Implementation of the Indonesian National Health Insurance Programme: How Satisfied the Insured Participants and Healthcare Providers?
Eva Yusuf, Ph.D1
Research Director- Myriad Research and Senior Lecturer at Doctoral Program of School of Management and Bussiness Bogor Agricultural Institute
Abstract
Social health insurance is seen as a mechanism that helps mobilize resources health, pool risk, and provide more access to healthcare services for the poor. Indonesia Government since January 2014 has implemented the National Health Insurance Programme (JKN) to help promote access to healthcare services for Indonesians. This study examined how satisfied the insured participants and healthcare providers towards the services provided by the Social Security Management Agency (BPJS Health) in the first year of the JKN implementation. The study took place in 24 cities/districts of Indonesia representing 12 regional offices of BPJS Health. Data was collected through face to face interviews with 17, 820 insured participants who have experienced in receiving healthcare services from BPJS Kesehatan healthcare providers in the past six months. Meanwhile, the total number for the respondents for the Healthcare Providers is 1,170. The survey instrument was developed based on the findings from qualitative research: indepth interviews with Healthcare Providers and FGD with the insured clients in 5 cities. The survey found that both insured participantsand healthcare providers were satisfied with BPJS Health in delivering the JKN program. Insured participantswere satisfied with the services they have obtained from healthcare providers. However, participants at primary healthcare facilities has significantly lower satisfaction level than participants at secondary heathcare facilities. Better facilities and medical equipment, better services from medics and paramedics, better drugs availability and quality, along with assurance in obtaining proper and timeline treatment, all contribute to the higher satisfaction level. Meanwhile, despites their satisfaction towards BPJS Health, healthcare providers at primary level still dissatisfied with the claim payment system. Indirect payment system through local government contributes to the lower satisfacion level. Policy makers need to consider improvement on the facilities and service qualities at primary healthcare facilities in order to enhance participants’ trust. Otherwise, referral system implementation under JKN system might not be effectively implemented as Participants are more prefer to get treatment from secondary healthcare facilities. Meanwhile, better and faster payment to primary healthcare providers are needed so that the providers at primary level has similar satisfaction level as the secondary healthcare providers whom received direct payment from BPJS Health. Moreover, Providers needs to be informed with current regulations or standard operating procedures so that they will apply those rules properly. Finally, this study suggests that empathy attributes are the key factor in building both participants’ and providers’ satisfaction level. Special attentions needs to be put on “human” aspect of the service providers.
Keywords:
National health insurance, Social health insurance, Universal health coverage, Perceptions, Satisfaction, Loyalty, Healthcare Providers, Insured Participants, Indonesia
Background
Indonesia has long implemented social health insurance (SHI), but it grows very slowly due to inconsistent implementation of SHI principles (Thabrany, 2012). However, in 2004, The Indonesian government is committed to introducing National Health Insurance Programme, and by 2019 to cover a projected population of 257.5 million (Simmonds and Hort, 2013). A national system of Health Insurancewill integrate existing schemes, combining contributions from the formal and informal workforce with the government’s contributions for the poor into a single pooled fund. Regional government schemes will also be progressively integrated (Road Map towards National Health Insurance (2012).
In 1 January 2014, the country has had the National Health Insurance Program (hereafter JKN) as a realization of the National Social Security as mandated by Law Number 40 of 2004 on National Social Security System (SJSN). Through this program, every citizen will get comprehensive health care covering promotive, preventive, curative and rehabilitative services with affordable cost through the insurance system. Being an insured participant, at the time of treatment, only needs to follow established procedures and show a membership card to receive needed health service. Under the JKN system, all insured participant who need healthcare should first consult a primary healthcare facility, namely Puskesmas, Family Doctor or Clinic which has a collaboration with the Social Security Management Agency (hereafter BPJS Health). Health service of a higher level facility such as hospital can be accessed on the basis of referral from the primary healthcare facility, except for emergency. If this procedure is not followed, BPJS Health will not cover the cost incurred.
