Behavioral Analysis of Health Service use of the Ilaga Community Health Center, Puncak Regency Central Papua Province

The aim of this research is to analyze utilization behavior service health, Ilaga District Community Health Center, Puncak Regency, Central Papua Province. The type of research used is descriptive qualitative. Data was obtained using interviews and analyzed qualitatively. The results of the research showed that people seeking treatment in the Ilaga District used the Community Health Center as a place for treatment and as a referral place to other health service institutions (referrals) so that the community was enthusiastic in utilizing the Community Health Center services. Not all people have health insurance due to low knowledge and lack of support from health workers in assisting health services in arranging membership for the National Health Insurance Social Security Administering Body (BPJS). Security disturbances disrupt the accessibility of community health services in the event of conflict, especially from armed criminal groups.

The aim of this research is to analyze utilization behavior service health, Ilaga District Community Health Center, Puncak Regency, Central Papua Province.The type of research used is descriptive qualitative.Data was obtained using interviews and analyzed qualitatively.The results of the research showed that people seeking treatment in the Ilaga District used the Community Health Center as a place for treatment and as a referral place to other health service institutions (referrals) so that the community was enthusiastic in utilizing the Community Health Center services.Not all people have health insurance due to low knowledge and lack of support from health workers in assisting health services in arranging membership for the National Health Insurance Social Security Administering Body (BPJS).Security disturbances disrupt the accessibility of community health services in the event of conflict, especially from armed criminal groups.

INTRODUCTION
The era of enactment of Law Number 2 of 2021 concerning the Second Amendment to the Special Autonomy for the Provinces of Papua and West Papua begins with Law Number 21 of 2001 concerning Special Autonomy for the Province of Papua.Apart from being aimed at improving the previous law, this law was also implemented to ensure the continuity of providing special autonomy funds for the Provinces of Papua and West Papua, as well as accelerating development and increasing equitable development in Papua.One of the new mandates from this law is that revenues within the framework of Special Autonomy must be used based on a master plan that prioritizes the principles of good financial management.
Health is one of the service sectors that has a specific nature in the implementation of Special Autonomy in Papua, where the performance of development implementation during the 20 years of the implementation of Special Autonomy is still far from expectations.There are many factors that cause the performance of health services in Papua to remain low compared to other regions, including those related to the number of health facilities and personnel, governance of health facilities and personnel, geographical conditions, transportation facilities and infrastructure, supporting facilities and infrastructure, public awareness, and others.The preparation of a master plan for the future, especially in the field of good and realistic health services, is of course expected to be a key solution in resolving health service problems in Papua (Sumule et al., 2022).
Infrastructure problems and unequal distribution of health workers are the roots of problems that cause each other.In the provinces of Papua and West Papua, not all districts/cities have Regional General Hospitals (RSUD).Community health centers generally tend to be concentrated in urban areas or districts that have existed for a long time.The unavailability and operation of Regional General Hospitals (RSUD) in several districts means that people have to be referred to hospitals in other districts.This condition certainly has implications for quite high operational costs.Sick people seeking treatment will also usually be accompanied by family or companions.The cost of accessing health services is becoming increasingly expensive.Unequal distribution also occurs for health workers.
Health workers are more focused on hospitals or health centers in the city center.Even in several districts, the number of health workers, including medical personnel, is very minimal.Many Regional General Hospitals (RSUD) and Community Health Centers do not have specialist doctors or even general practitioners.One of the factors that contributes to the lack of doctors in remote locations is security and safety factors (Sumule et al., 2022).
Report from the Indonesian Central Bureau of Statistics in 2022, the number of hospitals in Indonesia was 3,072, an increase of 0.99% compared to 2021, which was 3,042 units.Public Health Centers in Indonesia will reach 10,292 units in 2021 and in 2022 there will be an increase of 10,435 Community Health Centers.
The results of the 2018 Basic Health Research stated that easy access to Health service facilities are related to distance and timetaccess to health facilities in addition to socio-economic and cultural status.In terms of travel time to health service facilities, 67.2% of the population can reach health service facilities in less than or equal to 15 minutes and 23.6% can reach health facilities in 16-30 minutes, while the rest need more than half an hour to reach health facilities. .Meanwhile, distance shows that 94.1% of households are less than or equal to 5 km from health service facilities and only 6% are more than 5 km away (Ministry of Health of the Republic of Indonesia, 2019).
Naumi's research (2018) states that 14.3% of residents who live far away always use the community health center, while the population who live close to the community health center and always use the community health center is 51.9%.This means that the reality of distance and transportation becomes an obstacle for people to reach the health center so that more people who live nearby visitthanpeople who live far away.In addition, factors related to the use of community health centers are individual characteristics (age, education and perception of illness), health service providers (availability of health personnel) and accessibility (distance and means of transportation).
Factors that identify and potentially influence a person to utilize health services according to Green in Notoatmodjo (2007) are predisposing factors which include knowledge, attitudes, beliefs, beliefs, values and perceptions, enabling/supporting factors, namely the availability of facilities.health/health facilities, affordability, distance and transportation facilities and factors reinforcing/reinforcement that is manifested in the attitudes and behavior of health workers or is support from leaders, community figures, family and parents.
Research by Sandora et al., (2021) explains that the use of health service facilities is influenced by several things, including decreasing people's purchasing power, decreasing people's interest in seeking treatment because they feel dissatisfied with the service, dissatisfied with the quality of the medicine they obtain and dissatisfied with the rates.services, geographical access to health services is difficult.People who are better able to utilize health service facilities are twice as likely as people who cannot afford them.This situation illustrates that people who cannot afford to have limited access to utilize health service facilities.
The Puncak Papua Regency Health Service reports that the ratio of community health centers to population in 2022 will be 6.9 per 100,000 population.There was a decrease of 0.2 per 100,000 population from the previous year's ratio (7.1) assuming that each community health center served 14,525 residents.The decrease in this ratio was due to the increase in population while the number of community health centers remained the same.Apart from that, to ensure equality and affordability of health service facilities for the community, several Pustu (Subsidiary Health Centers) have been built in villages and even in hamlets, which by 2022 will number 37 Pustu.The ratio of sub-community health centers to population is 19.6 per 100,000 population.
The results of the initial study in Ilaga District showed that the number of people who used health services in 2020 was 3,530 patients, in 2021 there were 6,610 patients and in 2022 there were 2,700 patients and in January -June 2023 there were 2,100 patients.This is thought to be closely related to factors that influence patients as service users to reuse Ilaga District services.Apart from that, as reported by Kompas.com,there is a threat of security problems from armed criminal groups who vandalized government building facilities including the Community Health Center building and also attacked civilians and health workers, which recently occurred around August and October 2023 (Katingka, 2023).
Based on these problems, researchers are interested in conducting research with the title "Behavior Analysis of Utilization of Health Center Health Services in Ilaga District, Puncak Regency, Central Papua Province"

