THE EFFECT OF POLICY IMPLEMENTATION OF BASIC HEALTH SERVICES DURING THE COVID 19 PANDEMIC (Study of Implementation of Basic Health Services in West Java Province)

Facing the Covid 19 pandemic, Indonesia is faced with the quality of essential health services that are still not optimal in various provinces. The main problems of vital health services that have emerged in West Java Province include the number and infrastructure of public health centers, the affordability of services and types of services such as maternal and child health, immunization, nutrition, environmental health and coverage of public health nursing performance. service quality variable, the theoretical approach of Fitzsimmons & Fitzimmons (2011) is used with Tangibles, Reliability, Responsiveness, Assurance and Empathy factors. The research method used is an informative survey approach by collecting data from library analysis sources and field experiments, including questionnaires, observations, and interviews. The sampling method used is Plain Random Sampling. The selected sample (n) was 92 people. The data analysis methodology used is route analysis. The results of the study reveal the positive and significant impact of policy implementation on the effectiveness of the quality of critical health services. In addition, it was also found that communication effectiveness variables that affect the quality of essential health services in West Java Province are also found


INTRODUCTION
Health programs in Indonesia strive to increase understanding, desire and capacity to live a healthier life for all to realize the highest degree of health as a representation of the general wellbeing as alluded to in our constitution (Andrianto & Nursikuwagus, 2017;Ulumiyah, 2018;Djasri, 2012). The Health Service is organized based on the National Health System (SKN), which is an agreement that puts together different activities of the Indonesian nation in an organized and mutually beneficial manner to achieve the highest health status (Adisasmito, 2007;Saputra et al., 2015;Putri, 2014). The actors in the implementation of health development are the community and government (central, provincial, district/city). Thus within the government environment, both the Central and Local Governments must work together synergistically to carry out planned, integrated and sustainable health services to achieve the highest health degree (Suprianto&Mutiarin, 2017;Mujiati&Yuniar, 2016;Christasani&Satibi, 2016).
To improve human resources quality, health development policies are done (Notoatmojo, 2008;Pasaribu, 2015). Health development has a positive relationship with improving the quality of human resources. A high degree of health and nutritional status will increase productivity, which will increase community income or community welfare (Adrianto&Ningrum, 2010;Utami, 2012;Ramadhanti, 2020). Health Service Policy is one of the main components. The critical role of development as it is now can be seen from its contribution to increasing the productivity of the current generation and the productivity of future health services (Ariati, 2013;Atmarita, 2004) The Effect of Policy Implementation of Basic Health Services During the Covid 19 Pandemic (Study of Implementation of Basic Health Services in West Java Province) (Tati Sarihati, and Pandji Santosa) Health policy in Indonesia is formulated based on the framework mentioned above, but the implementation mechanism would be affected by the dominant fiscal, political and bureaucratic frameworks (Sumampouw&Roebijoso, 2017). Therefore, as stated by Walt & Gilson (1994), the development of health services in a country cannot be separated from the social, economic and political structures that exist in that country, that the system strongly influences the existence of fundamental rights in every citizen in the health sector. The Social, geographic economy of an area is also sufficient to influence the community's needs in getting health services (Smith, 1997). The application of an economic development strategy that tends to be capitalistic, the acceptance of unstable state opinions, the privatization of health and the development of the pharmaceutical industry, which foreign companies dominate, are factors that have a strong influence on people's opportunities to obtain health services. Therefore, these factors will impact community opportunities to get health services (Macinko et al., 2003).
Essential health services are one of the health services that must be administered by local governments (Marniyati et al., 2016) Usman et al. (2007) show that fundamental health problems are critical national issues that need to get more in-depth attention from the government.
In West Java Province, there were 1,088 health centres in 2019, consisting of 292 inpatient health centres and 796 non-inpatient health centres. Based on the national requirement that one puskesmas serve a minimum of 25-30 thousand residents. The ratio of population per health centre in West Java from 2015 to 2019 is still above 40,000. This means that one puskesmas serves 40 thousand people. To achieve the standard of 1 puskesmas to do 30 thousand people, in West Java, 1,623 health centres are needed. This means that West Java still lacks 537 health centres. District/city areas with a ratio of health centres per population close to ideal conditions (1:30,000 people) are found in 3 districts/cities, namely Tasikmalaya City, Bandung City, Kuningan Regency. There are ten city districts with a ratio of health centres to a population more significant than the average of West Java Province 1: 44,829, namely Bekasi Regency, Bekasi City, Depok City, Bandung Regency, Bogor Regency, West Bandung Regency, Cianjur Regency, Purwakarta Regency, Cimahi City and Karawang Regency.
