Does Extended Autonomy of Public Service Agency Lead to A Better Performance ? A Case of Indonesian Community Health Centers

The aims of this study were: (1) to evaluate the performance of community health centers (Puskesmas) that implement PPK BLUD (Pola Pengelolaan Keuangan Badan Layanan Umum Daerah, a specific type of Financial Management of Local Public Service Agency); (2) to explore the factors affecting the performance of Puskesmas in implementing PPK BLUD; and (3) and to find out, if any, the benefits of the implementation of PPK BLUD. This study was conducted at seven Puskesmas that have implemented PPK BLUD in Balikpapan City, East Kalimantan, Indonesia. Performance in this study was evaluated using three aspects: financial aspects, service aspects, and overall benefits for the society. Design of the evaluation refered to Permendagri 61/2007 and Perdirjen Perbendaharaan Kementerian Keuangan No.PER-54/NT/2013, with several adjustments. Documents analysis and interviews were conducted to answer the research questions. The result showed an increase performance of Puskesmas after two and a half years implementation of PPK BLUD. The average performance of financial aspect was lower than the other two aspects. Puskesmas which have implemented PPK BLUD have better performance than the non-BLUDs Puskesmas. Factors that affected the performance of Puskesmas in implementing PPK BLUD were human resources, infrastructures, as well as support from health department, local government and the legislative board. Implementation of PPK BLUD allows Puskesmas to increase their revenue by improving their services, efficiency, and effectiveness.