Prior and since the inception of the NHI, many studies have been carried out on the system, model, policy and legal, scheme, methods, financial and economic perspectives of the Indonesia NHI (for examples: Thabrany, 2009; Lagomarsinoet.al., 2012; Dalinjong and Laar, 2012; Fuady, 2013, Simmonds and Hort, 2013; Rokxet al., 2013; Harimurtiet al., 2013). However, there is limited studies on micro perspectives of the JKN implementation, such as how satisfied the insured participants and healthcare providers towards the service quality of JKN program that has been implemented by BPJS Health? What are the determinants of the satisfaction and loyalty level? What aspects should be improved by BPJS Health in enhancing the participants and providers’ level of satisfaction, and which one to be prioritized ? This study gave an insight and understanding of how satisfied participants and providers towards the first year of JKN implementation leads by BPJS Health. The information is considered important for BPJS Health and Indonesian Government, and might also be important for other countries that are planning to introduce the NHI/mandatory health insurance.
Conceptual model
The SERVQUAL model was applied in this study as the service quality that have been provided by BPJS Health to insured participants and healthcare providers can be assessed through the five dimensions of SERVQUAL, namely: tangible, empathy, reliability, responsiveness and assurance. There are indeed other conceptual models that can be used to measure service quality. Yet, disagreements about the best method to measure service quality still exists (Yaghi, 2010). According to Lee (2007), service quality is difficult to conceptualize and measure because it is an elusive and abstract concept, which makes objectivity difficult. This issue occurs because of the four service characteristics: intangibility, heterogeneity, perishability and inseparability (Ladhari, 2009).
According to Brady and Cronin (2001), there are two major conceptualizations of service quality. They are the American school and Nordic school, with the American school dominating the literature (Prayag, 2007). The American school defines service quality as- the customers’ assessment of the overall excellence or superiority of the service (Zeithaml, 1988), while Gronroos (1984) from the Nordic school defines perceived quality as a consumption process in which the customer is part of the service process that leads to an outcome result.
The American school measures service quality by using a scale called the SERVQUAL which is the most widely used scale (Stodnick and Rogers, 2008). According to Santouridiset.al (2009)- the most prominent instrument for service quality measurement among researchers, practitioners and managers is SERVQUAL.
Specific to healthcare services, Hu et al. (2011) stated that measurement of customer satisfaction has received increasing emphasis recently due to clinicians’ and researchers’ desire to measure outcomes that reflect the patient’s unique perspective. Nowdays, healthcare facilities must focus on customer demands for consistency and meeting needs, for clear policies regarding service quality, and for up-to date medical treatment (Tang and Cheng, 2010). Further, all of these can help to improve and increase the loyalty of both customers and healthcare facilities staff members.
In the context of JKN implementation, it is important to measure the insured patients and healthcare providers’ perceptions toward the service quality that has been provided by the implementing body (BPJS Health), as it will have significant impact on their satisfaction and loyalty towards the BPJS Health. There are many studies showed the relationship between perception on service quality with satisfaction and then utimately leads to loyalty (Buttle, 1996; McAdam et al., 2003; Seth et al., 2005, Edvardsson, 2005, Bontis and Brooker, 2007). BPJS Health needs to understand how satisfied and loyal the insured participants who pay the monthly premium although it is mandatory for them. It is also crucial for the Agency to assess the satisfaction and loyalty of the healthcare providers as they are not only consist of Government Healthcare facilities but also Private healthcare facilities who joint the Program on voluntary basis.
Customer satisfaction is regarded as customers can get more benefits than their cost (Liu and Yen, 2010). Customer satisfaction plays the most important role in total quality management (Hu et al., 2011). Understanding the outcomes of customer satisfaction, including customer loyalty and the intention to continue their relationship with a particular healthcare services remain relatively unexplored despites its importance (Bei and Chiao, 2001). According to Hu et al. (2011) the Swedish Customer Satisfaction Barometer (SCSB) model established in 1989 was the first National Customer Satisfaction Index Model pertaining to purchased and consumed products and services. Due to the success of the SCSB model, more and more nations and areas have modified this model to construct different types of National Customer Satisfaction Index Models, such as the American Customer Satisfaction Index (ACSI) Model, the UK Customer Satisfaction Index Model, the European Customer Satisfaction Index model, among others (Groonholdtet al., 2000).
