Analysis Of Internal Factors Affecting The Implementation Of Maturity Rating Policies In The Healthcare Public Service Agency Of Indonesia

This study aims to address the gap in the literature by examining the internal factors affecting the implementation of maturity rating policies in Indonesian healthcare settings. This study employs a multimethod-qualitative approach in line with the adopted philosophy, enabling researchers to capture dynamic and contextual elements of organisational actual settings. This research draws several conclusions that are relevant to the implementation of business maturity policies, especially in the context of health care institutions in Indonesia. First, the implementation of the Maturity Rating policy has a significant impact on organizational governance, covering aspects of People, Process, and Technology. Benefits include managerial improvements, operational efficiency, compliance with legal requirements, and financial transparency and accountability. However, it is important to be aware of potential risks, especially conflicts of interest that can undermine objective evaluations.


Introduction
Public services manifest the Indonesian government's responsibility to its citizens, as Law No. 25/2009 mandated concerning public affairs.However, the image of public services in Indonesia has been under the spotlight because of their poor performance and protracted bureaucracy (Bazarah & Pujiastuti, 2022).It was visible during the COVID-19 pandemic when the response to strategic issues was sluggish, resulting in socioeconomic losses (Arfan et al., 2021).Critics were especially harsh on healthcare for its lack of speed, quality and performance (Lestariningsih et al., 2018).
The government has acknowledged this problem for quite some time and attempted to reform public services by implementing a public service agency (PSA) in 2005.The PSA is a new pattern of government financial administration in line with the issuance of Law No. 1/2004 on State Treasury, which was then elaborated in Government Regulation No. 23/2005 on the Financial Management of Public Service Agencies.This entity aims to provide services to the community by supplying superior quality goods or services by applying financial governance principles prioritising productivity, efficiency, and effectiveness.
The significance of business transformation in public institutions has recently escalated because of these problems.Reflecting on international cases of technologydriven change, large budget allocation was not solely the key to achieving the desired outcome.Based on the report by the World Bank (2023), the financial pledge towards digitalisation went through a substantial surge, amounting to 120 billion USD, until 2020.Nevertheless, the outcomes are ineffective and have not been notably manifested in executing public services (Omar, Weerakkody, & Daowd, 2020).Public reformation appears to be a superficial gesture to alleviate public criticism.Similarly, Mahmood et al. (2020) mentioned that alterations do not change the actual situation but solely serve as cosmetic modifications.Fundamental transformation should address the problems, and experts believe adopting the transformation model can be one of the best approaches.
As a follow-up step to healthcare transformation, the Indonesian government adopted one of the business processes re-engineering theories from the private sector, namely the Capability Maturity Model (CMM).The success of CMM is proven by previous research in developed and developing countries (Weerakkody, et al., 2021).However, researchers' consensus agrees that no CMM model is universally applicable to all business models.Maturity assessment could give better input for decision-making and policymaking if the indicators used are appropriate to produce comparable results (Weerakkody, Janssen, & El-Haddadeh, 2021).Thus, CMM implementation necessitates a rigorous method evaluation.
Nevertheless, public criticism regarding performance has yet to subside, especially during the pandemic recovery.PSA depend heavily on the state budget, promoting the importance of a governance transformation (Arfan, Mayarni, & Nasution, 2021).Thus, evaluating the CMM model is essential to ensure compatibility with the purpose of performance improvement.Indonesian PSA transformation requires a proven strategy and causes minimal disruption.The current research is limited to CMM usage, and evaluating the method has never been done (Kemintang, 2022;Marzal & Jumaili, 2022).So, this study aims to address the gap in the literature by examining the internal factors affecting the implementation of maturity rating policies in Indonesian healthcare settings.This study employs a multimethod-qualitative approach in line with the adopted philosophy, enabling researchers to capture dynamic and contextual elements of organisational actual settings.The internal dynamics of an organisation encompass a range of factors, such as social norms, cultural values, and behavioural patterns, which are distinct to that particular entity (Radcliffe, 2018).The lack of generalizability, as observed in quantitative studies, may also be attributed to this phenomenon.Furthermore, the recently implemented policies have not yet enough evidence for quantifiable trend measurement, making qualitative analysis irrelevant to the study.

