Factors that influence the Quality Dimensions of National Health Insurance Participant Satisfaction with Outpatient Services at the Teunom Community Health Center

ABSTRACT


INTRODUCTION
The degree of health and wellbeing of every person in the globe can be improved by using health services.Everyone has the right to get medical treatment, and the government is in charge of ensuring that all healthcare is high-quality, secure, effective, and reasonably priced for all societal strata.Increased accessibility and dispersion of community health centers and other basic healthcare services are some of these initiatives, according to Bappenas (2010) (1).
Based on WHO data, it shows that 5.7 to 8.4 million people die due to low quality health services every year in low and middle income countries, representing up to 15% of total deaths in these countries.60% of patients in need of health care die due to poor service quality and 40% of deaths are due to lack of utilization of the health care system, especially in low and middle income countries (3).
It can be estimated that high quality services can prevent 2.5 million deaths from cardiovascular disease, 900,000 deaths from tuberculosis, 1 million deaths of newborns, and half of all maternal deaths each year.Poor service quality results in a loss of people's productivity in the country so that it can be estimated that they will experience losses of 1.4 to 1.6 billion each year (3).
Health is a human right and is one component of welfare that must be achieved via health services, according to Republic of Indonesia Law No. 36 of 2009.It is necessary to have a system that controls the implementation of initiatives to uphold citizens' rights to a healthy lifestyle by giving community health services first priority.The government is in charge of administering public health insurance via the National Social Security System (SJSN) for individual health efforts, according to UU no.36 of 2009 article 20 paragraph 1 (1).
The Health Social Security Administering Body (BPJS) is a legal organization created to manage health insurance programs, specifically in the form of health protection to ensure that participants receive health care benefits and protection in meeting basic health needs made available to everyone who has paid contributions or whose contributions are paid by the government.Specifically for National Health Insurance (JKN) it will be administered by the Health Social Security Administering Agency (BPJS), implementation of which will begin on January 1 2014 (4).
Every Indonesian person has a right to and an obligation to participate in the National Health Insurance Program, one of the Social Security Programs stipulated by Law Number 40 of 2004 about the National Social Security System.In order to create a cross-subsidy and community mutual cooperation mechanism in health insurance based on a social security system based on social insurance, every citizen and foreign worker who has worked in Indonesia for at least 6 (six) months is required to participate in the social security program.
Based on BPJS data, the number of JKN participants was recorded at 133.5 million people, in 2018 it was 156.8 million people, in 2019 it was 171.9 million people.And in 2020, the number of JKN program participants as of April 1 2020 was 175,739,499 people, as of June 1 2020 there were 177,443,940 people, and as of July 1 2020 it had reached 178,384,288.Every person has the right to obtain health services as stated in Law Number 36 of 2009 concerning health that every person has the right to obtain safe, quality and affordable health services (6).
The number of National Health Insurance participants registered at Teunom Health Center has significantly decreased over the past few years.JKN participants registered at Teunom Health Center in 2020 are 13,099, while the number of pesetas in 2022 was 12,871 (14).Teunom Health Center is the second-largest community health center within the Aceh Jaya District Health Service, which has 22 assisted villages.Data on patient visits at the Teunom Community Health Center over the last three years also shows fluctuating numbers, namely in 2020 there were 34,908 people, in 2021 there were 25,477 visits recorded, but in 2022 there was a decrease in visits where the number of visits was 20,937 (15).
In the initial data collection carried out by researchers, it can be seen that the Teunom Community Health Center has 22 service rooms on two floors, the first floor consisting of a registration room, patient waiting room, examination room, laboratory room, pharmacy room, KIA/KB, children's polyclinic.nutrition room, dental clinic, emergency room, delivery room, medicine warehouse, inpatient room, immunization room, midwife care room, nurse inpatient room, medicine warehouse and meeting hall.Meanwhile, the second floor consists of the head of the community health center and the management room (15).
Teunom Community Health Center continues to have a number of service-related issues, as evidenced by a number of complaints that were collected from the suggestion box recap on May 30, 2022.These complaints included those about patients who were perplexed because they did not know the officers on duty in the poly service section as well as those about services that were delivered later than expected, the officers being unfriendly, and long wait times (15).Based on the description above, the researcher is interested in conducting research entitled "Factors that influence the quality dimensions of National Health Insurance patient satisfaction in outpatient services at the Teunom Community Health Center, Teunom District, Aceh Jaya Regency".
Based on the background of the problem, the formulation of the problem in this research is what factors influence the quality dimensions of National Health Insurance patient satisfaction in outpatient services at the Teunom Community Health Center, Teunom District, Aceh Jaya Regency.

