Master of Public Health

Managing Healthcare Organisations

Coursework 2015
2159631

Word count: 4952 words [excluding references]

Managing Healthcare Organisations 2159631

Learning from the implementation of the Indonesian

National Health Insurance (NHI) at the hospital-level:
the place of culture and politics in managing change

Introduction

National Health Insurance (NHI) was rolled-out in Indonesia on 1 January 2014 to provide universal
health coverage for all Indonesian citizens as a solution for the problems of limited access to essential
health services and impoverishment related to health spending (World Health Organization, 2013, The
Lancet, 2014). However, problems soon followed its implementation at the hospital-level, as the new
scheme led to increased utilisation of hospital services while resources were actually limited.

Hospital managers play a key role in this national health system reform, as they were responsible for
implementing changes and adjustments to the new scheme at the hospital level. So, to help them
understand the change process surrounding NHI implementation at the hospital level, this essay will
discuss a case of a hospital that has implemented the program, and study the dynamics of change
management and how politics and culture contribute to the process. This essay will also explore the
challenges faced by the manager, and what further actions should be taken to improve the outcome.

National Health Insurance

The newly implemented Indonesian National Health Insurance (NHI) scheme is built upon the
unification and expansion of three previously existing public insurance services which had already
covered about 116 million citizens, comprising the poor, civil servants, pensioners, and employees
working in formal sector (The Lancet, 2014, Guinto et al., 2015). The new scheme offers an expanded
coverage to those who relied upon the out-of-pocket payment scheme, i.e. self-employed citizens and
informal sector employees, who now have to pay their premiums to the public agency that runs the
NHI (Guinto et al., 2015, The Lancet, 2014). By being a member of NHI, citizens are eligible for
receiving a wide range of health services, including promotive, preventive, curative, and rehabilitative
services, all free at the point of delivery (Guinto et al., 2015).

However, NHI implementation is not without challenges. Indonesia is currently facing a serious
shortage of health professionals, with the average density of physicians of 2.4 per 10,000 populations
(The Lancet, 2014, Global Health Observatory, 2011). Health facilities are concentrated in urban
areas, and there are too few hospital beds and resources to provide adequate services for all the
citizens (The Lancet, 2014). Poor quality of care also remains a problem. Around 35 percent of
Indonesia’s hospitals have not been accredited (IRIN, 2014).

Indonesian healthcare system is suffering from severe underfunding. Indonesia has only allocated 3
percent of its annual gross domestic product for health within the period of 2010-2014, far below the
common consensus of the minimum 5 percent (World Bank, 2014). As a result, the standard tariff for
the Disease-Related Group (DRG) reimbursement system in NHI has been set very low (Faizal, 2014).

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Figure 1. Problems surrounding the implementation of National Health Insurance (NHI) at the hospital-level

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Implementation at the hospital-level

Implementation of NHI at the hospital-level does not require any dramatic change in the
administrative system, because it does not differ greatly from the previous insurance schemes.
However, the sudden increase in service utilisation has often burdened the hospitals with a high
number of patients, and the quality of service is often compromised (Figure 1) (Wirdana, 2014). In
addition, the absence of clinical guidelines and standards of treatment at the national level has
frequently led doctors to improvise their own practice, prescribing unnecessary medications or
inefficient suboptimal treatment (Rahmawati et al., 2009). Critics have also been targeted to the low
healthcare standard tariff, low remuneration rate, and burnout of healthcare providers (Faizal,
2014).

To provide a better understanding on change management surrounding the introduction of NHI at the
hospital-level, this essay will discuss a case of a public hospital that has implemented the scheme
since January 2014. Information was obtained from an interview with a general physician working at
the hospital during the transition period. However, due to some ethical considerations, the identity of
the hospital will be concealed in this paper, and the name “Hospital A” will be used instead.