Research Methods Research Design
Moreover, the research involves a synthesis of case studies and comparative studies, explicitly emphasising the governance of health service public service agencies.These methodologies aim to identify commonalities and disparities in adopting maturity ratings in Indonesia and other countries.This approach was selected based on its alignment with the unique attributes of PSA as a public institution, which necessitates an in-depth analysis due to its intricate nature (Thanh & Thanh, 2015).
It will help to achieve the main objective of this study, which is to examine the effects of implementing maturity policies on PSA governance while also identifying internal factors that may influence the maturity level.By doing that, the maturity model evaluation is expected to uncover significant managerial patterns to help generate best practices.The findings will serve as valuable input for decision-makers and policymakers, facilitating the optimal achievement of the goal of enhancing PSA performance.
The present study utilises secondary and primary data to construct a case study close to the original nature of the business.The utilisation of both approaches is advantageous as it facilitates a more comprehensive exploration of issues and enables the identification of organisational patterns that have yet to be uncovered by the current maturity research.Further, using both methods enables triangulation to validate the theory with the actual perception of the actors (Leech & Onwuegbuzie, 2007).
It ensures the dependability of the result and reduces bias.In addition, the case study approach entails gathering data and literature and analysing problems to yield more detailed outcomes (Yin R. , 2009).This approach also has been chosen due to its comprehensive nature, which facilitates a thorough understanding of the present circumstances (Denscombe, 2017).It stimulates the ability to compare against international best practices to generate an optimal model for measuring maturity in the Indonesian PSA context.
To enhance the dependability of the research, this study will gather secondary data from diverse sources, including academic books, journals, scientific publications, and prior research conducted in a similar context.Furthermore, to improve the credibility of the discourse and hypothesis, the present study exhibits the outcomes of evaluating the maturity rating slated for execution in 2022.The process of obtaining actual secondary data utilises a freedom of information (FOI) system governed by the legal provisions outlined in Law No. 14 of 2008, which pertains to the disclosure of public information within the purview of the Indonesian government.According to Savage and Hyde (2014), this approach is deemed a potent instrument for bolstering research as it is cost-effective and economises on the time required for data collection.
In addition, to enhance the accuracy of the managerial aspect measurements, the study will incorporate data sourced from the Indonesian statistics management agency.The data collected is not for quantitative analytical purposes but pertains to the perceptions of recipients of health services.The data will be used to identify management's areas of weakness in delivering promised services.This deficiency could indicate a recurring trend of inadequate administration from an external point of view.According to Dongmo and Onojaefe (2013), the data from outside stakeholders' reliability is higher when used to measure the quality of services provided by public institutions.
Along with secondary data, this study incorporates primary data collection through semi-structured interviews.This approach is designed for individuals actively assessing PSA maturity and possessing expertise in PSA policy development.Interview results will be used to triangulate the research findings by juxtaposing diverse perspectives, encompassing both the scholarly realm and the practical application in the field.The utilisation of data acquired from various sources and the incorporation of expert views from multiple viewpoints are anticipated to enhance the credibility of this study's findings while mitigating potential biases and errors.
This approach aims to yield research outcomes that closely approximate an objective truth (Natow, 2020).Every question has been carefully formulated to address each research inquiry to ensure validity.By employing this approach, the findings may exhibit raised focus and reduced inconsistency in research aims.In addition, the study used open-ended questions to facilitate a more comprehensive exploration of information.Also, before conducting the subsequent interview, the researcher evaluated the answers to anticipate new contextual development.

Hasil dan Pembahasan Organisational Maturity Model Adoption in Indonesian Public Service Agency
CMM is a newly adopted method to transform Indonesian public services.It is widely believed that there is no universal model for it, and each adoption requires certain adjustments according to the nature of the business.The study on the technical instructions of CMM adoption provided by the Directorate of Development of Financial Management-Public Service Agency (DFM-PSA, 2020) also supports a similar notion.The research found that the primary impetus behind the theory's adoption is the expectation of PSA as the vanguard in public service delivery.
The aim is to align services prioritising customer satisfaction, professionalism, and excellence.Moreover, the motivation is bolstered by growing uncertainty.The recent Covid-19 pandemic poses an unprecedented challenge to public services sustainability like never before (Mahendradhata, et al., 2021).It caused a massive economic downturn, leading to a notable decrease in government revenues.Meanwhile, state expenditures persistently rise to uphold the affordability of public services.Thus, keeping optimal service levels amidst uncertainty is imperative to prevent macroeconomic and political instability.
According to DFM-PSA (2020), adapting cutting-edge technology and optimising assets is the most efficient approach to promoting service quality.Hence, CMM is regarded as a viable solution due to its proven theoretical ability to identify improvement areas effectively.It is also motivated by inherent dynamism, which enables adaptability to the specific priorities set forth.However, the modification requires a meticulous evaluation to identify its merits and drawbacks for long-term use.

