Administrative Workload and the Limitations of Operational Reliability in BOK Implementation at Puskesmas: A Qualitative Study Using the HRO Framework

Abstract

Strengthening primary healthcare through promotive and preventive financing, such as the Bantuan Operasional Kesehatan (BOK) program, is essential for achieving Indonesia’s Minimum Service Standards (SPM). However, national evidence suggests that increased financing does not necessarily lead to improved program performance. Frontline administrative workload, organisational capacity, and operational reliability remain critical factors shaping implementation outcomes. This study examined the workload experienced by BOK managers at Primary Healthcare (Puskesmas) and its implications for operational reliability, using the High Reliability Organisation (HRO) framework.

A qualitative descriptive approach was applied using purposive sampling of BOK managers involved in planning, budgeting, and reporting. Data were collected through in-depth interviews and document reviews, and were analyzed thematically using an inductive–deductive process informed by the five HRO principles.

Five themes emerged: (1) heavy administrative workload and vulnerability to operational failure, (2) rigid and oversimplified policy guidance, (3) limited sensitivity to real-time operational demands, (4) organisational resilience dependent on individual effort rather than system support, and (5) restricted decision-making authority among frontline experts. These findings indicate that current BOK implementation remains dominated by a compliance-driven administrative model that constrains organisational reliability and hinders SPM achievement.