Introduction
The Law (Undang-undang-UU) Number 1 Year 2004 on State Treasury is a law established in the framework of state financial reforms undertaken by the government of Indonesia.Article 68 and 69 of this law stipulate the financial management of Public Service Agency (Badan Layanan Umum-BLU).BLU is established to improve services to the public in order to promote the general welfare and enrich the life of the nation.BLU is part of the central government while the Local Public Service Agency (Badan Layanan Umum Daerah-BLUD) is part of the local government.
To execute the mandate of the law above, The Regulation of Minister of Internal Affair (Peraturan Menteri Dalam Negeri-Permendagri) No. 61 Year 2007 on the Technical Guidelines for Financial Management of Local Public Service Agency which specifically regulates financial management of BLUD in local government was issued.This regulation describes that a local working unit can form a BLUD if it has duty and function as public service provider.Article 5 of this regulation states that some of the public services are to provide public goods and/or services to improve the service quality and quantity for the communities.Furthermore, article 6 of Permendagri No. 61/2007 states that the supply of goods and/or services is especially for health services.By the issuance of this regulation, the central and local governments continue to encourage health agencies providing health services directly to the public to implement Financial Management of Local Public Service Agency (Pola Pengelolaan Keuangan Badan Layanan Umum Daerah-PPK BLUD) (Kemendagri, 2013).
The purpose of implementing PPK BLUD is to enhance effective and efficient services in line with sound business practices.Implementation of PPK BLUD is expected to increase professionalism, transparency, and accountability in order to improve the performance of public services.To improve services, especially in the health sector, the Directorate General of Regional Finance Ministry of Internal Affairs and the Ministry of Health encourage local governments to implement PPK BLUD in local hospitals and community health centers (Pusat Kesehatan Masyarakat-Puskesmas).Until December 2014, the number of local hospitals which have implemented BLUD is 279 hospitals (44 percent of 639 local hospitals in Indonesia).Meanwhile, the number of Puskesmas BLUD is 209 or 2 percent of the 9.671 Puskesmas in Indonesia (Kemendagri, 2014;Kemenkes, 2015).
Among the 209 Puskesmas that have implemented PPK BLUD, there are seven Puskesmas located in the city of Balikpapan.The implementation of PPK BLUD at these seven Puskesmas began in July 2013 to present.After more than two years of implementation, the performance evaluation has not been conducted to assess the effectiveness of PPK BLUD at Puskesmas in the city.Balikpapan City is the first local government in Kalimantan and the fifth in Indonesia that implements PPK BLUD for its Puskesmas.So, it is necessary to evaluate the performance of those Puskesmas.
This performance evaluation is consistent with one of the administrative requirements of BLUD implementation set out by Permendagri No. 61/2007.When a Puskesmas leader proposed to establish Puskesmas BLUD, the Puskesmas leader shall sign a statement of willingness to improve service quality, financial performance, and benefits to the community.BLUDs leaders should also do an agreement with the region head every year.In the performance agreement, the head of region requires BLUD leaders to organize a public service, and therefore, BLUD leaders have the right to manage the fund listed in the Budget Implementation Document (Dokumen Pelaksanaan Anggaran-DPA) of BLUD.Improved performance as explained above can only be known by doing performance evaluation of the Puskesmas after implementing PPK BLUD.Apart from responding to the administrative requirements of BLUD, performance evaluation is also needed to find out the level of achievement of predetermined organizational goals.Performance evaluation in this study is divided into three aspects, which are: financial aspects, services, and benefits to the community.This is in accordance with the requirements of forming BLUD as listed in Permendagri No. 61/2007.
Research on the performance evaluation of Puskesmas BLUD is very important, yet it is rarely performed.Study on understanding PPK BLUD in Puskesmas is important to do because of the following reasons.First, prior research on PPK BLUD were mostly conducted in the context of hospital BLUD (see for example Wildana, 2008;Meidyawati, 2010;Hidayanti, 2011;Lituhayu, 2011;Surianto, 2012;Wijayaningrum, 2012;Puspadewi, 2013;and Sandiwara, 2013).The results of the study on hospital performance, however, cannot be generalized to to Puskesmas because of their different characteristics.Hospitals are more likely on curative and rehabilitative activities, while Puskesmas as primary health care providers tend to be at the first level of promotive and preventive health activities.Second, while some studies have investigated Puskesmas (e.g.Sutiarini, 2011;Sunuwata , 2014;and Raafiuddin, 2014) their focus were on the readiness of Puskesmas to become BLUD.Different with those previous studies, this current paper investigates the performance of Puskesmas after become BLUD and also compares performance Puskesmas BLUD with those non-BLUD.Third, Permendagri 61 year 2007 article 44 stipulates that after become Puskesmas PPK BLUD, then Puskesmas shoud be evaluated.However, until this study was conducted those Puskesmas PPK BLUD has not been evaluated.Therefore, this study was performed.Finally, this study was conducted because, to the best of our knowledge, none of prior studies had evaluated the performance of Puskesmas PPK BLUD using three criteria as stated in Permendagri No. 61 year 2007: financial, services, and overall benefit.
Based on the explanation above, the purposes of this study were (1) to evaluate the performance of Puskesmas in health department (Dinas Kesehatan Kota-DKK) of Balikpapan after implementing PPK BLUD, (2) to investigate factors affecting the performance of Puskesmas in the implementation of PPK BLUD, and (3) to observe the benefits of PPK BLUD implementation in Puskesmas.
Following the introduction, a review of literatures is provided in the next section.Then, the research design will be presented and followed by the research results and analysis.This article will be summarized with conclusions, recommendations and limitations of the study.