Of the three models, the ACSI model has proven to be the most popular, and has been implemented in many areas outside America, such as Europe and Asia. ACSI Institute would regularly use the American Customer Satisfaction Index (ACSI) to evaluate patient satisfaction with hospitals in the United States (American Customer Sastisfaction Index, 2013). This study adopted the basic ACSI conceptual model, as shown in Figure 1.
Figure 1.Basic ACSI conceptual model
Research model
Figure 2 is a research model of insured participants or healthcare providers that depicts five antecedents derived from SERVQUAL model, including the tangible attributes, the empathy attributes, the reliability attributes, the responsiveness attributes, and the assurance attributes with respect to BPJS Health services. Three consequences derived from ACSI model were also included: perceived value, satisfaction, and loyalty. Participant or Providers loyalty was the ultimate dependent variable in the model.
Figure 2.Research model of insured participant and healthcare providers’ satisfaction and loyalty
Methods
Study Design
The study design consists of two stages, namely the qualitative and the quantitative stage. The qualitative stage, that is explorative by nature, aims at obtaining service attributes in all contact points of the BPJS Kesehatan service, both for the participants and the healthcare providers. The participants had a Focus Group Discussion (FGD), while the healthcare providershad in-depth interviews. Ten FGDs and 25 indepth interviews with participants and providers, respectively, were conducted in 5 cities. The results from the qualitative research stage were then used to design questionnaires for the quantitative stage.
Measures
Two set questionnaire for each insured participant survey and healthcare provider survey were developed. The questionnaires composed of five sections were designed to collect data from participants and providers. The five sections included: the service quality scale, the satisfaction scale, the perceived value, the loyalty scale, and finally the personal basic information section. The service quality scale referred to the findings from qualitative study that had been conducted prior the survey. It is consist of 37 items scale for insured participant and 26 items scale for healthcare providers. The satisfaction scale of this study composed of 6 items, while the perceived value consist of 3 items, and then 4 items for loyalty. All the rated questions were measured on a five-point scale. Table 1 explains the constructs and measurement indicators in the questionnaires of this study.
Table 1.Constructs and measurements in the questionnaires
| Questionnaire | Constructs | Measurement Indicators |
| Insured Participants | Tangible | Facilities and room cleanliness; facilities and room comfortness; devices availability; drugs availability; personnel availability |
| Empathy | Sincere, attentiveness, friendliness, politeness, patience, willingness to handle complanits of doctors, paramedics, administrative staffs | |
| Responsiveness | Speed in services: admission officers other staffs; speed in patient handling; speed in complaint handling | |
| Reliability | Clarity in insured or non-insured treatment; easiness in getting treatment; doctors’ capabilities/competencies; drugs quality; accuracy in complaint handling | |
| Assurance | Certainty in receiving treatment; equality in treatment; security in receiving treatment; value for money; assurance in problem solving | |
| Perceived value | Benefits obtained as insured participants | |
| Satisfaction | Satisfaction towards each dimension; overall satisfaction from all experiences; importance of services attributes | |
| Loyalty | Willingness to continue as insured participants; willingness to pay premium on regular basis; willingness to recommend BPJS Health to others; willingness to tell others positive things about JKN and BPJS Health | |
| Healthcare Providers | Tangible | BPJS staffs’ visit adequacy to providers; information sharing adequacy to Providers and Public; adequacy of BPJS Health’s offices; accessability of BPJS Health’s offices |
| Empathy | Seriousness of BPJS Health in dealing and coordinating with Providers; BPJS Health’s attentiveness and seriousness in handling Providers’ complaints; friendliness; politeness; patience in compplaint handling | |
| Responsiveness | Speed in giving requested information; speed in delivering services; easiness in contacting BPJS Health’s people; willingness BPJS Health in answering questions; speed in complaint handling; speed in claim verification | |
| Reliability | Clarity in insured vs un-insured treatment; clarity on rights and obligations as providers; payment accuracy; clarity of referral system; clarity of information on chronic diseases program; primary and secondary coordination quality; quality of problem solving | |
| Assurance | Knowledge of BPJS Health’s staffs; BPJS Health’ payment assurance; BPJS’ Health assurance on problem solving | |
| Perceived value | Benefits obtained as Providers | |
| Satisfaction | Satisfaction towards each dimension; overall satisfaction from all experiences; importance of services attributes | |
| Loyalty | Willingness to continue as Providers; willingness to enhance partnership; willingness to recommend BPJS Health to other non-Providers; willingness to tell others positive things about BPJS Health |
Data Collection
A pilot test was carried out first, before the questionnaires was used in the national survey. Questionnaires that had been examined for its validity and reliability, as well as revised based on the pilot test result, was then used in the national survey. The data collection took place simultaneously in 24 cities/districts across Indonesia, and it represented cities/districts that has been managed by all 12 Regional Offices of BPJS Health. The participants and healthcare providers had structured face-to-face interviews.