Hospital A is a public hospital located in one of the biggest cities in Indonesia, with a total capacity of
356 inpatient beds and 115 medical doctors, accredited as a type-A hospital. The hospital is headed by
a Director and two Deputy Directors, namely the Deputy Director of Medical Services and the Deputy
Director of Finance and General Affairs. The first deputy is responsible for issues related to medical
services in the inpatient and outpatient, while the latter for human resources, marketing, accounting,
finance, and planning. Being a state-run health facility, Hospital A had no option but to adopt the NHI
scheme in January 2014, as regulated by the Government.

Power, culture, and politics in change management

Contrary to the classical model of planned change coined by Kurt Lewin (1947), change is
increasingly seen as an unpredictable process, unintentional, and involving relatively informal self-
organising, to which the slow, linear, and mechanistic nature of the planned change approach can be
overly simplistic (Liebhart and Lorenzo, 2010). Some experts argue that managing change should
start by understanding the change characteristics—its form, size, time of occurrence, and the internal
or external factors which come into play (By, 2005). Then, appropriate strategies are developed based
on the type of the change— in line with the contingency theory proposed by Dunphy and Stace (1993).
Managers should develop the skills to find the most effective approach for a certain circumstance (By,
2005, Burnes, 2004), probably by a balanced combination of both planned and emergent change
approaches (Liebhart and Lorenzo, 2010). Additionally, managers should focus more on developing
readiness and resourcefulness to facilitate change rather than merely following some prescriptive
steps for a specific change process (By, 2005).

Culture and change management

According to Burnes (2011), change is a complex and open-ended analytical, political, and cultural
process. Along the process, managers have a wide range of options that they can choose to deal with
every circumstance. Managerial choice is important in dealing with the complexity of change,

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particularly because managers are not robots that unquestioningly follow the ‘rational’ recipes of
success (Burnes, 2011).

Culture is one of the thing managers base their choices on. Culture refers to ‘the unique configuration
of norms, values, beliefs, ways of behaving and so on, that characterise the manner in which groups
and individuals combine to get things done’ (Eldridge and Crombie, 1974:78) It was shaped by a
number of factors, such as the organisation’s history, society’s values and characteristics, and
technology (Allaire and Firsirotu, 1984). Understanding culture is important in managing change, not
only because it will determine the appropriate choice of strategies, but also because it can guide the
behaviours of an organisation’s members without detailed instructions from the manager or extensive
discussions on how to deal with particular problems (Sathe, 1983). Therefore, managers would expect
that by modifying culture to some extent, they may improve their chance to achieve their goals.

However, there are some challenges and limitations related to culture change. Firstly, there is little
agreement about the nature of culture (whether it is an attribute or a metaphor), and whether or not it
can be changed (Scott et al., 2003). Furthermore, Filby and Willmott (1988) questioned the manager’s
capacity to control culture, considering that individual’s values and beliefs are also shaped by
experiences outside the workplace—media, social activities, and past history. Even if it can be
changed, further reservation is expressed by a number of authors in relation to the ethical issues.
Secondly, research on the relationship between culture and performance, especially in health care
setting, is still inconclusive (Doherty et al., 2013). For example, we are not sure if a strong unitary
culture can improve organisational performance, or it will suppress diversity and prevent alternative
strategies from arising when a problem occurs (Schein, 1985, Burnes, 2011). Thirdly, any attempt in
changing a culture is likely to be met with resistance (Burnes, 2011). In a complex and large
organisations, such as hospitals, different subcultures, which rooted from ethnic, religious, social class,
gender, occupational, and divisional diversity, might coexist within the organisational culture. While
some subcultures can be categorised as enhancing cultures (i.e. amplifying the dominant culture) or
orthogonal cultures (i.e. accepting the dominant culture), some others can be regarded as counter
cultures (i.e. challenging the dominant culture) (Scott et al., 2003). Ultimately, outcomes of the
attempts of changing culture are unpredictable and can be deleterious. That is why it is important to
assess the cultural risks prior implementing a culture change (Johnson et al., 2008).

