Understanding patient satisfaction and loyalty in public and private primary health care.

Background: The quality of health centers, patient satisfaction, and loyalty are three key factors that enable health care providers to improve their services and cost-effectiveness. This study, therefore, aims to determine patient satisfaction and loyalty in public and private primary health care centers. Design and
Methods: Data were obtained from a cross-sectional design of 1470 self-administered questionnaires and analyzed based on mean, standard deviation, and correlation coefficients.
Results: The results showed respectively a strong and moderate correlation between patient satisfaction and loyalty in private (r=0.767) and public (r=0.54) primary health care centers, respectively. In addition, in both centers patients received adequate medical services, with social aspects as the least important factors affecting patient satisfaction. Conclusions: In conclusion, primary health care practices need to recognize the needs that influence patients' satisfaction and loyalty, to improve the quality of their services. ©Copyright: the Author(s).

Introduction

Competition among health care centers helps to improve the quality of their services and promotes innovative interventions, thereby benefiting patients as consumers. Health care management facilities are guided by professionals and collaborate with insurance companies in accordance with the various compliance laws. Furthermore, when health insurance is properly regulated with equal benefits provided to providers and patients, the competition also increases. According to studies, private healthcare services received more patient satisfaction compared to public hospitals. Consequently, private care is more competitively aggressive in achieving its target patients.[1-3]

The quality of health centers, patient satisfaction, and loyalty are three key factors that enable health care providers to improve its services and cost-effectiveness. Studies showed that the following important factors influence patient satisfaction: (1) timely visit, (2) compassionate professionals, (3) accurate medical bills, (4) effective communication skills, (5) promptness in delivering health services, and (6) willingness to support others. Patient satisfaction also affects other dimensions of healthcare services, including retention, which is the key factor that determines their willingness to return to the same center. In addition, the provision of high standard health services, motivation, and showing appreciation help to retain patients.[4-7]

Other factors that determine their willingness to return to the same health center or make positive recommendations include loyalty, trust, and satisfaction. Therefore, it is important to determine the driving forces that influence patients’ willingness to return for more services in order to implement effective strategies for maintaining their loyalty.[8]

Trust is an important predictor of patient loyalty to doctor in primary health care centers. It has been demonstrated to have a positive effect on health outcomes, including a willingness to seek treatment from previous medical personnel and adherence to prescribed medicines. Therefore, trust is the fundamental aspect of doctor-patient relationship aides emotional support, public norms and a qualified, competent person.[9,10]

Irrespective of the numerous barriers associated with accessing adequate health services, primary health care (PHC) remains a keystone of providing essential public services in a community. PHC delivers integrated patient care with adequate funding, wellmanaged, and high-quality services. This strategy tends to create a long term doctor-patient relationship, thereby generating more profits.[11,12] The key steps for strengthening primary health care include delivering a better quality of health services, ensuring the fairness of National Health Insurance, providing competent family doctors, and effective management. The Indonesian government supports primary health care services under the National Health Insurance.[13]

In Indonesia, the provision of adequate health care depends on public and private hospitals. However, the Indonesian government has set accreditation standards for measuring these qualities, including the need to collaborate with national health insurance. In addition, PHC need to prepare, improve, maintain their facilities and deliver services based on scientific knowledge and evidencebased practice.[13]

The Indonesian national health insurance benefits cover patients in a wide variety of services, and its system is directly linked to referrals. In addition, patients are able to access all public and private health care services, which have a contract system with Indonesian National Health Insurance. Approximately 75% of the total populations in Indonesia are covered by this insurance, which helps to regulate, maintain, keep its contract system, credit, and conduct appropriate services.[14] Other existing studies ascertained that 55% of patients were satisfied with the primary care services provided, and the majority of the complaints stemmed from issues regarding the National Health Insurance practices.[15,16] Therefore, this study aims to investigate patient satisfaction and loyalty in public and private primary health care.

Design and Methods

An analytic observational study with a cross-sectional design was used to measure patient satisfaction and loyalty in primary health care. The simple random sampling method was used to collect data from 470 respondents chosen in two types of primary health care, with patient satisfaction and loyalty measured by selfadministered questionnaires that were tested for validity and reliability. All respondents were informed of the risks involved in carrying out the research before participating and free to withdraw at any time without giving reasons. Research approval was obtained from the Health Ethics Committee of the University of Muhammadiyah Malang in April 2019. The data obtained were analyzed based on mean, standard deviation, and correlation coefficients in SPSS 22 to determine the correlation between patient satisfaction and loyalty in public and private primary health care centers.

Results and Discussion

The results showed characteristics of respondents in private and public PHC while analyzing the mean score, SD, and crosstabulation in accordance with patient satisfaction, loyalty, and correlation analysis, as shown in Tables 1-4.

Table 1 shows that most patients in both private and public PHC were female above 45 years and without the intention of leaving. Additionally, 75% of patients that attend private PHC had employer-based subsidy health benefits, which provides them with the option to choose the right membership suitable for their primary health care services. Therefore, patients easily move to other types of health services without proper consent and notification, and this leads to constraints on health care providers and additional capital payments.[14] The government has heavily subsidized all patients in public PHC for health insurance coverage. The public sector tends to provide easy access to health services by enabling people to take advantage of National Health Insurance and meeting with qualified family doctors. Conversely, private PHC tend to prescribe more types of drugs which are expensive and inappropriate with patient conditions.[17,18]

Table 1.

Characteristics of respondents in private PHC and public PHC.