Sampling
Systematic random sampling was applied in selecting participants and healthcare providers. BPJS Health shared the roster of participants and healthcare providers from which the random samples were taken. The participants respondents consist of outpatients and inpatients at primary and secondary healthcare facilities. They were screened-out if they never used BPJS Health’s services at healthcare facilitiess in the past six months. The interviews were conducted at home or at healthcare facilities, where ever they were more convenient with. Meanwhile, the providers consist of head or director of Public Health Centre (Puskesmas), Clinics or Hospitals, and were interviewed at their office.
Statistical analyses methods
The study first applied SPSS version 20.0 to process the descriptive statistics analysis, reliability analysis on the effectivenequestionnsires, and understand the profile of the respondents and the internal consistency and relation between various variables. In addition, this study also tested and verified the relationship between five groups of quality attributes (tangible, empathy, reliability, responsiveness and assurances attributes), perceived value, satisfaction and loyalty through structural equation modelling (SEM) and applied LISREL 8.5.1 software as the SEM analysis tool.
Results and Discussion
The sample included 17,820 insured patients and 1,170 healthcare providers. At the national level, the samples provided 1% margin of error at 99% confidence level. For insured participants, it was devided into two groups of sample, namely Government-insured participants (PBI) and self-insured participants (Non-PBI). Both groups consists of samples who obtained services from primary healthcare providers and secondary healthcare providers. The later consist of outpatients and inpatients. Meanwhile, for healthcare providers, the sample consist of primary and secondary healthcare providers of both Government and Private-owned.
Pre Analysis
Factor analysis and reliability analysis followed the standard procedure for the pre analysis. In tems of reliability, we used Cronbach’sα coefficient to test the unity of the subscales in the service quality scale. For insured participant questionnaire, the Cronbach’sα coeeficient for the tangible, empathy, reliability, responsiveness, and assurance attributes was 0.935, 0.963, 0.877, 0.945 and 0.925, respectively. The Cronbach’sα coefficient for the whole scale was 0.983, which suggests that the overall reliability was excellent. The Cronbach’sα coefficient of participant’s perceived value was 0.763, of participant’s satisfaction was 0.913, and participant’s loyalty was 0.824, which also shows that the reliability was good to excellent.
For the healthcare providers, the Cronbach’sα coeeficient for the tangible, empathy, reliability, responsiveness, and assurance attributes was 0.866, 0.925, 0.936, 0.903, and 0.821,respectively. The Cronbach’sα coefficient for the whole scale was 0.964, which suggests that the overall reliability was excellent. Meanwhile, the Cronbach’sα coefficient of provider’s perceived value was 0.718, of provider’s satisfaction was 0.879, and provider’s loyalty was 0.860 which also shows that the reliability was good to excellent (Santos, 1999).
Participants and Providers’ Satisfaction Level
Overall satisfaction score of the insured participants towards healthcare facilities (BPJS Health’s Providers) were 4.01 (out of 5) for primary heathcare facilities, and 4.04 for secondary facilities as shown in Table 2. Better facilities, better quality of personnels, and better quality of drugs at secondary healthcare facilities contribute to the higher score of satisfaction. In addition, participants perceived that secondary healthcare providers have provided them with value for money benefits: services received is more than premium they have paid.
Meanwhile, Providers’ overall satisfaction score towards BPJS Health’s services were 3.72 (out of 5) for primary healthcare providers and 3.80 for secondary healthcare providers. No significance difference between the two. Looking at the measures, as has shown in Table 3, secondary healthcare providers were significantly more satisfied than primary healthcare providers in terms of their partnerships quality with BPJS Health. For primary healthcare providers who have indirect payment mechanism through local government, satisfaction of this payment method is significantly lower than the secondary providers whom receive the payment directly from BPJS Health.
