Implementation of Health Promoting Hospital in Government and

Private Indonesian Hospitals: Is There Any Difference?

Emma Rachmawati, Sarah Handayani

Yuniar Dwi Putri and Gabriela Luftania Rivai

Faculty of Health Sciences, Universitas Muhammadiyah Prof DR HAMKA (Uhamka), Jl. Limau II Kebayoran Baru Jakarta

12130, Indonesia

Keywords: Health Promoting Hospital, Implementation, Private Hospital. Government Hospital.

Abstract: Health promotion in hospitals (HPH) has been a challenge for hospital regarding the reorientation of health

services. This study aims to evaluate the implementation of HPH in government and private hospitals in

Jakarta, Indonesia. A cross-sectional study was conducted through a survey and self-assessment tools

involving 223 hospital employees, using proportional random sampling and bivariate analysis (α= 0.05). The

results showed that employees in both hospitals (government and private) had good knowledge towards HPH

(74.8% and 76.9%). However, the participation of the employees was poor in HPH training (20.9% and

10.2%), as well as in HPH-related activities (45.2% and 25.9%). The proportion of employee with good

attitude towards HPH in the government hospital (77.4%) was higher than in the private hospital (51.9%),

and was significantly different (p= 0.006). The HPH national standard for both type of hospital had not been

well achieved (52.2% and 52.8%), and no significantly different. However, the implementation of standard 2,

3, and 4 of HPH showed the significantly different, but not for standard 1 (“the hospitals have health

promotion regulations”). The management in both hospitals should enforce the socialization, activeness, and

HPH training for employees to improve the achievement of HPH standards.

1 INTRODUCTION

Health-Promoting Hospital (HPH) has experienced

various developments in many countries in the world

since the Ottawa Charter from WHO for health

promotion in health services. During these three

decades, the role of the health service sector must

move towards health promotion to further contribute

to health at the population level (Johansson,

Weinehall and Emmelin, 2009), far beyond its

responsibility in providing curative and clinical

services. Health Promoting Hospital aims to provide

comprehensive high quality medical and treatment

services through health promotion activities to

patients, hospital staff, and the community as part of

the hospital's routine identity and practice (Kemenkes

RI, 2011). That is, the hospital integrates health

promotion and prevention efforts and policy and

rehabilitation services into curative services.

WHO has the HPH standard used by the hospital

in various countries, which is including five

standards: (1) Management Policy Standard, (2)

Patient Assessment Standard, (3) Patient Information

and Intervention Standard, (4) Promoting a Healthy

Workplace Standard, and (5) Continuity and

Cooperation (World Health Organization/Regional

Office for Europe, 2004). At the national level

(Indonesia), regulation of the Minister of Health no.

004 of 2012 concerning Technical Guidelines for

Hospital Health Promotion needs to be adjusted to the

development of science, legal needs, and the latest

development of HPH standards at the global level.

Then in 2019, Indonesia began to apply the latest

standards based on the Regulation of the Minister of

Health of the Republic of Indonesia no. 44 of 2018

chapter IV article 11 concerning the standard of

organizing Health Promoting Hospital (HPH)

covering four standards namely (1) the hospitals have

health promotion regulations ; (2) the hospital

conducts a health promotion assessment for patients,

patients' families, hospital human resources, hospital

visitors, and communities around the hospital; (3)

The hospital carries out health promotion

interventions and (4) the hospital carries out health

promotion monitoring and evaluation (Kemenkes RI,

2018).

In addition to providing professional education

and training for health professionals in hospitals

170

Rachmawati, E., Handayani, S., Putri, Y. and Rivai, G.

Implementation of Health Promoting Hospital in Government and Private Indonesian Hospitals: Is There Any Difference?.

DOI: 10.5220/0010758200003235

In Proceedings of the 3rd International Conference on Social Determinants of Health (ICSDH 2021), pages 170-176

ISBN: 978-989-758-542-5

related to changing health service orientation, HPH

frameworks can vary greatly depending on targeted

health determinants to be achieved. Clarity, good

understanding (well thought), and shared views of all

parties involved are vital and are a condition for

running and developing HPH. The results of some

studies showed that there were differences in the

approaches to health promotion efforts according to

the perceptions of hospital health professionals

towards the health promotion efforts and their

strategies to handle them in their daily practice

activities (Johansson, Weinehall and Emmelin,

2009). This evidence shows that not all health

professionals in health services can able to identify

health promotion in their daily roles so that it can

bring unnecessary misunderstandings and become

obstacles in implementing HPH standards going

forward. The main challenges faced are lack of funds,

personnel, time management, and personal skills, and

efforts are needed to convince hospital leaders and

management as top priorities (Guo et al., 2007). Also,

with the diversity of health promotion activities, the

HPH effort requires a variety of skills from various

health professionals (health promotion and other

health professions) and non-health, so that this HPH

effort is a team activity (Tzenalis, 2014).

