| Abstract|| |
Background: National Health Insurance in Indonesia that is processed by Social Security Agency of Health or known as Badan Penyelenggara Jaminan Social (BPJS) has been conducted for 2 years. The Public Health Center (PHC) as the partner of BPJS should have satisfied the patients. The preliminary study showed that 5 of 10 informants were not satisfied by the service of PHC. Objectives: This research aims to determine the satisfaction of BPJS' patients in some PHCs in Padang. Setting and Design: The design of this research is a Quantitative by observing the quality services and patients' satisfaction, which is based on five dimensions proposed by Parasuraman and Zeithm: Reliability, Responsiveness, Assurance, Empathy, and Tangible. This study was conducted in PHCs in Padang from September to November 2015. The populations were all of BPJS' patients who visited the PHCs of Padang. Samples were obtained by using cluster sampling selected from three PHCs with the total of 150 respondents. Statistical Analysis Used: The data were tested by using validity and reliability test and all of the data were valid and reliable. The data were displayed in univariate way to describe the quality and patients' satisfaction as well as the priority to improve the quality and the satisfaction by using Cartesian Diagram. Result: The results of this study showed that from the 18 attributes of services, the patients' satisfaction has been reached on two attributes, namely, “polite and friendly services” and “neatness and clean performance officers.” It is priority to improve four service attributes, that is,“speed of service,” “the ability of officers,” “attention,” add “equipment” for enhancing the quality of service
Keywords: Public Health Centers, quality of PHC, patient's satisfaction, BPJS (Social Care of Health Insurance)
|How to cite this article:|
Astiena AK, Syah NA. The analysis of patients' satisfaction of National Health Insurance in some public health centers in Padang. Ann Trop Med Public Health 2017;10:109-16
|How to cite this URL:|
Astiena AK, Syah NA. The analysis of patients' satisfaction of National Health Insurance in some public health centers in Padang. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Sep 17];10:109-16. Available from: http://www.atmph.org/text.asp?2017/10/1/109/205547
| Introduction|| |
Patient' satisfaction is an output of health services, thus patient's satisfaction is one of the goals of health quality of service improvement. Patients will be satisfied if the performance of health services equals or exceeds to their expectations. Meanwhile, patients will not be satisfied if the performance of health services is lower than the level of their expectation.,, A public interest in using health services that have been organized by the agency of Social Care of Health Insurance [BPJS (Badan Penyelenggara Jaminan Sosial)] is very high, especially with the obligation of the entire population to participate in BPJS on January 1, 2019. Nowadays, nearly 150 million of the total 250 million people of Indonesia (60%) have participated in BPJS, which made it as the largest health insurer in the world. This achievement should be balanced by providing the best quality services to patients either provided directly by BPJS or by its partners [Public Health Centre (PHC)]. One of indicators to measure the quality of PHC services is the satisfaction of patients/service users of PHC.
| Methodology|| |
It uses descriptive quantitative that describes the level of patients' satisfaction by five dimensions of the quality of health services, which are proposed by Parasuraman, Zheitmal, and Berry. The study was conducted in September and November 2015. The research located in PHCs of Padang (Kuranji subdistrict) and samples were obtained by cluster sampling. All of PHCs are: PHC of Ambacang, PHC of Belimbing, and PHC of Kuranji and it is set based on quota sampling as many as 50 respondents.
This is in accordance with the decision of the Minister of Health No. 129 Year 2008, in order to determine the sample in the study of patient's satisfaction it has to constitute at least 50 people, and then the total number of respondents became 150 patients. The inclusion criterion was the patients who possessed BPJS card and have got service at the Health Center (in the second arrival). The exclusion criterion is if the patients refuse to be interviewed.
