Questions/Answers

Safety and security are essential conditions to achieve a progressive socio-economic development. However, very few governments could provide those conditions to the people, especially emergency responses in a life and limb threatening situation. In the Indonesian context, an integrated national emergency response management has not yet existed. In emergency, a person is seeking help by calling several numbers because the involved agencies such as police, firefighters, and hospitals, are not connected to each other. In 2015, Dr. Iskak Regional Public Hospital, Tulungagung District, East Java Province has pioneered the establishment of Public-Safety Center (PSC) to provide an integrated emergency response. By calling one number namely 119 or (0355)320119, people can access multiple agencies: closest police units, nearest health centers, firefighter station, hospital, disaster management unit, and military posts. After assessment from the call center, relevant response vehicles and personnel will be dispatched to the emergency location. In average, the response time is 10 minutes. In the case of medical emergency, while waiting for the deployment, people can help victims on the spot by using telephone or video call assisted by qualified personnel. All victims or patients are treated based on the Patient Acuity Category regardless their socio-economic status, sex, age, race, religion, tribe, and other attributes. Based on the Category, patients will be classified on three zones: Red Zone for life and limb threatening condition, Yellow Zone for critical condition, and Green Zone for non-critical condition. By 2017, 125 (24.5%) of 509 districts in Indonesia have replicated the innovation. The Indonesian Ministry of Health has enlarged the innovation scope by establishing the 119 National Command Center to handle nation-wide medical emergency and to coordinate all PSCs. Rising indispensably in emergency cases, Specialist in Emergency is now on the process to be legally recognized as a new medical specialty in Indonesia.

The overall objectives of the initiative are to reduce mortality rate resulting from emergency cases, to increase response time, and to improve the effectiveness of emergency management among different agencies in Tulungagung District, East Java of Indonesia. Before the innovation begins, the region suffered from a high mortality rate of less than 24-hour in emergency department reaching 14.5 deaths per 1.000 population. The casualties were dominated by traffic accidents (40%), heart attacks (10%), and stroke (10%). In fact, deaths from those cases could be prevented through a quick response time since the leading research concludes that the initial 5-minute intervention from the first responder makes the greatest difference to a victim. Because each emergency case needs different responses, either police officer, firefighter, ambulance, or all of them, therefore, an easy access to the emergency response team, simultaneous assistances from qualified personnel, and a coordinated dispatch unit are critical to increase response time to approximately 10 minutes. Since most emergency cases will be resulting to medical treatments, Tulungagung dr. Iskak Regional Public Hospital is establishing a Public-Safety Center to integrate emergency resources and management among public agencies and is using a single telephone number to request help in emergency.

The initiative fits to the second category namely making institutions inclusive and ensuring participation in decision-making based on the following five reasons. Firstly, Public-Service Center as an integrated emergency management is new, unique, and innovative as an idea, policy, practice and structure within the context of Indonesia. This is the sole system in Indonesia that handling major cases of emergencies under one management. Secondly, the innovation enhances responsiveness of government to the demands and needs of citizens because the platform of Public-Safety Center has been used nation-wide in the form of 119 National Call Center as a medical emergency system under the Ministry of Health. Thirdly, the innovation promulgates new regulation to extend access to public services and developmental opportunities, since the innovation has endorsed the establishment of a new medical specialty namely the Specialist in Emergency. Fourthly, it promotes anti-discrimination and inclusion of all people because all victims or patients are treated based on the Patient Acuity Category regardless their socio-economic status, sex, age, race, religion, tribe, and other attributes. Fifthly, it institutes locally multi-stakeholder engagement processes by coordinating police department, military commands, health centers, firefighter, and disaster management units in handling emergency cases.

This initiative improves the delivery of public services by performing several outstanding activities based on three SGDs' goals. Firstly, Public-Safety Center (PSC) at dr. Iskak Regional Public Hospital is managing emergency team, including budgeting sustainability, quality control, and public dissemination. It allows all public to access an effective institution to providing a coordinated dispatch team and increasing response time in emergency handling accurately and impartially. Thus, it aligns with Goal 16 of the SDGs: promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable, and inclusive institutions at all levels. Secondly, PSC ensures equal opportunity and eliminates discriminatory practices in accessing emergency cases by treating victims using “Patient Acuity Category” without any exceptions nor screening toward their background. It also enables poor people to access the emergency services for free. It realizes Goal 10 of the SGDs: reduce inequality within and among countries. Thirdly, PSC could reduce the mortality rate, the number of global deaths and injuries such as road traffic accidents, mother and children, abused women, heart attack, stroke, and other emergency cases. It supports the accomplishment of Goal 3: ensure healthy lives and promote well-being for all at all ages.

