kemayoran, Tambora, and Kramat had only one staff in charge. The staff in charge was directly appointed by the Head of CHC without any specific criteria, as confirmed by some informants. Drug Sub-Directorate of the Ministry of Health had trained some of these IPWL staff or officers for assessment and therapy procedure. Funding for IPWL was entirely given by the Ministry of Health through advertisement.
From the observation, the fare paid by the Ministry of Health was different from the one charged by CHC. As an example, the fare paid for counseling on basic addiction was IDR 50,000, while for CHC was IDR 5,000. § Communication among Implementing Agencies All informants said that coordination among related organizations had been done, although they were not all actively involved. Communication between health institutions was already better than to the non-health institutions. Of the 30 respondents, only three of them stated that the most difficult task to do was to coordinate with other relevant institutions. They also stated it was difficult for CHCs to work alone without the help of other institutions. § Characteristics of Implementing Agencies Six health centers with good policy performance also showed good implementing agency characteristics such as good organizational structure, developing values, relationships, and communication.
While three of other the six health centers with lower performance also showed rather low characteristics.
However, it was found that in the three health centers with good performance, the officers said that the characteristics of the executing agency were not so good causing the individual performance to become low. § Attitudes of Implementer From the six health centers with good performance, three health centers health centers showed good attitude reflected through good and timeliness services, no bad stigma against addicts, ability to serve all the patients, and ability to overcome boredom at work.
Of the 30 respondents, there were four people showing rather negative attitude and leading to low individual performance, which in turn affected the performance of health centers.
During one of the interviews, the staff in charge did not immediately accept a drug addict patient coming to submit the results of the laboratory because the patient came at noon and he was asked to come back another day. § Social, Economics, and Political Factors company requires.
Economic level brings effect on access to health services. This is supported by the data that Central Jakarta with higher economic level than four other regions show higher number of addicts with Report Obligation who can access health services.
From the data obtained, the best performance of health centers is found in Central Jakarta, followed by North Jakarta, East Jakarta, West Jakarta, and South Jakarta.
From the qualitative data, it is known that almost all the informants agree that social, economic, and political factors have not been so supportive toward Report Obligation of drug addicts.

The researchers had a very limited time to conduct
the study as the permission took much to get and the bureaucracy was complicated; 2. There were not any targets or clear indicators to be achieved by CHCs acting as IPWL; 3. There were IPWL officers being moved to other places, getting promoted, or going back to school, and yet, there were no substitutes. § Characteristics of IPWL Officers IPWL officers were mostly doctors aged between 24-30 years and had already been working to serve patients of drug addiction for 5-10 years. It can be concluded that most of the IPWL officers are already quite experienced to serve cases of drug addiction.
However, some officers were still new in the service of drug addiction cases and had never received training. Efforts were made to transfer knowledge through mentoring by the mental health service coordinator. § Policy Performance The objectives of the policy to set CHCs as IPWL are in line with Article Number 2 of Government Regulation No. 25 of 2011, which is to fulfill the rights of drug addicts in need of treatment and/or care through medical rehabilitation and social rehabilitation.
The performance policy itself refers to assessment toward changes or trends as a result of the implementation of a policy (Dwiyanto, 2009). 5 In addition, it is said that performance policy is the assessment of achievement against standards and policy targets.
The data showed that all Report Obligation patients coming to CHCs got medical rehabilitation through methadone therapy.
In such cases, internal control performed by the coordinator of PWL team and the head of the health center become so crucial. It is important to hold scheduled team meetings. Providing motivation and support to the new team members to be more confident in serving patients with addiction must be done regularly.
In addition, it is important to monitor the performance of the policy so that interventions can be done to improve the performance. § Standards and Targets Based on the data, of the twelve (12) CHCs, six (6)  From the data obtained, two health centers were open for only a day in a week. The number of days of service will directly affect performance.
Basic counseling procedure is given to drug addicts during Report Obligation process, yet further counseling is given by considering patient's condition.