METHODS
The research design uses quantitative methods using an analytical survey using a cross sectional study approach.This research was conducted at the Teunom Community Health Center, Teunom District, Aceh Jaya Regency.The reason for choosing this location is that many patients or those visiting the Community Health Center are still not satisfied with the services provided and received.This research will be conducted from August to November Based on table 1, it is shown that of the 99 research respondents, the majority of respondents answered that the officers' technical competence was good, 84 respondents (84.8%) and the minority of respondents answered that the officers' technical competence was not good, 15 respondents (15.2%).Access to services The majority of respondents answered that access to Teunom Health Center services was affordable for 78 respondents (78.9%) and the minority answered that it was not affordable for 21 respondents (21.2%).The majority of respondents said that human relations were not good, namely 68 respondents (68.7%) and the minority said that human relations at the Teunom Community Health Center were good, namely 31 respondents (31.3%).Convenience The majority of respondents answered uncomfortable as many as 57 respondents (57.6%) and the minority answered comfortable as many as 42 respondents (42.4%).Information that the information conveyed was correct was 74 respondents (74.7%) and a minority stated that the information conveyed at the Teunom Community Health Center was incorrect as many as 25 respondents (25.3%).The majority of respondents said that punctuality at the Teunom Community Health Center was not good, namely 63 respondents (63.6%) and a minority said that punctuality at the Teunom Community Health Center was good, namely 36 respondents (36.4%).Patient satisfaction: The majority of respondents answered that they were satisfied, namely 70 respondents (70.7%) and the minority said that they were not satisfied, namely 29 respondents (29.3%).

Technical competence, access to services, human relations, comfort, information, timeliness.
The comfort variable shows that of the 99 research respondents, the majority of respondents answered that they were uncomfortable, 57 respondents (57.6%) and the minority answered comfortable, 42 respondents (42.4%).In the information variable, the majority of respondents said that the information conveyed was correct, namely 74 respondents (74.7%), and a minority said that the information conveyed at the Teunom Community Health Center was incorrect, namely 25 respondents (25.3%), but in the timeliness variable, the majority of respondents said that the timeliness at the Teunom Community Health Center was not good, namely 63 respondents (63.6%), and a minority said that punctuality was not good, namely 36 respondents (36.4%).
Based on the patient satisfaction variable from 99 respondents, the majority of respondents answered that they were satisfied, namely 70 respondents (70.7%) and the minority said that they were not satisfied, 29 respondents (29.3%), this was because from several aspects of measuring satisfaction, the majority of patients said less satisfied with health services.

The Teunom Community Health Center's technical competency and patient satisfaction will be examined.
The researcher's assumption is that the majority of respondents value the appearance of officers more, where officers always appear neat and attractive using complete service attributes.such as doctor's coats, masks, gloves and identification marks, thereby increasing the level of respondents' trust in the ability of officers to provide health services.From the appearance of the officers on duty, respondents assessed that the doctors or health workers had extensive knowledge because they had work experience and a long period of service at the health center.The better the patient's trust, the easier it is for a health worker to make changes, including improving the quality of health services.If text competency in health services is not good, it can cause various things ranging from deviations from health service standards to fatal errors which can cause harm to the patient's life and reduce the quality of health services.
Based on these results, it can be concluded that the higher the patient's sense of trust in the health service provider, the more satisfied the patient will be while experiencing the service at the health center, in other words, the more fulfilled the technical competence provided by the health center to the patient, the higher the satisfaction obtained by the patient.According to the notion, technical competence is related to the talents, abilities, and appearance of officers, supervisors, and support employees.Technical competency refers to officers' capacity to adhere to set service standards in terms of accountability or dependability, correctness, reliability, and consistency.