Politics in change management

Similar to the cultural perspective, power-politics perspective also holds that organisations are not
rational entities (Lewis, 2002). In many cases, organisational life is dominated by political power
battles, as according to the pluralism theory (Burrell and Morgan, 1979), organisation is a loose
coalition of individuals with merely a passing interest in the goals of the organisation. Organisation
can thus be seen as a political system in which conflict and opposing views exist because everyone is
pursuing their own self or group interest (Lewis, 2002). Understanding politics in change management
is crucial, because the decisions and actions of an organisation are shaped partly by shifting coalitions
of individuals trying to protect or enhance their own interests (Lewis, 2002, Burnes, 2011).

Politics can be defined as the exercise of power for the deployment of influence, while power usually
refers to the possession of resources to meet a certain goal (Burnes, 2011). Although the word
‘politics’ often have a negative connotation, it is in fact a natural process in the organisational context,
as resources are scarce and people are competing for their needs (Lewis, 2002). Power is different
from authority. Authority is gained by someone from his position in the organisation, while power is

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an individual’s capacity to influence decisions, gained from his bases of power (i.e. legitimate power,
reward power, coercive power, information power, referent power, and expert power) (Burnes, 2011).

In gaining support to achieve a certain goal, a manager needs to build his bases of power. This can be
achieved by using the tactics referred to as political ploys, power tactics or influence tactics (Table 1)
(Burnes, 2011, Champoux, 2011).

Table 1. Various tactics to gain power and support

Tactics Methods
Reason - present facts and information to logically support an argument
Friendliness/ingratiation - using flattery or showing kindness prior to making a request
Coalition - joining forces with others
Bargaining/compromise - exchanging favours or benefits for a desired outcome
Assertiveness - forcefully making a request or demanding compliance
Higher authority/ upward - gaining support from superiors
appeal
Sanctions - using punishment to force compliance
Inspirational appeal - focusing on values to arouse emotional support for a proposal
Selective information - keeping unfavourable information from others
Scapegoating - blaming someone else
Networking - making friends with those in power
Rule manipulation - modifying rules to favour friends
Consultation - involving someone in a decision process to influence him

Although important, political behaviour in change management also receives criticisms. Deployment
of a certain type of power may have undesirable implications. Coercive power can be counter-
productive because people might view it negatively and resent it, while the use of remunerative power
may lead to inflation. Criticisms also arise from the concern that some methods of political tactics are
considered unethical. Additionally, politics may be used for self-interest, interfering with rational
decision making, and keeping the organisation away from reaching its goals.

Managing change at the hospital-level: analysing the case

Type of change

The implementation of NHI has brought about multidimensional changes at the hospital-level.
Hospitals were required to adjust their administrative, financial, and healthcare services in order to
function under the new scheme. The changes implemented at Hospital A (Table 2) can be categorised
as emergent, rather than planned, because they were triggered by an ‘unpredictable’ event in the
external environment (i.e. the Government’s regulation) (Burnes, 2011, Huczynski and Buchanan,
2013). The new insurance scheme was set out by the Government in relatively a short notice, and
many hospitals were not prepared for the implementation.

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Table 2. Changes implemented at Hospital A following NHI implementation.

Problems being Implemented changes

addressed
Lack of understanding  Conducting an introductory session to NHI for all staffs at the beginning of
about the new scheme the implementation.
High patient load  Discharging inpatients sooner and let the recovery be completed at home.
 Shortening the individual time of contact during outpatient consultation.
Limited range of  Choosing the second line treatment when the first line treatment is not
medications covered covered by the insurance.
by the insurance
Limited range of  Not doing any supporting examinations or tests if not urgently needed.
examinations covered
by the insurance  Conducting one test at a time, starting from the simple one, and not
proceeding to the next if no further test is needed.
Low healthcare  Asking the outpatients to do more frequent visits due to the limited number of
standard tariff for each medications can be given for each visit.
disease
 Cross-subsidizing from other patients (e.g. patients from the private clinics
who paid for the service using an out-of-pocket scheme)
 Claiming as many diagnoses or abnormalities as possible, even though
sometimes they belong to the same diagnostic entity, to earn more
reimbursement.
 Establishing a team to review insurance claims, involving doctors, to make
sure that all the conditions that can be claimed have been claimed
Poor quality of care  Conducting routine morning meetings to discuss problems occurring from the
implementation of NHI
Late reimbursement  Postponing the payment of health providers