Research conducted by Hser, Yih-Ing, et al. 2011 in
China shows that scheduled counseling or motivational counseling helps increasing retention in treatment although the exact difference is not known. 8 According to Van Meter and Van Horn, identification of performance indicators is a crucial stage in the implementation of the policy. The indicator may be a direction and at the same time a tool to assess the extent to which policy goals have been achieved (Winarno, 2012). 3 The foregoing may occur due to two reasons, as proposed by Van Meter and Van Horn (Winarno, 2012). 3 The first reason is the many tasks to handle with a complex nature or purpose. The second is that the lack of clarity on tasks to handle is deliberately created to guarantee a positive response from the implementing organization or implementer.
To set the ideal number of patients to be served as an indicator of the performance CHC acting as IPWL is somewhat difficult because their main job is not as outreach health centers. The Outreach and Assistance Task Force of National Narcotics Agency (BNN) daily executives shall carry out the tasks.
Therefore, to reach the targets and indicators set by Directorate General of Health Management Efforts (BUK) of the Ministry of Health, each CHC must determine their own target, as an example of one of the CHC decides that all patients visiting CHC must be served, as they are the targets. Then, adherence to service standards must also be assessed.
The quantitative data showed that three health centers are not obedient to the specified standards. It also affects policy performance of the health centers. § Resources Resources refer to how much financial support and human resources are available to support the implementation of the policy.
The service standard of Report Obligation requires a PWL team consist of a general practitioner in charge and other health professionals trained with basic counseling on drug addiction.
However, we found that not all health centers had a team because officers were transferred, went back to school, and got a job promotion. There were no substitutes yet. One health center solving this problem by contracting a doctor to serve drug addicts.
Indeed, not all CHCs had the capacity to contract the workers as it depended on the income level of the health centers. As health centers commonly experience manpower shortage, we have to evaluate the performance of existing available personnel, as this will help to form positive impact on motivation, responsibility, and engagement to the organization (Gibson, 2000). 9 In addition to officer's shortage, we found that some staffs or officers less qualified. This is supported by qualitative data obtained from the new staff feeling that they did not have sufficient capability to serve drug addicts. Even a new personnel was immediately placed to serve.
To overcome these problems, Heads of CHCs, in accordance with Jakarta's Governor Regulation No. 150 of 2009 on the Organization of the Department of Health, regularly report to the Head of Department of Health to ask for trainings for on basic counseling for officers who have not been trained.
While waiting for the realization of the training, new officers go through orientation under the guidance of the general practitioners in charge.
Regular and facilitative supervision will lead to decrease turn over on drug addiction officers as found in the study "A Model for Predicting Clinician Satisfaction with Clinical Supervision" (David Best, 2013). 10 To financially support the plan, the entire budget is charged to the Ministry of Health through the claims procedure.
Nevertheless, the qualitative data showed that the claims procedure was difficult due to administrative problems and these funds would go to the BLUD of the health centers. Therefore, finally it is difficult for IPWL officers to obtain payment for consulting services by the Ministry of Health.
Besides, the amount of cost per unit of activities paid by the Ministry of Health is different from the amount stated in Governor Regulation No. 68 of 2012 on Health According to Dwiyanto (2009), the tendency of executing actors can be directly affected by the availability of resources. For example, if the source of funds and human resources are available, then the executors will more likely to encourage adherence as they hope to get benefits from the available resources. 5 To improve policy performance, coordination with other members of the organization, in addition to support of those in power of funding, is obviously indispensable. 5

§ Communication among Implementing Agencies
Narcotics problem is a problem that requires extensive coordination among institutions in charge of the problem. There are several institutions involved in handling narcotics problems ranging from BNN or BNNP, the Ministry of Health, the Ministry of Social Affairs, Department of Health, Community Health Centers, Non-Governmental Organizations, and the community itself.
Successful implementation often requires inter-agency mechanism. The more complex and broader working area of the policy, the more it needs for better communication among relevant institutions (Dwiyanto 2009). 5 Each institution has a strategic role; thus, they have to harmonize the role of coordination and communication among implementing agencies or related institutions.
National Narcotic Agency (BNN) is a non-ministerial government institution in charge of bringing together all components of the community and the nation in prevention and eradication of drugs abuse and illegal distribution of narcotics, psychotropic substances, and other additives. BNN also coordinates with the police in their duties.
The Ministry of Health is responsible for establishing regulations related to medical services for drug addicts and policy evaluation services.
