THE EVALUATION OF INDONESIA'S BASIC EMERGENCY OBSTETRIC CARE PROGRAM EVALUASI PROGRAM LAYANAN OBSTETRI DAN NEONATAL DARURAT

The research was motivated by the ineffective implementation of the Basic Emergency Obstetric and Neonatal Care (PONED) program at the Bangetayu Public Health Center in Semarang City. This ineffectiveness is primarily due to inhibiting factors such as poor communication, human resource shortages, and inadequate facilities and infrastructure. These challenges have negatively impacted the quality of health services provided to the community and have prevented the program from achieving its objectives. This study aimed to evaluate the implementation of the PONED Program at health centers to determine the factors driving and inhibiting its success. This descriptive and qualitative research was conducted at the Bangetayu Public Health Centre, one of the primary healthcare centers with Basic Emergency Obstetric and Neonatal Services (PONED) in Semarang City. The purposive sampling method was used to collect data from 15 informants through interviews. Public compliance with the program could be seen from the very high participation of citizens in PONED socialization. Community participation in identifying problems and determining the PONED strategy with stakeholders differs from the activities budgeted in the Regional Revenue and Expenditure Budget as deconcentration funds. Program efficiency in task delegation could have been better, although not optimal. Program effectiveness/relevance still needed to be fully practical. This evaluation showed that the authority factor greatly influenced the operation of the three indicators. The authority factor of the City Government of Semarang concerned the application of a merit system and the principle of deconcentration in monitoring, as well as special allocation funds for physical/non-physical infrastructure, including competency improvement. Factors supporting the implementation of the PONED Health Center Program found that there were aspects of stakeholder collaboration that determined the success of the program, in addition to aspects of resources, aspects of implementers' attitudes, and aspects of bureaucratic structure .


INTRODUCTION
Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR) are indicators of a country's progress in the health sector (Chasanah, 2015).Furthermore, MMR refers to death risks due to complications during pregnancy and childbirth.Central Java Province is one of Indonesia's most significant contributors to MMR, although statistically, a decrease was recorded from 2015 to 2018.Previous research (Desita, 2012;Rachmawati and Suprapto, 2010;Valentina and Suryoputro, 2016;Susanti and Marom, 2019;Yuningsih, Marom & Maesaroh, 2019) recommended the importance of continuing the evaluation of the PONED Program as an innovation in the health sector so that the community can feel the benefits.Specifically, the MMR in Semarang City (one of the cities in the Province of Central Java) is presumed to be evenly distributed because, in almost every sub-district, there are cases of maternal mortality.Law No. 36 of 2009 and Semarang City Regulation No. 2 of 2015 concerning Health as well as Maternal and Child Safety are regulations adopted to support the Maternal and Child Health (MCH) program.These regulations serve as an effort to reduce maternal mortality by understanding the importance of primary health.Furthermore, the Semarang City Government, through the City Health Office made total efforts by establishing the PONED (Basic Emergency Obstetric and Neonatal Services) Public Health Center and PONEK (Comprehensive Emergency Obstetric and Neonatal Services) Hospitals in 2013 as well as gradually maximizing the functions and duties.PONED Public Health Center is an inpatient facility that can render 24 hourly services for pregnant women during antenatal and postpartum, as well as newborns with complications, either through routine visits or referred by the cadres or midwives.Over time, to reduce the occurrence of MMR in Semarang City, mothers, in particular, have yet to fully benefit from the implementation of PONED, even though there was a decline in the data acquired in 2015.Based on these data, it was evident that an increase was recorded from 2013 to 2015, while a less significant decrease was experienced from 2016 to 2018.Irrespective of the fact that the PONED Public Health Center was established and implemented in 2013, the maternal mortality rate in Semarang City was still high from this period to 2015.However, a decline was recorded from 2016 to 2018.In 2018 there were 19 cases of MMR.Eclampsia Bleeding Disease: CVA, Ca Sepsis Others CKD, Typoid Source:https://dinkes.semarangkota.go.id/asset/ upload/Profil/Profil%20Kesehatan%202018.pdf.
Based on the graph in Figure 3, in 2018, 37% of maternal deaths were due to eclampsia.The majority of the expectant mothers already had hypertension risk factors, which were aggravated by diseases, such as the ineffective implementation of maternal and child policies to reduce MMR.This was due to several obstacles that need to be quickly resolved and addressed due to a lack of human resources, such as a limited number of doctors, nurses, and midwives that constitute the core team rendering 24 hourly PONED services.Moreover, pregnant women did not yet understand this program.Therefore, when faced with complicated delivery, such as obstructed labor at midwifery), they were unwilling to be taken to the PONED Public Health Center.This was because prospective patients felt that they were unable to overcome this problem because of the unavailability of health workers on-site, equipment, and drugs.