Estimation of Model
The final structural equation model of Participants satisfaction and loyalty are given in Table 4, while the model of Providers are shown in Table 5. The GFI and RMSEA of the participant model was 0.853 and 0.069, respectively. Meanwhile, for the provider model, the GFI and RMSEA was 0.781 and 0.088, respectively. This shows the overall goodness-of-fit of the model.
From Table 4, the t-values of the covariance for each pair among the tangible attributes, the responsiveness attributes, the empathy attributes, the reliability attributes, and the assurance attributes were 45.128, 59.364, 57.510, respectively, while the corresponding correlation coefficients were 0.893, 0.806, and 0.951, respectively. This suggests that the five attributes had a mutually positive correlation. The managerial implication of this finding is the improvement on one atribute will have positive impact to the others.
Furthermore, based on the SEM analysis result, the t-value of the relationship between tangible and perceived value was 2.135, which indicated that the relationship was significant (p<0.05). Therefore, improvement on the tangible attributes at primary and secondary healthcare facilities will have positive impact on participants’ perception on the value of the BPJS Health’ services. Similarly, empathy and assurance attributes has significant relationship (p<0.001) with participants’ perceived value, with t-value of 30.336 and 22.886, respectively. Empathy that has been expressed by medic and paramedic personnel at primary and secondary healthcare facilities, along with assurance that the participants can get the proper and appropriate treatment, leads to better perception on the value of the BPJS Health’s overall services.
The perceived value of participants, along with reliability and responsiveness of the services provided by BPJS Health has significant relationship with satisfaction, with t-value of 5.012, 74.537, and 80.1, respectively (p<0.001). Therefore, to improve participants’ satisfaction level, BPJS Health not only needs to improve tangible, empathy, and assurance attributes, but also needs to enhance the reliability and responsiveness of ofpersonnels at healthcare facilities, BPJS Centre, and BPJS Health’s branch offices.
Meanwhile, satisfaction of participants has significant positive relationship with loyalty, with t-value of 21.036 (p<0.001). Therefore, BPJS Health needs to maintain or even enhance the participants’ satisfaction level, especially among the premium payers (Non-PBI participants), in order to ensure their loyalty.
The provider’s model shows a relatively different story. From Table 5, the t-values of the covariance for each pair among the reliability attributes, the tangible attributes, the assurance attributes, the empathy atributes, and the responsiveness attributes were 14.966, 15.837, 14.016, 18.404, respectively, while corresponding correlation coefficients were 0.724, 0.872, 0.655, and 0.834, respectively. This also suggests that the five service quality attributes had a mutually positive correlation. Improvement on BPJS Health’s reliability, for example, will have positive impact on the BPJS Health’s assurance in the providers’ perspectives.
Providers’ perceived value towards BPJS Health’s services was significantly related to the agency personnels’ empathy and reliability that have been shown to providers (t-value of 9.126 and 5.856, respectively). Looking at both models, it can be seen that empathy was the central attributes that plays a significant role in developing positive perceived value towards BPJS Heatlh.
Satisfaction of the providers was significantly related to perceived value of providers towards BPJS Health, along with tangible, assurance, and responsiveness attributes, with t-value of 4.592, 9.113, 18.035, and 23.726, respectively. This suggests that the attributes that have direct correlation with satisfaction was relativey different. While tangible and assurance attributes were indirectly correlates with satisfaction of the participants, in the providers’ model these two attributes directly correlate with providers’ satisfaction level. The implication of this findings are two folds. Firstly, BPJS Health needs to have closer relationship with providers through information sharing and more visits in order to obtain better providers satisfaction level. Secondly, assurance on the payment as well as in problem solving were required by the providers.
Finally, the providers’ model suggests that the loyalty of providers was significantly related to their satisfaction. BPJS Health needs to maintain or even enhance the satisfaction level of its providers in order to obtain better loyalty. In this regards, special attention needs to be put on private healthcare providers who voluntary joined the JKN system.