By their scale, the implemented changes can be seen as incremental adjustments, given that the
hospital had been delivering service for patients with the old insurance schemes for years, and no
major changes in the hospital structure or business strategy were carried out following the
introduction of NHI (Dunphy and Stace, 1993). Though the Government set a specific date to mark
the beginning of NHI implementation, the change process at the hospital-level actually happened in a
continuous manner, because alignments to respond the changing environment were introduced
gradually, without clear starting and ending points (By, 2005).

Change driver and style of management

The hospital Director was responsible for the functioning of the hospital, but the Deputy Director of
Finance and General Affairs was appointed to lead the change process, and regarded as the main
driver of change. The changes in Hospital A were mainly conducted in a directive style, with an
occasional participative approach. Decisions and strategies were mostly made by the top managers
(i.e. the Director, Deputy Directors, and Divisional Directors), and translated into a set of instructions
to be delivered to the relevant departments/units. Briefing sessions for all employees were hold
several times, but during the sessions, communication mainly happened in one direction. Staffs’
feedbacks were gathered during the routine morning meetings, but decision-making was left to the top

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managers. A special team under the Deputy Director’s supervision was established to monitor the
implementation process.

It is difficult to judge whether the directive style of change management adopted by Hospital A was
appropriate, given that the emergent change approach does not provide us with one best model for all
situations. However, according to Burnes, directive style is more preferable in the times of crises,
when quick decisions for transformational change are needed, because it is effective for a structural
change, but not the behavioural one (Burnes, 2011). That statement might explain why the use of
directive style in this case has faced no resistance, and was effective in achieving the managers’
objectives. Directive style is useful to avoid uncertainty, provide clarity, and speed in responding to
the challenges from the external environment (Johnson et al., 2008). During the early implementation
period, many new regulations were introduced and regularly revised, while Hospital A was closely
watched by the media. Following instructions from the top executives without questioning would be
the safest option. Moreover, the high workload and great responsibilities of healthcare providers at the
hospital do not give them enough time for engagement in consultative sessions with the managers.
Unless there is a significant problem that may affect their practice, most health providers tend to leave
managerial decisions to the managers. Ultimately, national culture may also play a role. Some
societies tend to respect more decisive and directive managers (Champoux, 2011), and studies have
shown that large power distance has been a part of Indonesian organisational culture, which might be
accentuated by the perceived gap in social status between doctors (who usually hold the higher
manager positions) and other health professions (Gupta et al., 2002).

Political process

In implementing the changes described above, the manager was to face different groups of interest
and power (Figure 2).

Figure 2. The mapping of stakeholders in the implementation of NHI at Hospital A.

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From Figure 2, we can see that in a public hospital like Hospital A, directors as strategic managers
have great legitimate, reward, and coercive power from their position as the formal authority
representing the interest of the Government. Senior doctors hold a great amount of expert power and
referent power, but they are hardly interested to the scheme as they consider it immature. The scheme,
with its low standard healthcare tariff, would potentially threaten the welfare of health providers and
increase their workload. That is why low interest is also expressed by junior doctors, nurses, and
other health professionals. This group, however, have less power, not because they are unimportant
in healthcare service, but simply because many of them are temporary staffs, which can be easily
dismissed from their jobs. Interestingly, patients as the main consumers of healthcare service
constitute the most powerless group. Although they are very much benefited from the new insurance
scheme, many of them are uneducated, and since they do not pay for the service, they do not have any
reward power to influence hospital services.

If the manager is to follow the theory, then groups of health professionals should be left with minimal
effort, while group of senior doctors should be kept satisfied, and patients should only be kept
informed. However, in the real context of change, these stakeholders are not static. They actively
participated in the political process, and they can change their positions anytime by constructing their
bases of power or as a response to internal or external factors. Patients, for instance, can obtain a great
power with the help of media. In turn, the news about poor healthcare services in the media may
potentially shift the healthcare providers even further to the lower interest area, as they are often
blamed by the public for any flaw in the system.