Furthermore, this was related to suboptimal fund management and allocation, facilities and infrastructure that did not satisfy minimum standards, ineffective communication among elements, and bureaucratic structures.Government regulations implemented to assist and monitor PONED Public Health Center services have not been completely maximized, thereby leading to unskilled human resource practices.Meanwhile, specific information sources stated that there were no doctors, and the midwives were not confident enough to provide emergency care.Moreover, it was perceived as a routine activity because the PONED service implementers were unable to understand the purpose or aim properly.
The Bangetayu Public Health Center is one of six (6) hospitals in Semarang City that Based on this background, the identified problems were the ineffectiveness of the implemented program at the Bangetayu Public Health Center due to certain inhibiting factors such as poor communication between the stakeholders and the community, lack of human resources, as well as unsupportive facilities and infrastructure.All of these certainly affected the services rendered to the community.Therefore, the expected goals still need to be implemented appropriately.
Based on these conditions, changes, and efforts were needed to accelerate the achievement of the PONED program goals.Therefore, the decline in MMR recorded in Semarang City was because one of the progress indicators of an area was viewed from the aspect of health services provided for the community.For these reasons, preliminary studies were investigated and evaluated to determine maternal mortality and services rendered to pregnant women through the implemented PONED program in Bangetayu Public Health Center Semarang.

MATERIALS AND METHODS
This qualitative research adopted a descriptive design to determine the evaluation of the Bangetayu PONED Public Health Center Program in Semarang City, which was implemented in 2019.In addition, primary data was obtained at the Semarang City Health Office.The subjects consisted of the Head of the Public Health Division of the Semarang City Health Officer, that of the Public Health Center, Midwives and Doctors in the PONED Public Health Center area, and several representatives of the community including numerous pregnant women.In total, there were 15 informants.Meanwhile, primary and secondary data were collected based on observations, interviews, and documentation.These were analysed using the various interactive stages proposed by Miles, Huberman, and Saldana (2014), namely data collection, data condensation, display data, and conclusion: withdrawal/verification.Furthermore, validity testing was carried out using source triangulation, where information is acquired by interviewing different informants to obtain accurate data in the field.Moreover, validity is ensured by analysing and comparing the information acquired from interviews with the conditions in the field through observation and documentation.

Results
The Public Health Center was located on the Highway leading to Wetan Village, Genuk Subdistrict.Its service work areas included Bangetayu Wetan, Kulon, Karangroto, Kudu, Penggaron Lor, and Sembungharjo.Each has 39 civil servants led by the Head of the Public Health Center and assisted by the Leader of the Administration, as well as medical, paramedical, and administrative personnel.Furthermore, there was one honorary staff member and 16 community service personnel to serve the six sub-districts, which had 63,916 people.Bangetayu is a sub-district in an industrial area.The service area of the Bangetayu Public Health Center covers 6 villages with an area of 1167 ha, including a total population and an average population density of 63,916 and 5477 people/ha, respectively.
Public Management.Internal and internal factors in management greatly affected the management model that was applied to improve organizational effectiveness, as presented by Quinn & Cameron (1983) The existence of this internal and external environment in public management in Indonesia is studied by Tompkins (2005) in the rational goal model, internal process model, human relations model, and open system model.The rational goal and internal process models coloured public management in Indonesia during the New Order.Its characteristics always prioritizing compliance with established structures, processes, rules, and emphasizing fairness or equity.In the reform era, public management was marked by a series of reforms according to the New public management paradigm, such as decentralization, accountability, and performance appraisal.The next paradigm was the new public service, where the orientation of the bureaucracy was to public service, improving the public service system, and following the new public governance, which emphasizes the involvement and cooperation of the government, the private sector, and the community in the preparation of five-year program and activity plans and annual plans.
Internal Process Models.This internal process model could be understood through the laws and regulations governing the formation of organizational structures and work procedures at the ministry level through Ministerial Regulations at the provincial, district/city levels through Law Number 23 of 2014 concerning Regional Government and Regional Regulations.Another example was the bureaucratic reform as outlined in Presidential Decree number 81 of 2010 concerning the Grand Design of Bureaucratic Reform 2010-2025 and its implementing regulations.This arrangement was in line with the new public management paradigm.