Adopted Maturity Model
The secondary data findings show that the government adopts the traditional CMM, as Persse (2001) put forth.This is noticeable in the parallelism between the five levels of maturity and the requirements for each level.The application of CMM is carried out through several modifications to fit the characteristics of public organisations, like the general adoption of business process re-engineering (Weerakkody, Janssen, & El-Haddadeh, 2021).The CMM has been modified in the following ways: 1) General Objectives Modification, the goal of CMM extends to all managerial facets.It is not just exclusive to technological advancement (Paulk-a, Curtis, Chrissis, & Weber, 1993).2) Assessment Methods, the model proposed by Persse (2001) has been criticised since it cannot measure intricate organisation.To adjust for this, the assessment combines result-based and process-based approaches.It enables complete measurement of diverse managerial factors.3) Indicators and Criteria, the type of indicator modification aims to improve the assessment's thoroughness, while the weighted scoring reflects the priority.This adaptation has been tailored to the organisation's nature (DFM-PSA, 2020).
The modifications can increase flexibility while tackling the restrictive shortcomings, as previously suggested by Andreasen and Gammelgaard (2018).Giving customer experience a great deal of scoring could emphasise customer-centric best practices.Also, making innovation a distinct criterion will encourage closer attention to the continuous improvement of the business.

Basic Principles
Based on the assessment handbook, CMM in Indonesia delineates organisational maturity into five levels (DFM-PSA, 2020).Also, the measurement was modified into two approaches.1)Result-based Evaluation, Quantitative measurement is employed to assess maturity.A quantifiable method is convenient for evaluating performance.2) Process-based Evaluation, this approach assesses the qualitative extent of process depth to ascertain maturity.The evaluation process encompasses the outcomes and entails a comparative analysis of the inputs.
Both approaches utilise targets as a fundamental reference point for assessing outcomes.The table below presents an outline of the evaluation of both entities at each stage of development.
Table 1 Maturity Assessment Approach (DFM-PSA, 2020) The table illustrates a positive correlation between the maturity level of an organisation and its performance, indicating that higher maturity levels are associated with more outstanding performance outcomes.This relationship is attributed to the organisation's commitment to continuous innovation and improvement.Hence, utilising CMM principles is anticipated to serve as a definitive framework for management, encompassing immediate decision-making and formulating long-term organisational development strategies to attain sustainability.Predictable Performance meets part of the target and/or shows a trend of significant improvement.
The organisation can maintain output quality through a series of control processes.5 Optimising Performance meets all targets and/or shows an improvement trend.
The organisation is oriented towards innovation and continuous improvement.

Unique Assessment Criteria and Indicator
The government claims that the universality of criteria enhances comparability (DFM-PSA, 2022).Further, the assessment comprises two primary aspects: financial aspects, which carry a weight of 20%, and external services and total quality management (TQM), which weighs 80%.These aspects are then elaborated, resulting in 23 indicators below: Table 2  In contrast to the assessment method utilised in the past, which primarily concentrated on financial and service dimensions, the current adoption of the CMM theory encompasses a broader scope of governance by integrating Total Quality Management (TQM).Indeed, there is a growing emphasis on examining managerial authority, as evidenced by the allocation of up to 55% weightage to the assessment of internal factors.This suggests that internal aspects play a prominent role in determining the success of an organisation.

Current Assessment Result
The maturity assessment was conducted once in 2022 for all PSAs (DFM-PSA, 2022).In healthcare clusters, 106 public service agencies were evaluated.To conduct a straightforward analysis, the result is compared based on the criteria as follows: The figure above shows variations in the final maturity across different criteria.Hospitals under the jurisdiction of the Ministry of Health exhibit a significantly higher level of maturity in comparison to health centres, police hospitals, and army hospitals.Another critical point is that health centres' financial management exhibits the lowest level.Nevertheless, they achieved the highest public service score that, indicated their efficiency.To investigate the managerial themes, the assessment is broken down as follows: Despite the PSA's organisation model being introduced in 2005, there appears to be a substantial maturity gap.It highlights the diverse managerial themes and fragmented best practices across various entities.Therefore, role model organisation has yet to emerge.The amalgamation of financial resources from the state budget and PSA's revenue should confer a significant benefit to achieve high maturity.Nevertheless, the management appears incapable of effectively harnessing the advantage.The initial and managed maturity levels can be observed from 16 of 23 indicators.It is surprising, considering an operational tenure of more than 15 years.This implies that the system lacks comprehensive documentation, fails to achieve desired performance targets, and/or displays a lack of progress.Nevertheless, CMM utilisation is effective in exposing vulnerabilities.This allows decision-makers and policymakers to leverage future strategies.