Literature Review
To improve the efficiency and effectiveness of governance in Indonesia, the government has reformed the management of state finance.(Restianto & Bawono, 2015).This new paradigm in the management of state finance is intended to improve government services to the public.
One of the country's financial management reform undertaken by the government is the provision of flexibility in financial management for government agencies.This flexibility is particularly given to agencies that provide direct services to the public.The flexibility of financial management is given to the the agency by establishing BLU.According to Restianto & Bawono (2015), BLU is expected to be a real example of the application of results-oriented financial management.
In the financial management of BLU, a change occurs, from traditional budgeting on inputs (input) or process oriented to performance-based budgeting on results (output) oriented.
Financial  SKPD) or sub-unit of SKPD in a local government which is set up to provide services to the community in the form of supply of goods and/or services without a priority to seek profits.In carrying out its activity, BLUD refers to the principles of efficiency and productivity.The definition of PPK BLUD according to Permendagri No. 61 Year 2007 is a pattern of financial management which provides flexibility to implement sound business practices to improve services to the public in order to promote the general welfare and enrich the life of the nation.Financial management of BLUD is an exception from the general financial management of governmental organization.
Related to research on BLUD in health sector, most of the previous studies were conducted in BLUD hospitals.Research on the performance of BLUD hospitals under the Ministry of Health among others had been conducted by Wijayaningrum (2012).She examined the influence of financial management flexibility in Sardjito Hospital before and after the implementation of PPK BLU.The results show that PPK BLUD implementation revealed an improvement in financial performance.The efficiency and effectiveness of financial management and activities in that hospital increased after the implementation of PPK BLUD.Research that specifically address the performance evaluation on local hospitals after the implementation of PPK BLUD were, among others Wildana (2008), Lituhayu (2011), Surianto (2012), Puspadewi (2013), andWijayanti (2015).They generally showed the same results.They observed an increase in financial and service performance of the local hospitals after applying PPK BLUD.Hidayanti (2011), however, found that the change of status into BLUD did not make Ulin Hospital in Banjarmasin being able to improve the health of its financial performance quickly.Statistical analysis showed no significant different in term of financial performance before and after the implementation of BLUD.Supporting the research of Hidayanti (2011), Sandiwara (2013) also found that the financial performance of local hospital after the implementation of BLUD had no significant changes compared to prior implementation.However, the performance of services was increased.Meanwhile, according to Amintasih (2010), the service quality of local hospital in Karanganyar after being turned into BLUD did not show any significant changes.
Studies related to BLUD in Puskesmas among others were performed by Sunuwata (2014), Raafiuddin (2014), andSutiarini (2011).They examined the readiness of the Puskesmas before the implementation of PPK BLUD.Sunuwata (2014) concluded that Puskesmas in Kulon Progo were not fully ready to implement PPK BLUD yet, especially with regard to the technical requirements.In addition, Noor et al. (2015) examined the performance of Puskesmas in Sleman after implementation.Noor et al. (2015) found an increase in financial performance, especially in profit margin, cash ratio and debt to asset ratio indicators.As the non-financial performance, in general, customers were satisfied with the services provided by the Puskesmas.

Research Design
The research was conducted at all Puskesmas in Balikpapan City, Indonesia that have implemented PPK BLUD.Those Puskesmas have formed BLUD following the decree of the Mayor of Balikpapan on 27 December 2012.However, the application of PPK BLUD began on July 1, 2013.Until this research was conducted, the performance evaluation on those Puskesmas after implementing PPK BLUD had never been arranged.It was the rationale behind the selection of the object of study.
The method used in this research was a qualitative method.This study aims to evaluate and explore information relating to the performance and benefits of implementing a policy.The research results were obtained through secondary data analysis and in-depth interviews with the participants.A qualitative approach involves activities such as asking questions and procedures, as well as collecting specific data from the participants and analyzing the data inductively from particular to common themes and interpreting the meaning of data (Creswell, 2014).The approach used in this qualitative research method was the case study approach.This study sought to examine a program on a particular type of organization, namely the implementation of BLUD financial management policy at Puskesmas in Balikpapan.According to Stake (1995) in Creswell ( 2014), a case study is a research strategy that is done by looking at a program, event, activity or group of individuals.
The data used in this research were primary data and secondary data.The primary data were obtained through interviews with the participants, while secondary data were obtained from the collection of documents on each research objects.Interviews were conducted using a semi-structured interview approached to gain more detailed information from the participants.In-depth interviews were conducted for the participants and consist of: head of Puskesmas BLUDs, finance officers, head of the health resources of Balikpapan health department as the companion of Puskesmas in implementation of BLUD, and patient of both BLUDs and non-BLUDs Puskesmas.
Those participants were selected because we believe they were the most knowledgeable people related to the topic studied.In other words, we selected them using purposive sampling approach.Financial aspects as specified above have lower weight than the other aspects because financial aspects on public sector organizations are not the key success factors in organizational performance.This is because the primary purpose of public sector organizations is not to maximize profit (profit-oriented), but to increase services to the community (Mahsun, 2006).The principal tasks of Puskesmas are to organize public health efforts through health promotion and preventive activities.Thus, aspects of the services and benefits to society are becoming more important than the financial aspect.
Measurement of the performance of each aspect is described as follows: 1) Financial Aspects a) Financial Ratio Indicators of performance appraisal in financial ratio aspects are as follows.2) Service Aspect Service aspects are measured by the growth of patient visits and Community Satisfaction Index (Index Kepuasan Masyarakat-IKM).