Human Relations Model.This human relations model could be understood from the Law Number 5 of 2014 concerning the State Civil Apparatus and its implementing regulations that followed the New public management and New public governance.Reforms related to the open systems model could be seen from the Law Number 14 of 2008 concerning the disclosure of public information and its implementing regulations, including e-governance regulations.This model followed the new public governance paradigm.
On the other hand, the reform of the strategic management model in Indonesia was implemented through Law Number 25 of 2004 concerning the National Development Planning System and its implementing regulations.The reform of the rational goal model could be observed through the development planning process at the national, provincial, district/city levels.Thus, reforms related to the rational goal model tended to be biased towards strategic planning and pay less attention to two other strategic management functions, namely: implementation and evaluation.
Empirically, public management in dealing with various affairs was often inadequate, failing public organizations that give authority to administer certain affairs, such as health affairs.This happened because of the neglect of the public management environment, such as the influence of public policies referenced by government organizations, political, social, cultural, geographical, economic, science and technology conditions, and globalization.
Public management is organized in diverse environments, and cultural variations affect reality in public administration.Therefore, the locus dimension and focus factors concerning management principles, theories, or models were indispensable as a form of accountability.Program evaluation included program results, which was one form of audit, in addition to financial and Susanti et,al.
Evaluation of the basic emergency compliance audits, and economy and efficiency audits (Safritz, 2017).
Program evaluation systematically examined the government's activities regarding their current or future effects.This program evaluation used management and related organizational data on the program as a whole.This was important considering that the program results determined whether the results or benefits were in line with the program objectives, in the most cost-effective manner possible.
Types of Program Evaluation.There were various types of program evaluation according to Safritz (2017).Ex ante facto evaluation was an evaluation to assess the impact and results of the program before the program was implemented.
Process evaluation sought to examine the operational aspects of the program as the program progresses within the organization's management process.Ex post facto, postmortem evaluation looked at the program after completion and was relevant when there were repetitive activities.This study sought to determine changes in the policy infrastructure so that the results aligned with the objectives.Perspectives in evaluation vary, so managerially, there was a suitability of the nature and purpose, efficiency, and effectiveness of the prioritized goals, so evaluation standards were needed.
Evaluation Standards.Safritz (2017: 571) revealed that program evaluation generally refers to three standards, namely: (1) compliance, (2) efficiency, and (3) effectiveness/relevance. Compliance basically conducted an audit of: whether government business transactions were carried out in accordance with regulations, so the specific questions were: (1) Were all financial transactions involving revenue and expenditure of resources consistent with the authority granted?(2) Were financial records and reports provided in accordance with prescribed accounting standards?(3) Were transactions carried out accurately and free from fraud?Efficiency standards refered to the following questions.(1) Were government agencies more optimal?(2) productivity of the resources they expend?
(3) Were responsibilities for certain tasks delegated?(4) Were employees sufficiently qualified to perform their duties?(5) Was wastage of resources avoided?Effectiveness standards dominate the program evaluation environment.
Effectiveness questions included: (1) Were the various objectives involved in the program compatible? (2) How much reduction was there in the problem?(3) Was it possible to commit additional resources to the program to achieve the objectives?(4) What would happen if the program did not exist?Thus, there was a close relationship between aspects of program effectiveness and efficiency, although sometimes the relationship was reversed.For example, a program that was relatively inefficient but still effective (wasting resources but still getting the job done) or one that was relatively efficient but not effective (may use its resources optimally but has little impact on the problem it was designed to fix).
Based on three evaluation standards, namely (1) compliance, (2) efficiency, and (3) effectiveness/relevance; The results of this study were as follows.
Research compliance standards showed that the financial transactions of the Public Health Center came from the Semarang City Regional Expenditure Budget (APBD) receipts and a small portion of public funds in collaboration with the Social Security Administrator (BPJS).
Likewise, the expenditure of the Public Health Center depended on operational funds from the Semarang City Regional Budget.PONED revenues and expenditures were recorded so local governments could routinely monitor them.The authority of the Public Health Center to innovate could have been bigger, considering the limited authority given.Based on financial records and reports in this study, it was not obtained from the main source at the Public Health Center.However, the Semarang City Regional Budget noted that the amount of government spending on health fulfills 20% of the total Regional Expenditure Budget.Financial reporting from the Public Health Center met the accounting standards set by the government because the Semarang city government always monitored the existence of PONED.This PONED Bangetayu transaction was accurate and ready to be audited at any time.