Discussion of the case study
Indonesian healthcare's good governance can be addressed as the best practice of systems, procedures, and methods with transparency and accountability (CGI, 2021;Purwanti, 2022).However, the current governance faces severe criticism in accessibility, quality, infrastructure, and governance (Lestariningsih et al., 2018;Bazarah & Pujiastuti, 2022).While transformation is regarded as the best solution to provide optimal, expeditious, high-quality, and unbiased services (Abd Aziz et al., 2015;Daily et al., 2018), progress has yet to meet expectations.The organisation remains disorderly, evidenced by the low maturity level.
Nevertheless, the findings demonstrate that CMM holds significant promise in exerting influence over various aspects of governance.It can transform the upper echelons' behaviour and progressively traverse to the foundational stratum (Weerakkody, Janssen, & El-Haddadeh, 2021).Hence, the CMM's role may transcend from managerial guidance to an organisational development framework.
Lessons learned from the case study indicate the favourable outcomes associated with the adoption of CMM in healthcare governance, which can be summarised as follows:

Improve Decision-making
The CMM necessitates the utilisation of analytical proficiencies, thereby directly fostering decision-making capabilities by enabling data-driven decision-making and evidence-based management (Provost & Fawcett, 2013).

Increase Efficiency and Effectiveness
Uneven resource allocation jeopardises service quality.Also, PSA cannot dissociate itself from agency costs and obligations that further hinder efficiency (Yesilkagit, 2004).CMM ensures optimal resource utilisation without compromising quality by prioritising important issues, nurturing professional managers, and streamlining business processes (Kohler, Mackey, & Ovtcharenko, 2014).

Promote Legal Compliance
Complex legal and ethical dilemmas are associated with dynamic political and socioeconomic factors (Mir & Sutiyono, 2013).The potential of CMM lies in its ability to offer guidance to achieve operational autonomy while adhering to governmental regulations.It is feasible due to established legal compliance within mature organisations.

Improve Risk Mitigation and Responsible Management
Deficiencies in human resource capabilities complicate bureaucratic practices and risk ignorance (Aini, 2021).This is exacerbated by generous government funding support.Choi (2016) argues that this setting fosters mismanagement and fraud.CMM adoption ensures professional risk management by establishing a transparent and unbiased performance evaluation system.

Stakeholders Engagement
The evaluation of business maturity emphasises stakeholder relationships as a crucial information source.Mature organisations are characterised by their capacity to effectively address diverse expectations and needs (Paulk-b et al., 1993;Asri & Ahmad, 2018).

Transparency and Accountability
The CMM can foster transparency and accountability in financial management.Health organisations are entrusted with significant responsibilities for managing public funds.The organisation's emphasis on professionalism and commitment to prudent financial management is reflected in its maturity prioritisation to eliminate fraud (Abd Aziz, Ab Rahman, Alam, & Said, 2015).
While the study presents a range of favourable implications for implementing CMM in public governance, it also identifies specific adverse outcomes that warrant attention.These include: 1. Notable differences characterise the managerial themes exhibited by the four distinct types of health services.The purported cause is attributed to variances in the intricacy of the governing organisations (Bannister & Connolly, Forward to the past: Lessons for the future of e-government from the story so far, 2012).The assessment should consider the presence of a principal-agent framework, wherein PSA typically adheres to the leadership of the overseeing institution.There is concern that this phenomenon may diminish the dependability of the comparative outcomes due to the introduction of bias.2. The potential drawback lies in its tendency to prioritise formality over objective examination (Mahmood, et al., 2020;Omar, et al., 2020).Management should demonstrate professionalism to ensure the assessment's objectivity.Sometimes, an appraisal may involve an external third party (Davis & Hanna, 2016).3.There is a concern that CMM may impede improvisation and innovation, as Sørensen and Williams ( 2002) noted.Monitoring policy adoption is necessary to prevent managers from becoming entrenched within a rigid and predetermined structure.Additionally, it is vital to possess a heightened consciousness and a cultivated mindset to consistently challenge one's boundaries through innovative adaptation.
Based on the discourse presented, it can be inferred that CMM can yield both advantageous and detrimental effects on healthcare governance.Overall, the advantages surpass the potential drawbacks, particularly in organisational development.Nevertheless, policy adoption requires a significant investment, so it is essential to acknowledge potential risks that affect reliability.The failure of policy may be regarded as a waste of public funds.