a) Growth of Patient Visits
Growth of patient visits are measured through patient visit data on each unit of service in Puskesmas.The formula for the growth of each patient visits above is: The scores for each productivity growth over the patient's visit are: Table 4 Service Performance Indicators -Growth of Patient Visits Interval Score Productivity Growth Score Growth of patient visit > 1,10 2 1,00 < Growth of patient visit < 1,10 1,5 0,95 <Growth of patient visit < 1,00 1,25 0,90 < Growth of patient visit < 0,95 1 0,85 < Growth of patient visit < 0,90 0,5 Growth of patient visit < 0,85 0 Furthermore, to obtain a total score service aspectthe growth of patient visits is calculated by: 1) Non-24 hours Puskesmas = Number of scores obtained / 16 x 17.5 percent.The formula of total score of service aspects-IKM: = Number of scores obtained / 28 x 17.5%

2) 24 hours
3) Benefits to the Community Aspect The assessment of this aspect is used to measure the efforts to improve the quality of public services in health care and conformity to the requirements in accordance with the needs of society.Performance measurement of benefit to the community aspect is measured through outcomes indicators of health Minimum Service Standards (Standar Pelayanan Minimum-SPM).
Based on the Regulation of Health Minister No. 741/2008 on Minimum Service Standards for Health in the regency/municipality, the types of service and performance indicators of primary health care are as follows.Total score of benefit to the community aspect is calculated using the formula: = Number of scores obtained / 36 x 35%

4) Results of Performance Evaluation
Performance evaluation results are based on the total score obtained.The total score is the summary of the scores on finance, services, and benefits to the community aspects.The scale of score is number 1 (one) to 100 (one hundred).

Result and Discussion
The scoring results of the performance evaluation on each Puskesmas showed an increase of each Puskesmas at the end of 2015 compared to the beginning of the implementation of BLUD.Among the three Puskesmas, which are Puskesmas Baru Tengah, Mekar Sari, and Prapatan, showed increasing results from A to AA. Puskesmas that showed highest increase performance was Puskesmas Prapatan with 9.41 percent of increase score.Puskesmas that shows lowest increase was Puskesmas Kariangau with 3.71 percent of increase score.The results were shown in the following tables.Results of performance evaluation on each Puskesmas revealed that indicators of financial management compliance have consistently increased at all Puskesmas BLUD.This showed an increase in accountability and orderliness of Puskesmas in management and financial reporting.
The following chart shows an increase in average total score of overall assessment at Puskesmas BLUDs.This graph shows that the average of overall performance score of Puskesmas tend to increase until 2014, but slightly decreased in the first half of 2015.