This Regional Expenditure Budget funding was the Central Government funds provided in the context of deconcentration, so this program was purely central assistance implemented in the regions.The successful implementation of regional authority to implement Central Government assistance depended on the community's assessment of the need for PONED.For this reason, community participation with the Bangetayu Health Center was needed to implement PONED.The identification of needs to be done according to the needs of residents through the role of the community, cadres, and the health center needs to be discussed with stakeholders.This need from below was then translated into activities to support the benefits of PONED in the Semarang City Regional Expenditure Budget.The needs studied together were sought for solutions and strategies by involving stakeholders.These stakeholders must be active in every stage of the process and in the strategies prepared for the activities in the Regional Expenditure Budget.This means spending funds and filling in relevant activities to support PONED.
The efficiency standards of this study indicated that the government's optimal implementation of PONED needs to be studied further.This was because of the perception of Public Health Center services in the eyes of the community needs to provide optimal services.Factors that influenced this included insufficient human resources for PONED due to the absence of specialist doctors, needing to be open 24 hours according to applicable regulations, and slow service for emergencies compared to hospitals.The absence of specialist doctors could be delegated to trained midwives, but the employee transfer system often needed to pay attention to the needs of the Public Health Center in the PONED team.Operationally, human resources performed dual tasks in the PONED team so that the team members received training that was different from that of the PONED team.Waste of resources occurred because doctors and medics were carrying out tasks outside their authority due to insufficient competence and the absence of routine training from the Semarang city government.
The human resource factor could have been better due to the lack of skilled and competent employees and departmental support in providing training sessions.On the contrary, it did not necessarily hinder the provision of quality services to the community because they were used to learning while working to overcome these problems.
Furthermore, this was supported by the data stated in the Strategic Plan of the Bangetayu Public Health Center, including the number of personnel employed in 2019.Based on the table, it was evident that the Bangetayu Public Health Center needs certain types of human resources, namely dentists and laboratory technology experts.Each medic (analyst) and midwife had 1 or 2 officers.This shortage greatly affected the effectiveness of the services provided.However, assuming this issue was not addressed immediately, it was certainly bound to impact the success of the program.Another obstacle was the need for more training sessions for the PONED teams.This ultimately hindered efforts to improve the quality of human resources because the relevant skills were lacking, and in the end, health services rendered to the community were not optimal.
It was also the main factor that needed to be considered in addition to other resources.It was the determining point for the success of the program.It played a massive role in achieving set goals.The lack of human resources, both in quality and quantity, certainly impacted the services provided, assuming that the Public Health Centre needed to adopt an adequate step to minimize the risk due to the lack of competent employees in the respective fields.Furthermore, it hindered the implementation process of the PONED program.
Another factor that causes inefficiency is that the existing facilities and infrastructure need to be maximized.This was due to deficiencies in several aspects, such as small inpatient building spaces, poor equipment, limited delivery or action rooms that only had one unit, and the unavailability of supporting equipment for emergency services.
The PONED program at the Bangetayu Public Health Centre was quite efficient, from the services provided to the implementers' attitudes.However, in terms of facilities and infrastructure, it was still ineffective due to the lack of various supporting aspects, such as existing buildings and equipment.This caused the services rendered to be less optimal because it collided with the existing conditions.
Effectiveness standards dominated the program evaluation environment.Various stakeholders involved in the program did not have the same perception to raise and empower PONED.Limited program socialization, lack of competence resources, and inadequate infrastructure so that the objectives of PONED have not reached the expected targets.The constraints faced by the PONED by the Public Health Center could not be handled by the Public Health Centre themselves; but required attention from the government, especially the Semarang City Health Office.The addition of additional resources for the program was carried out by increasing the number of employees although not all of them were in accordance with the operational needs of PONED.PONED would be effective if it was supported by a PONED team with advanced competence and training, and was supported by a competency-based employee transfer system that was tailored to the needs of the PONED Health Centre.If the mutation was carried out without paying attention to this, then what happened was that PONED could not function optimally in providing public services.
The PONED Program at the Bangetayu Public Health Centre has been ineffective due to the several obstacles encountered during its implementation.It focused on services rendered to pregnant women and efforts to reduce maternal mortality, especially in areas within its scope.In addition, it was expected to be able to provide maximum service to the community in terms of reducing maternal mortality rates.This was inconsistent with the conditions on the field, both in terms of service delivery and supporting facilities and infrastructure.Based on the table, there was a decline in the number of maternal mortality rates at the Bangetayu Public Health Center, although, in reality, it did not align with the maximum support from other factors, which ultimately led to the program's ineffectiveness.However, the decline in maternal mortality rate needs to be appreciated because irrespective of the limited number of available resources, they were able to prove their skills and competencies by maximizing and optimizing existing capabilities to render the best service to the community.Furthermore, this effect was evident in the people's response regarding the standard services rendered to fulfil their needs.
