Characteristics and Perceptions of the Community Regarding National Health Insurance in the Participation

: This study aims to examine and analyze the characteristics and perceptions of the community regarding the National Health Insurance (Jaminan Kesehatan Nasional or JKN) in Toba district, as well as the participation of individuals in the JKN program. The research methodology employed in this study is quantitative in nature, utilizing a cross-sectional design. The population for this study consisted of 206,199 individuals, and the sampling technique employed was the Slovin method, resulting in a sample size of 399 participants. Based on the test results, there is a relationship between age and the community's perception of the national health insurance program (JKN) and their participation as JKN participants in Toba district. Gender also has a relationship with participation in the National Health Insurance program. The number of family members is also related to participation in the National Health Insurance program. Knowledge is associated with participation in the National Health Insurance program. The current needs of the community are related to participation in the National Health Insurance program. Expectations are associated with participation in the National Health Insurance program. Perceived product quality is also related to participation in the National Health Insurance program.


Introduction
The Law Number 40 of 2004 on the National Social Security System (SJSN) aims to provide comprehensive social security for the population of Indonesia.The National Health Insurance (Jaminan Kesehatan Nasional or JKN) is a social insurance program based on the principle of mutual cooperation and is mandatory for all residents of Indonesia according to the Law Number 40 of 2004 (Nurvita, 2019).Through this program, it is hoped that it can fulfill the basic health needs of the Indonesian people so that the health status of the Indonesian people can be improved (Idaiani & Riyadi, 2018).
According to the World Health Organization (WHO), Universal Health Coverage (UHC) is a healthcare financing system that ensures every individual has equitable and fair access to the necessary, quality, and financially affordable health services, including promotive, curative, preventive, and rehabilitative care.The government's target in this program is to achieve a minimum of 95% population coverage under the National Health Insurance (Jaminan Kesehatan Nasional or JKN) throughout Indonesia by the beginning of 2019 (Rumengan et al., 2015).
In 2019, the Indonesian government targeted the inclusion of the entire population of Indonesia as participants in the National Health Insurance (Jaminan Kesehatan Nasional or JKN) program.However, in 2015, the proportion of the Indonesian population enrolled in the JKN program was 53.4%.The breakdown of participants based on payment sources was as follows: 34.0% covered by the government, 4.3% by employers, and 3.9% self-paying, while 57.8% of the population were not yet enrolled in the JKN program.To achieve the 100% target by 2019, efforts were focused on increasing the participation of the wage earners and selfpaying individuals (Suprianto & Mutiarin, 2017).
As of November 30, 2020, the number of participants in the JKN program reached 223,066,814 individuals.The breakdown of participants was as follows: 96,510,132 individuals under the National Budget (PBI APBN), 36,190,096 individuals under Regional Budgets (PBI APBD), 17,547,500 individuals under the Non-Working Population (PPU-PN), 37,823,381 individuals under the Informal Sector (PPU-BU), 30,637,339 self-employed individuals, and 4,358,393 individuals categorized as non-workers.However, the achievement of health insurance coverage still falls far short of the government's target to achieve Universal Health Coverage (UHC) by 2019, with a minimum coverage of 95% of the entire Indonesian population (Saputra et al., 2015).
According to BPJS Kesehatan, throughout the year 2021, the percentage of participants in the National Health Insurance (Jaminan Kesehatan Nasional or JKN) program, compared to the total population of Indonesia, was 86.07%, equivalent to 235.719 million individuals.This number represents an increase compared to 2020, which had 222.461 million participants.The remaining 13.93% of the Indonesian population has yet to become JKN participants.Referring to the financial report of BPJS Kesehatan, the composition of JKN program participants in 2021 is as follows: 42.42% are Participants Receiving Premium Assistance (PBI), 25.46% are Wage Workers (PPU), 17.15% are Non-Wage Workers and Regional Government Non-Wage Workers (PBPU BP Pemda), 13.11% are PBPU participants, and 1.86% are BP participants.The total revenue from insurance premiums collected by BPJS Kesehatan in 2021 from PBI, non-PBI, and PBPU BP Pemda participants amounted to Rp 143.32 trillion.This figure indicates an increase compared to 2020, which amounted to Rp 139.85 trillion.
According to the Central Statistics Agency of North Sumatra in 2021, data on JKN/KIS participants as of March 2021 indicated that there were approximately 11.4 million individuals enrolled, divided into PBI (National/Regional Government Budget) and non-PBI categories.Overall, in 2021, the population of North Sumatra with National Health Insurance (Jaminan Kesehatan Nasional or JKN) coverage amounted to 75.37%.The data collected since 2019 shows an increasing trend, despite occasional increases in premiums.In 2021, there were limitations in the Allocation of Health Maintenance Funds for PBI in the Province of North Sumatra, resulting in the non-active status of some participants.Consequently, the JKN PBI participation rate decreased to 60% (SUMUT, 2020).
Based on the data obtained from Toba district, the number of residents registered as JKN-KIS participants until April 2021 was 81% (117,087) out of a total population of 144,505.In March 2022, the number of individuals registered with BPJS Kesehatan in Toba district was 113,747.The number of individuals not registered as JKN participants was 30,758.There are multiple factors that influence community participation in the National Health Insurance (Jaminan Kesehatan Nasional or JKN), including education, income, knowledge, perception, family support, family size, occupation, and information.Based on the aforementioned background, the aim of this study is to determine the relationship between the characteristics and perceptions of the community regarding the National Health Insurance (JKN) and their participation as JKN participants in Toba district.

