THE QUALITY SERVICE FOR PATIENTS OF BPJS WITH ANTENATAL PATIENTS SATISFACTION IN THE COMMUNITY HEALTH CENTERS IN TEGAL CITY

The Social Insurance Administration Organization or known as BPJS is one form of social protection to ensure the community in order to realize the provision of health insurance and meet the health needs of the community. To realize the 1945 Constitution, article 28 and Law no. 36 of 2009, the government must provide health services that are equitable, fair, and affordable for the people of Indonesia. In the service of pregnant women patients will get satisfaction in the service at the health center both independently and in collaboration, therefore every pregnant woman needs to require at least four visits during the antenatal period, namely one visit during the first trimester, one visit during the second trimester and two times visit during the third trimester. The purpose of this study was to determine the quality of BPJS patient services with antenatal care patient satisfaction at the Community Health Center in Tegal City. The study design was descriptive-analytic with the cross-sectional approach. The population in this study were all pregnant women in the Community Health Center in Tegal City in July 2019. The sampling technique used in this study was the accidental sampling technique, with the total sample obtained was 70 respondents. The results of this study are the characteristics of respondents about BPJS ownership obtained; all respondents already have BPJS (100%), most respondents were at the gestational age 4-6 months gestation (42.9%), and most respondents were multipara (61.4%). The satisfaction of pregnant women in terms of tangibility, reliability, assurance, responsiveness, and empathy, most respondents were satisfied with ANC services at the Community Health Center in Tegal City. Keywords : BPJS, antenatal care, quality


Introduction
One indicator in determining the degree of public health is the Maternal Mortality Rate (MMR). The maternal mortality rate in Indonesia was the highest compared to other ASEAN countries. Based on the Indonesian Demographic Health Survey in 2016, maternal mortality in Indonesia reached 235 per 100,000 live births. [1] The maternal mortality rate in Central Java in 2015 reached 287 / 100,000 live births and increase to 291/ 100,000 live births in 2016. While the Infant Mortality Rate (IMR) in Central Java Province in 2015 amounted to 293 / 100,000 live births and an increase in 2016 to 327 / 100,000 live births. An effort to reduce MMR and IMR is by implementing antenatal care (ANC). [2] The Social Insurance Administration Organization or known as BPJS, is a Public Legal Entity explicitly assigned by the government to organize health insurance for the people of Indonesia. The implementation of the health program continues to be improved by the government because BPJS participants, partners, or health facilities continue to grow. To realize the 1945 Constitution, article 28 and Law no. 36 of 2009, the government must provide health services that are equitable, fair, and affordable for the people of Indonesia. [3] The Community Health Center is the primary health care unit as one of the leading public services of the district/city government. In the appendix to the decision of the minister of health of the Republic of Indonesia number 128 of 2004 regarding the basic policy of Community Health Center which stated that Community Health Center is a technical implementing unit in the district/city health office that is responsible for delivering health services at the first level in a comprehensive, integrated, and sustainable manner. [4] Each Community Health Center carries out a professional nursing service strategy related to patient satisfaction aimed at keeping the home health service growing where patients will feel satisfied if the health services obtained following what the patient needs [5] . Wulansari (2012) stated that the level of satisfaction of pregnant women towards the quality of antenatal care services could not be separated from midwife services alone. However, there were services from nurses and doctors, if the service performance or skills of midwives, nurses or doctors were not in line with the expectations, patients will feel dissatisfied and vice versa if the quality of service skills of midwives, nurses and doctors per the expectations of patients will feel satisfied. [6] Nurjanah stated that in the daily experience of a patient's dissatisfaction, often found dissatisfaction with the attitude of health workers, the behavior of officers and employees, delays in the service of doctors and nurses, lack of communication and information from officers, length of admission, cleanliness and environmental order. [7] Each Community Health Center carries out a professional nursing service strategy related to patient satisfaction aimed at keeping the home health service growing. Patients will feel satisfied if the health services obtained following what the patient needs. Patient satisfaction is essential for a health service because, with patients who were satisfied with health services, patients will return to use the health services. However, if patients feel dissatisfied with the service they get, they will inform others about their bad experiences about the service.
Sundari (2017), in her study, stated that there was a significant relationship between patient satisfaction and the quality of antenatal care (ANC) services from midwives private practice in the BPJS network [1] .
The purpose of this study was to determine the quality of BPJS patient services with antenatal care patient satisfaction at the Community Health Center in Tegal City.

