THE PREMIUM ASSISTANCE BENEFICIARIES OF NATIONAL HEALTH INSURANCE’S EXPERIENCE IN USING HEALTHCARE IN KEDIRI

National Health Insurance (Jaminan Kesehatan Nasional: JKN) demonstrates government’s commitment providing health insurance to all Indonesians. Hoped that JKN can improve the health levels of its citizens, including the poor and vulnerable; i.e Premium Assistance Beneficiaries Of National Health Insurance (PBI JKN), so that the productivity of family economies increase and intergenerational cycles of poverty can be broken. Despite wider coverage of JKN, however, the poor were still disadvantaged in the healthcare market. Our preliminary study in Kediri shows that PBI beneficiaries complain about the service of healthcare they have received. This study aims to explore the healthcare experience of PBI JKN in Kediri through a qualitative case study approach using in-depth interviews with 10 informants of PBI who had previously been selected purposively. The findings support an understanding of PBI experience from the PBI’s perspective of accessibility, service procedures, and service quality of healthcare in Kediri. According to the informants’ perspective of accessibility to healthcare, all of them stated that the healthcare is accessible. From the informants’ perspective of service procedures, most of the informants stated that the flow of health services provided is quite detailed and complete, although some informants are not satisfied with the way the health service is served. The results suggest that there are several issues that must be addressed in order to enhance the quality of care for example therapeutic communication, and the PBI experience in relation to increase the quality care. In addition, policy-makers, managers and all healthcare workers must ensure that patients especially PBI beneficiaries are satisfied of the services provided regardless of their membership status .


Introduction
In 2018, WHO 70th annyversary theme was "Universal Health Coverage, everyone, everywhere" it means that ensuring everyone, in everywhere can access essential quality health services without suffering financial hardship.To ensure the inception of National Health Insurance Program or universal health coverage as mandated by the 1945 Constitution of the Republic of Indonesia and Law No. 40 of 2004 regarding the National Social Security System (referred to as Sistem Jaminan Sosial Nasional SJSN), Indonesian's government launched the National Health Insurance system in early 2014, aims to create an integrated and sustainable health system that provides equal, on-time, comprehensive basic health care to all Indonesians.The system requires all individuals to join and be covered by the program (Mundiharno & Thabrany, 2012).This National Health Insurance Program (Jaminan Kesehatan Nasional or JKN) held by National Health Insurance Bureau (Badan Penyelenggara Jaminan Sosial Kesehatan) is one of the government's commitment to achieve Universal Health Coverage (UHC) which guarantees equal rights for everyone to get access to health services that safe, quality, and affordable (Djamhari et al., 2020).
The government has provided a membership scheme for Premium Assistance Beneficiaries (Penerima Bantuan Iuran PBI) as protection so that the poor can avoid impoverished health.However, this attempt is not direct eliminate other problems such as equity in health services.Equity in providing health services is an equal opportunity for justice and equality to two or more groups in terms of health services (Nurrahmah et al., 2017).The positive impact of the JKN program has been felt directly by public, JKN can also directly reduce the cost burden of Indonesian for accessing health facilities and it also has improved fulfillment of basic health rights of all levels of society, including the poor and underprivileged groups through the PBI scheme (Da Costa et al., 2018).
Despite wider coverage of JKN, however, the poor were still disadvantaged in the healthcare market (Johar, Pujisubekti, Soewondo, Kunthara Satrio, & Adji, 2017).Based on prior study, it specified that PBI has low health service utilization of healthcare in JKN with a very low claim ratio (Gustaman & Bachtiar, 2018) Meanwhile, according to Bate and Robert (2008) Experienced-based Design in healthcare, especially its underlying concepts, methods and practices, is a basic tool for developing customer focused health care services.The "experience" is defined as "how well people understand it (in this case: the services), how they feel about it when they are using it, how well it serves its purpose and how well it fits into the context in which they are using it".Knowing patient experience could indicate that this is a remarkably more powerful approach than what is meant in patient-led services (Bate & Robert, 2008).So it is important to know the experience to service improvement and innovation process of JKN.From our preliminary study in Cerme Village Kediri, shows that PBI beneficiaries complain about the service of healthcare they have received.Based on prior background, this study aims to explore the healthcare experience of PBI JKN in Kediri so that stakeholders related can improve the healthservices provided especially satisfaction of PBI beneficiaries regardless of their membership status.

Method
This study is qualitative case study approach using in-depth interviews to explore the healthcare experience in using inpatient or outpatient JKN healthcare service from the PBI's perspective of accessibility, service procedures, and service quality of healthcare.Located in Cerme Village, Grogol, Kediri East Java Province on October until December 2021, 10 informants of PBI were previously been selected purposively using Snowball sampling technique, i.e selecting one or two key informants, then asking them to suggest the next informant to provide the phenomena we are studying.Due to saturation of data, our informants total were 10 consists of 5 informants having experience in using inpatient healthcare, and the rest were having experience in using outpatient healthcare.
Accessibility is defined as the ability to reach quality health services, service procedure is defined as the ease of service stages provided to the community in terms of the simplicity of the service flow (Kamarni, 2011), and service quality is seen from the professionalism of the employee or person in charge of servicing JKN PBI patient.The data that had been collected from the interview was then transcribed verbally and then compiled for descriptive analysis.The data collected includes the characteristics of the informants as well as the experience of PBI JKN while accessing health services, how the service procedures and the service quality are served.

Characteristics of Informants
Based on the Table 3 majority of informants are women within age 61-70 years old, and 5 of them having experience in using inpatient healthcare and 5 others having experience in using outpatient healthcare.

