The effect of the availability of paying places on the regularity of paying the National Health Insurance (NHI) contributions of independent NHI participants post the policy of increasing contributions in Muna district, southeast Sulawesi province

Currently, Social Security Administrator (SSA) Health is still facing big problems in the form of non-compliance and regularity in paying public health insurance contributions. The low compliance with paying NHI contributions will have an impact on the availability of funds in health services. The purpose of this study was to determine the effect of the availability of a place to pay with the regularity of paying dues for independent NHI participants after the increase in fees in Muna Regency, Southeast Sulawesi. This type of research is quantitative research using a cross sectional study design. This research was conducted in Muna Regency in 2021, with a total sample of 98 people. Sampling using side purposive technique. Data analysis was carried out univariate and bivariate. Presentation of data in the form of frequency distribution accompanied by explanations. The results showed that there was no effect of the availability of payment facilities on the regularity of paying dues for independent NHI participants after the contribution increase policy in Muna Regency, Southeast Sulawesi Province with a value of p = 0.095 (p>0.05). Conclusion; there is no effect of the availability of payment places on the regularity of paying the contributions of independent NHI participants. Recommendation; the need for SSA to increase cooperation with service providers for payment of contributions so that the community does not have difficulty paying NHI contributions.


Introduction
If you look at the records in the health profile, it is found that in general the world's population is suffering and increasing cases of death are caused by lack of access to basic health services. It is estimated that there are as many as 150 million people every year in low and middle income countries experiencing suffering as a result of health expenditures and there are as many as 100 million people or the equivalent of three people every second experiencing poverty as a result of self-financing for their health [1]. Therefore, the presence of the national health insurance program can be seen as a solution to achieve an increase in health status for the entire population by ensuring that all people can receive quality health services without experiencing financial difficulties. To avoid cost constraints, an insurance system was developed in an effort to achieve Universal Health Coverage [2].
Currently the main problem in public health, where the government as the organizer of government and international health organizations around the world is a challenge in terms of health financing. For most countries, this challenge is due to weak health financing policies. The strategy is recommended to deal with issues related to international health policy, implementation of various program interventions including the formulation of health insurance policies to maintain public health [3]. The World Health Organization encourages all countries to develop health insurance for the entire population [4]. National health insurance is an important way to achieve an increase in public health status by ensuring that all people can receive quality health services according to their needs and desires, without experiencing financial difficulties [1]. To avoid cost constraints, an insurance system was developed in an effort to achieve Universal Health Coverage (UHC) [5].
Currently, Indonesia is ranked 101 out of 149 countries that have the lowest health index. In Southeast Asia, Indonesia's health status is below that of Thailand, Malaysia, Vietnam, and Laos. This means that the health status of the Indonesian people is still far behind compared to neighboring countries, so it must get more attention from the government to improve health services and insurance, where the government has a major role in regulating, fostering and supervising every activity to achieve equitable health throughout the world. territory of the Republic of Indonesia [6].
Currently, the number of SSA health memberships in Indonesia continues to increase despite the fact that it is not matched by participant compliance in paying contributions. The development of membership coverage continues to increase where in 2019 there were 222, 02, 996 people, in 2020 there were 222.4 million people and in 2021 it had reached 229,514,068 people. This shows that there is a significant increase in the number of participation in the national health insurance in general [7].
Since the beginning of its implementation, the NHI program has continued to run a deficit. In fact, the deficit is predicted to reach IDR 28 trillion by the end of 2019 [7]. According to SSA health, the deficit is caused by the high number of people suffering from chronic diseases so that the cost of health services increases. The high health burden is not matched by an adequate amount of contributions. If this deficit problem is not addressed immediately, it will have an impact on decreasing the quality of health services, the trust of service providers and service users so that the welfare of the community will decrease. If the deficit problem is not immediately addressed, UHC will be difficult to achieve. The problem of the NHI deficit at the national and regional levels has a pattern that is almost the same, including the problems, namely the contribution of contributions which is still low, far below the claims for the guarantees provided and the lack of compliance of participants in paying contributions, especially in the category of Non-Wage Recipient/independent Workers [8].