Therefore, strategies to approach the stakeholders should also consider the potential power they may
have if they were approached in a different way. The hospital financial and administration team,
which works directly under the command of the Deputy Director as the change manager, have no
significant power against the manager. However, since they were handling claims and complains from
all the departments, they could be a potential source of innovations and ideas for improvement. It is
beneficial to involve them further as one of the key players, rather than just keep them informed.

So far, the implementation of change at Hospital A has been going smoothly. That is because the
manager has adequate bases of power: (1) legitimate power from his position, (2) reward power to
give the subordinates incentives for positive outcomes, (3) coercive power to give sanctions whenever
needed, (4) information power about the whole strategy, (5) referent power from his likable
personality, and (6) expert power from his previous experience and education in financial
management (Champoux, 2011). Also, the manager has used appropriate political tactics, such as:

 Networking – building a good relationship with the media and have them publish the
hospital’s successes in implementing the change
 Reasoning – using logical argument to gain support from health providers
 Consultation – involving the senior doctors in supervision of the change process
 Assertiveness – giving commands to subordinates in addressing problems that need quick
decisions
 Upward appeal – getting support from the hospital director and senior managers

Further actions

The changes described in Table 2 have helped Hospital A survive the transition to the new system,
especially by keeping the cash flow in balance. However, without further changes, it is questionable
that the changes would sustain and the quality of working lives could be maintained.

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While the strategies applied by the manager are able to maintain the providers’ monthly income, the
number of patients they have to treat per day is far greater than it was in the past, leading to
exhaustion and dissatisfaction. Quality of care is still a concern, too, as each patient can only have a
short time of contact with the healthcare providers. Then, trying to balance the cash flow using the
revenue from the hospital’s private clinics can only be useful in the short term. In 2019, all citizens
would be covered by the NHI, and there might be no more patients going to such clinics. Additionally,
claiming as many abnormalities from a single disease entity may have deleterious implications to the
macro system. By the end of the first year of NHI implementation, the Government declared a major
deficit in NHI due to excessive claims related to ‘over-diagnosis’ (Tarigan, 2015).

For those reasons, the manager should think of other ways to improve the system’s efficiency.
Possible solutions may include:.

• Evidence-based practice—to ensure cost-efficiency, healthcare providers should only provide

treatments that have been proven to be effective. Any kind of practice that is not according to
the guidelines, such as prescribing antibiotics for common cold, should be stopped.
• Collaborative patient-centred care—evidence has shown that an integrated collaborative
practice can shorten the length of stay, improve efficiency, and increase patient safety (World
Health Organization, 2010). By communicating with other health professionals from different
departments and making a shared decision-making in planning treatments for patients with
chronic conditions, for example, unnecessary procedures, overlapping medications, and
repeated history taking can be avoided, saving the providers’ time and cost. At the same time,
the quality of care will be improved.
• Partnerships with other health facilities—to address the problem of patient overload,
Hospital A can create partnerships with the local health centres, so that outpatients with
simple complaints may be treated or followed-up at the primary care level. Partnerships in
establishing an online system with the neighbouring hospitals might be useful to be able to
quickly refer patients to other facilities when the inpatient wards at Hospital A are fully
occupied.

However, because the proposed solutions are so much related to health providers’ behaviours and
habits in practice, it is doubted that structural changes would be enough.

Culture change

According to Beer and Nohria (2000), managers have two ‘levers’ for managing strategic change.
Theory E stresses on economic value and associated with top-down changes of structures, systems,
and financial incentives. Theory O, on the other hand, puts emphasis on organisational capability,
including culture change. Both levers are essential, and a successful change requires a sequential
combination of both.