The implementation of HPH in hospitals is still

running slowly, including hospitals in Indonesia.

Mainly the hospital experience in applying the latest

HPH standard (2018) is still in its early stages and has

not been much researched or studied. The problems

in the implementation of HPH are the lack of clear

strategies and tools for its implementation (7), lack of

funds, personnel, time management, and professional

skills (5), the timing of HPH activities depends on the

results of coordination with other sectors, human

resources in the HPH section are limited, the hospital

has not yet socialized the standards and instructions

for HPH implementation (8), HPH team has never

received special training on the implementation of

HPH, and assessment of promotional needs for

patients is still one-sided without involving patients

more deeply in order to assess the needs of health

promotion for patients appropriately and beneficially

(9). Although it is difficult to see the short-term and

long-term impacts of HPH, some studies showed that

the implementation of HPH standards had a positive

impact in hospitals and closely related with QA

(Quality Assurance) (Põlluste et al., 2007).

In terms of achieving HPH standards, a

descriptive-analytic survey study found that the

average value of compliance with WHO HPH

standards of private hospital scores higher than in

state hospitals. In general, the highest score is for

patient information standards, and interventions in

both types of hospitals, and the lowest score is for

patient assessment (11). Another survey showed that

the compliance score with HPH standards as follows:

88,8% were at weak to moderate level, and only one

hospital (11.1%) was at a good level (12). The results

of previous study conducted in 2018 at three private

Muhammadiyah Hospitals in Jakarta, Indonesia,

showed that total achievement scores in each HPH

national standard in the hospitals were still not

optimal, ranging from 49.8% to 61.4%. The level of

achievement of all standards varied in each HPH

standard indicator (13). This study aimed to compare

the implementation of the latest HPH national

standards in private and government hospitals in

Jakarta, the capital city of Indonesia. The result can

be used to engage policy makers in evaluating the

HPH program implementation based on the evidence.

2 METHOD

This quantitative study design is cross-sectional. The

population is permanent employees in Fatmawati

General Hospital (owned by government) with 2448

employees and Pertamedika HospitalMedika (private

hospital) with 927 employees. In the year of 2019, the

two hospitals are Type B, located in South Jakarta,

Indonesia, which were chosen purposively. The total

sample taken proportionally was 225 permanent

employees in both hospitals, namely 115 people in

General Fatmawati Hospital and 108 people in

Pertamedika Hospital. The exclusion criteria for

respondents are permanent employees who are taking

a day off or sick.

The survey and self-assessment tools conducted

during July 2019. The questionnaire was covered the

characteristic of respondents (education, activeness in

HPH activities, and participation in HPH training),

knowledge, and attitude. Self-assessment tool based

on four HPH standards from the Ministry of Health of

the Republic of Indonesia. It is contained in the latest

Hospital Accreditation Guidelines, namely the

National Standard for Hospital Accreditation First

Edition. It has been effective since January 1st, 2019,

and issued by the Hospital Accreditation Commission

of Indonesia. The achievement of HPH standards

categorized by: not achieved, partially achieved, and

achieved. The number of valid items of each HPH

national standards are: 6 items (standard 1), 5 items

(standard 2), 5 items (standard 3), 5 items (standard

4). Each HPH standard instrument showed a good

reliability score (Cronbach's α-value > 0,7).

Comparative analysis of variables was carried out

Implementation of Health Promoting Hospital in Government and Private Indonesian Hospitals: Is There Any Difference?

171

using a non-parametric test to analyze the difference

in two independent means with α = 0.05.

The ethics review has been approved by the

Health Research Ethics Commission of University

Muhammadiyah Prof DR HAMKA (Approval Letter

03 / 19.06 / 048 dated June 16, 2009).

3 RESULTS

3.1 Sample Description

The following table (Table 1) shows the distribution

of respondent based on some of their characteristics.

