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A Comparison of Patient Satisfaction When Using the Insured and Non-insured in Public Health Center (Puskesmas Kasihan 1) Indonesia

BACKGROUND: In Indonesia, the health sector has experienced a very significant development. Fair and equitable health care is one way to fulfill the health rights of each individual. Therefore, puskesmas are required to provide good service quality through conformity to standards with customer needs. The creation of service quality will certainly create customer satisfaction for service users when using health assurance and non-assurance. AIM: This study was to know a comparison of patient satisfaction when using the insured and non-insured in Public Health Center (Puskesmas Kasihan 1) Bantul, Indonesia. METHODS: This study was a cross-sectional study, with 222 samples with 111 respondents using health assurance and 111 non-assurance. Samples were collected with a cluster sampling technique taken from nine service polyclinics in Puskesmas Kasihan 1 Bantul. Data were analyzed using independent sample t-test. RESULTS: The study found that the average patient satisfaction with health insurance was 34.76 more than the average patient satisfaction with non-health insurance was 29.10. Based on the results of the analysis, the mean ± sd of patient satisfaction with health insurance was 29.10 ± 3.04 compared to the satisfaction of non-health insurance patients, namely, 34.76 ± 3.61 with a Sig value of 0.000, which means that there is a significant difference between patient satisfaction using the insured and non-insured. CONCLUSIONS: Patients when using the health insured are more satisfied than patient’s non-insured.


Introduction
Puskesmas are a primary (basic) health facility, where patients receive initial care before being referred to a secondary health facility such as a hospital [1]. Puskesmas are one of the first-level health service facilities that are the benchmark of health development in Indonesia [2]. The population of Indonesia is increasing from year to year, with the increasing population, it is necessary to add additional health service facilities and strengthen JKN (Jaminan Kesehatan Nasional Indonesia or National health insurance) to encourage people to be more aware of health [3].
Based on data from the Ministry of Health (Kemenkes) in 2019, the number of Puskesmas in the Special Region of Yogyakarta by district or city is 121 Puskesmas, consisting of 49 inpatient Puskesmas and 72 non-inpatient Puskesmas [4]. Puskesmas are a health facility that is always required to provide quality services. This is a challenge for health agencies to change the paradigm of consumers or patients that health services, primary healthcare, are much better with the main target of patient satisfaction [5]. The targets in evaluating patient satisfaction are public services, service standards, and the provision of information and education [6]. Customer satisfaction has a significant effect on customer loyalty [7].
The issue that has developed in the electronic media is about complaints from the public that there are differences in the health services provided by health facilities, in this case the puskesmas to general patients compared to patients using JKN, where the puskesmas prioritize general patient services compared to the services of patients using JKN [8]. JKN has opened up participants' accessibility to services, but the wide variation in rates between hospital classes has had a negative impact on participants [9]. Based on the research, the longest waiting time at Puskesmas Lubuk Begalung is 1 h 50 min. About 30% satisfied, 70% of patients said that they were not satisfied with the health services at the Puskesmas [10] and quality of service in Puskesmas impact on patient satisfaction [11].
Based on this issue, the researcher is interested in conducting research with the aim of knowing a comparison of patient satisfaction when using the insured and non-insured in primary health services (Puskesmas Kasihan 1) Bantul, Indonesia. https://oamjms.eu/index.php/mjms/index

Research design
This type of research is quantitative analytic with a cross-sectional research design. Quantitative analysis is research that uses samples to be analyzed using sample statistical tests and the results are generalized to the population from which the sample is taken. The cross-sectional research design is an activity of collecting data in a study that is carried out at once in a certain time, and each research subject is only conducted one time data collection (observation) for all the variables studied, during the study.

Respondents
In this study, the sampling technique used is probability sampling, with cluster sampling type, namely, the sampling technique carried out by grouping research subjects or analytical units that are close to each other. With a total of 222, with 111 respondents each sample using insurance and non-insurance.

Instruments
Data were collected using questioner, which has been validity test using 30 respondents at Puskesmas Kasihan 2, the results of the validity test r arithmetic > r table (0.361), the results obtained Cronbach's alpha value > 0.6 with a value > 0.9, so it can be concluded that the patient satisfaction questionnaire is declared valid and reliable ( Table 1).