Patient's satisfaction is measured by five indicators of health quality services (Tangibles, Responsiveness, Reliability, Assurance, and Empathy) and it is then compared with the patient's expectations at service performance [Figure 1]. The expectation level was measured by using a Likert's Scale with the graduations:“Strongly Important (SI)” if scale is 5,“Important (I)” if scale is 4,“Neutral (N)” if scale is 3,“Unimportant (UN)” if scale is 2, and“Strongly Unimportant (SUN)” if scale is 1. The levels of performance of health services are:“Strongly Good (SG)” if scale is 5,“Good (G)” if scale is 4,“Neutral (N)” if scale is 3,“Not Good (NG)” if scale is 2, and“Strongly Not Good (SNG)” if scale is 1.
|Figure 1: A Framework Concept of the Research (adapted from Marshall and Murdoch|
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Data were collected by using a questionnaire consists of about 18 patients' satisfaction questions. The validity test used Pearson Product Moment and the reliability used Cronbach Alpha. The analysis of data used computer programs Microsoft Excel and SPSS. Data are presented in univariate in the form of patients' satisfaction index as well as the priority of improving quality of health services by using Cartesian Diagram.
| Result|| |
A datum collection tool (questionnaire) is stated to be valid if it is able to measure and can reveal the data that will be observed correctly (valid). The validity of this research was conducted by comparing the value of r count (a correlation of total item) with the value of r table. If the value of r count is greater than the value of r table, then the item is declared with a valid questionnaire. Conversely, if the value of r count is smaller than the value of r table, then the questions on the questionnaire will be declared invalid. The validity of test results can be seen in [Table 1]. From [Table 1], it is known that each of the questions on each dimension that attributes to service quality has the bigger value of r count than the value of r table (0.159). Thus, each item dimension that attributes to service quality is declared“valid.”
|Table 1: Results on Validity Test Questions of Item in Service Dimensions|
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Data reliability test is intended to measure the consistency of the construction of the study attribute. Test equipment is stated reliable at estimation, whereas the measuring instrument (questionnaire) is measured repeatedly by different samples. It can be seen in [Table 2]. From [Table 2], it can be seen that all questions of five dimensions of satisfaction were declared being reliable because it has the value of Cronbach Alpha that exceeded 0.159.
|Table 2: Results on Reliability Test Questions in Dimensions of Services Quality|
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The respondents' characteristics can be seen in [Table 3]. It describes that the main criterion of ages comes to the category of“51–60” years (25.3%), the main criterion of sex comes from“females” (74.7%), the main level of education goes to undergraduate (52.7%), the number of visits is“very often” (64.7%), and then the main status of satisfaction goes to“satisfied” (55%).
Analysis and Discussion of Each Attribute Service
An analysis dimension of reliability (Reliability) can be seen in [Table 4]. From [Table 4], it can be seen that in the dimension of reliability, the total value of services (2.508) is lower than expectations (2.870). An analysis of dimension of responsiveness (Responsiveness) can be seen in [Table 5]. From [Table 5], it can be seen that in the dimension of responsiveness, the total value of services (1.924) is lower than expectations (2.198). An analysis of dimension of assurance (Assurance) can be seen in [Table 6]. From [Table 6], it can be seen that in the dimension of assurance, the total value of services (2.586) is lower than expectations (2.929). An analysis of dimension of attention (Empathy) can be seen in [Table 7]. From [Table 7], it can be seen that in the dimension of Empathy, the total value of services (1.911) is lower than expectations (2.195). An analysis of dimension of physical evidence (Tangibles) can be seen in [Table 8]. From [Table 8], it can be seen that in the dimension of Tangibles, the total value of services (2.583) is lower than expectations (2.911). Then, an analysis of satisfaction of BPJS' patients can be seen in [Table 9]. From [Table 9], it can be seen that from the 18 attributes of quality of care of patients, only two attributes are capable of satisfying the patients, namely the polite and friendly service with appropriateness value -0,48 (90.2% if X/Y multiplied 100%) as well as the neatness and cleanliness of the performance of officers with appropriateness value -0,41 (91.5% if X/Y multiplied 100%) Meanwhile, other 16 attributes are considered unable to satisfy the patients.
Priority of Improvement of Patient's Satisfaction
The priority of improvement of service quality and patients' satisfaction in the future is shown in the Cartesian Diagram [Figure 2]. From the diagram, it can be explained that there is a relation between the vertical, Expectation curve and the horizontal, Performance curve. The more the vertical curve rises, the more the expectation will be. In the same thing, the more the horizontal moves to the right, the more the performance will be.
The results on the interpretation of the pictures can be explained as follows:
Attributes to service quality and satisfaction that are located in Quadrant I are
- Attribute No. 7. The quick action when it is required by patients.