Relationship between access to services and patient satisfaction at Teunom Community Health Center in 2022.
The researcher assumes that there is no relationship between variable access to services and patient satisfaction because it is geographically located on the cross-district road connecting West Aceh Regency and Aceh Jaya Regency, which is easily accessible by two-wheeled or fourwheeled vehicles, so the majority of people are in the Health Center's work area.Teunom can access health services both socially and economically, even though there is no public transportation, patients can still look for other alternatives such as vehicles to go to the health center and in emergency situations patients can contact health workers to visit their home because Aceh Jaya has the Sawue Ureung Saket program ( visiting sick people) in line with this geographically it can be said that geographical access to the Teunom Health Center is relatively easy.
The distance of the health center from the patient's house does not have an influence on the service satisfaction felt by the patient because some patients whose homes are not very close to the health center still come by looking for alternatives such as renting a vehicle for treatment at the Teunom Health Center and are satisfied with the services provided.However, the results of this research are in accordance with the theory which states that access means being available whenever and wherever needed by society.Access to health services can be said to be equity (fair/equitable) if health services are distributed based on geographic, socio-economic status and community needs.

Human relationships on patient satisfaction at the Teunom Community Health Center in 2022
According to the researchers' assumptions, this occurred because respondents were dissatisfied with the service of officers who were less friendly towards patients, the attitude of officers who were less friendly during registration, officers who could not comply with patient wishes, such as patients wanting to ask for a referral but the health center could not issue a referral because it was related to rules and there are also officers who give priority to people they may know in this case which could be considered to give a negative impression.This dissatisfaction can give rise to unfavorable perceptions for respondents regarding the quality of service at the Teunom Health Center where the concept underlying the relationship between health workers and patients is a relationship of mutual trust, empathy, care, autonomy and mutualism.
Personal considerations might have an impact on increasing patient loyalty.Because personal attention is regarded to be directly related to the level of patient satisfaction with all the quality of service they have gotten from all parties, including medical workers, it plays an important role in achieving patient happiness.

The relationship between comfort and patient satisfaction at Teunom Community Health Center
The researcher's assumption, based on observations in the preliminary survey, the researcher saw that the condition of the bathroom used by patients/visitors looked less clean and smelled of urine, patient dissatisfaction with the comfort variable was also due to the waiting room still lacking chairs so that if there were many patients visiting then some patients were forced to standing while waiting for your turn to be served.Patient dissatisfaction is based on the patient's statement regarding the cleanliness of the bathroom, which is considered less clean and smells of urine, thus disturbing the patient's comfort when using the bathroom.
The results of this research are in accordance with Wibowo's theory (2014) which states that comfort is closely related to the beautiful environment of the Puskesmas, cleanliness of the room, cleanliness of the room/WC, completeness of the room, medical equipment and cleanliness of the Puskesmas environment.Convenience is an important factor to attract patients which can ensure continuity of treatment.

The relationship between information and patient satisfaction at the Teunom Community Health Center in 2022
The results of this research are supported by Wibowo's theory (2014) which states that quality health services must be able to provide clear information about what, who, when, where and how health will be and/or has been implemented (53).In this case, the Teunom Community Health Center also tries to provide service information as clearly as possible by providing information regarding the organizational structure, service flow, types of services, patient rights and obligations, service hours, and so on in the form of notice boards, binaries or banners.Apart from that, health education, outreach and distribution of brochures related to health information are often carried out.
Patients as the controlling source in health services must obtain the necessary information regarding both the disease and the medication given because this information will help patients to participate in making medical decisions and determine the success of the patient's recovery.

