The relationship of health insurance ownership with the utilization of health services in coastal rural and urban communities (Case Study: Kapoiala Health Centre, Soropia and Nambo Health Centre) Southeast Sulawesi Province, Indonesia, 2023

Background: Health is a human right and every citizen has the right to receive health services. Therefore, the Indonesian government must guarantee that every resident gets quality health services through the implementation of national health insurance as a global commitment for every country to implement universal health coverage. In Indonesia, the number of Social Security Administrator participants reached 248.77 million people or the equivalent of 90.73% of the entire population of Indonesia which was recorded at 274.20 million people, while in Southeast Sulawesi the number of Social Security Administrator participants was 8,071,716 people. Method: The type of research used is descriptive quantitative with a cross-sectional study approach, namely looking for the relationship between ownership of health insurance and utilization of rural and urban coastal community health services (case studies: Kapoiala Health Center, Soropia Health Center and Nambo Health Center) The number of samples in this research was 1,040 people consisting of 535 urban coastal respondents and 505 rural coastal respondents. The sampling techniques are purposive sampling and accidental sampling. The analysis used in this research is chi-square analysis. Results: The results of the study show that there is a significant relationship between ownership of health insurance and utilization of health services with a ρvalue (0.037) < 0.05 in the working areas of the Kapoiala Health Center, Soropia Health Center and Nambo Health Center, Southeast Sulawesi Province, Indonesia. Conclusion: There is a significant relationship between ownership of health insurance and utilization of rural and urban coastal community health services in the working areas of Kapoiala Health Center, Soropia Health Center and Nambo Health Center, Southeast Sulawesi Province. Therefore, it is necessary to increase the acceleration of social security administrator membership to reach 100% UHC through regional government and central government schemes. social security administrator needs to increase socialization with various media that are more effective in increasing community participation in becoming social security administrator participants.


Introduction
Health is the right of every citizen and the Government has the responsibility to ensure that all residents receive health services through the national health insurance program scheme (1)."Health is a Fundamental Human Right" is a World Health Organization (WHO) concept to ensure that everyone can live healthily to produce.Ownership of these rights by a person clearly reflects two absolute obligations for every person or institution that seeks and provides health services, namely making the sick healthy and maintaining the healthy.So it is the obligation of every country in the world to ensure that these rights can be fulfilled and accepted by the entire population (2).The social security administering body is a legal entity established to administer the health insurance program to realize the provision of guarantees for the fulfillment of the basic needs of a decent life for each participant and/or their family members (3).
In Indonesia, the number of social security administering body of Health participants at the end of 2020 was recorded at 222.46 million people.This figure is reduced by around 1.64 million people compared to the previous number in 2019 of 224.1 million people.(4).The increase in the number of participants cannot be separated from the enactment of Presidential Regulation 64/2020 concerning Health Insurance, which contains health insurance funding policies including contribution policies (5).In 2022, there will continue to be a significant increase reaching 248.77 million people or the equivalent of 90.73% of the entire population of Indonesia which is recorded at 274.20 million people (4).
Southeast Sulawesi has a total of 8,071,716 social security administering body participants (6).According to data from the Southeast Sulawesi Health Service in 2021, the population in 2021 was 2,669,840 people with a total membership of 2,469,046 people, of which there were 1,729,431 people who included Contribution Assistance Recipient (PBI) participants, Wage Recipient Worker (PPU) participants.as many as 516,674 people, non-wage worker (PBPU) participants as many as 190,132 people, and non-worker participants as many as 32,809 people, while non-NHI participants as many as 200,794 people (7).
Health insurance is a tool that provides support to people to maintain their health without facing economic burdens or financial problems.Health insurance plays a crucial role in maintaining people's health, especially when they are sick, so that people's health needs are met and health care costs can be guaranteed (8) Health insurance can be a source of funding for health services, originating from the public sector (such as National Health Insurance) or from the private sector (in the form of private health insurance).Social health insurance funding generally depends on income, while private health insurance tends to depend on the level of risk or type of disease experienced (9) In Indonesia, with the establishment of the Social Security Administering Body, which is an institution formed to administer the National Health Insurance Program (NHI), it is hoped that Social Security Administering Body service coverage can cover all Indonesian society so that underprivileged/poor people can access health services.Utilization of health services is the use of health service facilities provided in the form of outpatient health examinations, inpatient care, home visits by medical personnel or other forms of activities arising from the use of health services (10,11).
Community health centre is a health service facility that carries out public health efforts and first-level individual health efforts, by prioritizing promotive and preventive efforts, to achieve the highest level of public health in its working area.First level Community Health Efforts (UKM) are any activities to maintain and improve health as well as prevent and overcome the emergence of health problems targeting families, groups and communities.First level Individual Health Effort (UKP) is an activity and/or series of health service activities aimed at improving, preventing, curing disease, reducing suffering due to disease and restoring individual health.(12).Therefore, realizing the importance of social security administrator for poor people in utilizing health services, especially Community Health Centers, it is necessary to examine the essence of ownership in its utilization.

