Model Autonomy of Self-Finance Management for Primary Health Care to Enhance Workers’ Satisfaction

This study aimed to find an appropriate model of autonomous self-finance management in primary health care (PHC) to enhance workers' satisfaction. This was a cross-sectional study in which data were collected through self-administered questionnaires from 204 workers in ten Regional Public Service Agency for Primary Health Care (RPSAPHC)/ in using the partial least squares and structural equation model (PLS-SEM). A total of 73 indicators were used to examine the PHC transformation process to enhance workers' satisfaction. The indicators were grouped into three variables depending on workers' satisfaction: intrinsic, extrinsic, and general satisfaction. In addition, there were five independent variables: financial accountability, generating income, structuring human resources, increasing service quality, and consumer satisfaction. Model autonomy was reflected by all the indicators (cross-loading > 0.70, Cronbach’s alpha > 0.70, average variance extracted > 0.5) affecting workers’ satisfaction (path coefficient = 0.196, p-value = 0.002). The management should apply five indicators (financial accountability, increasing income, structuring human resources, improving service quality, and customer satisfaction) affecting workers' satisfaction to transform the PHC. Puskemas Badan Layanan Umum Daerah Pusat Kesehatan Masyarakat


Introduction
The new public management concept was implemented and reformed in primary health care (PHC), predominantly in local government. This concept has shown improvement; however, public service reform still faces obstacles toward transformation processes; these obstacles are mainly related to human resources. [1][2][3][4] Human resources need to be considered as they play an important role in the success of operational management to achieve organizational goals. A previous study showed that threequarter of the respondents were dissatisfied with their working conditions. 5 Doctors working in public health care facilities feel burdened with higher administrative work compared to those who work in private ones. 6 Furthermore, health workers in the first-level services complain that their salaries are not worth the services they provide. 7,8 Since 2007, PHC has been granted the autonomy to manage its budget in Indonesia. This regulation is called Regional Public Service Agency for Primary Health Care (RPSAPHC)/Badan Layanan Umum Daerah Pusat Kesehatan Masyarakat (BLUD Puskesmas). 9 However, less than 50% of the PHC comprehend this autonomy's philosophy and flexibility. 10 Human resources departments are not yet (in terms of reforms) ready for autonomy. 11,12 Some inhibiting factors of autonomy in PHC lie in the transformation process of the operational management and the challenges in terms of fairness as perceived by employees. 11 An evaluation showed that the reform was not balanced to accommodate its function; thus, PHC policies require a comprehensive review. 13 The new autonomy is needed to improve the operational management of public services through an effective transformation process. 14 In organizational environments, such as education, experience, and government support must be considered because they can influence the achievement of organizational goals. 15 Similarly, PHC reform requires key elements as specific indicators to improve performance. 16 Some components reflecting autonomy are important in the transformation process of PHC management: financial accountability, generating income, structuring human resources, increasing quality services, and customer satisfaction. 17 The PHC needs to reflect financial accountability and gain income that will increase re venue and incentivize their workers. 18,19 For health services to change, improving human resources is really important. 20 Whereas improving the quality of health services is increasingly vital, health centers must also pay attention to patient's satisfaction. 21 Ultimately, the satisfactory results of the transformation process may be generated by satisfied workers, which in turn will result in satisfied consumers. 22 The partial least squares method created a structural model that can map paths with many variables. 23 This study aimed to find an appropriate mo del of PHC autonomy by examining components in the transformation process through the operational management of autonomous self-finance management (SFM) to enhance workers' satisfaction, with the following moderation effects: educational background, working experience, and government support in the Tangerang District, Banten Province, Indonesia.