Graph 1 Average Total Score of Performance Evaluation on BLUD
The decline in the first half of 2015 on the chart above was partly due to the increasing number of Minimum Service Standard (SPM) objectives that have to be achieved.This led to the realization of several indicators of SPM in some Puskesmas being under achieved.All Puskesmas also cited that delays in the issuance of decree on capital expenditures was resulted in the budget on capital expenditure not being realized until the end of 2015.Here were some excerpts of related interviews.
"Oh that's because the target increases automatically.The target of pregnant mother increases...In essence, if the target is bigger, automatically the variance is bigger.So, for example, if previous year say 347, then the following year suddenly increased to 437, automatically to chase the target is very difficult" -Head of Puskesmas A "For example, by 2015, we had budgeted capital expenditure, but the Decree of capital expenditure until the end of the year did not come out, so we could not achieve the target."-Head of Puskesmas E The following table shows the average score of performance evaluation results of each aspect of the evaluation.From the table above, it appears that financial aspect has the lowest score compared to other aspects, which is 64.88 percent.This is mainly because the BLUD status given to Puskesmas was still a partial BLUD status.The flexibility given to the partial BLUD was very limited.A partial BLUD status did not have the flexibility in investment and debt management.The government of Balikpapan City also did not give flexibility to the Puskesmas BLUD with partial status in the procurement of fix assets (until year 2015), the management of fix assets (such as selling or leasing unused assets), and limited flexibility in cooperation with third parties and hiring non-government professionals.
Limitations in flexibility of partial BLUD status, led to less flexibility to innovate in implementing fair business practices in order to increase its services revenue.As a result, all Puskesmas experienced deficit especially in periods with depreciation charge (the second half of 2014 and 2015).This means that the Puskesmas revenue, including revenue from APBD, APBN, and grants, during the period, had not been able to cover operating and non operating costs.The ratio of total services income in the observation period did not obtain the maximum score (score 2.5).The average ratio of revenue services at all Puskesmas throughout the period amounted to 27.76 percent, far from the criteria of best value of at least 65 percent.This reflected a big dependence on APBD and APBN.
Overall, the interviews showed that all participants support an increase in performance after the implementation of PPK BLUD.It was seen in some of the participants answers.Improved performance was mainly due to their flexibility in the use of BLUD budget, so that Puskesmas, among others, could guarantee the availability of medicines and other consumable supplies in Puskesmas so the service performance could be improved.It was seen in some of the participants answers.
"In terms of service, we are more upward than downward.For the SPM itself, there was a decline because of its target,... sometimes the targets that were not rational for us, so it was difficult to achieve.But in terms of achieving the SPM, we perform better year after year"-Head of Puskesmas C.
"With good financial performance then we have, for example, enough tools and consumables ... so can provide a better service too.With the BLUD I do not have to wait from the service agency"-Head of Puskesmas D.

Comparison Between BLUD Puskesmas and non-BLUD Puskesmas
In addition to evaluating the performance of Puskesmas BLUD, it was also conducted a benchmark with the performance of Puskesmas in Balikpapan City that had not implemented PPK BLUD yet.To get a better comparison, the benchmark was conducted at the same time period.Benchmarking was only arranged on services and benefits to community aspects.Financial aspect could not be compared, because Puskesmas that had not implemented PPK BLUD was not a reporting entity, so there was no obligation to prepare financial statements (balance sheet, operation report and cash flow report).The number of Puskesmas taken for comparison was seven Puskesmas, in accordance with the number of research objects.
The following table illustrates the results of the performance evaluation scores of services and benefits to community aspects in Puskesmas non-BLUD.According to the performance evaluation results presented in Table 9 and 11, the following is the comparison table of average performance score between Puskesmas BLUD and non-BLUD.Table 12 and chart 2 show that the average score of performance on Puskesmas BLUD, both on service and benefit aspects, is higher than the non-BLUD.The variance of these two aspects is 6.25 percent.

Graph 2 Performance Comparison on BLUD and Non-BLUD
From interviews with several patients on Puskesmas BLUD and Non-BLUD, all patients agreed to an increase and improvement of Puskesmas services, both in facilities and personnel service performance, particularly for the BLUD one.Average performance score both in service and benefit to the community aspects in general were getting better.Some of the interviews show: "What I reliazed is that the condition is getting better.From the service aspect, from what we had experienced, we have received better than before.Now in the service center... there is more adequate because more personnel.As in the service center now there are three (personnel,) so our patients do not wait too long" (Patient of Puskesmas Karang Joang).
"In my place, there is an citizen post there, the doctor always comes, and also the nurses, and pharmacist, .. However, despite the improvement of services in Puskesmas BLUD, interviews with the Puskesmas non-BLUD patients stated that the Puskesmas services were not optimal yet.The lounge area was too warm and sometimes less friendly officers were still being experienced by the patients.From interviews with Puskesmas patients above, it can be concluded that the service of Puskesmas that have implemented PPK BLUD are better than Puskesmas non-BLUD.When the convenience of the patients in the waiting room is interrupted, for example, Puskesmas BLUD can immediately provide the necessary facilities without waiting for the procurement from health department, as well as experiencing the hospitality of the staff in serving patients or in conducting activities in the community.Staff in Puskesmas BLUD is required to improve their personal service performance which is influenced by their provision of services.The amount of the compensation services that is received by each personnel is strongly influenced by their personal performance assessment.