Method
This study is a quantitative research with a crosssectional design.It was conducted in Toba district, during the period of October-December 2022.The population of this study includes the entire community of Toba district in the year 2022.The sample was determined using the Slovin's formula, which involved selecting 30 percent of the total number of sub-districts (kecamatan) in Toba district.From the 16 sub-districts, five sub-districts were selected for the study, namely Tampahan, Sigumbar, Narumonda, Pintu Pohan, and Lumban Lobu.The total number of respondents in these selected sub-districts is 399.The data for this study were collected through primary data obtained directly from respondents using questionnaires, as well as secondary data obtained from the Profile of Toba District, Health Department Profile, turnover data, and population data of Toba District.The data analysis involved univariate analysis to examine the frequency distribution of respondent characteristics, knowledge, perception of needs, expectations, product appearance, and participation.Bivariate analysis was conducted to explore the relationship between two variables using cross-tabulation and the chi-square statistical test.Multivariate analysis was employed to determine which variables were most associated with community participation in the JKN program.This was done through simple logistic regression by analyzing each variable individually.If a variable had a significance value (p-value) of less than 0.25, it was further analyzed together using multiple logistic regression analysis.

Result and Discussion
From table 1, the frequency distribution of the characteristics reveals the following: The largest group of respondents falls within the age range of 15-64, with 228 individuals (56.8%).The smallest group consists of individuals aged 0-14, with 72 individuals (18.0%).The group aged >65 comprises 99 individuals (25.1%).The most common occupation among the respondents is Housewife, with 198 individuals (49.62%).The least common occupation is Civil Servant (PNS), with 80 individuals (20.0%).Entrepreneurs comprise 121 individuals (30.32%) of the respondents.The majority of respondents have completed Senior High School (SMA), with 163 individuals (40.85%).The smallest group consists of respondents with primary education (SD), with only 2 individuals (0.05%).Junior High School (SMP) is the educational level for 69 respondents (17.29%).The most common income range among respondents is 500,000-2,500,000, with 150 individuals (37.59%).The least common income range is above 5,000,000, with 35 individuals (8.77%).The largest group of respondents has a medium-sized family with 5-7 members (51.12%).The smallest group consists of respondents with less than 4 family members, with 31 individuals (7.76%).From Table 2, the frequency distribution of knowledge among self-paying participants in Toba District is as follows: out of the 399 respondents, 256 respondents (64.1%) stated that their knowledge was moderately good, while 143 respondents (35.8%) stated that their knowledge was not very good.From Table 3, the frequency distribution of the perception of needs among self-paying BPJS participants in Toba District is as follows: out of the 399 respondents, 298 respondents (76.4%) stated that their needs were considered appropriate, while 101 respondents (25.3%) expressed that their needs were not fully met.From Table 4, the frequency distribution of the perception of expectations among self-paying BPJS participants in Toba District is as follows: out of the 399 respondents, 290 respondents (72.6%) stated that their expectations were considered appropriate, while 109 respondents (27.3%) expressed that their expectations were not fully met.From Table 5, the frequency distribution of the perception of product appearance among respondents in Toba District is as follows: out of the 399 respondents, 305 respondents (76.4%) stated that the appearance of the JKN product was considered appropriate, while 94 respondents (23.5%) expressed that the appearance of the product was not fully satisfactory.From Table 6, the frequency distribution of community participation among self-paying BPJS participants in the working area of Toba District is as follows: out of the 399 respondents, 250 respondents (62.2%) stated that their participation level was classified as high, while 149 respondents (37.3%) expressed that their participation level was classified as low.From table 7, The chi-square test resulted in p=0.000, which is less than the significance level (α=0.05).Therefore, the null hypothesis (H0) is rejected, and the alternative hypothesis (Ha) is accepted.This indicates that there is a significant relationship between the age of the community regarding JKN and their participation in JKN Health Insurance in Toba District in the year 2022.The chi-square test resulted in p=0.000, which is less than the significance level (α=0.05).Therefore, the null hypothesis (H0) is rejected, and the alternative hypothesis (Ha) is accepted.This indicates that there is a significant relationship between the gender of the community regarding JKN and their participation in JKN Health Insurance in Toba District in the year 2022.