There are three significant issues on public service delivery in Indonesia. At the top is the unresponsiveness of public service agencies toward people's needs. Due to the patronage culture and the nature of monopolistic in public service industry, such things as delay, uncertainty, and red tape have become the people's problems when dealing with public officials. In addition, discriminatory practice by prioritizing upper class people to receive much better public services is taking place while poor people have been denied receiving a certain public service. The last issue is the coordination failure among agencies to perform public service delivery due to egocentrics from each agency causing the quality of public service delivery deteriorates. The implementation of Public-Safety Center has successfully addressed those issues. Emergency responders are standing by for 24-hour and 7-day a week to be dispatched to any place throughout the region. Response time has reached 10-minute and immediate assistance to bystanders in helping victims is provided through telephone or video call. PSC treats every victim equally without pre-screening and provides the services that are free of any charges. Under one management of PSC, several public agencies are able to work harmoniously and collaboratively.

Public-Service Center (PSC) in Tulungagung has impacted positively large groups of population throughout the region. Because the emergency response is accessible to anyone, people can easily seek help from PSC whenever they are in emergency situation. The report handlers in the call centers speak in local dialects to reduce miscommunication and improve the delivery speed. The utilization of GPS technology enables the nearest team dispatch to an emergency spot quickly and accurately. People are assisted through information communication technology to be the first responders while waiting for the emergency response team. Most importantly, they can seek help from various agencies by dialing one number and acquiring the services for free. As the result, the most benefited group is the poor people who have been practically excluded from receiving certain public service, e.g. ambulance, because their inability to pay. Since PSC is implementing "Patient Acuity Category" promoting anti-discrimination, now they can receive equal and impartial emergency services. Eventually, this accessible service can reach the minority groups, those who live in remote areas, children and women, and other vulnerable groups. Hence, the positive impacts can really be felt by people in all circles and places.

In Indonesia, lives are considered as cheap. Many deaths have happened because of high-cost, uncoordinated, and unreliable emergency management. To seek help, people must call several numbers: 110 for police, 113 for firefighters, 118 or 119 for ambulance, and 129 for disaster team. In addition, emergency management is a complex business in Indonesia that has a large area and diverse conditions: 5.1 million square kilometers, 17.504 islands, 1.340 tribes, 652 languages, and 250 million population. As a result, the establishment of a centralized emergency management is unfavorable and unrealistic due to high variability among regions, in particular, geographic location, languages, and socio-cultural. As an illustration, traffic accident protocols in archipelago districts relying on water transportation will be different from districts relying on land transportation. In rural areas, people are using local dialects, not Bahasa Indonesia, to communicate. In this context, Public-Safety Center (PSC) in Tulungagung is innovative because it has improved the quality of lives' protection and is setting the best practice of emergency management in Indonesia. If needed, the call center can use local language and information communication technology to overcome barriers of time and place.

Indonesia is a large country that not possesses an existing integrated emergency management in nation-wide. As the result, Indonesians have difficulty to contact public agencies and to receive proper responses timely in the case of emergency. Public is often disappointed reading bad news about inadequate responses in emergency cases that resulting in deaths. As a contrast, emergency management in advanced countries is handling multiple agencies to dealing with almost all cases of emergency using a single phone number such as 911 in America and 112 in Europe. Based on those best practices, Tulungagung dr. Iskak Regional Public Hospital is adapting the system at the district level under the name of Public-Service Center (PSC). PSC serves 1 million population in 1 million square kilometers. It incorporates police officers, health centers, hospital, firefighters, and disaster units. Furthermore, it expands to include military force especially dealing with disaster and terrorism-related emergency cases.

The initiative used financial resources in total initial outlays and annual operational costs, respectively, worth approximately IDR30.2 billion (USD411,556) and IDR1.075 billion (USD78,882). The largest fraction of money (IDR22 billion/USD299,809) was spent to upgrade thehospital using bank loan and national budget. The number of human resourcesneeded is more than 200 people. Additional resources are information and technology such as GPS (Global Positioning System) devices and telephone/video call applications. The breakdown of financial and human resources is as follows: 1. Dr. Iskak Regional Public Hospital: Hospital upgrading IDR22 billion (USD299,809);Initial outlay IDR3.5 billion (USD256,824); Annual operational costIDR450 million (USD33,020); 100 people; Call center. 2. Health Agency: Ambulance IDR3.9 billion (USD286,176); Annual operational cost IDR300 million (USD22,014); 32 Public Health Centers; 3. Police Department: Initial outlay IDR300 million (USD22,014); Annual operational cost IDR100 million (USD7,338); 19 police posts; Command center. 4. District Military Command: Initial outlay IDR100 million (USD7,338); Annual operational cost IDR75 million (USD5,503); 19 military command posts; Command center. 5. Regional Disaster Management Agency: Initial outlay IDR100 million (USD7,338); Annual operational cost IDR75 million (USD5,503); 30 people; command center. 6. Firefighter: Initial outlay IDR100 million (USD7,338); Annual operational cost IDR75 million (USD5,503); 26 people.