Most of the studied sample were medical (78.9%),

had higher level of education (96,9%), never had

HPH training (83,4%), never participate in HPH

activities (64,1%), in good knowledge towards HPH

group (75,8%), and had a moderate level of attitude

towards HPH (66,8%) (Table 1). Meanwhile, it

showed that there are almost equal proportion

between the good and moderate perception towards

HPH standard implementation (Table 1). It also

shows that there is a small percentage of employees

to be involved in training and HPH activities in both

types of hospital. Of their employees with good

attitude towards HPH more a government hospital

(77,4%) than the private hospital (51.6%).

The statistical values of the observed variables are as

describes in table 2.

Table 2 above shows that the statistics for the

three variables in each hospital have almost same

mean value. In details, the mean value of employee

knowledge towards HPH is 11.4 and 11,46 means that

the employee answered 81,4% of the questions

correctly. Also, for the employee attitude towards

HPH, it has shown good scores, namely 26,56 and

27,26 (highest score=36). Meanwhile, for the

employee perception regarding with the HPH

standard achievement, it can be seen that their

achievement is still low (mean scores are 34,29 and

34, 25). The highest score is 63, meaning that the

achievement of HPH implementation is only around

54,4%.

Furthermore, table 3 shows the resume of the

comparison test results of the observed variables

between government and private hospitals. It can be

seen from table 3 above that there were no

significantly different between average scores of

employee’s knowledge towards HPH, the

implementation of HPH standard (total), and standard

(1) (the hospitals have health promotion regulations)

(p>0.05). While the attitude towards HPH, and the

Table 1. Characteristic distribution of respondents

Category RS Pertamedika

(private hospital)

RSUP Fatmawati

(goverment hospital)

Total

n % n % n %

Education

≤ High School 5 4,6 2 1,3 7 3,1

> High School 103 95,4 113 74,8 216 96,9

Job

Non Medical 16 14,8 31 20,5 47 21,1

Medical 92 85,2 84 55,6 176 78,9

HPH trainin

Neve

96 88,9 90 78,3 186 83,4

Eve

11 10,2 24 20,9 35 15,7

Missing 1 0,9 1 0,9 2 0,9

HPH activities

Neve

80 74,1 63 54,8 143 64,1

Eve

28 25,9 52 45,2 80 35,9

Knowledge towards HPH

Good 83 76,9 86 74,8 169 75,8

Moderate 25 23,1 29 25,2 54 24,2

Attitude towards HPH

Goo

52 48,1 26 22,6 74 33,2

Moderate 56 51,9 89 77,4 149 66,8

HPH Standard Implementation

Goo

51 47,2 55 47,8 112 50,2

Moderate 57 52,8 60 52,2 111 49,8

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Table 2. Statistics distribution of the observed variables

Statistics Mean Median Modus Std Dev Min Max

RS Pertamedika

rivate hos

ital

)

(

n= 115

)

Knowled

e 11,4 12 12 1,69 7 14

Attitude 26,56 25 25 3,34 19 32

HPH Standard

implementation

34,29 37 42 7,52 21 42

RSUP Fatmawati (government hospital) (n= 108)

Knowled

e 11,46 12 12 1,55 7 14

Attitude 27,26 27 26 3,11 19 32

HPH Standard

lementation

34,25 34 30 6,19 21 47

Table 3. The results of comparative test of the average scores of observed variables between government hospital ( x

) and

private hospital ( x

) (α=0,05)

Variables

Average1

(

)

Average2

(

)

p-value

(

)

Sig.

Knowledge towards HPH 11,46 81,85 11,4 81,42 0,143 No

Attitude towards HPH 27,26 85,18 26,56 83,0 0,006 Yes

Total implementation of HPH Standard 34,25 54,36 34,29 54,42 0,968 No

(1) the hospitals have health promotion

regulations

9,53 52,94 9,03 50,17 0,092 No

(2) the hospital conducts a health

promotion assessment for patients,

patients' families, hospital human

resources, hospital visitors, and

communities around the hospital

8,31 55,40 7,11 47,40 0,000 Yes

(3) The hospital carries out health

romotion interventions

8,26 55,0 11,6 77,33 0,000 Yes

(4) The hospital carries out health

romotion monitorin

and evaluation

8,24 54,67 6,50 43,33 0,000 Yes

achievement of standard 2, 3 and 4 showed a

significant difference. The average score of at

government hospital are higher than private hospital

for attitude, standard 2 and standard 4. This is

different for the standard 3, where the average score

of private score is higher than government hospital. It

seemed that the private hospital carries out more

health promotion interventions than government

hospital.