The chi-square test resulted in p=0.000, which is less than the significance level (α=0.05).Therefore, the null hypothesis (H0) is rejected, and the alternative hypothesis (Ha) is accepted.This indicates that there is a significant relationship between the number of family members of the community regarding JKN and their participation in JKN Health Insurance in Toba District in the year 2022.The chi-square test resulted in p=0.000, which is less than the significance level (α=0.05).
Therefore, the null hypothesis (H0) is rejected, and the alternative hypothesis (Ha) is accepted.This indicates that there is a significant relationship between the knowledge of the community regarding JKN and their participation in JKN Health Insurance in Toba District in the year 2022.The chi-square test resulted in p=0.000, which is less than the significance level (α=0.05).Therefore, the null hypothesis (H0) is rejected, and the alternative hypothesis (Ha) is accepted.This indicates that there is a significant relationship between the community's perception of their needs regarding JKN and their participation in JKN Health Insurance in Toba District in the year 2022.The chi-square test resulted in p=0.004, which is less than the significance level (α=0.05).Therefore, the null hypothesis (H0) is rejected, and the alternative hypothesis (Ha) is accepted.This indicates that there is a significant relationship between the community's perception of their expectations regarding JKN and their participation in JKN Health Insurance in Toba District in the year 2022.From Table 8, Variables with p-values less than 0.05 were examined, and it was found that one variable, namely "expectations," entered the model as a candidate.Overall, this model can predict the magnitude of influence with an overall percentage of 87%, while 13% is influenced by other factors.The variable that significantly influences the occurrence of participation in JKN is "expectations," as indicated by the coefficient B value.The value of p=0.87 indicates that for each unit increase in the expectations of community participation in JKN in Toba District, the likelihood of participation increases by 0.87 or 87%.However, without the specific logistic regression equation you obtained, I am unable to provide the exact equation for predicting the influence of age, knowledge, current needs, expectations, and perceived product on the occurrence of participation in JKN.

Relationship between the Age Characteristics of the Community Regarding JKN and Participation in JKN Health Insurance in the Toba District Area, 2022
After analyzing using the chi-square test, it was found that p=0.000< α=0.05, indicating that the null hypothesis (H0) is rejected, and the alternative hypothesis (Ha) is accepted.This suggests that there is a relationship between the age characteristics of the community regarding JKN and their participation in JKN health insurance in the Toba District in 2022.
These findings are consistent with the research conducted by Anom Dwi Prakoso (2020), which showed that older PBPU individuals had a higher likelihood of being willing to pay BPJS Health Insurance premiums (OR=24.57;p<0.001) (Prakoso & Sudasman, 2020).Additionally, male PBPU individuals had a higher likelihood of being willing to pay BPJS Health Insurance premiums (OR=96.23;p<0.001).In line with the study conducted by Lesmana & Sugiman (2020), age is related to the choice of BPJS Health Insurance coverage class.The majority of individuals above the age of 31 were registered as BPJS participants and were willing to pay premiums for class 2 and 3. On the other hand, individuals below the age of 31 tended to be unregistered as BPJS participants.
In contrast, a study by Hasmayanti (2021) found that after analyzing using the chi-square test, the p-value obtained was 0.459>0.05,indicating that the null hypothesis (Ho) is accepted.This means that there is no significant relationship between age and community participation in the JKN program in Dusun Batu Noni, Anggeraja Subdistrict, Enrekang District (Hasmayanti, 2020).
These various findings indicate that the relationship between age and participation in JKN may vary across different contexts and populations, highlighting the importance of considering local factors and characteristics when interpreting research results.