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The initiative has inspired a number of innovations that bring huge impacts on emergency management in Indonesia. In the national level, Public-Safety Center has been replicated by 125 districts out of 514 districts in Indonesia (24.5%). Medical emergency teams in those PSCs are coordinated by the 119 NCC (National Command Center) managed by the Indonesia Ministry of Health, that is also established after the initiative in Tulungagung begun. In addition, the initiative has endorsed the legalization of pre-hospital services and specialist in emergency. Furthermore, the initiative’s business model has been adapted by various institutions in Indonesia. As an illustration, the utilization of call center or command center and the implementation of information and communication technology has been popular. Selection process by using the Patient Acuity Category has endorsed the eradication of discrimination and promoted impartial public service. Multi stakeholder coordination has been encouraged because PSC (Public-Safety Center) in Tulungagung is successful at engage with various agencies. In the regional level, the initiative has sparked some other innovations in Tulungagung specifically to reduce mortality and morbiditysuch as Acute Coronary Syndrome of coronary heart attack, Comprehensive Emergency Obstetric Neonatal Services of mother and childbirth, and Integrative Children Social Protection Service Unit.

The initiative is sustainable because it aims to create safe environment and communities, which are the basic necessities of every human being and the rights of all citizens. Safety and security are also the enabling factors for socio-economic activities that bring welfare to the society. By ensuring the provision of indiscriminate and impartial emergency responses to everyone, public have confidence and trust in their government. This harmonious condition will eventually unleash everyone's potentials. In addition, the number of visitors to the city will increase because Tulungagung can provide them safety and security while doing business. Tourists are not afraid to visit the city and its surrounding because they can access qualified emergency services. In fact, on the economic side, there has been a significant increase in income per capita of the Tulungagung population from IDR27,825,669 (USD2,041) in 2015 to IDR30,335,481 (USD2,226) in 2016 and a positive trend on economic growth rate from 4.99% in 2015 to 5.02% in 2016. Since 2015, the initiative has served people and changed people's attitude in relation with emergency services. There has been a significant increase on frequency of emergency calls from 707 calls in 2015 to 1,325 (almost twofold) in 2017. This numbers exhibit the dependency and deeper engagement from public audiences to Public-Safety Center in Tulungagung.

The initiative will be sustainable, in terms of time durability because it has secured the following factors: 1. Legal: a. Presidential Instruction No. 4 of 2013 on the Road Safety Decade Program which mandates that each district to establish a Public-Safety Center (PSC) or an Integrated Emergency Management System. b. Indonesia Minister of Health Regulation No. 19 of 2016 on Integrated Emergency Management System. c. Article 16 of Tulungagung District Regulation on Public Service specifies rights and obligation of the relevant stakeholders in the region to actively participating in the implementation of Tulungagung PSC. d. Tulungagung Regent Regulation No. 29 of 2015 on the establishment of Integrated Emergency Management System in Tulungagung. e. Tulungagung Regent Decree No. 188.45 / 245/013/2016 on the forming of Team Coach and Team Coordinator of PSC. 2. Technology: Software system and the maintenance at Public-Safety Center have been developed independently that ensuring optimum utilization and avoiding third party inferences. 3. Financial: a. Budgeting allocations in the Regional Budget have been provided annually for all involving agencies. b. dr. Iskak Regional Public Hospital has combined financial resources from the regional budget and from hospital operation. c. Financial incentive is given to each personnel who is providing assistance to people or patients in every emergency case. 4. Community participation: Communities have been already aware of their rights and actively advocate for qualified and sustainable public services, including PSC.

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Evaluation on the initiative is conducted in a yearly basis. The evaluation utilizes survey and interview methods to measure the evaluation performance and customers' satisfaction. To ensure the quality and validity of the evaluation, a third party is procured to conduct it properly. The hired agency is required to have a strong background on survey and other research activities. Scientific method is employed to avoid bias and miscalculation. Random sampling method is used to choose the sampling frame from the list of public service users. The evaluation incorporates community complaints. In addition to the surveys and interviews, internal evaluation activities are conducted frequently by all stakeholders, including the central government officials, regional government agencies, civil-society organizations, and the whole network of Public-Safety Center. To ensure the equipment works properly at all times, monitoring and maintenance of equipment is performed regularly to the primary assets such as vehicles, computers, ambulances, GPS, telephones, and medical equipment in the ambulance.