Method
This study used a cross-sectional method. Data were collected from self-administered questionnaires consisted of 78 questions filled out by health care workers in ten RPSAPHC of Tangerang District, Banten Province, Indonesia, from January to February 2019. The population of this study consisted of 289 health care workers, 24 and following the Morgan's table, the sample size in this study was 244, with a confidence of 99% and a margin of error of 3.5%. 25 Several steps were taken to ensure there was no missing data. 26 This study used a partial least square for structural equation modeling (PLS-SEM) composite scheme with the SmartPLS 3.0 software (free version), 27 to analyze variables on autonomous SFM toward workers' satisfaction and the moderation effect, which consisted of 73 indicators. The theoretical model adopted in this study was associated with the operational management of RPSAPHC, workers' satisfaction, and organizational environment ( Figure 1). 16,17,22 This study consisted of two main variables, eight subvariables, and three modifier variables measuring 73 indicators. The following constructs made up this model: workers' satisfaction was the dependent variable, which referred to the degree to which individuals felt positive or negative about their jobs ( Table 1). The workers'   satisfaction was measured using 20 indicators, which were divided into 12 intrinsic indicators, six extrinsic indicators, and two general indicators. Intrinsic job satisfaction reflects the tasks and how people feel about their job. Extrinsic job satisfaction paid attention to aspects indirectly or only slightly related to doing the duties. General job satisfaction refers to working conditions and working with coworkers. The independent variable consisted of five sub-variables: financial accountability (FA), generating income (GI), structuring human resources (HR), increasing service quality (ISQ), and satisfying consumers (SC). Each component had ten indicators; thus, 50 indicators were consolidated into the SFM. In modifier effects, there were three indicators: educational background, working experience, and government support.
Respondents were asked to indicate their level of agreement with the indicators of the SFM, as stated in a fivepoint Likert scale questionnaire ranging from 1 ("not good") to 5 ("best"). The questionnaires related to workers' satisfaction were asked on another five-point Likert scale ranging from 1 ("very dissatisfied") to 5 ("very satis fied"), which referred to the Minnesota Satisfying Questionnaire. 28 The respondents filled out the characteristics, education, working experience, and government support. Table 2 shows the sociodemographic data of the health care workers of ten RPSAPHC in the Tangerang District, Banten Province, Indonesia. The 204 respondents were aged 18-40 years (64.7%). In terms of the characteristics of sex, education level, working experience, and monthly income, 84.3% were females, 84.3% attained senior high school, 65.3% had more than five years of working experience, and 71.5% earned above the minimum wage of Tangerang District, which amounted to Indonesian Rupiah (IDR) 3,555,834.67. The permanent and non-permanent employment statuses were 55.4% and 44.6%, respectively. As much as 80% of health care workers were satisfied with the intrinsic indi-cators, and 60% were dissatisfied with the extrinsic and general indicators.

Results
The results of the analysis of the outer model are presented in Table 3. The composite validity in Table 3 shows that the building indicator of the variable is feasible because of the strong correlation between variables and indicators (original sample >0.70 and p-value<0.05).
The discriminant validity in Table 4 shows that the indicators are a makeup variable. The results of the crossloading of intrinsic, extrinsic, and general variables indicate that the correlation with workers' satisfaction is more substantial than the SFM variable. Another indicator that can be used as a determinant of convergent validity is the average variance extracted (AVE); both latent variables should be ≥0.50. Composite reliability (CR) was used to determine the construct measures' internal consistency reliability, which must be greater than 0.7. Cronbach's alpha was applied to measure the reliability   This model explains that autonomous SFM, which consists of five unify, has a positive effect on workers' satisfaction, with a coefficient of 0.201 and p-value of 0.002. Education, length of experience, and government support did not affect the relationship between SFM and workers' satisfaction (O<0.196).