The Relationship between Gender Characteristics of the Community Regarding JKN and Participation in JKN Health Insurance in the Toba District Area, 2022
After analyzing using the chi-square test, the obtained p-value of 0.000< α=0.05 indicates that the null hypothesis (H0) is rejected, and the alternative hypothesis (Ha) is accepted.This indicates that there is a significant relationship between the gender characteristics of the community regarding JKN and their participation in JKN health insurance in the Toba District in 2022.
This finding is consistent with the research conducted by Anom Dwi Prakoso (2020), which demonstrated that gender is associated with the willingness to pay BPJS Health Insurance premiums.Male PBPU individuals have a 6.18 times higher likelihood of being willing to pay BPJS Health Insurance premiums (≥Rp 25,500) compared to female individuals (Prakoso & Sudasman, 2020).
Similarly, a study by Rhoza et al. (2016) found that male household heads are more likely than female household heads to make decisions to participate in national health insurance by enrolling in BPJS Kesehatan (Rhoza et al., 2016).
According to Mathauer et al. (2008), gender is one of the characteristics associated with the ownership of social health insurance among informal sector workers in Kenya.Males have a higher likelihood of enrolling in social health insurance schemes as they are often the family breadwinners in Kenya.
These findings collectively highlight the influence of gender on the participation in JKN health insurance and emphasize the need for gender-sensitive policies and interventions to ensure equitable access to healthcare services.

The Relationship between the Number of Family Members of the Community Regarding JKN and Participation in JKN
Health Insurance in the Toba District Area, 2022.
After analyzing using the chi-square test, the obtained p-value of 0.000< α=0.05 indicates that the null hypothesis (H0) is rejected, and the alternative hypothesis (Ha) is accepted.This suggests that there is a significant relationship between the number of family members of the community regarding JKN and their participation in JKN health insurance in the Toba District in 2022.
These findings are consistent with the research conducted by Hasmayanti, who found a similar relationship between the number of family dependents and community participation in the JKN program in the Dusun Batu Noni, Anggeraja Sub-district, Enrekang District (Lasut et al., 2021).The study showed that there is a correlation between the number of family members and community participation in the program, as larger family sizes imply a greater number of family members with needs that must be met (Hasmayanti, 2020).
However, these findings are not consistent with the research conducted by Puspitasari (2017), which found no significant relationship between the number of family members and participation in JKN among non-wage workers, with a p-value of 0.462 (Puspitasari et al., 2021).

The relationship between public knowledge about the National Health Insurance (JKN) and participation in the JKN health insurance program in the Toba District in 2020
After analyzing using the chi-square test, the obtained p-value of 0.000 is less than the significance level of 0.05.Therefore, the null hypothesis (H0) is rejected, and the alternative hypothesis (Ha) is accepted.This indicates that there is a relationship between public knowledge about JKN and their participation in the JKN health insurance program in the Toba District in 2022.
These findings are consistent with the research conducted by Salma Binti Purwaningsih (2015), which stated that 70 respondents (52.2%) had insufficient knowledge about JKN, while 64 respondents (47.8%) had good knowledge.The statistical test results show that there is a relationship between knowledge and participation in JKN (Binti Purwaningsih et al., 2016).
In contrast, the study by Eri Witcahyo (2016) found that the respondents had low knowledge about JKN.This was evidenced by 33.9% of non-JKN participants stating that they did not understand JKN.Additionally, 46.4% of non-JKN participants found the JKN procedures to be complicated.These were the reasons given by most of the 112 respondents for not participating in JKN.
High knowledge is influenced by education level.According to Gerungan higher education clearly affects a person's thoughts, opinions, decision-making, and actions, including planning for their family's health, such as participating in JKN.

The Relationship Between Public Perception of Healthcare Needs and Participation in the National Health Insurance (JKN) Program in the District of Toba, 2022
After analyzing the data using chi-square test, the obtained p-value of 0.000 is less than the significance level of α=0.05, leading to the rejection of the null hypothesis (H0) and the acceptance of the alternative hypothesis (Ha).This indicates that there is a significant relationship between the public perception of healthcare needs and the participation in the National Health Insurance (JKN) program in the District of Toba in 2022.
According to the Health Service Use theory proposed by Andersen in the study conducted by Debra et al. (2015), individuals' healthcare utilization behavior is determined by the severity of their illness and the perceived need for healthcare services (Aasi et al., 2015).As the severity of the illness increases, individuals have a greater need for healing and thus require healthcare services.Similarly, as the need for healthcare services increases, individuals have a higher desire to utilize those services.
However, these findings contradict the study by Salma Binti Purwaningsih (2015) (Binti Purwaningsih et al., 2016), which states that individuals with good knowledge about JKN will carefully consider joining the program, while those with limited knowledge may prioritize their daily needs over participating in JKN.

