Based on the in-depth interviews with key respondents, 7 external shocks were identified as hospital disruptions in Indonesia. These external disruptions include policies, changes in the paradigm of hospital management, changes in markets and consumer behavior, technological advances, disasters, the politicization of health services, the economy, and conflicts (war). In addition, the results of the interviews also identified the hospital's barriers that impact the hospitals to becoming resilient hospitals. The shocks and barriers that the hospitals face are illustrated in Fig. 1.
External Disruptions
Most respondents highlighted policy as one of the shocks in disruption era. Policy disruption mentioned by the respondents includes hospital policy changes initiated during the Covid-19 pandemic, such as health service digitization, which became mandatory to using electronic medical records and telemedicine. Changes in the use of domestic medical devices pharmaceutical products and implementing a standard class of inpatients unit (KRIS) were also introduced. One key informant stated:
“Policies, for example, one day the government will enforce a standard class of inpatient unit (KRIS). When implementing this policy, the hospital will redesign the master plan, make infrastructure adjustments to carry out KRIS, and implement KRIS” (I.13)
Some respondents also mentioned that hospital policies that were established long ago are still disrupting hospital operations such as BPJS payment rates policies for hospitals that have not changed in the last 6 years, as illustrated below:
“We know exactly that by working with BPJS it means that approximately 80–90 percent are BPJS patients. We know that the BPJS regulation is indeed the obstacle is, the current rates used since 6 years ago, are no longer relevant to the current condition of hospitals. The course of the disease, even for this catastrophe, which has a large portion, costs quite a lot, and this is also increasing, so the cost becomes large. So it's true that the funding from BPJS seems to have needed to be revised to suit the current conditions and the current disease.”
Another shock that was raised by the majority of respondents was regarding the shifting of the hospital management paradigm. Several respondents reported that in the last decades, hospital industrialization has faced a major shift in terms of changing the financing system in hospitals from fee service to the INA-CBGs system, BPJS as a single-payer for national health insurance, as highlighted below by one of the respondents:
“shifting, service transformation, back several years ago, the hospital used the concept of provider base. who was the provider? doctor, hospital. He determined everything, how much it cost, etc. Since the implementation of the national health insurance system through BPJS, it started to go in there, eventually shifting to cost-based, all costs were calculated; it was like a tsunami for doctors who were used to setting their rates. But now, people can seek health treatment anywhere at the same price. this is an extraordinary disruption” (I.15)
Some respondents also predicted there would be a big shift in hospital care if the mono-loyalty of medical staff is implemented and linked to the application of the Health Facilities Information System (H.F.I.S) BPJS as explained below:
Doctors can practice in 3 places, but it will no longer be possible in the future because there will be mono-loyalty. This is a challenge for hospitals, especially private hospitals, because they usually use specialist doctors from government hospitals (I.6).
The changes in the market and consumer behavior were also mentioned as factors leading to hospital disruption. The changes in health service delivery using online consultation and online delivery has influenced patient behavior.
And then the demand for drug delivery and teleconsultation has recently increased, now they are probably used to shopping online with gadgets, so they also hope to shop for health from home, so we as hospital practitioners feel right, there are changes and demands like that(I.16)
From a social aspect, especially regarding patient behavior, patients don't want to spend a long time in the hospital because they are afraid. this is a challenge (I.16)
Another shock that some respondents mentioned is technological advancement, as technology is seen as one of the disruptions that has changed the hospital business, such as the rapid development of medical device technology, the use of Artificial Intelligence (AI), and the use of robots in health services as illustrated below:
Yes, of course, we know that in the context of this disruption, of course, many our jobs will be taken over by digital, for example, or let's say one thing might also be robotics, for example, that's what happened (I.13)
Disruption due to politics includes political influence in determining strategic positions in hospitals, especially in government hospitals. In some hospitals, managers who are appointed do not have the required qualifications and experience. In addition, respondents identified a concern about the fact hospital policies keep changing when the leadership changes, which impact on the continuity of some aspects of hospital functions as stated by one respondent.:
must be freed from politics, from political attachments. Because normally, health is always used as a political commodity ahead of elections, the election of the president, regional head, or council members. But once the election is over, that's it; let it go again. when it comes to health, it must be based on the plan. Changing the regional head, changing the president, the policy change, something we have planned is suddenly cut short in the middle of implementation (I.7)
The other important point mentioned repeatedly is a ‘disaster’. Some key informants explained the condition of Indonesia, which is located in a disaster-prone area. Disasters such as earthquakes, floods and landslides are very common, hence causing disruptions of the normal functioning of hospitals.