The relationship between timeliness and patient satisfaction at the Teunom Health Center in 2022
According to the researcher's assumption, this is due to a mismatch between the service time provided and the patient's expected time.delays in health services provided by health workers at the Teunom Community Health Center caused by delays in the arrival of doctors and health workers during working hours at the Community Health Center, which makes the service time for patients longer than the stipulated time, the doctor on duty must visit inpatients first.In the past, this made outpatient services late, resulting in a backlog of patients seeking doctor's services, which made it take longer for patients to receive services.So, this delay has an impact on the queuing time for taking medicine One of the patient's perceptions of service quality is reliability, namely the ability to carry out promised services on time.This is consistent with the hypothesis that patients will be less motivated to seek health services that involve a lengthy examination process, especially if health staff have little interaction with patients who are waiting during the waiting period.Under these conditions, patients may consider the health services at that location to be of poor quality and feel less satisfied

CONCLUSION
Based on the research results, the Technical Competency variable does not have a significant influence on National Health Insurance (JKN) patient satisfaction in outpatient care at the Teunom Community Health Center, Teunom District, Aceh Jaya Regency (p-value = 0.140).The Access to Service variable does not have a significant influence on National Health Insurance (JKN) patient satisfaction in outpatient care at the Teunom Community Health Center, Teunom District, Aceh Jaya Regency (p-value = 0.647).The variable human relations have a significant influence on National Health Insurance (JKN) patient satisfaction in outpatient care at the Teunom Community Health Center, Teunom District, Aceh Jaya Regency (p-value = 0.001).The Comfort variable has a significant influence on National Health Insurance (JKN) patient satisfaction in outpatient care at the Teunom Community Health Center, Teunom District, Aceh Jaya Regency (p-value = 0.000).The Information variable does not have a significant influence on National Health Insurance (JKN) patient satisfaction in outpatient care at the Teunom Community Health Center, Teunom sub-district, Aceh Jaya Regency (p-value= 0.731).The timeliness variable has a significant influence on National Health Insurance (JKN) patient satisfaction.in outpatient care in Aceh Jaya Regency (p-value= 0.037) The dominant factor that has an influence on National Health Insurance (JKN) patient satisfaction in outpatient care at the Teunom Community Health Center, Aceh Jaya Regency is comfort (OR= 6,600).Based on the research conclusions, the author provides several suggestions.It is hoped that the Health Service will carry out monitoring, analysis and evaluation regarding the quality of services at each Community Health Center in its working area.Write a warning letter to the puskesmas regarding services at the puskesmas that are not on time.Monitor the facilities and infrastructure at the puskesmas and make provisions for the lack of facilities at the puskesmas, such as waiting chairs and adequate parking.Create an effective communication training plan for health workers at community health centers in Aceh Jaya Regency.Follow up on all issues related to services at community health centers to further increase the satisfaction of patients visiting community health centers.Puskesmas Heads of Puskesmas are expected to be able to improve the performance and motivation of their staff, especially regarding the timeliness of health services.For the quality team at the puskesmas to be more responsive to feedback in the form of criticism and suggestions from patients who come for treatment at the puskesmas.Improving the ability of staff in communicating with patients/visitors by holding training or training on effective communication with health workers.For Puskesmas staff/health workers who have more direct contact, especially at the patient registration counter, to be more friendly in responding to and responding to patient complaints.Equipping supporting facilities, in the form of chairs in the patient waiting room.Improving monitoring of service support facilities so that service support facilities such as bathrooms are always clean.Create and activate an online queuing application that makes it easier for people to register and queue, thereby reducing the number of queues at health centers and reducing waiting times.Society The public is expected to more openly express constructive criticism of government-owned health service facilities (Puskesmas) so that the information needed to measure patient satisfaction becomes easier in order to improve the quality of services in the future.

Table 1 .
Frequency distribution based on technical competency in the Teunom Community Health Center work area in 2022.