Workload Challenges in the Implementation of Health Operational Assistance (BOK) Policy and Its Influence on Achieving Minimum Service Standards (SPM) at the Primary Health Care Level in Tasikmalaya District

Abstract

Strengthening primary healthcare through promotive–preventive financing mechanisms such as the Bantuan Operasional Kesehatan (BOK) program is central to achieving national Minimum Service Standards (SPM) in Indonesia. However, national evaluations indicate that increased funding does not automatically translate into improved program performance or service outcomes. Organisational capacity, administrative workload, and operational reliability at the frontline level significantly determine implementation effectiveness. This study aimed to explore the workload experiences of BOK program managers at the Primary Healthcare (Puskesmas) level and analyse their implications for operational reliability using the High Reliability Organisation (HRO) framework.

A qualitative descriptive design was employed, utilising purposive sampling, with key BOK managers responsible for planning, budgeting, and reporting. Data were collected through in-depth interviews and document review. They were analysed thematically using a combined inductive–deductive approach guided by the five core HRO principles: preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise.

Five major themes emerged: (1) high administrative workload and risk of operational failure, (2) oversimplification of policy and limited flexibility, (3) low sensitivity to real-time field operations, (4) weak organisational resilience relying on individual compensatory effort, and (5) limited decision-making authority for frontline experts. These findings reveal that current BOK implementation is dominated by a compliance-based administrative paradigm that undermines organisational reliability and constrains achievement of SPM indicators.

Structural reform is required to enhance reliability through integrating reporting systems, redistributing workload, strengthening adaptive mechanisms, and empowering technical decision-making. Without adopting HRO-based reform, BOK risks remaining a low-reliability system incapable of meeting primary health performance targets.