Table 2.Participants’ Satisfaction Mean Score
| Dimension | Item | Satisfaction Mean Score | t- Value | |
| Primary Healthcare | Secondary Healthcare | |||
| Tangible | Restroom cleanliness | 3.95 | 4.01 | 4.28** |
| Waiting room comfortness | 3.97 | 4.03 | 4.16** | |
| Waiting room cleanliness | 3.99 | 4.03 | 2.83** | |
| Seat availability at waiting room | 3.95 | 4.03 | 5.40** | |
| Availability of medical personnel | 3.97 | 4.03 | 4.19** | |
| Examination room cleanlines | 4.01 | 4.06 | 4.17** | |
| Drugs availability | 3.93 | 3.99 | 4.18** | |
| Medical devices completeness | 3.92 | 4.03 | 7.97*** | |
| Empathy | Doctors’ sincere in patients handling | 4.06 | 4.06 | 0.21 |
| Paramedics’ sincere in patients handling | 4.05 | 4.04 | 0.30 | |
| Administrative personnels’ sincere in patients handling | 4.03 | 4.04 | 1.05 | |
| Medic and paramedics attentiveness in patient handling | 4.03 | 4.03 | 0.31 | |
| Medic and paramedic attentiveness in complaint handling | 4.03 | 4.05 | 1.29 | |
| Doctor friendliness | 4.08 | 4.10 | 1.12 | |
| Nurse and midwives friendliness | 4.05 | 4.07 | 1.75 | |
| Doctor politeness | 4.08 | 4.09 | 0.51 | |
| Nurse and midwives politeness | 4.05 | 4.07 | 1.30 | |
| Doctor’s patience in patient handling | 4.07 | 4.08 | 0.90 | |
| Nurse and midwives’ patience in patient handling | 4.02 | 4.05 | 2.49** | |
| Medics and paramedics willingness to handle patients’ complaint | 4.01 | 4.06 | 3.41** | |
| Responsiveness | Admission personnel speed | 3.95 | 3.99 | 2.99** |
| Medics and paramedics speed in patient handling | 4.01 | 4.02 | 0.74 | |
| Medics and paramedics speed in complaint handling | 3.97 | 4.03 | 4.77** | |
| Reliability | Clarity in insured or non-insured treatment | 3.89 | 3.96 | 5.57** |
| Easiness in getting healthcare services | 4.03 | 4.03 | 0.50 | |
| Appropriateness of types of doctor vs disease | 4.01 | 4.05 | 2.92** | |
| Capabilities of doctors in patient handling | 4.04 | 4.05 | 0.45 | |
| Diagnose accuracies | 4.04 | 4.08 | 3.73** | |
| Doctor ability in explaining the disease to patients | 4.04 | 4.08 | 3.02** | |
| Doctor ability in explaining the prescribed drugs | 4.04 | 4.05 | 1.13 | |
| Drugs quality received by patients | 3.97 | 4.01 | 2.52** | |
| Accuracy in complaint handling | 4.01 | 4.03 | 1.51 | |
| Assurance | Certainty in receiving treatment | 4.04 | 4.04 | 0.60 |
| Equality in treatment between BPJS insured participants vs private insured participant | 3.99 | 4.01 | 1.69 | |
| Feeling secure during treatment | 4.02 | 4.04 | 1.19 | |
| Value for money: premium paid vs services received | 3.99 | 4.04 | 3.57** | |
| Competencies in problem solving | 3.99 | 4.05 | 4.71** | |
| Overall Satisfaction | 4.01 | 4.04 | 2.53** | |
| Note: ** P-value < 0.01; *** P-value < 0.001. | ||||
Table 3.Providers’ Satisfaction Mean Score
| Dimension | Item | Satisfaction Mean Score | t- Value | |
| Primary Healthcare Providers | Secondary Healthcare Providers | |||
| Tangible | BPJS Health’s visit frequencies to Providers | 3.49 | 3.69 | 3.74** |
| Adequacy of BPJS Healh’s sharing information sessions to Providers | 3.51 | 3.58 | 1.36 | |
| Adequacy of BPJS Health’s offices at regional level | 3.53 | 3.61 | 1.37 | |
| Accessability of BPJS Health’s offices | 3.68 | 3.76 | 1.38 | |
| Empathy | BPJS Health’s personnel sincere in dealing/coordinating with Providers | 3.75 | 3.84 | 1.80 |
| Attentiveness of BPJS Health towards Provider’s complaint | 3.69 | 3.83 | 2.84** | |
| BPJS Health’s sincere in complaint handling | 3.76 | 3.85 | 1.98** | |
| BPJS Health’s staffs friendliness | 3.94 | 3.96 | 0.45 | |
| BPJS Health’s staffs politeness | 3.98 | 3.96 | 0.42 | |
| Patience of BPJS Health’s staffs | 3.94 | 3.95 | 0.15 | |