To overcome this problem, the Government has increased the dues for all classes, both contributory and independent recipients of assistance. The amount of contributions that must be paid by NHI participants is based on the provisions stipulated by Presidential Regulation Number 75 of 2019 concerning Presidential Regulation Number 82 of 2018 concerning Health Insurance which was signed by President Jokowi on 24 October 2019. This Presidential Regulation regulates the amount of contributions for the poor who are classified as In the Contribution Assistance Recipient (CAR) Participant segment, it is set at Rp.42,000 per person per month, up from the previous Rp.23,000. The second segment is Non-Wage Recipient Workers and Non-Employees or better known as independent participants also underwent adjustments. Independent class 3 participants are IDR 42,000 per person per month, an increase from the previous IDR 25,500. Class 2 is set at Rp.110,000 per person per month, up from the previous Rp.51,000. Class I is Rp.160,000 per person per month, up from the previous Rp.80,000 [9]. As a result of the increase in fees, not a few NHI participants have proposed lowering their service class. According to the President Director of SSA health, 372,924 participants who dropped out of service class. A total of 153,466 participants or 3.5% dropped from class I and 209,458 people or 3.3% dropped from class II [7].
In the Muna Regency area, the number of NHI participants was recorded as of December 31, 2019 as many as 225,628 people. NHI CAR participants who received allocation of state revenue budget funds were 100,850 people, NHI CAR participants who received allocations of regional expenditure budget Regency/city funds were 81,272 people. NHI CAR participants who received allocations of Provincial regional expenditure budget funds were 2,486 people. While the number of Civil Servant Wage Recipients is 30,014 people. Wages Recipients Private employees are 777 people. Non-Wage Recipient Workers as many as 6,255 people and Non-Workers as many as 3,974 people [10]. Muna Regency is one of the regencies that achieved UHC, but with the increase in NHI contributions since July 2021, people feel their inability to pay NHI contributions, this has an impact on non-compliance and regularity in paying contributions. Data as of October 31, 2021, shows that the total number of independent NHI participants is 6,454 with arrears status of 4,244 people, far more than the non-arrear status of 2,199 people [10].
Before the research is conducted, an initial survey is conducted to find out the problems that occur in the field, which can be used as a basis for conducting research. The results of the initial survey showed that there were several problems that occurred, such as the large number of arrears of independent NHI contributions, some unresponsive NHI Independent owners who were in an inactive condition due to frequent arrears in contributions, the large number of arrears causing participants to be unmotivated to pay contributions, and the increase in NHI contributions became an additional burden. for independent NHI participants during the covid-19 pandemic. The purpose of this study was to determine the effect of the availability of a place to pay on the regularity of paying dues for independent NHI participants after the increase in fees in Muna Regency, Southeast Sulawesi in 2021.

Material and methods
This type of research is quantitative research using a cross sectional study design. The cross sectional research design is a research design by measuring at the same time by measuring the independent and dependent variables. This research was carried out in Muna Regency in 2021, with a research sample of 98 people. Sampling using side purposive technique. Purposive sampling is a sampling technique based on the consideration of the researcher by establishing special characteristics that are in accordance with the research objectives so that it is expected to be able to answer research problems [11]. Data analysis was carried out univariate and bivariate. Presentation of data in the form of frequency distribution accompanied by explanations.

The place of payment
Payment Points are the availability of adequate payment points that have collaborated with SSA Health and are easily accessible so that they can obtain NHI contribution payment services and are guaranteed by SSA Health. The distribution of respondents based on the place of payment for independent NHI participants after the contribution increase policy in Muna Regency, Southeast Sulawesi Province, is as presented in table 1.  Table 1 shows that out of 98 respondents (100%), most of the respondents said that there were 58 respondents (59%) available for independent NHI contribution payments, and a small number of respondents said that there was no place for independent NHI contribution payments to be made. that is equal to 40 respondents (41%).