The Relationship Between Public Perception of Expectations Regarding the National Health Insurance (JKN) and Participation in the JKN Program in the District of Toba in 2022
After analyzing the data using chi-square test, the obtained p-value of 0.004 is less than the significance level of α=0.05, leading to the rejection of the null hypothesis (H0) and the acceptance of the alternative hypothesis (Ha).This indicates that there is a significant relationship between the public's perception of expectations regarding the JKN program and their participation in the JKN health insurance program in the District of Toba in 2022.
According to Parasuraman, Zeithaml, and Berry as cited in Qhisti's research (2015), assurance is the guarantee provided to consumers, which includes the staff's ability, politeness, and trustworthiness, as well as freedom from danger or risk.The behavior of employees is expected to build trust, and the company is expected to create a sense of security for its customers (Lusiana et al., 2019).In this study, the researcher used indicators including the staff's positive attitude, friendliness, and politeness in serving JKN patients.These positive attitudes and behaviors should start from the frontline, such as the registration counter, and should be consistently displayed to ensure patient satisfaction.The number of staff depends on the needs of the hospital in providing services (Cahyani & Katmini, 2021).
In terms of healthcare service implementation, the number of healthcare staff should also be adjusted to the healthcare services provided.For example, the number of diseases that can be treated in a hospital depends on the number of doctors, infrastructure, and supporting staff (Listiyana & Rustiana, 2017).The capabilities and skills of the hospital staff should be continuously improved to ensure excellent healthcare services.Currently, the abilities and skills of hospital staff are often measured based on their level of education, with the expectation that their education corresponds to their competencies.
Based on the research conducted by Widiastuti in 2015, 100% of respondents who received premium assistance from the government (PBI) expressed satisfaction with the healthcare services provided by community health centers (Puskesmas), possibly due to receiving financial support from the government.Additionally, the improved quality of Puskesmas due to ISO accreditation might also be a contributing factor.The only dimension of quality that was relatively lower in Puskesmas compared to the other three healthcare facilities (FKTP) was empathy, with only 89.58% of respondents in Puskesmas expressing satisfaction, while the other three FKTPs had a satisfaction rate of 100%.

The Relationship Between Public Perception Based on the Appearance of JKN Products and Participation in the JKN Health Insurance Program in Toba District in 2022
After analyzing the data using chi-square test, the obtained p-value of 0.161 is greater than the significance level of α=0.05, leading to the acceptance of the null hypothesis (H0) and the rejection of the alternative hypothesis (Ha).This indicates that there is no significant relationship between the public's perception based on the appearance of JKN products and their participation in the JKN health insurance program in Toba District in 2022.
In a study conducted at Langkapura Community Health Center in Bandar Lampung, it was found that the contribution of BPJS (Healthcare and Social Security Agency) in socializing the program was not significant.BPJS only conducted socialization when specifically invited by the parties interested in organizing it.The district and sub-district authorities were mainly involved in distributing BPJS cards to eligible recipients of premium assistance (PBI).Indirect socialization efforts were made through leaflets and banners displayed at Langkapura Community Health Center (Putri & Murdi, 2019).
These findings differ from the study conducted by Forman in 2009, which showed that among 15 respondents of the Jamkesmas program, 13 respondents (86.67%) perceived it positively due to the absence of additional fees and the ease of administrative processes.However, 2 respondents (13.33%) expressed a negative perception of the program due to their assessment of the service quality rather than the program itself

Conclusion
Based on the research findings regarding the relationship between public perception of the National Health Insurance (JKN-KIS) and their participation in the JKN-KIS program in the working area of Minasa Upa Community Health Center, it can be concluded that there is a relationship between age, gender, family size, knowledge, perceived needs, expectations, and the appearance of JKN-KIS products with the participation in the National Health Insurance in Kabupaten Toba.Therefore, it is recommended for the BPJS Kesehatan agency to maintain and improve the quality of their services, which can be achieved through the five dimensions of service quality: tangible, reliability, responsiveness, assurance, and empathy.

Table 1 .
Frequency Distribution of Characteristics of the Community in Toba District, Year 2022

Table 2 .
Frequency Distribution of Knowledge of BPJS Kesehatan Participants in Toba District

Table 3 .
Frequency Distribution of Community Perception of JKN Needs in Toba District

Table 4 .
Frequency Distribution of Community Perception of JKN Expectations in Toba District

Table 5 .
Frequency Distribution of Product Appearance of JKN in Toba District

Table 6 .
Frequency Distribution of Community Participation in Toba District

Table 7 .
Relationship between Age, Sex, Number of Family Members, Knowledge, the Community's Needs and the Community's Expectations of the Community Regarding JKN and Participation in JKN Health Insurance in Toba District, Year 2022