| Responsiveness | Speed of BPJS Health in responding to information request | 3.73 | 3.83 | 2.17** |
| Speed of BPJS Health’s in providing services | 3.78 | 3.84 | 1.23 | |
| Easiness in contacting BPJS Health’s staffs | 3.76 | 3.89 | 2.82** | |
| Willingness of BPJS Health’s staffs in responding to questions | 3.81 | 3.89 | 1.87 | |
| Speed of BPJS Health’s staffs in responding to complaints | 3.75 | 3.83 | 1.69 | |
| Speed in claim verifications process | 3.64 | 3.84 | 4.13** | |
| Reliability | Clarity on insured vs un-insured treatment | 3.70 | 3.68 | 0.41 |
| Clarity on the rights and responsibilities of Providers | 3.76 | 3.78 | 0.46 | |
| Ontime payment | 3.63 | 3.85 | 4.5** | |
| Clarity on the chronic diseases program | 3.71 | 3.68 | 0.61 | |
| Easiness of referral system implementation | 3.63 | 3.69 | 1.15 | |
| Coordination quality of primary and secondary providers | 3.61 | 3.64 | 0.58 | |
| Quality of problem solving | 3.69 | 3.73 | 0.87 | |
| Assurance | BPJS Health staff’s knowledge on JKN system | 3.80 | 3.85 | 0.97 |
| Certainty in receiving claim payment | 3.64 | 3.88 | 4.93** | |
| Certainty given on problem solving | 3.72 | 3.81 | 1.99** | |
| Overall Satisfaction | 3.72 | 3.80 | 1.67 | |
| Note: ** P-value < 0.01; *** P-value < 0.001. | ||||
Table 4.The estimation of the regression (path) coefficient and correlation coefficient of the participant model
| Path | Estimates of Covariance | Standard Error | t-value | Correlation Coefficient |
| Tangible ↔ Responsiveness | 0.101 | 0.002 | 45.128 | 0.893*** |
| Empathy ↔ Responsiveness | 0.219 | 0.004 | 59.364 | 0.806*** |
| Reliability ↔ Assurance | 0.282 | 0.005 | 57.510 | 0.951*** |
| Tangible à Perceived Value | – | 0.008 | 2.135 | 0.022* |
| Empathyà Perceived Value | – | 0.008 | 30.336 | 0.319*** |
| Assurance à Perceived Value | – | 0.008 | 22.886 | 0.237*** |
| Perceived Value à Satisfaction | – | 0.005 | 5.012 | 0.030*** |
| Reliability à Satisfaction | – | 0.007 | 74.537 | 0.750*** |
| Responsiveness à Satisfaction | – | 0.006 | 80.100 | 0.612*** |
| Satisfaction à Loyalty | – | 0.014 | 21.036 | 0.215*** |
| Perceived Value à Loyalty | – | 0.014 | 38.877 | 0.469*** |
Note: *P-value<0.05; **P-value<0.01; ***P-value<0.001
Table 5.The estimation of the regression (path) coefficient and correlation coefficient of the provider model
| Path | Estimates of Covariance | Standard Error | t-value | Correlation Coefficient |
| Reliability ↔ Tangible | 0.290 | 0.019 | 14.966 | 0.724*** |
| Reliability ↔ Assurance | 0.256 | 0.016 | 15.837 | 0.872*** |
| Tangible ↔ Assurance | 0.235 | 0.017 | 14.016 | 0.655*** |
| Empathy ↔ Responsiveness | 0.358 | 0.019 | 18.404 | 0.834*** |
| Empathy à Perceived Value | – | 0.029 | 9.126 | 0.333*** |
| Reliability à Perceived Value | – | 0.031 | 5.856 | 0.209*** |
| Perceived Value à Satisfaction | – | 0.017 | 4.592 | 0.809*** |
| Tangible à Satisfaction | – | 0.017 | 9.113 | 0.242*** |
| Assurance à Satisfaction | – | 0.029 | 18.035 | 0.623*** |
| Responsiveness à Satisfaction | – | 0.016 | 23.726 | 0.575*** |
| Satisfaction à Loyalty | – | 0.047 | 2.585 | 0.092* |
| Perceived Value à Loyalty | – | 0.048 | 10.440 | 0.435*** |
Note: *P-value<0.05; **P-value<0.01; ***P-value<0.001
Policy Recommendations
This study has shown that satisfaction level of JKN participants at primary healthcare facilities is significantly lower than secondary facilities. In this regards, Ministry of Health should be able to improve the quality of primary healthcare facilities, especially in terms of facilities and medical equipment, service quality of medics and paramedics, and availability and quality of drugs provided. The facilities and service gaps should be reduced between the two facilities so that participants’ trust on primary healthcare facilities can be enhanced.