Similarly, Tichy (1983) proposed that a successful change is an combination of political, technical,
and cultural aspects (Figure 3). Changes in technical system are aimed to arrange financial or
technical resources to produce a desired outcome. Political system changes are intended to distribute
resources and power. Cultural system changes are designed to determine what values to be shared
among the organisation members, what objectives to pursue and what beliefs should be hold.

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Figure 3. The T, P, C Theory of strategic change (Tichy, 1983)

Given that framework and the challenges that remained, I would argue that the changes that have been
implemented at Hospital A only deal with the problems at a superficial level (systems and
structures—the Theory E), and are not sustainable. Cultural and political changes as the ‘second lever’
of change are needed, to develop a new way of thinking and a new working habit.

While opinions are divided between culture as an attribute (i.e. something that the organisation has)
and culture as a metaphor (i.e. something that the organisation is) (Huczynski and Buchanan, 2013,
Scott et al., 2003)—and therefore it is debatable whether culture can be managed or just tolerated—I
myself hold that culture should be analysed in different levels: (1) visible artefacts, (2) espoused
norms, (3) values, and (4) underlying basic assumptions (Schein, 1985, Cummings and Huse, 1989).
Discussion about culture change should clearly define which level of culture is being addressed, and it
could be argued that change is feasible at the superficial levels: artefacts and norms (Burnes, 2011,
Schein, 1985).

Diagnosing culture

Culture change generally starts with diagnosing the organisation’s culture. In this step, the manager
identifies the existing culture, lists organisational changes needed to implement a new strategy, and
assesses cultural risks (Cummings and Huse, 1989).

There are several methods that can be used to understand the existing culture, such as surveys or
iterative interviews, but here, I would use the cultural web analysis to show the manifestations of
culture in several aspects (Figure 4). The reason why I am using the cultural web is because it is
useful not only to identify the existing culture, but also to describe the culture changes we would like
to see in the future (Johnson et al., 2008).

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Figure 4. The cultural web of Hospital A, showing the comparison between the present and future (expected) cultures.

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From the figure above, it could be argued that the culture of Hospital A is characterised by tribalism,
individualism, and conservatism. The overall culture can be classified as the role culture according to
Handy’s classification (Handy, 1993). In order to provide a better service and patient-centred care,
Hospital A should adopt the task culture, marked by flexibility, integration, less hierarchy, and
teamwork (Konteh et al., 2011). Considering that the change may pose a significant cultural risk,
strong commitment from the change agents is needed.

Implementing culture change

Unlike the changes implemented in Table 2, culture change at Hospital A would be transformational
in scale and carried out in a planned manner. Lewin’s unfreeze-change-refreeze model may be used in
this context (Lewin, 1947), and participative approach, rather than directive approach, may be
adopted.

Drawing upon the strategies developed by Cummings and Huse, culture change at Hospital A would
follow the following steps (Cummings and Huse, 1989):

1. Formulate a clear strategic vision. In 2014, Hospital A declared its new vision to be a high-
quality hospital delivering a ‘safe, trustworthy, and satisfying’ service. This is a good starting
point as the new culture also shares the same goal. Now the manager has to effectively
communicate the new values and norms, for example by drawing upon the cultural web analysis
above.
2. Display top-management commitment. The hospital Director needs to create a sense of urgency to
convince all the top managers to commit to the new values. Then, such commitment may be
symbolically expressed by signing a declaration in front of the employees at a special ceremony,
or hanging banners displaying the new vision and norms.
3. Model culture change at the highest level. To create a more fluid environment and less rigid
hierarchy, the senior executives must be willing to blend in with the employees and break
interdepartmental barriers, for example by having lunch at the employee’s canteen, wearing the
same outfit with them, arranging a hospital outing day etc.
4. Modify the organisation to support organisational changes. The hospital should develop a new
clinical pathway that enables interdepartmental collaboration and multi-disciplinary teamwork.
Nurse and doctor stations in each department could be integrated to facilitate multidisciplinary
discussions. Some staff restructuring might also be needed to redistribute power among different
health professions.
5. Select and socialise newcomers and terminate deviants. Since Hospital A is a public hospital,
terminating existing staffs that do not fit the new culture is unlikely. However, promoting and
rewarding staffs that show desired behaviours are necessary.
6. Develop ethical and legal sensitivity. In implementing the changes, such as in restructuring the
organisation, the manager should always make sure that his conduct does not violate the new
values, and all the adjustments he makes are ethical and just to employees.