Regularity of Paying Dues
Regularity in paying NHI contributions is an act of regularity or punctuality in paying National Health Insurance contributions by respondents, where the payment time has been determined no later than the 10th of each current month as stipulated in the 2021 Presidential Regulation. The distribution of respondents is based on the regularity of paying NHI participant contributions. independently, is presented in table 2.  Table 2 shows that of the 98 respondents (100%), most of the respondents are not regular in paying NHI contributions, namely 54 respondents (55%), and a small proportion of respondents who regularly pay contributions are 44 respondents (45%).  The effect of the availability of payment points on the regularity of paying dues for independent NHI participants after the contribution increase policy, using the Chi Square statistical test, obtained a p-value = 0.095 (p>0.05), so Ha is rejected and it is interpreted that there is no effect of the availability of payment places on the regularity of paying dues for independent NHI participants after the policy of increasing contributions in Muna Regency, Southeast Sulawesi Province.

Bivariate Analysis
A big dilemma faced by the government, the NHI budget deficit has increased from year to year. The burden of health services also experienced the same thing. On the one hand, health services are required to provide optimal health services, marked by better service quality and increasing community satisfaction. In the midst of a dilemma, the government through Presidential Regulation Number 64 of 2020 concerning the Second Amendment to Presidential Regulation Number 82 of 20I8 concerning Health Insurance, in which the regulation changes the NHI contribution rate by increasing the amount of contributions for all classes of NHI services. With the issuance of these regulations, there was controversy in the community. The government received a sharp spotlight, especially the SSA which was considered irrational for the increase in contributions. The urge to review the policy continues to emerge, for various reasons, for example, dues will burden the community during the Covid-19 pandemic, health services do not provide optimal services, SSA transparency does not exist, and service inefficiencies continue to increase.
The government's decision to increase NHI contributions with the reason to increase state revenues and reduce the burden on the state budget in 2021, however, this policy is considered very burdensome to the community due to the Covid-19 pandemic situation. The place of payment of contributions has a relationship with the continuity of healthy fund participation. Healthy fund participants who can access the place for payment of contributions will increase the continuity of being a participant of the healthy fund but on the contrary, healthy fund participants who have difficulty in accessing the place for payment of contributions will reduce their continuity of being a participant of the healthy fund [12] The research findings as presented in table 1 show that, in general, the independent NHI participants stated that there were more places for payment than the independent NHI participants who stated the unavailability of the NHI dues payment. This shows that the more availability of places for payment of contributions, the easier access to places for payment of NHI contributions will be, on the contrary, the less places for payment of NHI contributions, the more difficult it will be to access places for payment of NHI contributions. This happens because the availability of payment places affects the ease with which participants pay NHI contributions, because one of the problems often faced by independent NHI participants in paying NHI contributions is the difficulty and the unavailability of easily accessible places for payment of contributions. However, with the availability of many and easily accessible places for payment of contributions, it will encourage people to comply and be willing to pay dues voluntarily.
Another factor that also affects the regularity of paying NHI contributions is the distance to the place of payment. Distance to the place of payment of contributions is one of the factors that encourage a person to be regular in paying NHI contributions. Therefore, for the convenience of SSA Health services, it is necessary to cooperate with various service providers for payment of contributions with the aim of making it easier for NHI participants to access these payment points. Likewise, in considering the distance traveled by participants to the nearest payment place from the community's residence, it is necessary to pay attention to the payment service provider. In fact, there is an influence on the availability of places, mileage and travel time for service places with regular payment of dues, where someone who will pay dues has previously thought and sorted out how to find and find a place to pay dues according to their wishes and desires.