- Attribute No. 8. The knowledge and abilities of the doctors to make a diagnosis of the disease.
- Attribute No. 12. A special attention to every patient.
- Attribute No.17. Completeness, readiness, and cleanliness of the tools used.
Attributes that are located in Quadrant II are
- Attribute No. 5. Doctors and Nurses have to act quickly in helping patient's grievance.
- Attribute No. 6. Officers provide a clear and easy to understand information.
- Attribute No. 10. Services were polite and friendly.
- Attribute No. 11. Security guarantee and trust to services.
- Attribute No. 14. Services to all patients regardless of social status.
- Attribute No. 15. Cleanliness, neatness, and comfort of the room.
- Attribute No. 18. Neatness and cleanliness performance of officer.
Attributes that are located in Quadrant III are
- Attribute No. 1. The procedure of admission BPJS' patient is quick and accurate.
- Attribute No. 2. Check-up services, mediation, and care are quick and accurate.
- Attribute No. 3. Schedules of hospital services are carried out appropriately.
- Attribute No. 4. Procedure of services is straightforward.
- Attribute No. 9. The skill of doctors, nurses, and other personnels in working.
- Attribute No. 13. Attention to the complaints of patients and their families.
- Attribute No. 16. The arrangement of the exterior and interior of the room.
None of the attributes fall into this quadrant.
| Discussion|| |
Validity and Reliability Test
The study assesses patients' satisfaction using Questionnaire proposed by Supranto (2011). Validity and reliability test is reconducted on the patients of BPJS in PHC of Kuranji. From the 18 questions, all the questions declared that it is valid and reliable. The validity question of the study shows that the questions really measured the satisfaction of BPJS' patients and the results are consistent (reliable). Thus the measuring instruments that were used would test both its validity and reliability.
Patients' Satisfaction in Public Health Centers in Padang as a whole
From [Table 3], it is known that the numbers of respondents who are satisfied with the services of BPJS in the PHCs (the indicator of satisfaction ≥ 90%, based on Kepmenkes (Health Minister's Decision) No. 129 Year 2008 is only 55% (83 respondents). In the same case, Wilantara (2015) stated about the satisfaction of patients of BPJS on the first service in Lampung City,“It was found that only 32.5% of BPJS patients in PHCs who are satisfied and 55.2% of BPJS' patients to doctors who were satisfied as well.”
In this moment, this research becomes the challenge of PHC as a friend of BPJS' services, even for BJPS itself to improve the services of sanity in PHC. The satisfaction of patients concerns with much of expectation compared to the health services given by the health worker. PHC can improve the satisfaction of patients by improving the health services at some dimensions, such as Reliability, Responsiveness, Assurance, Empathy, and Tangible. On the other side, board insurance of BPJS has to give a good tool and infrastructure that include a training and development of skill to health workers in BPJS. Then, BPJS needs to give an understanding toward the member insurance of BPJS to adjust their expectation with PHC that has a function as a facilitator of health service on the first level.
Patient's Satisfaction Based on five Indicators
The satisfaction of BPJS' patients is assessed by using five indicators of patient's satisfaction, namely, Reliability, Responsiveness, Assurance, Empathy, and Tangibles.
Reliability is the reliability of services, which services that are provided can be reliable to solve the health problems that are experienced by patients. In this study, the value of the patients' perception toward health officials' services is lower than they expected. From the four attributes of satisfaction, none of them exceeded the value of patients' satisfaction (the conformity value was less than 90%). Therefore, PHC should be able to improve the quality and patient satisfaction by
- Establishing the procedures admission of patients quickly and accurately.
- Check-up services, medications, and cares must be run quickly and accurately.
- The schedule of hospital services must be carried out appropriately (a visited doctor, treatment, and rest).
- The procedure of services has to be straightforward.
Responsiveness is a manifestation of the service quality of patients' care in the form of quick responses of health officers in serving the patients. In this responsiveness, the average patients' assessment of the quality services provided that the officers are less than they expected. From the three attributes of satisfaction, none of them exceeded the value of patients' satisfaction (the conformity value is less than 90%). Therefore, PHC should be able to improve quality and patient satisfaction by
- Improving the ability of doctors and nurses to be responsively resolving the patients' complaints.