Facing the current pandemic situation, the condition of the types of health services provided by the Puskesmas as the spearhead of essential health services for the community has not shown a favourable condition, if you can see in the table below: With a negative range of each service's percentage of achievement between 0.05% to 23.2% in the table above, all types of essential services in West Java Province have not been optimal. Several other indications show that the quality of critical health care is not yet sufficient: 1. Number of health workers at Puskesmas who have not reached the standar. 2. MCH data collection for maternal and child health services still has not surpassed the set target. 3. The collection of data from the Independent Practice Midwives and other health facilities is not optimal; 4. Public awareness and knowledge about the importance of standard prenatal care are still lacking. 5. Has not reached the target service coverage for postpartum visits to have a check-up at the puskesmas 6. Inadequate aspects of service facilities and infrastructure, such as inpatient places. Compared to the total private/individual health service facility, the percentage of each primary health service facility dominates with the amount of 79.59% compared to the percentage of Puskesmas 4.51%. 7. Low achievement of Public Health Nursing. 8. Decreased community participation in the implementation of health service programs; Policy implementation is implementing a program to achieve the goals of Edwards III's policy (Sarihati et al., 2019). According to Edward III, the effectiveness of the policy execution is determined by the efficiency of the coordination variables, the capital, the architecture and the bureaucratic structure as seen in the figure below: Related to the above concept, Edwards III in (Sarihati et al., 2019) states that "Four critical factors or variables in implementing public policy: Communication; resources, dispotions or attitude and bureaucratic structure "that simultaneously interact with each other to help or hinder the implementation of government policies. In the context of public services, Fitzsimmons & Fitzimmons (2011) state that the quality of the service is complex in order to determine the extent to which the quality of the service can be seen from five dimensions, i.e: Tangibles (touchables) to involve the presence of employees and other physical facilities, such as equipment or equipment supporting services; Reliability, that is, the capacity to deliver the sort of service promised to consumers accurately and correctly; Responsibility, understanding or willingness to support customers and provide swift service; Assurance (guarantee), awareness or insight, politeness, faith on the part of service providers, as well as respect for customers and sympathy (attention) in the form of desire on the part of service providers to approach, offer security and attempt to understand the desires and needs of consumers.
Policy implementation is one of the processes of the public policy cycle. The position of policy implementation is so important in public policy, where the importance of policy implementation is explained by (Wahab, 2005), namely that policy implementation is more important than policy formulation. (Winarno, 2002) explains that public policy implementation is a tool where various actors, organizations, procedures, and techniques work together to carry out policies to achieve the expected goals.
According to (Nugroho, 2004) defines policy implementation as a way for policies to achieve their goals. Both opinions have the same conclusion, namely that policy implementation is a way to achieve what is the goal of a policy. The definition of Winarno explains implementation in more detail by describing the parties involved in implementing the policy, such as organizations, actors (government and non-government) and the systems that are in the implementation of the policy itself.

METHOD
In this study, the explanatory survey method was used by linking the causality between the studied variables and explaining the causes of the phenomenon occurring in general and universal, as Singarimbun (2008) stated. The data in this study were taken from 2 (two) sources, namely: 1. Primary data sources, namely data obtained directly from the research field, namely from officials and community receiving necessary health services. 2. Secondary Data Sources, namely data obtained from documents, laws and regulations, health service program reports and previous research results relevant to the research object.
To collect data within the framework of using the Explanatory Survey research method, data collection techniques refer to the opinion of Neuman (2007), namely: 1. Observation, namely data collection techniques carried out through direct observation in the field of the object's activity being researched, the implementers and officials' behaviour to be interpreted through theoretical parameters. 2. In-depth interviews, through direct questions and answers with respondents and informants. The data obtained were confirmed by cross-checking, especially to the stakeholders involved. 3. Questionnaire/Questionnaire, which is a data collection tool with a list of questions and statements to selected respondents to find out the facts, activities, behaviour and interpretations of respondents and to explore comparative information more fully with alternative answers categorized in the form of numbers following a Likert scale pattern (Mueller, 1986).
The study population was all the West Java Provincial Health Office employees who served either directly or indirectly in basic health services to the community. The population element is 329 people (N = 329). The sampling procedure used was a basic random sampling process. The sample size of this study was 92 participants(n = 92). Data validity was tested using the total item correlation technique and data reliability with Cronbach's internal consistency alpha (Kerlinger, 1986). This research's statistical analysis is a descriptive statistical analysis and path analysis (Riduwan, 2007).