Method
The study design was descriptive with a cross-sectional approach that serves to provide an overview of the object under study through the samples that have been collected by analyzing and making conclusions. The population in this study were all pregnant women in the Community Health Center in Tegal City in July 2019, amounting to 70 people, using accidental sampling technique that is a sampling of respondents by chance who met the criteria as a sample. The analysis in this study was univariate. Based on Table 1, the results of all respondents already own a BPJS (100%). BPJS is one of five programs in the National Social Security System, which listed in Law Number 40 of 2004 concerning the National Social Security System. The influence of BPJS Health membership on pregnant women assisted by health workers where the government provides health services for pregnant women. [8] With BPJS ownership for the community now, it can be used as a guarantee of public health maintenance. The community will be better protected if one day they get the disease because by having health insurance (BPJS), they can be freed from medical expenses. It also applies to pregnant women when they had antenatal care without having to pay. [9] Table 2 shows that the majority of respondents were pregnant in the second trimester or 4-6 months (42.9%). The coverage of services that can be received by pregnant women, in this case, is antenatal care including examining pregnant women at least four times during pregnancy, supporting examinations include laboratory tests (blood, urine), HIV screening, STIs and consultation with dental specialists, specialist doctors and experts nutrition. [1,6] Pregnant women expected to check their pregnancy routinely. Maternal examination during pregnancy should be done at least four times, namely once in the firsttrimester pregnancy, once, in the second-trimester pregnancy, and the third-trimester pregnancy twice.