“Then about disruption, specifically for Indonesia. In a year there are around 3992 disasters that happen. It means that every day we have 8 disasters happen, and then maybe around 56 times per week, per month, multiply it may be up to 300. What does that mean, it means that disaster is a necessity in Indonesia, and the trend is increasing”. (I.19)
Most of the respondents mentioned that hospitals should be aware and be prepared to face global warming that causes climate change. Likewise, some key respondents emphasized the need for hospitals to be prepared for non-natural disasters such as pandemics that occurred few years ago.
“We were not ready, so far, there hasn't been a pandemic since we were in Europe before, right? We were unaware, so we didn't prepare the infection room based on needs s. As soon as he explodes, unpreparedness occurs”(I.17)
Finally, some respondents also mentioned the economy, which affect the ability to pay because of high inflation and rising cost, as well as conflicts (wars), e.g. the war between Russia and Ukraine, as having a devastating impact because of the shocks and disruptions that they causing.
“While our hospital services have not returned to normal like before the pandemic, not completely normal yet. Recently, operational costs are still the same, maybe even higher with inflation, all taxes have increased, and other costs have also increased. Many things in our economy, people's Ability to Pay has fallen” (I.9)
Barriers to Hospital Resilience
Several respondents also explained that several things make it difficult for hospitals. They mentioned barriers such as the organizational capacities of hospitals, which include poor organizational culture as illustrated below:
“Because firstly, there is always an organizational culture, this belongs to the government, the government buys it, we never feel that we belong, so we don't want to struggle to support the hospital. But how can you support yourself if you don't have a good business plan and activity? In the end, you have to wait for the patients to come, your patients are more than 80 percent are only BPJS patients, while at X hospital, they have 75–80 percent non-BPJS.” (I.15)
Another barrier stated by respondents is weak cooperation cross-sector as stated by one respondent:
No support for health service from another ministry. Cooperation. Why? For example, we hear about the issue of oxygen scarcity during a pandemic. Oxygen is not the Ministry of Health authority; oxygen is the Ministry of Industry because oxygen is an industrial gas, but one type is medical oxygen, and so far, the Ministry of Health did not expect that the demands would be over capacity (I.17)
Besides that, most of the respondents also identified the application and practice of traditional hospital management as important barriers, as illustrated by the following quotes:
”hospital in Indonesia is not like those abroad, having a customer first and marketing value”(I.12)
“…University hospitals and government hospitals' monthly revenue with very big resources is only 4–5 billion. Private hospital with a similar amount of bed, and human resources has bigger revenue, they gain 40 billion monthly. How come? The hospital board committee should identify the gap. Private hospital has a good brand image, why do government hospital not build branding image as well?”(I.15)
The other important barriers mentioned is inadequate managerial skills of leadership and HR capabilities as illustrated below:
……..the inability of hospital managers to understand the concept of management (I.14)
So, if we look at it now, from the position of director to the middle manager, especially at the Regional Hospital, not all of them are chosen by considering their job competency (I.5)
In addition, a lack of business mindset in managing hospitals also mention as barrier to be resilient hospital, as explained by one respondent.
Hospital in Indonesia serves so many patients that they do not target the amount of patient. Abroad, hospitals are shown as an industry. They create medical tourism hospitals and become device. In Indonesia, hospitals are not shown as an industry. (I.12)
Finally, resistance to change is also one of the barriers mentioned by respondents. The respondent gave an example of when the human resources were resistant to digitalization as illustrated below:
“..In the past, everything was done by man; now, they will use technology a lot because it will make the job easier. One of the obstacles that I experienced during my time as the main director of the hospital was implementing electronic medical records. The doctors have to input data, and they think it takes time for them, rather than handwriting” (I.13)