To improve the number and participation of addicts in Report Obligation activity is one of the tasks of the Outreach and Assistance Task Force of National Narcotic Agency (BNN) executive secretary.
Guidance and supervision of CHCs acting as IPWL is conducted by Department of Health in accordance with the Governor Regulation No. 150 of 2009. However, in reality, qualitative data shows that supervision and monitoring on Report Obligation was no running well; it has been mentioned previously that effective and facilitative supervision will affect the satisfaction of the officers.
From the qualitative data, it has been revealed that communication among institutions was hard. For example, communication with social services was difficult to do when officers wanted to refer addicts to social services to get social rehabilitation.
Communication should be designed as a reference, such as how often regular meetings will be held. Communication between the implementing bodies also represents the presence of mutual support among the implementing agencies.
According to the informants, there were not any meetings or cooperation with other organizations or institutions outside CHCs.
To harmonize the communication among the implementing agencies, it takes active participation of institution holding the jurisdiction related to preventing drug abuse (Dwiyanto 2009). In the case of drug abuse, active participation of BNN as the one holding jurisdiction is needed to harmonize communication between implementing agencies.
In the relationship among organizations, there are two most important types of implementation activities namely advisory and technical assistance. § Characteristics of Implementing Agencies The characteristics of implementing agencies refer to organizational structure, developing values, relationships and developing communication within the organization (Abdul, 2012). 11 According to Van Meter and Van Horn, as cited in Winarno (Winarno, 2012), there are some elements as the characteristics of the implementing agencies that will affect the implementation of a policy. 3 From the data on competence of personnel, the number of officers in PWL team, the level of internal control by the coordinating team, coordinator of health services, and Head of CHCs, it can be concluded that the program is still not running well. Similarly, external supervision by the Department of Health has not been effective or facilitative.
Faced with the demands of successful implementation on which many obstacles are found, members of the institution finally make their own policies to overcome the circumstances, which are usually against the policies or the policy goals. For example, there is such a big gap in the performance of PWL officers.
There are also other problems. Most of the officers feel incompetent to carry out the compulsory tasks they have. The appointed coordinator is not actively involved in the service. Other members of the organization are less concerned about their jobs, resulting in chaotic situation when they are absent. It is often said that everyone in the CHCs does not care about the matter outside their duties, even indifferent shown by the heads. 3 To overcome the above problems, the role of supervision and guidance is crucial to reveal differences in the effectiveness of implementation. The role should begin with the internal supervision at CHCs to the external supervision.
Given the nature of drug policy that is ambiguous completed with high conflict, the implementation of drug policy will be more effective done in directed top downer orientation. Therefore, the supervision and guidance is critical in the implementation. § Attitudes of Implementer According to Van Meter and Van Horn, attitudes and tendency will affect the performance of policy implementers. Negative attitude or tendency will oppose policy objectives.
From the observations and statements by informants, there were officers showing negative attitude against drug addicts. The informants felt that drug addicts or users would always complain the service they provide. In addition, the informants were uncertain that CHCs were able to provide the services required by drug addicts.
This view will cause conflict tendencies. Conflict tendencies will make changes to adherence that in the end will come to rejection of the policy objectives (Abdul, 2012). 11 § Social, Economic, and Political Factors Social, economic, and political will affect the performance of the implementing agencies. There are some questions to illustrate the influence. The question is whether the economic resources for the implementing agency are already supportive, the extent to which existing economic and social conditions will be affected by the implementation of the policy, public opinion on policy implementation, and the latter is whether the interests of private groups are mobilized to support or oppose policy (Winarno, 2012). 3 From the information provided by informants, it was revealed that only a small percentage of the public knew that CHCs acted as IPWL. They also confirmed that drug addicts were afraid to report as they feared to be TO (Target Operations) of the police, although there had not been any report on drug addicts being arrested by the police. The informants added that addicts visiting CHCs found it difficult to get a medical or social rehabilitation outside CHCs because of their financial inability.

CONCLUSION
We found that the implementation of Community Health Center as Report Obligation Recipient Institution (IPWL) for drug addicts or users in Jakarta was not been running well. Therefore we feel there is a need to evaluate the policy of setting up Community Health Center as Report Obligation Recipient