Based on information obtained from the informants, it was concluded that the PONED program at the Bangetayu Public Health Centre still needed to be more effective.This occurred due to several factors, such as unskilled and incompetent human resources and lack of departmental support in terms of conducting training sessions for the employees.However, on the one hand, unskilled labour did not necessarily hinder the fulfilment of quality services to the community because the employees were used to learning from the work, thereby overcoming these problems.
The ineffectiveness of the PONED program was caused by the fact that the facilities and infrastructure still need to be fully maximized.This was due to certain deficiencies in several aspects, such as small inpatient building spaces, poorly equipped, and a limited number of delivery or auction rooms, which was only one, and needing more emergency services.The implemented PONED program was quite good regarding the implementers' attitudes.However, as regards facilities and infrastructure, it was ineffective because of poorly equipped buildings.Therefore, the services rendered occasionally are less optimal.Another ineffective attribute was the communication factor, which was an important aspect of the implemented policy.The program certainly involved a reciprocal relationship between the agents and target groups because it influenced the set goals.
Based on the information obtained from the informants, it was concluded that the PONED program was ineffective.This was due to several obstacles such as lack of human resources and supporting facilities as well as poor communication skills.Meanwhile, these three factors were extremely important in implementing an emergency management program for pregnant women to reduce maternal mortality in Semarang City.
This indicator was presumed to be effective and, at the same time, ineffective because the officers' responses were good while that of the community was poor.However, it was perceived as effective in certain conditions, such as when the community has recently experienced complications related to maternal health or pregnancy.The human instinct to get treatment causes them to respond appropriately to the Public Health Centre program, thereby improving their level of responsiveness.
Supporting Factors for the Implementation of the PONED Public Health Center Program comprise four indicators (Dunn, 2003, Subarsono, 2013).The fourth indicators were communication aspect, resource aspect, aspects of implementer attitude, and aspects of bureaucratic structure.The unit that oversight the PONED policy or the person in charge also had a way of communicating with colleagues and subordinates through the Si Emon Suka Jamu Program (Simulation on Maternal Obstetrics Neonatal Emergencies, Case Studies of Quality Control).This was described as a kind of training initiative used by the Bangetayu Public Health Center PONED Team to coordinate and improve the service process.However, this also acted a double because it improved the teams' communication skills and enabled them to carry out case studies and discussions and find common ground to motivate members, thereby rendering optimal and rapid services to the community and minimizing risks.

Communication
The Si Emon Suka Jamu program is supported by the PONED support network so that coordination between the Village Health Center (Ponkendes), village midwives, outpatient and non-poned health centres, auxiliary health centres, and Community-Based Health Efforts (UKBM) greatly supports the effectiveness existing communication.Emergency simulations that are generally attended by all the coverage networks show that the communication aspect that occurs between the networks is very good, so the increase in competence is also increasing.
Resource Aspect.The human resource factor was not completely good due to the lack of skilled and competent employees and departmental support in providing training sessions.On the contrary, it did not necessarily hinder the provision of quality services to the community because they were used to learning while working to overcome these problems.Furthermore, this was supported by the data stated in the Strategic Plan of the Bangetayu Public Health Center, including the number of personnel employed in 2019 (Table 1).The deconcentration funding factor and the not-yet optimal merit system in placing human resources in the City of Semarang indicate that there has yet to be full synchronization between the political will of the Central Government and the City Government of Semarang.Continuation of competency training is not followed by placing human resources in the right place.Mutations in human resources are a determining factor in aspects of resources that are running well, but Table 1 does not yet show a standard structure in a PONED.PONED can function optimally if it is supported by human resource factors placed at the Bangetayu Health Center according to their competence.The impact is that the PONED support network that should exist in each urban village only sometimes gets the maximum training according to the expected competencies.
Aspects of Implementer Attitude.The implementer's disposition was essential because it was related to the program.