4 DISCUSSION

The results showed that most of the employees in both

hospitals were higher education and medical group,

however, only a small proportion stated that they

participated in activities related to HPH (25,3%) and

received HPH training HPH (13,5%). This is

important information for each hospital management,

because the number of hospital staff who are active in

HPH training activities can strengthen the

relationship between HPH conditions, hospital

characteristics and self-evaluation of the overall

effectiveness of the organization in HPH (Lin and

Lin, 2011). The fact that there was a low involvement

of employees who participate in HPH training and

activities, supports several previous studies, where

the lack of trained HPH personnel, training, funds and

physical facilities are obstacles to implementing

health promotions in hospitals, so that the HPH

framework becomes difficult to understand by

employee (McHugh, Robinson and Chesters, 2010;

Tatang and Mawartinah, 2019). In this study, the high

education of employees did show the good score of

employees towards HP, but this was not enough to

support their activeness in HPH efforts.

According to the employee’s attitude towards

HPH, the results showed a significant difference

between government and private hospitals, and the

average score of government hospital employees was

better than private hospital. The previous study

Implementation of Health Promoting Hospital in Government and Private Indonesian Hospitals: Is There Any Difference?

173

showed different result that although the average

score of knowledge of employees in private

Indonesian hospitals towards HPH was low (55,9%),

but their attitude towards HPH was good (74,25%)

(Tatang and Mawartinah, 2019). Good attitude from

various profession (health or non-health) is important

in supporting clarity, good understanding (well

thought) and shared views, and is a prerequisite for

implementing and developing various public health

programs, including HPH program. HPH is a team

work that must be developed to be effective (Tzenalis,

2014). Cross-professional (medical and non-medical)

team work in hospitals related to HPH is important

because there are differences in the approach to health

promotion efforts according to the perceptions of

health professionals in hospitals and their strategies

for handling health promotion efforts in daily practice

activities. Not all health professionals in hospitals are

able to identify health promotion in their daily roles,

so it can lead to unnecessary misunderstandings and

become obstacles in developing HPH practices in the

future (Johansson, Weinehall and Emmelin, 2009).

With the high workload of employees in hospitals,

there is also a group called “demarcater”, namely a

group of health workers who explicitly separate

health promotion efforts, but in some cases they

actually behave as health promotion workers

(Johansson, Weinehall and Emmelin, 2009). They

think that HPH is enough to be handled by special

health promotion personnel and they feel that they do

not need to be actively involved in HPH activities,

HPH training is sufficient for HPH unit members,

besides the positive impact felt from the

implementation of the HPH program is difficult to

measure. However, they support HPH efforts to be

implemented and developed and involve the

community, and they also know that the HPH

program can ensure a safe, clean and healthy

workplace. The results of the research show that there

is a positive impact from the application of HPH

standards in hospitals which has brought

improvements to a number of indicators in hospitals

(Amiri et al., 2016). The positive impact of this HPH

is still not well socialized among hospital staff and

management, so that HPH has not become a priority

or focus in the health service strategy in hospitals.

This could be the reason for the low involvement of

hospital employees in HPH activities and training.

Regarding the achievement of HPH standards for

the two types of hospitals, the result showed that the

achievements were still not optimal and also did not

differ significantly. The results of previous studies in

other countries and in Indonesia are also similar, for

example a descriptive-analytic survey in 38 hospitals

from 5 (five) provinces in Iran found that the average

value of compliance with the WHO HPH standard (5

standards) was similar (54.1 ± 15.1), and the score of

private hospitals was higher than government

hospitals. In this study with similar average total

score of achievement, the result did not show a

significant difference between the two types of

hospitals. The other survey in teaching hospitals in

Iran also showed an achievement score of 55.5%

(medium level) (Afshari et al., 2016). The results of

previous studies in Indonesia at private hospitals in

DKI Jakarta also showed that the score was not

optimal (49.8% to 61.4%) (Tatang and Mawartinah,

2019).

Furthermore, for the achievement of standard 1

HPH, namely "Hospitals have Health Promotion

regulations", the achievement of standards is

considered to be in moderate/good enough condition

and there is no significant difference related to the

average score in the two types of hospitals.