Interview Findings
The primary data for this study was collected through interviews with ten officials/employees who were directly involved in assessing maturity ratings.These individuals represented four health service PSA sub-clusters and two PSA advisor organisations.The interviews were conducted throughout six sessions, three of which were conducted in a group format.Most participants consisted of employees affiliated with Healthcare PSA, specifically those who served as members of the maturity assessment team for the 2022 assessment.In addition, individuals from governance development organisations affiliated with PSA also arrived.

Research Participant
A purposive sampling technique was employed in selecting respondents to ensure that individuals directly involved in assessing organisational maturity were included in the study.Furthermore, the sample size was progressively expanded until the interview findings ceased to yield novel insights, at which point data collection was terminated upon reaching the point of saturation.The subsequent sources of participants in the interview are as follows:

Data Analysis
The researchers employed thematic analysis to identify and analyse recurring themes from the interviews conducted with the participants (Clarke, Braun, & Hayfield, 2015).This methodology was selected based on its inherent interpretive qualities, facilitating a more profound comprehension of the research context and enhancing pragmatic decision-making in subsequent endeavours.The process of processing qualitative data using the Delve Tool qualitative analysis.Based on the data analysis, the coding theme summary was derived as follows: The interview data analysis reveals that applying the organisational maturity theory in the Indonesian PSA exhibits distinct characteristics.This phenomenon is evident through its unique features, consequential effects on governance, and the internal factors that ascertain the level of maturity.To gain a deeper comprehension of the model, this study employs the matrix code x transcript below:

Kesimpulan
Overall, this study draws the following conclusions.Q1: What are the consequences of the business maturity policy for healthcare agencies' governance?
The implementation of maturity policy significantly impacts organisations' governance in all aspects of the PPT Framework, which are People, Process, and Technology.Nevertheless, this phenomenon yields advantageous outcomes and entails specific risks requiring vigilance.One significant advantage of adopting the CMM is managerial enhancement by improving decision-making abilities, operations efficiency and effectiveness, continuous improvement through weakness identification and promoting innovation.In addition, implementing CMM can yield significant adherence to legal requirements, facilitating risk mitigation, responsible governance, and fostering financial transparency and accountability.However, it is imperative to remain vigilant of various risks, particularly the possibility of conflicts of interest that can undermine the impartiality of the evaluation, give rise to unprofessional conduct, and curtail creativity and innovation.Q2: What are the internal determinants that impact the maturity level of healthcare agencies?
This study identifies internal factors that have the potential to impact policy effectiveness.According to research discoveries, even though the government initiated the policy, the inner managerial aspect exerts the most significant influence on success.The finding aligns with prior research, as it demonstrates the significance of internal factors, including leadership, business processes, human resource management, performance measurement, organisational culture, and risk management, in influencing organisational maturity.Moreover, the study uncovers novel insights suggesting that the level of infrastructure readiness can serve as a reliable measure of maturity, given its significant impact on the functionality and effectiveness of health services.Q3: What steps should be taken to achieve the desired outcome?
It is encouraged for the management to establish internal policies to facilitate CMM implementation.It could be done by introducing an incentive system to foster inner dedication and improving change readiness by utilising employee training and development.Research also suggests that organisations develop a comprehensive knowledge management system to ease knowledge transfer.Therefore, it is anticipated that employees will be prepared to provide assistance in the organisational transformation process and expedite the attainment of performance enhancement objectives.
Furthermore, it is anticipated that policymakers in the future will focus on enhancing the effectiveness of the maturity model employed by refining indicators and ensuring the evaluation process remains independent.To uphold service quality and gain a competitive advantage, it is imperative to prioritise infrastructure and technology factors.

Figure 1
Figure 1 Research Design (Sourced by Author)

Figure 3
Figure 3 Thematic Analysis (Sourced by Author)