The initiative evaluation has concluded that the outcome and impact of the initiative are significant to reduce mortality rate and to increase the number of requests, life expectancy, and public satisfaction as follows: 1. The number of emergency requests has increased by 46.6% from 707 calls (2016) to 1325 (2017). 2. The traffic accident rate decreased by 11%, maternal mortality rate decreased by 12.7% from 131.13 (2016) to 116.31 (2017) per 100,000 births, and infant mortality decreased by 19.3% from 8.96 (2016) to 7.51 (2017) per 100,000 births. 3. Death rate from the heart attack decreased by 53% from 68 (2016) to 32 (2017), heart attack rate decreased by 60% from 676 (year 2016) to 271 (year 2017) and death rate in less than 24 hours in emergency facility has been reduced to 10 per mil. 4. The life expectancy of Tulungagung population rose from 72.88 years old in 2016 to 73.40 years old in 2017. The 2017 number is higher than the life expectancy of East Java province and nation, which are 70.74 years old and 70.8 years old, respectively. 5. Public satisfaction index of hospital services has increased from 82.63 (in 2016) to 82.66 (in 2017).

The evaluation is using a number of indicators centering on the mortality rate, customer satisfaction, and minimum service quality. The indicators are derived from existing regulations that supervise the activities of Public-Service CenternamelyMinisterial Regulation of the Administrative and Bureaucratic Reform No. 16 of 2014 on Guidelines for Public Satisfaction Survey on Public Service Delivery and Ministerial Regulation of Health of the Republic of Indonesia No. 129 of 2008 on Hospital Minimum Service Standards as the following: 1. Mortality rate from traffic accidents, maternal, stroke, less than 24 hours, and other illnesses. 2. Terms of service and procedure. 3. Response time. 4. Fees and other charges. 5. Customer satisfaction 6. Product and service specification. 7. Behavior of officers in providing services. 8. Accessibilities to the services. 9. Compliance to the regulations and standard operating procedures. 10. Handling complaints, suggestions, feedback and follow-up. 11. Availability of disaster management team 12. Ability of handling and saving children and adults.

Relevant parties in Tulungagung that have contributed in this innovation consist of: 1. The Regent is the founder, the designer, and the evaluator of Public-Safety Center (PSC). 2. Legislative Council is designing and evaluating PSC by legalizing the initiative and evaluating its performance. The regulation concerning PSC ensures the sustainability of the initiative and involves financial resources allocated. 3. Bank of East Java is providing monetary assistance by lending money to upgrade the hospital, in particular, establishing and equipping the Emergency Facility. 4. Development Planning Agency is designing, implementing, and evaluating the initiative. 5. Agency of Finance and Asset Management is allocating budget in the establishment, execution and development of the program. 6. Health Agency and Public Health Centers are implementing pre-hospital service as an integral part of PSC. 7. Management of dr. Iskak Regional Public Hospital is the program's host, and the initiative's leader. 8. Police Department, and Management Agency, Firefighters, and Military Commands are implementing the initiative. They are integrating resources to dr. Iskak Regional Public Hospital to support an effective PSC. 9. Civil-Society Organizations, press, and public are evaluating the initiative. They have the ability to speak about their satisfaction at the delivery quality of PSC. Relevant parties in the national level that have contributed in this innovation consist of National Disaster Management and Indonesia Ministry of Health.

Key lessons learned from the initiative: 1. The success of public service delivery is centered on consistency and commitment from public agencies to provide better quality of services to the entire population. 2. Coordination failure among multiple agencies could be overcome by utilize a combination of steward leadership, effective communication, monetary supports, and technology adoption. 3. Financial constraints could be solved by modifying budgetary allocation without violating the existing regulations. 4. To maintain their relevancy to the society, public agencies should be sensitive and responsive to the needs of the whole population. 5. Safety and security are prerequisites to socio-economic development; thus, they must be prioritized by any administrations. 6. Legal binding laws or regulations are profound to maintain the sustainability of an innovation. The initiative could be improved by conducting a number of adjustments as follows: 1. Public dissemination about the initiative and how to benefit from it. It should reach all segments of population, specifically the most vulnerable groups. 2. Integrating more agencies to PSC to become more similar with 911 Emergency Management in advanced countries. 3. Establishing a National Emergency Management (not only medical emergency) by using a single number that connecting PSCs in all districts.