Implementation of this standard 1 give signals to the

commitment of good hospital management to

organizational development and to demonstrate to

staff the importance of health promotion (VHA,

2009). The implementation of standard 1 is supported

by the implementation of the latest HPH Guidelines

from the Ministry of Health of the Republic of

Indonesia which supports the formation of HPH

structures in each hospital, although it has not been

implemented optimally. For this reason, HPH is an

integrated part of an organization and becomes a

"core business", and not just a "side issue," but must

be included as part of the culture, direction and

strategy of the hospital. This requires the support of

high-level policy makers (hospital management) to

drive change (VHA, 2009).

This study also showed a low score (47.4%) for

the achievement of standard 2, namely "The hospital

carries out health promotion assessments / studies for

patients, patient families, hospital human resources,

hospital visitors, and the community around the

hospital", and the average score of private hospitals

lower than state hospital. HPH efforts are generally in

the form of activities such as "people-centered care"

and "healing environments" or health education to

patients, creating comfortable workspaces, or

community empowerment in priority health programs

at the local, national or global level. For this reason,

HPH in hospitals will be based on the results of the

analysis of the needs of patients, families, visitors and

the community around the hospital. In previous study,

it was stated that the assessment of the need for

promotion for patients still seemed one-sided (from

the hospital only) without involving the patient more

ICSDH 2021 - International Conference on Social Determinants of Health

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deeply in order to assess the need for health

promotion for patients appropriately and beneficially.

(Hakim, BZ and Fauzi, 2013). The strength of the

coherence of the needs of all parties is a key factor in

facilitating the introduction of health promotion in

health services (Dilani, 2008)..

Furthermore, the results of the study indicate that

the achievement score of Standard 3, namely the

hospital implementing the health promotion

intervention, shows a significant difference between

government hospitals and private hospitals. The

health promotion approach in hospitals leads to

contexts/settings where people live, work and play,

because the setting/location approach in the early

stages is a very interesting and feasible route that will

help the organization's actions for the success of a

health promotion effort (Poland, Krupa and Mccall,

2009). In this case, the employee considers that the

hospital is in accordance with the settings in the early

stages and is very feasible and interesting to be

achieved together through the involvement of

individual/group parties around the hospital location.

Another study also showed that private hospitals

scored higher in HPH interventions than government

hospitals in achieving this standard. Another study

also showed a score of 70.8 ± 8.1 and achievement

scores in private hospitals were higher than

government hospitals (Yaghoubi and Javadi, 2013).

These results are similar to the results of this study

which stated that the intervention score in private

hospitals (77.3%) was higher than government

hospitals (55%) and the difference was significant

(PV=0.000).

Finally, for the achievement score of Standard 4,

namely "Hospitals carry out monitoring and

evaluation of Health Promotion", this study shows the

achievement of 54.67% in public hospitals and

43.33% in private hospitals, and this difference is

significant. HPH activities must be reviewed after

implementation so that they can be improved and

make the activity better. In addition, public and

private hospitals can carry out routine evaluations

internally and externally through accreditation or the

application of ISO so that hospitals can improve the

achievement of HPH standards on a regular basis

(Groene, 2005). As stated earlier, this HPH has been

included in the National Standard Hospital

Assessment (SNARS), which has only been effective

since January 1, 2019 issued by the Indonesian

Hospital Accreditation Commission (KARS). This is

an opportunity for hospitals (public and private) to be

able to carry out monitoring and evaluation of HPH

efforts. The low score for standard 4 in private

hospitals could also be due to the fact that this hospital

still does not have an HPH unit that should be met

according to the HPH standard for this type of private

hospital (type B).

5 CONCLUSION

Knowledge and attitudes about HPH from employees

in public and private hospitals are good, but have not

been accompanied by high participation of hospital

employees in HPH activities and training. The total

achievement of HPH standards in the two types of

hospitals shows that it is not optimal (medium level)

and does not differ significantly. For this reason,

management in both types of hospitals needs to make

the right strategy in increasing the activity or

participation of employees in HPH efforts and further

socializing the positive impact of the HPH program

achievement.

ACKNOWLEDGEMENTS

Thank you to the management and all staff of

Pertamedika Hospital and Fatmawati Hospital, South

Jakarta, who are willing to participate in this research.

In addition to the UHAMKA Research Institute

which provided funding for this research grant. Thank

you also to the students, namely Yuniar, Gaby and

Vivi, who have helped a lot in collecting data in the

field, recording and processing data.

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