Factors
Affecting Performance in Implementation of PPK BLUD Factors that can affect the performance of Puskesmas in the implementation of PPK BLUD are divided into internal factors and external factors.The most influential internal factor is human resources.Human resources are required to improve their ability in managing PPK BLUD, as well as recording and reporting financial things.
Other factors that support the implementation are the commitment of all employees to learn financial management of BLUD and to understand the intent and purposes of this implementation in order to improve health services for the community.It includes a commitment to manage and to report transparent and accountable financial reports.The commitment by the management board of Puskesmas BLUD is needed in order to motivate employees in operating this BLUD policy and to make changes expected by the implementation of PPK BLUD.Other factors are the facilities and infrastructure that support the implementation of financial management of BLUD, such as financial information system that supports recording and generates real time and accountable financial reporting.
The external factors are the support from the health department and local government.The health department needs to provide mentoring and coaching to enhance Puskesmas understanding and ability in implementing PPK BLUD.Health department should also facilitate coordination among all Puskesmas, coordination with local authorities, consultants, auditors, and other concerned parties.The local government needs to provide support, either budgetary support, related regulations, assistance and training for Puskesmas.Another external factor is the support of legislative board, especially in the budget approval and the approval of establishment and improvement of the status of BLUD.

Benefits of the Implementation of PPK BLUD for Puskesmas
The benefit of applying PPK BLUD (i.e. the flexibility in financial management) is shifting a budgeting system from expenditure-oriented (cost/expense center) to profit-oriented (profit center).It allows Puskesmas to be more innovative in increasing revenues by improving service to the community and implementing a fair business practice.The efficiency and effectiveness of spending also increase as Puskesmas are motivated to increase the surplus (profit) while maintaining the quality of health services.It supports the performance-based budgeting which has been encouraged by the government.
Another benefit for health care services is ensuring the availability of consumable supplies (drugs, medical devices and materials) so Puskesmas does not run out of those medical supplies which are very important to the patients.Curative and rehabilitative activities at Puskesmas as well as preventive and health promotion activities for the community are not constrained due to lack of supporting infrastructure.This is because the Puskesmas can undertake their own procurement without waiting procurement or budget availability from the health department.Efficiency and effectiveness in the procurement of goods and services can also be increased with the BLUD status.Implementation of PPK BLUD also motivates employees to improve personal performance because of the reward and punishment system with the provision of services and remuneration.
The final benefit mentioned is the increasing accountability in financial management.Puskesmas becomes more systematic in making reports both on financial and nonfinancial.BLUD financial statements are not only audited by the Financial Audit Agency (Badan Pemeriksa Keuangan-BPK) but also audited by Accounting Firm (Kantor Akuntan Publik-KAP).In addition, in accordance with Permendagri No. 61/2007, the performance of BLUD will be assessed annually by the BLUD supervisory board.