PBI JKN Experience in Using Healthcare From The Perspective of Accessibility
Based on in-depth interviews with informants in Cerme Village, Grogol District, Kediri Regency, all the informants mentioned that the accessibility of healthcare is easy to reach.They access health services using transportation such as motorbikes, tricycles, bicycles, and cars.Judging from the type of transportation used, it proves that health services are close and affordable from the participants' residences.
" "When registering, we provide a photocopy of our card.Then queue to take the queue number and wait to be called one by one.
Next, we are waiting to be called based on the type of disease.Like for example number 2 toothache, please go to the dental poly" From 9 informants out of 10 consistently reported that the health services provided is good.They appraise from the way doctors treat participants with care, nurses who diligently check the condition of participants while undergoing hospitalization, and friendly administrative staff.
"Friendly, the nurse is friendly and the doctor is diligent" "Yes ma'am, nowadays these young people are so friendly" Nevertheless, there is an informant reported uncomfortable experiencing about the healthservice provided.Informant reported that when being examined by one of the doctors, the doctor said unpleasant words to him and make him uncomfortable.
"Yes, they are friendly, especially the registration officer, only the doctor's way of speaking is not to my liking, it's insulting.I came here to do a health check-up so that I can get well soon, why was I even reprimanded?"Health services in Cerme Village, Grogol District, Kediri Regency were apraised by 9 out of 10 informants as good.Based on in-depth interviews that have been carried out, they define good quality health service as medical personnel who are patient in serving them, the queuing in accessing health service is strict to the order, and the efficacy of the drugs given.
"The health center service is good.The queuing is always in order.If our requirements are complete, it is not complicated to get medical check up there" "…It's good.The health center staff, whether it's a nurse or whatever they're called... they're always check on my health.."

Discussion
According to Bate and Robert (2008) Experienced-based Design in healthcare, especially its underlying concepts, methods and practices, is a basic tool for developing customer focused health care services.The "experience" is defined as "how well people understand it (in this case: the services), how they feel about it when they are using it, how well it serves its purpose and how well it fits into the context in which they are using it."(Bate & Robert, 2008).From our findings, help us understand that in general PBI JKN in Cerme Village having good experience in accessing healthcare, though there are some unmet expectation.Their experience in using healthcare were assessed from perspective accessibility, service procedures, and service quality of healthcare.
Our findings relate to accessibility of health care is related to study conducted by Nurrahmah et al (2017), they mention that proportion of ease of accessibility to healthcare is bigger than the tough one (Nurrahmah et al., 2017).Study conducted Putri & Noer (2019) showed that JKN-KIS accessibility in terms of service availability, location accessibility was good (Putri & Noer, 2019).However, this shows that there are still people who have a higher level of difficulty or vulnerability when accessing services health.
Refers to the concept put forward by Margaret Whitehead (1985) in Nurrahmah et al (2017), that health equity is related to creating equal opportunities to access health and reducing health disparities to the lowest level.Whitehead asserts that equity in healthcare can be defined as equal access to care available for the same needs, equal utilization for the same needs, and equal quality of care for all.That is why we focused on perspective accessibility, service procedures, and service quality of healthcare, and from the results of this study indicates that the National Health Insurance policy in force in Indonesia and the contribution assistance provided by the government for the poor and near-poor are the appropriate policy models to address this issue related of accessing healthcare.(Nurrahmah et al., 2017) Regulation of the Minister of Health Number 75 of 2014 regarding Community Health Centers states that Puskesmas are health service facilities that carry out public health act and firstlevel individual health service, with prioritizing promotive and preventive, to achieve the highest public health degree in their working area.FKTP is the spearhead of health services and is used as the gate keeper in the national health system.JKN participants only need to bring their JKN-KIS card and identity card when registering at FKTP and FKTL, this is done to avoid using the card by others.Our findings relate to experience PBI according to health care service procedures are experienced that the procedures of health services do not make it difficult for PBI to understand and PBI rarely do experiencing problems about the flow of health services is provided.This contrary on study conducted Nurrahmah et al (2017) study results shows that 37.57% of respondents considered that the service procedures (registration, examination and referral ) that has been carried out so far is so-so, 34.82% rated it better, 11.76% did not know, 9.97% had not or did not use JKN, and 5.88% rated it worse.This means that the understanding of service procedures of healthcare need more socialization, and this is one of the biggest challenges in implementing JKN (Nurrahmah et al., 2017) Our findings related to experience in quality health service shows that most informants having positive experience, and only one who complaint about therapeutics communication.According to Nurrahmah (2017) it was found that the main improvement that needed to be made by JKN providers and health service providers is in the dimensions of service quality, followed by service utilization and access to services.On the service acceptance dimension, the JKN policy is still considered ineffective.

Conclusions and suggestions
According to the informants' perspective of accessibility to healthcare, all of them stated that the healthcare is accessible.From the informants' perspective of service procedures, most of the informants stated that the flow of health services provided is quite detailed and complete, although some informants are not satisfied with the way the health service is served.The results suggest that there are several issues that must be addressed in order to enhance the quality of care for example therapeutic communication, and the PBI experience in relation to increase the quality care.In addition, policy-makers, managers and all healthcare workers must ensure that patients especially PBI beneficiaries are satisfied of the services provided regardless of their membership status.

PBI JKN Experience in Using Healthcare From The Perspective of Service Quality Of Healthcare
Nursing Journal of Respati Yogyakarta, p-ISSN: 2088-8872; e-ISSN: 2541-2728