Results and discussion a. Characteristics of Respondents
Pregnant women who have a high risk of pregnancy will be examined more often to monitor the pregnancy. The majority of BPJS ownership were pregnant women in the second trimester because they should start preparing for early labor. [9] Health services in the BPJS are focused on First Level Health Services or at primary health facilities, such as in the Community Health Center. For this reason, the quality of these primary health facilities must be maintained following their standards, bearing in mind the effects of the implementation of the BPJS, which will result in increased public demand for excellent health services following existing service standards. Patient satisfaction is an essential element in evaluating service quality by measuring patient response after receiving services. The existence of an assessment of the services provided to patients means that health care facilities expected to remain following service standards and to develop. One of the efforts is to strengthen health facilities in health centers. Also, it expected that health workers who are at the primary health care level must have the ability. It must master the change in knowledge (updating knowledge) in which about predictions, signs, symptoms, diagnosis, and comprehensive management of various diseases because two crucial elements in efforts to improve health services are the level of patient satisfaction as service users and the fulfillment of established service standards [6,7] . Patient satisfaction is an essential element in evaluating the quality of service by comparing the results of the assessment on health services by patients with what expected in terms of health services. The evaluation is done by measuring the extent of the patient's response after receiving health services. With a good quality of service, will create excellent satisfaction for patients. One assessment of service quality is reliability, namely the ability of health workers to deliver the promised service in a timely and satisfying manner: responsiveness, namely the ability by health workers to help patients and provide responsive services. Empathy is the ease of communicating well and understanding the needs of patients. Quality of care is an effort to meet the needs and desires of patients as well as the accuracy of delivery in balancing patient expectations. [10]  Based on Table 3, the results show that most respondents were multipara (61.4%). If pregnant women have less than two children, satisfaction with the quality of ANC services is getting less, and vice versa, if more mothers have more than two children, the perception of pregnant women about the quality of ANC services will be better. [11] According to Maulana's study (2012), an assessment of the satisfaction of pregnant women on the quality of Antenatal Care services showed the level of satisfaction obtained by pregnant women had a significant relationship with parity (pvalue 0.05). [10] b. Satisfaction of Pregnant Women who Own BPJS on ANC Services Based on Table 4, the results of satisfaction in terms of tangible, reliability, assurance, responsiveness, and empathy aspects, the majority of respondents were satisfied with the ANC service at the Community Health Center in Tegal City.
According to Manuaba (2015), it is providing opportunities for midwives and other health workers for training and development to improve their competence. These competencies include training, which includes training on effective communication techniques and maternal and child health program management, in order to be able to convey the information needed by pregnant women to maintain a healthy pregnancy [11] . Also, the existence of comprehensive Antenatal service training and excellent service to improve the ability of midwives to provide quality antenatal services. With training in examining pregnant women, it is expected that the high quality of services provided by midwives to pregnant women can continue to improve. [12] All Community Health Centers in Tegal city had tried to improve the quality of their services. From tangibles aspects, namely by providing health facilities in the form of complete infrastructure, with a complete and clean condition, neat care rooms, and the appearance of health workers in a uniform and neat. If seen from the aspect of assurance in the first level of health services in the Tegal City area, it provides safe, complete medical records and able to provide information relating to the actions taken to patients. The level of patient satisfaction in terms of reliability is the ability of health workers in the Tegal City health center to provide services following the Standard Operating Procedures that have been set. If in terms of empathy, the Community Health Center provides services to facilitate patients in contacting health workers to communicate, so that patients are more comfortable to receive services related to maternal health services, such as antenatal care. [7,12] With this assessment, health service facilities expected to continue to develop and complement the infrastructure. The Community Health Center in Tegal City had tried to improve the performance of its health workers by trying to provide the best possible health services to patients. Patient satisfaction is the customer's response to the discrepancy between service delivery and what is expected in receiving service.
Expectations are directly proportional to the desire of patients to be able to enjoy the service satisfactorily. If the services provided are as expected, the quality is interpreted as pleasant and satisfying.
The results obtained show that the empathy of health workers affects BPJS patient satisfaction. Empathy is a personal concern and understands the needs of patients. The attitude of health workers who are patient and diligent in providing health services to patients without discriminating against one another can provide hope and satisfaction for patients. Empathy in question is the willingness of health workers to meet the health needs of patients, calm the heart, and be attentive, friendly, and thorough in each examination. Health workers are demanded to be more active and protect patients and families in connection with the issue of their dedication while on duty and regarding their professionalism. Empathy is manifested in being patient in handling patients, always providing motivation and encouragement to patients in this study, namely, pregnant women to be strong and optimistic and believe that they and their fetuses are healthy, officers are friendly and friendly to patients, and always act to calm patients. Therefore, the higher empathy when providing health services to patients, the higher the patient's assessment of service satisfaction obtained. [12,13] This study is in line with a study conducted by Kurniawati, which stated that someone's empathy had a positive effect on customer satisfaction. Therefore, health services must be able to pay attention and prioritize empathetic health services. The empathy referred to in this study is following the expectations of patient expectations in obtaining health services so that satisfaction appears. [14]

Conclusion
Characteristics of respondents based on BPJS ownership were found; all of them have BPJS (100%). Based on gestational age, most respondents were 4-6 months pregnant (42.9%), and the majority of respondents were multiparous (61.4%). The satisfaction of pregnant women in terms of tangibility, reliability, assurance, responsiveness, and empathy, most respondents were satisfied with ANC services in the Community Health Center in Tegal City. Suggestions for the Community Health Center management to always improve service quality so that with better service quality, patients will feel satisfied with the services provided. For patients should provide suggestions and criticisms related to the services provided so that it can be used as material for consideration for management to improve the quality of service to patients.

Acknowledgement
All author is very grateful to the Tegal City Health Office, Tegal City Health Center, and all Respondents.