Participants’ perception towards BPJS Health’s service quality was significantly related to tangible, empathy, and assurance attributes, and these lead to their satisfaction level. In this regards, Ministry of Health and BPJS Health needs to increase services capacity of the JKN through more recruitment of providers so that the huge numbers of BPJS Health participants can be treated properly and timely, while at the same time it will reduce the heavy workloads of primary and secondary healthcare facilities and personnels.
In terms of Providers’ satisfaction level, primary healthcare providers has significantly lower satisfaction mainly due to the claim payment. Indirect payment from local government authority (PEMDA) contributes to the lower satisfaction level as compared to secondary healthcare facilities whom receive direct payment from BPJS Health. In this regards, the payment system towards the primary healthcare providers should be improved.
Providers’ satisfaction level was significantly related to tangible and assurance attributes. This suggests that BPJS Health needs to enhance the frequency of socialization or information sharing with providers, especially on the new regulations or standard operating procedures. BPJS Health’s branch offices (Regional Offices) needs to be equipped with current and relevant information.
Finally, this study suggests that empathy attributes are the key factor in building both participants’ and providers’ satisfaction level. Consequently, special attentions needs to be put on “human” aspect of the service providers, in this case, personnels of providers and BPJS Health. Their workloads needs to be considered, their skills needs to be improved, and their income needs to be enhanced, so that they will deliver better and proper services.
Limitations of the Study and Further Research
Some limitations of the study should be noted. Firstly, the 37 items used in Participants model, and 26 items used in Providers model could be seen as somewhat arbitrary and limited. Further research might consider more items to better measure the responsiveness and assurance variable. Secondly, the Providers model’s goodness of fit might be improved in further research through better measurement indicators. Finally, the study was also limited to 24 districts and cities of Indonesia. Future research might investigate more areas to further ascertain whether the resuts are generalizable across all over Indonesia.
Conclusion
The JKN provides better access for Indonesian people to receive proper healthcare services. BPJS Health in the first year of the JKN implementation has successfully obtained good satisfaction level from both participants and providers. Despites the satisfaction level, some points of improvement are required. Improving facilities and personnel services quality along with drugs quality at primary healthcare facilities should be prioritized. As participants should follow the referral system, starting the treatment from primary healthcare facilities, then their trust towards primary healthcare facilities should be enhanced. Otherwise, the referral system might not be effectively implemented under JKN system.
In addition, improvement on the payment system of the primary healthcare providers should be considered by Ministry of Health. Current payment method from Local Government (PEMDA) makes the primary healthcare providers have lower satisfaction level than the secondary healthcare providers. Policy makers may consider similar payment method for both types of providers.
Structural equation modelling in this study shows that the satisfaction level of participants was directly correlate with their perceived value towards the services. This perceptions was significantly correlate with tangible, empathy and assurance attributes. This is the reason why BPJS Health needs to improve the facilities, equipment, and drugs quality. In addition, human aspects of the services is also need to be improved as this is related to empathy and assurance attributes.
For Providers, their satisfaction level was significantly correlated to tangible and assurance attributes. Intensive socialization to providers, sharing and updating current information or regulations are needed. In addition, assurance on the payment to providers is also required.