Discussion
The implementation of public service reform is still experiencing obstacles, especially related to human resources, [1][2][3][4] including reforms in the autonomy of PHC in Indonesia, otherwise called RPSAPHC, 7 which were authorized for SFM. In this cross-sectional study, 29 PLS-SEMs were used to examine the suitability of the model of autonomous self-finance management in PHC to enhance workers' satisfaction. All workers with at least two years of experience from the ten RPSAPHC in Tangerang District, Banten Province, Indonesia, were employed to demonstrate the transformation process of autonomy at each PHC and their satisfaction.
This study analyzed a total of 70 indicators grouped into independent variables of SFM (FA, GI, HR, ISQ, CS: 50 indicators) and dependent variables of workers' satisfaction (intrinsic, extrinsic, general: 20 indicators), which were significant enough constitute the model. These indicators aligned with the need to evaluate the autonomy of RPSAPHC reform, based on public administration and local systems that can produce a synergistic effect. 30 The indicator of FA and GI were part of the institutional reforms in public facilities that aimed to realize public accountability in budgeting, strengthening legislative oversight, and modernization of internal and external audits. 31,32 Strengthening HR followed experts' opinions, which stated that improving the appearance of PHC assessments with specific indicators was necessary. 33 Likewise, indicators of ISQ were in line with the review of PHC reform. 34 While, the importance of SC was in accordance with the review of RPSAPHC autonomy reform that reported patients' low satisfaction in which most were National Health Insurance (NHI) participants expecting good service. 35 In terms of workers' satisfaction, its indicators were in accordance with that of healthcare providers, who agreed that job satisfaction is a category for the performance-measuring domain. 36 Workers' satisfaction is part of a series of services that must not be interrupted, as it is interconnected with the other parts of the services.
After all the indicators were found to be significant, this study examined the relationship between auto no mous SFM and workers' satisfaction. This model explained that autonomous SFM influences workers' satisfaction. This study followed the need to apply key performance indicators to influence the transformation of local governments at the district level. 37 Similarly, the weakness of the RPSAPHC implementation lay in human resources. 38 Semarang District, Central Java Province, Indonesia, showed that job satisfaction of the health care workers in RPSAPHC was higher in non-RPSA ones, but only in terms of the indicators of coworkers. Workers in both the non and RPSAPHC had the same high satisfaction regarding spirituality. 39 The results of this study strengthen the policy of the Tangerang District Government to extend the autonomy of the current RP-SAPHC to all 43 PHCs in the district. 17 Similarly, policies at the central level seek to implement RPSAPHC at all PHCs in Indonesia. 40 Although the current implementation of the RPSAPHC autonomy cannot run optimally. 41,42 Most respondents had a high level of education (higher than senior high school), had more than five years of work experience, and earned an income above the minimum wage according to regulations issued by the Tangerang District Government (Table 2). These three  Alamin. Model Autonomy of Self-Finance Management for Primary Health Care to Enhance Workers' Satisfaction indicators of modifier variables had been shown not to affect the relationship between RPSAPHC and workers' satisfaction. These findings differ from a previous study reporting that the level of education was significantly associated with physicians' job satisfaction. 43 Government support in setting salaries is related to work motivation, which impacts job satisfaction. 44 Likewise, government support in the form of job control, such as in this study, had a modifier effect on the relationship between workload and job satisfaction. 45 Finally, while work experience was not an effect modifier, it was found to affect workers' performance alongside workers' satisfaction. 46 The data revealed that the number of respondents with permanent status as government officers was approximately the same as the non-permanent ones. Therefore, the Tangerang District Government and the Central Government need to take special considerations to determine the salary of workers. For the continuity of an organization, it is necessary to pay attention to human resources, as workers' salaries assess their attitude and job satisfaction. 47,48 The PLS-SEM analysis can be carried out quickly in specific populations through a cross-sectional approach. This model is designed to determine the respondents' reactions to autonomous SFM's ability to enhance workers' satisfaction at specific times. The RPSAPHC that is not fully ready for the autonomy process needs to be strengthened regarding its operational management, improving services, and satisfying workers. 49 Therefore, it is necessary to carry out a further study with a longitudinal approach to facilitate the comparison of changes in autonomous SFM and workers' satisfaction within the observation period. 50

Strengths and Limitations
The strengths of this study were determined through measuring the indicators of RPSAPHC: FA, GI, HR, ISQ, and CS, to enhance workers' satisfaction. These indicators of autonomy in PHC can influence workers' satisfaction resulting from policies that transform the PHC to be autonomous. This study is limited to the PHC in the Tangerang District, which has a specific environment that differs from PHC all over Indonesia. Even so, the Tangerang District is not very specific, considering that it is not far (about 19 km) from the Special Capital Region of Jakarta; thus, it has more access to changes. In addition, the Tangerang District includes the 11 most advanced regions in Indonesia. Lastly, similar changes at the district level can be considered for implementation.

Policy Implications and Future Study
This study is useful for policymakers, especially in developing autonomous SFM in PHC to enhance workers' satisfaction. The autonomy model developed in this study aligns with the statement on the urgency of political decentralization and regional autonomy through local perspectives by using a political decentralization/local democracy model approach. 20 The implementation of key performance indicators for government officers affected the provincial government's transformation (at the district level) in term of increasing the efficiency of its services to the public. 49,50 The results of this study have several implications for developing autonomy in PHC, particularly in supporting the policy of NHI in Indonesia, as RPSAPHC is needed because health care providers implement the NHI in Indonesia. Furthermore, people need high-quality services from PHC, and satisfied workers can provide this. This study contributes to the academic literature by applying PLS-SEM to explore the relationship between autonomous SFM and workers' satisfaction in public health centers. Subsequent studies can be conducted in other health centers to control the indicators of the autonomous SFM model in enhancing workers' satisfaction and ensure that the effect is clear compared to autonomy without SFM indicators.

Conclusion
This study shows that improving the management of autonomous health centers should be carried out comprehensively, covering at least five indicators: financial accountability, increasing income, structuring human resources, improving service quality, and customer satisfaction. The improvement of RPSAPHC should be followed by evaluating workers' satisfaction, including intrinsic, extrinsic, and general indicators. It is important to note that improvements in the management of RP-SAPHC should also be reviewed concerning workers' satisfaction, which could later be used as an input for further policies by taking into the notion that education, work experience, and government support do not affect workers' satisfaction.