- Health officers have to provide clear information.
- Taking an action quickly when patients need.
Assurance or guarantee is the patient's belief in the service that is provided by health workers that are able to cure the illness. Supranto (2011) stated that in the dimension of assurance, health workers must have knowledge, high skills, and be communicative with patients. In this dimension, the average value of respondents' perceptions of the service performance of workers is lower than the patient's expectations. From the four of satisfaction attributes, one of them goes beyond patients' satisfaction (conformity value is above 90%), the attribute“Polite and friendly service" has a value 90.2%. PHC can improve the quality and patients' satisfaction by increasing the criteria, such as
- Knowledge and ability of the doctors to make a diagnosis.
- Skills of doctors, nurses, and other official services in working.
- Security guarantee and trust to services.
Empathy is a service provided by health officer that contains the elements of attention to each patient and responsible for the safety and the comfort of patients. In this dimension, even the average perception of respondents on the performance of health workers is lower than their expectations. PHCs have to improve the quality and patient's satisfaction by means of
- Giving special attention to every patient.
- Paying serious attention to the complaints of patients and their families.
- Giving a service to all patients without looking on their social status.
Tangibles is the delivery of services, the physical elements that are involved in the health services, such as equipment, appearance of workers, and the room service: clean, neat, and tidy. In this dimension, the average perception of respondents on the performance of health workers is lower than the expectations. From the four of satisfaction attributes, one of them goes beyond the patient's satisfaction score (grades suitability of 91.5%), which is“the neatness and cleanliness appearance of health workers”. PHC can improve services to this dimension by increasing
- Cleanliness, neatness, and comfort of the room.
- Structuring the exterior and interior of the room.
- Completeness, readiness, and cleanliness of the tools used.
Priority of Health Service Improvement
Prior to service quality improvement and patients' satisfaction, it is measured by Cartesian Diagram that is based on the patient's perception of the service performances of health workers and their expectations [Figure 2]. Cartesian Diagram consists of four quadrants. Quadrant I means that it has a lower service performance, but its expectations are high. From the 18 attributes of patients' satisfaction, four attributes are located in Quadrant I. These four attributes should be prioritized in order to improve the quality and patients' satisfaction. The four attributes are“the quick action when patient needs, knowledge and capabilities of the doctors to make a diagnosis, a special attention to each patient as well as the completeness, readiness, and cleanliness of the tools used”. However, the PHC had successfully balanced the patients' expectations on the attributes that were located in Quadrant II of Cartesian Diagram with seven attributes. Quadrant II refers to high expectations and high performance of officials' services. These seven satisfaction attributes should be maintained in the future, namely,
- Attribute No. 5. Doctors and Nurses have to act quickly in helping patient's grievance.
- Attribute No. 6. Officers provide clear information and it is easy to understand.
- Attribute No. 10. Services are polite and friendly.
- Attribute No. 11. Security guarantee and trust to the services.
- Attribute No. 14. Services to all patients regardless of social status and others.
- Attribute No. 15. Cleanliness, neatness, and comfort of the room.
- Attribute No. 18. Neatness and cleanliness performance of officers.
Quadrant III of Cartesian Diagram means the low expectations and the low performance of services. It means seven service attributes in this quadrant are not prioritized to be compared to the other quadrants. The interesting thing is none of the attributes of service fills the Quadrant IV (high performances, low expectations). This means that there is no excessive care of health workers.
| Conclusions|| |
On an average, based on the five dimensions of patients' satisfaction, it was found that the numbers of respondents satisfied are 55% and dissatisfied are 45%. From the 18 attributes of quality service and patients' satisfaction, there are two attributes that exceed the indicator of satisfaction (90%), namely, the polite and friendly service as well as tidiness and cleanliness of the officers, whereas 16 other attributes are not achieved.
The authors would like to acknowledge the Dean of School of Public Health Andalas University who has funded this research, the Head of Public Health Centers of Kuranji, Ambacang, and Belimbing, and staffs on facilitating researchers to collect the data and society who have helped the researchers during the process of data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Adila Kasni Astiena
School of Public Health at Andalas University, Padang
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]