Methods
The type of research used is descriptive quantitative with a cross-sectional study approach, namely looking for the relationship between ownership of health insurance and utilization of rural and urban coastal health services in the working areas of the Kapoiala Health Center, Soropia Health Center and Nambo Health Center, Southeast Sulawesi Province.The number of samples in this research was 1,040 people consisting of 535 urban coastal respondents and 505 rural coastal respondents.The sampling techniques are purposive sampling and accidental sampling.Purposive sampling technique is a sampling technique with certain considerations by determining criteria that must be met by the research sample so that it is more representative (13).Data analysis consists of univariate analysis and bivariate analysis.Univariate analysis describes the characteristics of each research variable, while bivariate analysis is carried out on variables that are thought to be correlated using statistical testing, namely the chi-square (14).Based on the table above, it shows that the majority of respondents were 736 women (70.77%) and 304 men (29.23%).

Respondent Characteristic
Of the 1040 respondents, there were 529 (50.87%) people who had low education and 511 people (49.13%) who had high education.Of the 1040 respondents, the majority worked in the non-formal sector (non-government sector) as many as 981 people (94.33%) and in the formal sector as many as 59 people (5.67%).Of the 1040 respondents, the majority had low income (below minimum wage) amounting to 820 people (78.85%) and high income reaching 220 people (21.15%).Based on table 2, it shows that the majority of respondents utilized the Community Health Center Health services as many as 899 respondents (86.44%) while those who did not utilized them were 141 respondents (13.56%).Of the 1040 respondents, the majority had health insurance, 902 people (86.73%) and those who did not have health insurance were 138 people (13.27%).Table 3 shows that of the 899 who used health facilities, the majority had health insurance, 788 people (87.65%) while 111 people (12.35%) did not have health insurance.Of the 141 respondents who did not use health facilities, 114 people (80.85%) had health insurance and 27 people (19.15%) did not have health insurance.

Bivariate Analysis
The results of this study show that the ρ value (0.037) is <0.05, which means there is a significant relationship between ownership of health insurance and utilization of health services (community health centre) in Southeast Sulawesi Province.( 8) This is in line with research conducted by that there is a significant relationship between ownership of health insurance and utilization of services at the Tegal Gundil Health Center, Bogor City in 2020.From the results of the analysis, an OR value of 0.016 was obtained, meaning that respondents who did not have health insurance would utilize the services of the Tegal Gundil Health Center 0.016 times more.compared to those who have health insurance.
The results of the research above also show that the majority of respondents who use health services, reaching 88%, have health insurance, so it really helps the community in maintaining their health without having to think about very expensive costs.(15) Health insurance is a tool that can help people continue to maintain their health without having to be burdened by economic or financial problems.Health insurance has a very important role in maintaining people's health, especially during times of illness, so that people's needs are met and health costs can be guaranteed.Meanwhile, from this research, it is also found that those who do not use health services even though they have health insurance are people who use or choose to seek treatment at other health facilities such as clinics, hospitals which they think are more effective in dealing with the health problems they are experiencing.(8) Respondents have health insurance such as Social Security Administrator, Askes, they tend to choose to seek treatment at other facilities because the service is faster.Complete health facilities including facilities and infrastructure, parking space, comfortable waiting room and inpatient rooms.

Conclusion
There is a significant relationship between ownership of health insurance and utilization of rural and urban coastal community health services in the working areas of Kapoiala Health Center, Soropia Health Center and Nambo Health Center, Southeast Sulawesi Province.So, it is necessary to increase the acceleration of social security administrator membership to reach 100% UHC through regional government and central government schemes.Social Security

Table 1
Distribution of Respondents based on Gender, Education, Employment and Income

Table 2
Distribution of Respondents based on Health Service Utilization, and ownership of health insurance Source: Primary Data, 2023

Table 3
Relationship between ownership of health insurance and utilization of health services (Community Health Centre) Similar research also shows that those who have government-managed health insurance are 2.371 times more likely than those who do not have health insurance to utilize community health centre (AOR 2.371; 95% CI 2.320-2.423).Furthermore, those who have government-managed and private health insurance are 1.924 times more likely than those who do not have health insurance to utilize a Community Health Center (AOR 1.924; 95% CI 1.829-2.024).It can be concluded that ownership of health insurance is related to the use of health centers in Probolinggo.Those who have health insurance managed by the government have the highest opportunity to utilize Puskesmas services (16).