To improve SSA services that are more efficient, effective and accessible to all levels of society, the availability of a place to pay NHI contributions is a must. So with the availability of a place to pay NHI contributions, it will make the payment process easier. The place of payment of contributions has a relationship with the continuity of healthy fund participation. Healthy fund participants who have easy access to the place for payment of contributions will increase the continuity of healthy fund participation, but on the other hand if healthy fund participants have difficulty accessing the place for payment of contributions, it will reduce the continuity of healthy fund participation [12] The findings in table 2 show that generally there are more independent NHI participants who do not regularly pay independent NHI contributions than those who regularly pay independent NHI contributions. This shows that even though there are many places for payment of contributions and they are easily accessible, it does not necessarily mean that NHI participants will pay NHI contributions regularly, this is because there are other factors that influence a person to pay NHI contributions regularly, such as sufficient income, bad perceptions. for the health services they receive, family support, and the benefits of health services as well as easy access to places of payment.
One of the determinants of regularity in paying NHI dues is the availability of a place to pay NHI dues. A place for payment of NHI contributions as a form of public service provided by the government or private parties who have collaborated with the SSA with the aim of facilitating SSA services. Therefore, it is hoped that the availability of adequate and easily accessible payment points for the entire community will improve compliance and regularity in the payment of NHI contributions. It is also hoped that independent NHI participants who have the obligation to pay NHI contributions can take advantage of payment places that have collaborated with SSA Health.
From the results of statistical tests using Chi Square, p-value = 0.095 (p>0.05), so Ha is Rejected. This shows that there is no effect of the availability of payment facilities on the regularity of paying dues for independent NHI participants after the contribution increase policy in Muna Regency, Southeast Sulawesi Province. The results of this study are in line with research conducted by [13] in Mempawah Regency, West Kalimantan with p = 0.701 that there is no relationship between the distance of the respondent's residence and compliance with paying dues. Research conducted by [14] said that there was no relationship between distance to the place of payment and compliance with paying NHI contributions to independent participants in Bontomatene District, Selayar Islands Regency. Research conducted by [15] found that there was no significant relationship between education level, distance traveled to the place of payment of contributions and number of dependents on compliance with NHI contribution payments for independent participants. However, these findings are not in line with the results of research conducted by [16] in Nunukan Regency that the distance to the place of payment of contributions/geographical location of the place of payment of contributions has a significant relationship with the compliance of independent participants in paying contributions to the NHI program.
From the findings during the research, it was also found that respondents who said that payment facilities were available, most of the respondents did not regularly pay contributions compared to those who regularly paid NHI contributions. Meanwhile, respondents who stated that payment facilities were not available, most of the respondents regularly paid contributions compared to those who did not regularly pay contributions. This condition shows that the availability of an easily accessible place to pay NHI contributions does not necessarily motivate someone to pay regular NHI contributions, because there are other factors that also affect the regularity of paying independent NHI contributions such as income ability, understanding of health, knowledge and so on. Availability of places to pay NHI contributions such as ATM central, nearest banks, counter stalls, post offices, and minimarkets. Thus, although the variable where the contribution is paid does not have an influence on the regularity of paying independent NHI contributions, but efforts to increase the availability of easily accessible places for payment of contributions need to be paid attention to by the SSA.
Another condition that affects the ease of access to the place of payment is the travel time to the place of service. Travel time is the time it takes to travel a certain distance to a place. Travel time is closely related to the distance traveled so that the travel time to the place of payment of contributions is one of the determinants of health insurance participants in increasing the regularity of paying NHI contributions. Likewise, the distance to the place of payment of contributions has a relationship with the regularity of payment of healthy fund contributions, for participants who have close distances to the place of payment of contributions, it will increase the regularity of healthy fund participants in paying contributions and increase the continuity of healthy fund participation, and vice versa for participants who have long distances to the place of payment of contributions, it will reduce the regularity of healthy fund participants in paying contributions. Shorter travel time to the place of payment of contributions will increase the regularity of healthy fund participants in paying contributions, whereas participants who have a longer travel time to the place of payment of contributions will reduce the regularity of healthy fund participants in paying contributions, Kertayasa, (2010) in [17].

Conclusion
There is no effect of place of payment with regularity in paying contributions to independent NHI participants after the policy of increasing the contribution in Muna Regency, Southeast Sulawesi Province with a value of P-Value = 0.095 (p>0.05). Recommendation; the need for SSA to increase cooperation with service providers for payment of contributions so that the community does not have difficulty paying NHI contributions.