Potential challenges

Culture change is not simple. The manager would face some challenges in the process. Firstly, the
employees might not be able to sense the urgency, as everything seems to be going well at the
moment or in the short term. However, in my opinion, the manager can use what Bate (1999) called as

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‘opportunistic strategies’, using the momentum of NHI implementation to create a bigger vision
among the employees, and make Hospital A as a role model in health system reform.

Secondly, we should be aware that many types of subcultures might co-exist within the hospital.
Those subcultures might arise from ethnic, religious, gender, class, occupational, and divisional
diversity (Scott et al., 2003), and the manager should be able to identify which of those subcultures
are enhancing the dominant culture and which are against it. It is desirable for the manager to be able
to create a synergy between the different subcultures.

Thirdly, it is very likely that during the change process, the manager will face different groups of
conflicting interests. For example, an action research on cultural transformation in NHS England
conducted by Bate (2000) reported a group of senior managers that was being resistant to change as
they felt like being asked to give up their authority and power for nothing in return. This kind of
resistance is possible to arise at Hospital A, particularly from the doctors, who have always seen their
profession as leader and decision maker in patient care. The manager should be able to develop
political strategies as explained above to face such problems.

Conclusion

The implementation of NHI in Indonesia has brought about some challenges to the quality of care and
the quality of working life at the hospital-level, mainly due to the increase in number of patients and
low standard tariff set by the Government. To address this emergent change in the health system,
‘Hospital A’ has implemented some adjustments using the emergent change approach, which was
delivered in a predominantly directive style of management. The directive approach in this case has
been proven successful probably because the adjustments are incremental, and most of them only deal
with hospital structures. Also, the approach has provided clarity in times of uncertainty, and it fits the
national culture. Additionally, the manager was capable to apply political strategies to build bases of
power and gain support for change implementation.

However, there are some indications that Hospital A needs more than structural changes to sustain the
system nationally. Culture change was proposed to promote evidence-based practice, collaborative
patient-centred care, and partnerships with other health facilities. Analysis shows that the culture of
Hospital A can be characterised with tribalism, individualism, and conservatism. In order to improve
its services, Hospital A should leave the role culture and embrace the task culture marked by
flexibility and teamwork. A transformational planned change must be done, and manager should
always be aware that technical, political, and cultural aspects are very important in managing a
successful organisational change.

References

IRIN. 2014. Hopes and fears as Indonesia rolls out universal healthcare. IRIN, 14 January 2014.
ALLAIRE, Y. & FIRSIROTU, M. E. 1984. Theories of Organizational Culture. Organization Studies,
5, 193-226.
BATE, P. 1999. Strategies for cultural change, Oxford, Butterworth-Heinemann.

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BATE, P. 2000. Changing the Culture of a Hospital: From Hierarchy to NetworkedCommunity.