Conclusions, Limitations and Recommendations.
From the discussion that has been described above, it can be summarized as follows.First, there was an increase in the performance of Puskesmas BLUD compared with initial implementation of PPK BLUD.The average value of financial aspect performance obtained the lowest score compared to other aspects.The results of the comparison with the Puskesmas that have not implemented PPK BLUD, also showed the performance of Puskesmas BLUD are higher than the non-BLUDs.Second, factors that affect the performance of Puskesmas in implementation of PPK BLUD were divided into internal and external factors.Internal factors are human resources, facilities, and infrastructure.External factors are supports from the health department, local government and the legislative.Third, the benefit of implementing PPK BLUD (especially due to the flexibility of financial management) was shifting a budgeting system from expenditureoriented (cost/expense center) to a profit-oriented.Implementation of PPK BLUD allows Puskesmas to increase revenues by improving service quality to the public.The motivation to increase surplus (profit) also encourages efficiency and effectiveness of spending.Another benefit for health care services is ensuring the availability of medicines and medical materials so there is no shortage in the clinic.Curative rehabilitative activities at Puskesmas as well as preventive promotive activities in the community are not constrained due to lack of supporting infrastructure.Implementation of PPK BLUD also motivates employees to improve personal performance because of the reward and punishment system through the provision of services.Last benefit was the increasing accountability in financial management.
Recommendations that can be delivered through this research are as follows.First, providing flexibility in financial management for government agencies to implement fair business practices needs to be balanced with consistent coordination and assistance from the local government.The possibility of obtaining a surplus (profit) of course also be accompanied by the risk of a deficit (loss).So that, the local government, in this case the health department and financial department of the local government, need to maximize their monitoring of the implementation of PPK BLUD.
Monitoring can be done by making sure all the documents required in PPK BLUD, from planning document until reporting document have been made and reported by the Puskesmas every period according to regulations.In addition, the health and financial department and other relevant agencies should also undertake review and assessment of these documents to improve the quality of planning, implementation, and accountability of Puskesmas in order to implement PPK BLUD.Second, since the implementation of PPK BLUD at Puskesmas in Balikpapan has been running for almost three years, then the Health Department in Balikpapan should immediately assist the Puskesmas in proposing the status improvement from partial BLUD to full BLUD.Furthermore, the local government will examine and assess to raise or revoke the status of Puskesmas BLUD.Third, based on the interviews, the health department that facilitates the issuance of the regulation related to BLUD and also legal department of the local government that issues the regulations, need to improve their efforts so that the regulations can be issued on time.Thus, it can support the implementation of PPK BLUD.Finally, evaluation on the performance of Puskesmas in order to implement PPK BLUD should be carried out at least once each year according to Permendagri No. 61/2007.In addition, the Ministry of Internal Affairs should issue regulations related to the performance appraisal guidelines of Puskesmas BLUD, as the same as the Ministry of Finance issued Perdirjen Perbendaharan No. 54/2013 for the performance assessment for hospital BLU.Furthermore, local governments can refer to these guidelines to issue regulations related to the design and performance assessment indicators for Puskesmas in their respective regions.
The research objects have just implemented PPK BLUD for two and a half years, so that the performance trend analysis cannot be done on a long period.Partial BLUD status implemented by the research objects has very limited impact on the financial flexibility.Future studies need to examine the object of research with Full BLUD status to obtain the more in-depth evaluation results of the performance analysis.
Puskesmas = Number of scores obtained / 12 x 17.5 percent.b) Community Satisfaction Index (IKM) UU No. 25 of 2009 on Public Service mandates local governments to improve the service quality and ensure the provision of public services in accordance with the general principles of governance.One form of public service evaluation is to conduct an IKM survey.The following are service elements measured on IKM.

Table 1
Financial Performance Indicator-Financial Ratios

Table 3
Service Performance Indicators -Growth of Patient Visits

Table 5
Service Performance Indicators-Community Satisfaction Index (IKM)

Table 6
Service Performance Indicators-IKM Interval Score

Table 7
Health Minimum Service Standards (SPM) Indicators

Table 8
Criteria for Performance Assessment Puskesmas BLUD

Table 9
Results (Scoring) Performance Evaluation on Puskesmas BLUD

Table 11 Average
Total Score of Performance Evaluation on Non-BLUDs

Table 12
Comparison of the average performance score on BLUD and Non-BLUD "In the waiting room, we have to wait a long time at the counter .... Sometimes we wait a long time.Sometimes it's hot in the waiting room" (Patient of Puskesmas Manggar)."In the waiting room is less comfortable.Waiting room is hot, we have to wait a long time, it's hot...We are sick, and the queuing place is hot, it's not good...If they can give a fan facility then is great ... staffs are often chatting with his friends while they have to serve patients... .If they can, once the patient come they have to directly serve,... the staff should not have a chat with his/her friends.So we will not have to wait too long" (Patient of Puskesmas Gunung Bahagia).