Indicator	Category	Private PHC		Public PHC
		n	%	n	%
Age	<30 y.o	270	27.3	90	18.8
	31-45 y.o	630	63.6	180	37.5
	>45 y.o	90	9.1	210	43.7
Sex	Male	270	27.3	0	0
	Female	720	72.7	480	100
History of leaving PHC	No	990	100	480	100
	Yes	0	0	0	0
Membership status of health insurance	Government-based subsidy	0	0	16	100
	Employer-based subsidy	25	75	0	0
	Individual plans	8	25	0	0

The majority of patients stated that they were satisfied with their visits with doctors in both private and public PHC, as shown in Table 2. However, they were more satisfied with the biological and psychological aspects of M (SD) at 15.12 (1.05) and 14.33, respectively, provided by doctors in private PHC in comparison to the public. The social aspects were the least important factors affecting patient satisfaction in both health centers. Predictors of patient satisfaction include physical-psychological wellbeing and patients involved in decision making (P<0.00001). Other factors that contribute to satisfaction were age (P<0.02), care coordination (P<0.01), support from family, friends and relatives (P < 0.0001), and care continuity (P<0.001).[19] Several studies on better continuity of care, human resources, and comprehensive care were performed more in the private PHC. Meanwhile, public PHC ensures more access to health care services and facilities.[20-23] However, another study found that the quality of health care professionals might be influenced by delayed insurance payments, lack of competent doctors and inequality in the geographical distribution of health care.[24]

Table 2.

Mean, SD, cross-tabulation of patient satisfaction in private PHC and public PHC.

Indicator	Private PHC Mean (SD)	Responses (n, %)			Public PHC Mean (SD)	Responses (n, %)
		Very satisfied	Satisfied	Dissatisfied		Very satisfied	Satisfied	Dissatisfied
Biological aspect	15.12 (1.05)	840 (84.85)	150 (15.15)	0 (0)	14.94 (0.77)	270 (56.25)	210 (43.75)	0 (0)
Psychological aspect	14.33 (1.34)	780 (78.79)	210 (21.21)	0 (0)	13.75 (1.18)	300 (62.5)	180 (37.5)	0 (0)
Social aspect	12.36 (1.52)	600 (60.61)	390 (39.39)	0 (0)	12.94 (1.29)	240(50)	240(50)	0 (0)

Patient satisfaction is examined in four areas as follows: (1) analyze complaints and feedback, (2) hire capable workers, (3) evaluate outcomes of patients lost to follow-up, and (4) conduct a survey on their satisfaction in particular health services.[25] Private PHC reported significantly higher levels of patient satisfaction (73%) when compared to the public (52%). Furthermore, they deliver the most appropriate health care staff, opening hours, and comfortable facilities (OR 4.30; 95% CI: 3.29±5.62) with adequate privacy (OR 1.68; 95% CI: 1.28±2.21).[26] Patient satisfaction was also directly and positively affected by doctor’s behavior to improve disease, socioeconomic factors, quality of care, and their involvement during the treatment.[27-30]

Patient loyalty is a key to the success of healthcare professionals and hospital management. According to research, private PHC received more patient loyalty compared with its public counterpart. This study used three different aspects of care to measure patient loyalty, namely: (1) attending PHC with similar, (2) attending PHC with different cases, and (3) making recommendations for other PHC. The results from Table 3 showed that patients attending PHC with the same cases had the highest mean score of 10.91 (1.77) in private and 11.13 (1.20) in public. However, they were reluctant to make recommendations for other people to attend both types of PHC. Studies have shown that patients’ willingness to make referrals to certain health care providers was influenced by providing the right incentives.[25] The results from Table 4 show a strong correlation between patient satisfaction and loyalty in private PHC (r= 0.767). A value of 0.54 indicates a moderate correlation between patient satisfaction and loyalty in public PHC through the provision of high-quality biological and psychological aspects of care. Patient loyalty tends to continue as long as they receive better services compared to other health care providers. Therefore, further steps need to be taken to enhance patient-centered principles in primary health care services.[31,32]

Table 3.

Mean, SD, cross-tabulation of patient loyalty in private PHC and public PHC.

Indicator	Private PHC Mean (SD)	Responses (n, %)			Public PHC Mean (SD)	Responses (n, %)
		Very loyal	Loyal	Not Loyal		Very loyal	Loyal	Not Loyal
Attending PHC with similar cases	10.91(1.77)	810 (81.82)	180 (18.18)	0 (0)	11.13 (1.20)	330 (68.75)	150 (31.25)	0 (0)
Attending PHC with different cases	10.85 (1.09)	840 (84.85)	150 (15.15)	0 (0)	9.94 (1.77)	270 (56.25)	210 (43.75)	0 (0)
Making recommendations for others	8.18 (1.96)	660 (66.67)	210 (21.21)	120 (12.12)	7.38(1.41)	120 (25.00)	270 (56.25)	90 (18.75)

Table 4.

Correlation analysis between patient satisfaction, and loyalty in private/public PHC.

Correlations	Sig. value	Correlation coefficient	Interpretation
Satisfaction-loyalty in private PHC	0.000	0.767	Strong correlation
Satisfaction-loyalty in public PHC	0.001	0.54	Moderate correlation

Conclusions

In conclusion, primary health care practices need to recognize the various obligations that influence patient satisfaction and loyalty, which in turn affects the quality of services. By identifying these strengths and weaknesses, health care providers can allocate adequate resources to enhance the quality of their service. Therefore, the public health care needs to improve its services to achieve excellent quality and attract more patients.