Preliminary studies discovered a pattern of certain tendencies through the delegation of authority, delivery of orders, and execution of tasks.Furthermore, the tendency of implementers to carry out joint tasks was of great interest.This aspect or indicator was quite good.It was evident both in the disposition of the office to the Public Health Centre and other stakeholders, including superiors and existing employees.In addition, all program implementers at the Public Health Centre were highly committed and synergized to ensure the set objectives were adequately achieved.Likewise, the PONED Health Center referral flow has been running quite well and is not rigid in dealing with emergencies.The PONED support network always reports the presence of pregnant women and babies in the PONED health center so that they can be continuously monitored.However, the existence of the 24-hour PONED is always awaited by the PONED Team in full within 24 hours.The presence of a complete team during working hours and an emergency doctor who is called if there is an emergency indicates a lack of competent personnel to handle it.This means that the human resource factor as the executor of the PONED policy is not sufficient both in terms of quantity and quality.This factor also causes people to choose to go directly to the PONEK hospital, compared to the PONED health center.
Aspects of Bureaucratic Structure.During the implementation of the PONED program, the Public Health Center was concerned about the existence or availability of standard operating procedures (SOP), which was a guideline for the institution to direct and regulate actions that boost maximum and effective services and satisfy the needs of the community.The standard operating procedures as an indicator of implementing minimum service standards (SPM) in the health sector are not rigid in the implementation of the referral flow because it involves the humanitarian factor as a priority for the government's attention.The minimum service standards in the health sector are also regulated by regional government laws (Law Number 23 of 2014), meaning that the central government and local government implementers should be synchronous and sustainable in the success of the PONED Program.The referral flow in Figure 1 shows that the presence of pregnant women and babies is always recorded at the village, PONED, and PONEK levels.For this reason, the resource factor in the field is very important in collecting data, providing optimal services, and monitoring the presence of pregnant women and babies who require special treatment.This research looks at the fact that the Bangetayu Health Center already has standard operating procedures and minimum service standards in providing emergency services.Aspects of the bureaucratic structure contained in the PONED program are functional but have yet to carry out their functions optimally.This is in line with informants' responses regarding the existence of standard operating procedures and employee compliance in providing quality services to the community.Unfortunately, this quality service has not carried out its function optimally because it has not been supported by the competence of the bureaucratic structure implementing the PONED Program.

Discussion
This research on the evaluation program of the Bangetayu PONED Public Health Center program in Semarang City theoretically adopted public management theory by Safritz (2017) with three standards, namely: compliance, efficiency, and effectiveness.In addition to these three standards, there were other factors that needed attention to support the success of the PONED Program, namely: communication, resources, attitude of implementers, and bureaucratic structure.
Compliance.Compliance showed that PONED Program Bangetayu was very compliant with applicable regulations and tended to be passive in accepting existing programs.Regarding compliance in using financial resources, PONED Bangetayu was very compliant.This compliance made PONED Bangetayu less in making service innovations that were picked up in nature.Regional authority in implementing deconcentration programs should be an opportunity for regions to innovate in providing PONED services according to community needs.It was hoped that PONED would not only serve as a medium for service innovation in the health sector but also bring people closer to the benefits of the PONED program.Therefore, problem identification, problem-solving strategies, and the process of achieving and evaluating these strategies must be carried out among stakeholders.In this case, the PONED evaluation has not run optimally at the urban village level and has only been limited to the data collection stage.This meant that communication that had been established between stakeholders needed to be followed up with substance, monitoring, and evaluation.
The PONED program has been ineffective in terms of maternal health services.This was relevant to the fact that the evaluation process was still poor because it was not supported by coherent management, purpose, and internal or external factors.It ultimately became futile, and the evaluation process could have been more effective and efficient.
Efficiency.The Bangetayu Health Center lacked competent human resources and medical professionals.This dual function and the regional employee transfer system resulted in PONED not having a complete team.As a result, every medical and paramedical team in the PONED team had to work in duplicate.This meant that the PONED Team performed routine work as employees of the Community Health Center, and the PONED Team must be ready to serve at any time if needed with a picket system.This inefficiency was a waste of resources because public services were not able to be optimally provided.
The merit system that has not been implemented and limited competencies' training were the factors that caused the placement of human resources not to be by the PONED competencies.A teaching hospital was needed to become a competency training centre for the PONED teams, but until now, the teaching hospital has only prioritized competency training for specialist doctors.Therefore, the continuation of the PONED program required government policies related to competency training.
Effectiveness.In practice, responsiveness was quite effective.This was because the program implementers' and recipients' responses were slightly different, although, in the end, both offered satisfactory preferences for the community.According to the theory proposed by Dunn (2003), this indicator is related to the level of community satisfaction as the recipient of the rendered services.Based on the findings, they were satisfied with the implemented PONED Program.Despite the lack of inadequate facilities and infrastructure, this was evident in the officers' readiness to render emergency and other administrative services.Furthermore, they have proved this was not an obstacle in rendering rapid and excellent services to the community.