Public Administration, 78, 485-512.
BEER, M. & NOHRIA, N. 2000. Breaking the code of change, Boston, Harvard Business School
Press.
BURNES, B. 2004. Kurt Lewin and the planned approach to change: A re-appraisal. Journal of
Management Studies, 41, 977-1002.
BURNES, B. 2011. Managing Change, Financial Times/ Prentice Hall.
BURRELL, G. & MORGAN, G. 1979. Sociological paradigms and organizational analysis, London,
Heinemann Books.
BY, R. T. 2005. Organisational change management: A critical review. Journal of Change
Management, 5, 369-380.
CHAMPOUX, J. E. 2011. Organizational behaviour: integrating individuals, groups, and
organizations, New York, Routledge.
CUMMINGS, T. G. & HUSE, E. F. 1989. Organization development and change, St. Paul, West Pub.
Co.
DOHERTY, R., LOUGHREY, C. & HIGGINS, P. 2013. Organisational culture: a review of the
literature. Available: www.dhsspsni.gov.uk/organisational_culture_literature_review.docx.
DUNPHY, D. & STACE, D. 1993. The Strategic Management of Corporate Change. Human
Relations, 46, 905-920.
ELDRIDGE, J. & CROMBIE, A. 1974. A sociology of organizations., London, George Allen and
Unwin.
FAIZAL, E. B. 2014. Govt to revise health care tariffs in BPJS. Jakarta Post, 1 April 2014.
FILBY, I. & WILLMOTT, H. 1988. Ideologies and contradictions in a public-relations department -
the seduction and impotence of living myth. Organization Studies, 9, 335-349.
GLOBAL HEALTH OBSERVATORY 2011. Physician density per 1000 population (data by
country).
GUINTO, R. L. L. R., ZUWASTI CURRAN, U., SUPHANCHAIMAT, R. & POCOCK, N. S. 2015.
Universal health coverage in ‘One ASEAN’: are migrants included? Global Health Action, 8.
GUPTA, V., SURIE, G., JAVIDAN, M. & CHHOKAR, J. 2002. Southern Asia cluster: where the old
meets the new? Journal of World Business, 37, 16-27.
HANDY, C. 1993. Understanding organizations, Penguin UK.
HUCZYNSKI, A. A. & BUCHANAN, D. A. 2013. Organizational behaviour, Harlow, Pearson.
JOHNSON, G., SCHOLES, K. & WHITTINGTON, R. 2008. Exploring corporate strategy,
Edinburgh, Pearson Education Limited.
KONTEH, F. H., MANNION, R. & DAVIES, H. T. O. 2011. Understanding culture and culture
management in the English NHS: a comparison of professional and patient perspectives. Journal
of Evaluation in Clinical Practice, 17, 111-117.
LEWIN, K. 1947. Frontiers in group dynamics: concept, method and reality in social science; social
equilibria and social change. Human Relations, 1, 5-41.
LEWIS, D. 2002. The place of organizational politics in strategic change. Strategic Change, 11, 25-34.
LIEBHART, M. & LORENZO, L. G. 2010. Between planned and emergent change: decision maker's
perceptions of managing change in organisations. International Journal of Knowledge, Culture,
and Change Management, 10, 214-225.
RAHMAWATI, F., PRAMANTARA, I. D. P., ROHMAH, W. & SULAIMAN, S. A. S. 2009.
Polypharmacy and unnecessary drug therapy on geriatric hospitalized patients in Yogyakarta
hospitals, Indonesia. International Journal of Pharmacy and Pharmaceutical Sciences, 1, 6-1.
SATHE, V. 1983. Implications of corporate culture: a manager's guide to action. Organizational
dynamics, 12, 4-23.

14
Managing Healthcare Organisations 2159631

SCHEIN, E. 1985. Organizational culture and leadership: a dynamic view, San Francisco, Jossey-
Bass.
SCOTT, T., MANNION, R., DAVIES, H. T. O. & MARSHALL, M. N. 2003. Implementing culture
change in health care: theory and practice. International Journal for Quality in Health Care, 15,
111-118.
TARIGAN, M. 2015. BPJS Kesehatan deficit caused by fabricated claims. Tempo, 9 February 2015.
THE LANCET 2014. Indonesia strides towards universal health care. The Lancet, 383, 2.
TICHY, N. M. 1983. Managing strategic change: technical, political, and cultural dynamics, John
Wiley & Sons.
WIRDANA, A. 2014. Inadequate funding may hamper Indonesia health insurance system. The
Establishment Post, 10 November 2014.
WORLD BANK 2014. Health expenditure, total (% of GDP).
WORLD HEALTH ORGANIZATION 2010. Framework for action on interprofessional education
and collaborative practice. Geneva: World Health Organization.
WORLD HEALTH ORGANIZATION 2013. Research for universal health coverage. Geneva: World
Health Organization.

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