Data collection
Data collection was carried out directly at the research site in the form of a hard file by distributing questionnaires to respondents with a number of samples that had been determined by the previous researcher. This implementation is carried out by fulfilling the health protocol according to the procedures at Puskesmas Kasihan I Bantul Regency.
Before the researcher distributes the questionnaire sheet to the respondents, the researcher will explain the research objectives and the procedure for filling out the questionnaire. After understanding the objectives and procedures of the research, respondents were asked to fill out an informed consent form. Furthermore, respondents will be given a questionnaire sheet to be filled in.
This study uses a questionnaire to measure patient satisfaction due to the results of previous studies, there are no significant differences between the index of patient satisfaction using the Android and the questionnaire method [12].

Data analysis
Bivariate analysis is a data analysis conducted on two variables to analyze the differences between the two variables. Numerical research data have been tested for normality, using Kolmogorov-Smirnov and the results data are not normally distributed so that the test uses a non-parametric test with Mann-Whitney and the results are the same as the parametric test, to determine the mean and standard deviation analyzed using the independent sample t-test.

Ethical clearance
This research has received approval and research feasibility from the Ethics Committee of the Faculty of Health Sciences, Alma Ata University on Juni, 2021 Number: KE/AA/IV/10402/EC/2021. Respondents were given an explanation of the purpose and course of the research, respondents who agreed to participate then signed the informed consent. During the explanation, the respondent's personal information will be saved confidential, no side effects will be caused and the respondent is free to withdraw from the study at any time.

Results
Based on Table 2, it is known that the majority of respondents by gender are female, the characteristics of respondents according to age are most patients aged 17−25, the characteristics of respondents according to occupation are the majority of housewives, and the characteristics of respondents according to the last education level are high school. These data show that the data on characteristic's demographic majority respondents from the group are the same. Table 3, it is found that there is a significant difference between customer satisfaction with health insured between non-insured with a range of Mean ± SD on respondents with health assurance at 31. 15-38.37 and in non-health assurance respondents at 26, 06−32.14.

Discussion
Health care service quality indicators were the most influential determinants of patient satisfaction [6]. Patient satisfaction is an important indicator of health outcomes [13]. There is no doubt patient satisfaction that is an import ant indicator of health outcomes [13]. The result from this study shows that results did not show any significant difference in the level of satisfaction of primary health care services between rural and urban residence. Therefore, this study was only conducted in rural areas. The statistical test results show that there is a significant difference between customer satisfaction with health assurance between non-health assurance. Moreover, higher average satisfaction in patients with health assurance, supported by previous research that revealed, analysis result on difference of client satisfaction of national health insurance contribution assistance recipients, and national health insurance noncontribution assistance recipients showed significant difference between the service satisfaction of national health insurance contribution assistance recipients and national health insurance non-contribution assistance Recipients [14]. Same with research result Fenny, 2014 number of patients who use insured were satisfied at waiting time, friendliness of staff, satisfaction at laboratory or X-ray although not statistically significant [15].
This study shows that patient satisfaction with services is more dominant on average in the group with insurance because they do not incur costs when receiving treatment, supported by research [16], which shows that overall, 286 (75.5%) of the respondents were satisfied with the outcome of health care provided at the NHIS (National Health Insurance Scheme) clinic. A statistically significant association (p =.00) supported by research results which show the average level of satisfaction in the JKA (Jaminan Kesehatan Aceh) group increased significantly [17], primary health care practices need to recognize the needs that influence patients [18].
The results of the previous research conducted by Ratnawati 2020, howed that the insurance system was proven to significantly increase the satisfaction and loyalty of JKN patients [19]. This means that the Government of Indonesia's efforts to improve health status by establishing JKN can benefit the community, goals can also be improved through the variables of reliability, empathy, and responsiveness, while the loyalty of JKN patients is strongly influenced by satisfaction. Variables can increase satisfaction and loyalty of JKN patients in small hospitals including Puskesmas. Limitation that arises in a study is that the researchers did not conduct further analysis of the factors that affect patient satisfaction in the two groups.

Conclusions
Characteristics of the respondents in both groups are as follows: The majority are female, age range 17−25 years, work as a housewife, and the last education is high school. There is difference of patient satisfaction when using the insured and non-insured in Public Health Center (Puskesmas Kasihan 1) Bantul, Indonesia. Patients when using the health insured are more satisfied than patient's non-insured. Public Health Center needs to pay attention to non-insured patients to improve patient satisfaction and have an impact on improving service quality.

Author Contribution
First author -initiated idea, research question, and the searching method. Coauthors were contributed to substantially data analysis and discussion.

Ethical Approval
The ethics committee of Universitas Alma Ata with the number KE/AA/IV/10402/EC/2021