Supporting Factors for the Evaluation of the PONED Public Health Center Program.
Communication Aspect.The Si Emon Suka Jamu program was supported by the PONED support network, Therefore, coordination between the Village Health Center (Ponkendes), village midwives, outpatient and non-poned health centers, auxiliary health centers, and Community-Based Health Efforts (UKBM) greatly supported the effectiveness of existing communication.Emergency simulations that were generally attended by all the coverage networks showed that the communication aspect that occurred between the networks was very good so the competence was increased.
The unit that oversees the PONED program or the person in charge also had a personal method of communicating with colleagues and subordinates, called the Si Emon Suka Jamu (Simulation on Emergency Maternal Obstetric Neonatal, Case Study of Maintaining Quality) Program.The Bangetayu Public Health Center PONED Team adopted this kind of training session to coordinate and improve the service process.However, it also acted as a double because it improved the teams' communication skills and enabled them to carry out case studies and discussions and find common ground to motivate members, thereby rendering optimal and rapid services to the community to minimize risks.
Resource Aspect.Bangetayu's human resources health centre has met the quantitative requirements but not for the PONED program.The results of the analysis show that the PONED program for 24-hour service must be supported by an adequate quantity and quality of resources.Of course, medical and paramedical personnel will not work 24 hours, so there was a need for a shift system for PONED services.Apart from that, the lack of competency training for the PONED Team had an impact on the services provided.The limitations of the PONED team, lack of competency training, and limited facilities and infrastructure have not reduced the enthusiasm for the service.The synchronization factor of central and regional government policies, which was reflected in the central government's attention to bringing health services closer to the citizen level, showed that the sustainability of this program was a serious concern of the government.
Aspects of Implementer Attitude.The implementer's disposition was quite good.This was evident both in the disposition of the office to the Public Health Center and other stakeholders, including superiors and existing employees.In addition, all program implementers at the Public Health Center were highly committed, and they synergized with each other to ensure the set objectives were properly achieved.The merit system in areas that are not yet running well is not being implemented the PONED team barrier did its job.PONED competency training, which is obtained directly in the field, is a high-risk training facility.Supported by the PONED support network, coordination between the Village Health Center (Ponkendes), village midwives, outpatient and non-PONED health centers, auxiliary health centers, and Community-Based Health Efforts (UKBM) make policy implementers less rigid.The merit system in areas where it was not yet operational was not an obstacle for the PONED team in carrying out their duties.PONED competency training, which was obtained directly in the field, was a high-risk training facility under the supervision of PONEK.
Aspects of Bureaucratic Structure.During the implementation of the PONED program, the Bangetayu Public Health Center was concerned about the existence or availability of the standard operating procedure, which was a guideline for the institution to direct and regulate actions that boost maximum, effective, and efficient service, as well as satisfied the needs of the community.A standard operating procedure as a service indicator regulated in the minimum service standards has been implemented, even though it was only in the data collection stage and is not yet up to evaluation and follow-up.The existence of minimum service standards in the health sector as regulated in Law number 23 of 2014 and local regulations in the health sector showed the attention and commitment of the central and local governments always to collaborate to improve PONED services.

CONCLUSION
The result showed that program evaluation with indicators such as compliance, efficiency, and effectiveness/relevance were some factors responsible for the program's success.Public compliance with the program could be seen from the very high participation of citizens in PONED socialization.The Si Emon Suka Jamu program is supported by the PONED support network, so coordination between The Village Health Center (Ponkendes), Village Midwives, Outpatient and Non-Poned Health Centers, Sub subhealth centres, and Community-Based Health Efforts (UKBM) supports the effectiveness of existing communication.This excellent support network is a means to improve competency in the field.Program efficiency in terms of task delegation was quite good, although not optimal.
Evaluation of the basic emergency Human resources competence was inadequate, so a two-function system was needed.The two functions of PONED resources were both health centre medical staff and PONED teams, so the fatigue factor of human resources has not been considered.This factor was also strengthened by the merit system that has not run well in the Semarang City Government, as a result of which public services at PONED cannot be provided optimally.
Regarding effectiveness/relevance, the program still needed to be fully effective, although stakeholders perceived limited competence as an obstacle in PONED services.Emergency simulations always run smoothly, but if not followed by supporting factors, they will not function optimally.Thus, the existing procedures must be followed with adequate content substance (both the communication process and facilities and infrastructure).Thus, the ineffectiveness factors occurred because of the incompetence of human resources, inadequate facilities and infrastructure, and an un-optimal communication process.