RESULT AND DISCUSSION
To answer the research objectives, to determine the influence of policy implementation on the quality of essential health services, path analysis techniques are used. For the calculation of the path analysis, the writer used SPSS software. The results of the path coefficient can be presented in the following figure: R 2 = 85.6% : communication X 2 : resources X 3 : disposition X 4 : bureaucratic structure The outcome of the estimation of the route coefficient indicates that there is a positive effect on the quality of critical health services in the West Java Province of the policy delivery component, which involves connectivity, finances, disposal and bureaucratic structure. The direction coefficient indicates the direct effect on the endogenous variable of each exogenous variable. The immediate impact of the communication variable on the quality of essential health services is 0.160. One standard deviation from the resource variable is 0.308, one standard deviation from the disposition variable is 0.241, and from the bureaucratic structure variable, 0.368 one standard deviation. Meanwhile, the path coefficient's square explains the diversity or variance of primary health care quality, which the implementation variable can directly explain. This value is sometimes defined as the amount of direct influence resulting from exogenous variables on endogenous variables.
It can be seen that the communication variables explain 0.025 or 2.5% of the diversity of the primary health service quality variables, the resource variables explain 0.095 or 9.5% of the variety of the primary health service quality variables, the disposition variables explain 0.058 or 5.8% the diversity of the primary health service quality variables and the bureaucratic structure variables. Explain 0.136 or 13.6% of the variability of essential health services' quality through a linear relationship between variables. Meanwhile, the proportion of variance from the variable of crucial health service quality that can be explained simultaneously by the variable of policy implementation is 0.856 or 85.6%. It can be stated that 85.6% of the variation in the quality of essential health services can be explained by policy implementation.
After estimating the parameters or path coefficients, the next step is to test the path coefficients' significance either simultaneously or partially. The simultaneous model can be described as follows digure 3.
The F test coefficient is used to test the latter hypothesis. The results of the measurements using the SPSS program obtained a measured F value of 129,166 with a table F value of 2,476. The expected value of F is higher than the value of the table of F. It may be inferred that the null hypothesis is dismissed and that the first hypothesis is accepted, which means  that there is a parallel impact of policy enforcement on the efficiency of basic health care in the province of West Java. The magnitude of the simultaneous impact of policy implementation on the quality of essential health services is a determination coefficient of 0.856 or 85.6%.
Partial hypothesis testing was carried out to test whether individually each factor in policy implementation, including communication factors (X1), resource factors (X2), disposition factors (X3) and bureaucratic structure factors (X4), has had a major impact on the delivery of critical health care at the West Java Regional Health Office. The path analysis model can be described as follows:

Figure 4. Research Path Diagram with t-student value
The policy implementation variable's simultaneous influence on the quality of essential health services at the West Java Provincial Health Office is the coefficient of multiple determination, namely R2 = 0.856 or 85.6%. This means that simultaneously 85.6% of changes in the quality of essential health services are influenced by policy implementation variables, including communication, resources, disposition, and bureaucratic structure factors. Simultaneously, the remaining 14.4% is influenced by other variables not examined in this study.
The partial effect is the influence of exogenous variables individually on endogenous variables through other exogenous variables. After calculating the magnitude of the influence, the policy implementation variable's simultaneous impact on the delivery of critical health services at the Western Java Regional Health Office is the coefficient of multiple determination, namely R2 = 0.856 or 85.6%. Furthermore, the influence of communication on the quality of essential health services is 11.2%. The effect of resources is 25.4%, the power of the disposition is 17.3%, and the influence of the bureaucratic structure is 31.7%. From these results, it is known that the bureaucratic system gives the most significant impact on policy implementation on the quality of essential health services at the West Java Provincial Health Office. This means that the most dominant factor in improving critical health services is the bureaucratic structure.
The descriptive analysis results show the total score of the communication factor is 73.4%, resources is 69.0%, the disposition is 75.9%, and the bureaucratic structure factor is 66.2%. From the findings of this descriptive analysis, it can be evaluated that, in general, the execution of policies is going well; however, in particular, the bureaucratic systemic element, it is still perceived as low by some respondents. In order to increase the efficiency of critical health care, it is important to improve the bureaucratic system, including factors of clarity of job descriptions and division of labour, clarity of standard operating procedures, and cooperation/ coordination between work units.
In the context of the quality of essential health services, efforts to improve policy implementation will be reflected in the improvements in intangibles, reliability, responsiveness, assurance and empathy factors. The findings of the descriptive study demonstrate that the cumulative score for the observable element is obtained 71.4%, the reliability factor is 66.7%, the responsiveness factor is 74.1%, the assurance factor is 72.3%, and the empathy factor is 72.3% with a total score for the variable quality of essential health services of 71.1%. In general, the quality of essential health services can be useful, but some factors are still not well perceived by respondents, so it needs to be improved.