This study found that program evaluation generally referred to the three Safritz (2017) standards, namely: (1) compliance, (2) efficiency, and (3) effectiveness/relevance, it is necessary to add authority standards.This evaluation shows that the authority factor greatly influences the operation of the three indicators.The authority factor of the City Government of Semarang concerns the application of a merit system and the principle of deconcentration in monitoring, as well as special allocation of funds for physical/non-physical infrastructure including competency improvement.
Supporting factors for evaluating thePONED Health Center Program could be seen from several aspects.In the aspect of communication, the process has not been fully effective because of the uneven socialization process.In the resource aspect, lack of competence and lack of training for the PONED team resulted in a lack of skilled teams and inadequate facilities and infrastructure.In the aspect of the attitude of the implementer, the disposition in implementing the PONED program was quite good.This could be seen from the disposition of the office to the Community Health Center and other stakeholders, including supervisors and existing employees.In the aspect of the bureaucratic structure, the implementation of the PONED program at the Bangetayu Health Center regarding to the existence or availability of standard operating procedures was complete.Thus, these four factors needed to be strengthened regularly and required guidance from the Semarang City Health Office so that the PONED Program was in line with the establishment goals set by the government.For this reason, in the future, the authority factor for PONED Program officers will need to be reviewed to increase their competence factors.
Supporting the evaluation of the PONED Health Center Program can be seen from several aspects.In terms of communication, the process was not fully effective because the socialization process was not evenly distributed in all urban villages.This is because the PONED supporting elements at the urban village level still need to entirely have human resources.In terms of resources, the lack of competence and training for the PONED team resulted in a lack of skilled teams and inadequate facilities and infrastructure.In terms of the attitude of the executor, the disposition in implementing the PONED program was quite good.This could be seen from the office's disposition towards the Community Health Center and other stakeholders, including supervisors and existing employees.Aspects of the bureaucratic structure of the implementation of the PONED program at the Bangetayu Health Center regarding the existence or availability of standard operating procedures and minimum service standards were complete but not yet substantively.Thus, these four factors needed to be strengthened periodically and required guidance from the Semarang City Health Office so that the PONED program would be in line with the objectives set by the government.Another supporting factor that did not yet exist in Dunn (2003) was the collaboration factor of stakeholders because the sustainability of PONED was highly dependent on good collaboration between stakeholders, namely communities, Village Health Centers (Ponkendes), village midwives, outpatients and non-PONED health centers, auxiliary health centers, Community-Based Health Efforts, PONED, PONEK, Semarang City Health Office, Central Java Provincial Health Office, and the Ministry of Health as the representative of the Central Government in related departments.Thus, the supporting factor for implementing the PONED Health Center Program, which consists of four indicators (Dunn, 2003;Subarsono, 2013), needs to be added with a stakeholders' collaboration factor.

Figure 1 .
Figure 1 .Maternal Mortality Rate in Central Java Province from 2012 to 2018

Figure 2
Figure 2 Maternal Mortality Rate & Number Chart in Semarang City from 2012 to 2018 Source: Semarang City Health Profile 2017; Semarang City Health Profile 2018.

Figure 3
Figure 3 Graph of Cause & Time of Maternal Death in 2018 Aspect.The organizational communication aspect of the PONED Public Health Center Program in the scheme can be shown in the referral flow Evaluation of the basic emergency because the referral flow indirectly shows the communication process that occurs between patients and PONED.Hospitals that carry out Comprehensive Obstetrics and Neonatal Emergency Services (PONEK) located in the city of Semarang are a referral if the PONED Health Center cannot handle emergency obstetric and neonatal cases in support of the national program.The PONED Health Center is a referral center for various units: Village Health Center (Ponkendes), Village Midwife, Outpatient Health Center and Non-Poned Health Center, Supporting Health Center, and Community-Based Health Efforts (UKBM).Bangetayu Health Center has been equipped with these units, although it has yet to perform its functions optimally.The PONED support unit aims to provide health service facilities located in urban villages as a network of community health centres to bring access to and quality of health services closer.The organizational communication aspect of the PONED Health Center in the scheme can be shown as follows.

Figure 4
Figure 4 PONED Health Center Referral Flow Chart

Table 1 .
Number of Staff of Bangetayu Public Health Center Semarang City in 2019

Table 2
Number of Maternal Death Cases at Bangetayu Public Health Centre.