The data analysis shows that the communication factor affects essential health services' quality with a significant influence of 0.112 or 11.2%. This communication factor consists of good policy information delivery (transmission), clear/unambiguous delivery of policy information (clarity) and consistent delivery of policy information (consistency). Centered on the outcomes of the data collection and the products of the interviews, it is shown that the communication carried out within the framework of policy implementation has been carried out well, which shows that the total score for the communication factor is 73.4%. This reflects that the delivery of information. Information regarding policy objectives is well stated, clear and detailed. However, the consistency of the delivery of health service information to the broader community needs to be improved, given its positive impact in eliminating the risks that may arise due to delays in primary health services during a pandemic.
Service is basically concerned aspects of life that are very broad, deep government has a state life function to provide the best service to the community, start service in the form of arrangements or services others in order to make ends meet. According to Moenir (2006: 40) "The service concerning the fulfillment of a right, then it becomes an inherent right to follow on everyone". Another definition of service according to Lukman (1999: 6) is "a activities that occur in interactions directly between one person and another or machines physically, and provide customer satisfaction".
From the two opinions above it is understood that service is a process or activities in order to fulfill human needs according to their rights. From the government side, according to Pamudji (1994: 28) that "Public service as activities that aim to fulfill people's need for goods and services ". While Djaenuri (1999: 37) defines community service is "An activity which is embodiment of general government duties regarding the main duties of an agency to be able to serve the needs of the community maximally".
Resource factors affect the quality of essential health services, 0.254 or 25.4%. The resource factor consists of an indicator of the number of implementing officers, the implementing apparatus's authority, and the available supporting facilities. Widodo (2010) states that it will reduce the effectiveness and efficiency of implementing policies without sufficient and adequate equipment. Agustino (2016) argues that resources can include staff/employees or, more precisely, street-level-bureaucrat., information (how to implement policies and compliance of implementers with regulations), authority and facilities needed in implementing procedures that are very important in implementation Policy.
Based on the survey results, the resource factor is still considered low even though the total score is 69%. The number of implementing officers who are deemed inadequate in terms of quantity and quality is a rising phenomenon. Also, the distribution of the number of employees between sections varies significantly compared to the workload that is the responsibility of each section/division. This situation demonstrates that the division of the number of workers should consider the review of the workload of each segment on the basis of their primary duties and functions, considering that health professionals have a vital role to play in improving the highest level of health care to the population so that people can improve their understanding, desire and capacity to survive. Good enough that the highest quality of wellbeing is realized as an investment in the production of socially and economically efficient human capital and general welfare. In this context, the increase in the number of apparatus and efforts to include/implement training for human resources according to the required competencies gradually and increase health cadres' capacity through coaching, mentoring, and refreshing cadres still cannot answer the increasing service needs of the community.
The data analysis results showed that the disposition factor affected the quality of essential health services, amounting to 0.173 or 17.3%. The disposition factor consists of indicators of understanding of regulations/policies, adherence to procedures and sufficient expertise/abilities of the implementing apparatus.
The survey results provide an overview of the implementation of policies related to disposition factors, with a total score of 75.9%. This reflects that the policy implementation apparatus already has an adequate level of understanding of the regulations/ policies that apply in the implementation of work. Besides, employees' high compliance with policy procedures and placement of employees following their abilities/expertise is beneficial for policy implementation success.
The data analysis results showed that the bureaucratic structure factors affected the quality of essential health services by 0.317 or 31.7%. The bureaucratic structure factors consist of job description indicators/ work division, Standard Operating Procedure (SOP) and cooperation/ coordination between work units.
Overall, the bureaucratic structure factor in policy implementation is still not right, with a total score of only 66.2 in the low category, especially those related to job descriptions and cooperation between parties about policies that are not going well. This shows that collaboration in policy implementation among sections at the West Java Provincial Health Office has not been effective, which implies delays in service delivery. Likewise, the clarity of labour division is not following the potential resources possessed by human resources and the facilities that support it. Based on the outcome of the study, the effect of other factors was found to be 14.4% beyond the variables analyzed.

CONCLUSION
Simultaneously, the implementation of policies strongly influences the quality of essential health services at the West Java Provincial Health Office. This influence shows that policy implementation can work more effectively through effective communication, quality resources, attitudes in carrying out work, and a responsive bureaucratic structure.
The effect of policy implementation on the quality of essential health services is partially variable. The factor of bureaucratic structure and resources in policy implementation has the most outstanding value. It has a strong influence on the quality of essential health services at the West Java Provincial Health Office. In contrast, the lowest value and not significantly influential are communication and disposition factors. The results also reveal that the quality of essential health services at the West Java Provincial Health Office is not only influenced by the policy implementation variable.