THEORETICAL REVIEW Behavior Definition
Based on the Big Indonesian Dictionary, the definition of behavior is an individual's response or reaction to stimuli or the environment.Reporting from the Ministry of Health website, based on psychology, behavior has concrete meaning from the soul.In this context, human behavior is specifically divided into two, namely: Closed behavior, behavior that can only be understood by using certain tools or methods, for example thinking, sadness, fantasizing, and so on.Open behavior, behavior whose meaning can be directly known.The basis of human behavior is because there is encouragement from within.A business because there is a need.So behavior occurs because of the urge to fulfill needs.It can be concluded that behavior is human activity or activity that arises due to stimulation, whether it can be observed directly or indirectly (Gischa, 2021).
Behavior according to language is an action, deed or pattern of behavior that comes from the syllable behavior.Behavior is a complicated thing to formulate because human behavior is not a constant thing but is always developing and is not only determined by organic biological systems or instincts but is also determined by the human mind and soul.Behavior is a function of the interaction between an individual and his environment.This means that an individual and their environment will directly determine the behavior of the person concerned.Therefore, the behavior of one individual and another will differ according to their respective environments (Rosita, nd).

Health services
Health servicesis any form of activity and/or series of activitiesservicewhich is given directly to individuals or communities to maintain and improve their statusHealthcommunity in the form of promotive, preventive, curative, rehabilitative and/or palliative (Law no.17 of 2023About health)

Community Health centers
Community Health Center is a functional health organization unit which is a center for community health development which also fosters community participation in addition to providing comprehensive and integrated services to the community in its working area in the form of main activities (dinkes.inhukab.go.id, 2018).Puskesmas (Public health center) has supporting units, including auxiliary health centers and mobile health centers, auxiliary health centers, namely health service units that are simple and function to support and help carry out the activities carried out by the puskesmas (Public health center) within a smaller area (dinkes.inhukab.go.id, 2018).
Referring to Putri et al., (2017) Puskesmas (Public health center) 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.Puskesmas (Public health center) plays a role in development health-oriented in the region with the aim of creating a society that has healthy behavior (awareness, willingness and ability to live healthily); able to access quality health services, live in a healthy environment; and have optimal levels of health, both individuals, families, groups and communities.Putri et al., (2017) continued, it was said that in carrying out its functions, community health centers are obliged to implement health policies to achieve health development goals in their work areas and create healthy sdistricts.Structurally or administratively, the Community Health Center is under the administration of the district regional government, where technical guidance is provided by the Regency/City and Provincial Health Services.The regulations state that the Puskesmas (Public health center) functions as a provider of health services in the form of public health efforts (UKM) and individual health efforts (UKP).The position of the Puskesmas (Public health center) as the "organizer" of health services confirms that the Puskesmas (Public health center) is the first level Technical Implementation Unit of the Health Service.The Regency/City Health Service is responsible for implementing government aspects in the health sector in the district/city (Putri et al., 2017).

METHODOLOGY
The research design used in this research is qualitative research.According to Moleong (2017) qualitative research is a research procedure that produces descriptive data in the form of written wordsnorverbalization of people's observable behavior.This research seeks to provide an analytical picture of utilization behaviorserviceHealth Center in Ilaga District, Puncak Regency, Central Papua Province.
In every research, it is necessary to have informants or sources related to the research by interviewing them.According to Moleong (2017), research subjects are informants, which means people who are used to provide information about the situation and conditions of the research setting.The selection of informants was carried out using a purposive sampling technique or deliberate selection with several considerations that they were the ones who knew the research information best.The informants in question are informants who are directly involved or informants who are considered to have the ability and understand the problems related to utilization behavior analysisservicehealth center in Ilaga District, Puncak Regency, Central Papua Province, as many as 12 people.These informants include, among others; Head of Ilaga Community Health Center,Community/Traditional figures and religious figures, AndThere are 6 people in Ilaga District.Apart from that, to support the research data, a literature search/library study was also carried out (Sapioper et al., 2022;Tokang and Yumame, 2023), data was obtained from library sources that were relevant to the topic being studied (Muttaqin et al., 2022;Wambrauw, 2023).

Treatment Search
The research results showed that people in Ilaga District took advantage of health services and every time they were sick they went to the community health center, while other informants stated that if they were sick they went for treatment at another community health center and only took a health certificate or referral to Nabire Regency for treatment.This is because the patient is sick and serious so he asks for a referral letter.This is in line with research conducted by Goo (2019) stating that the community uses good community health center health services.
Efforts to seek treatment for the community are a behavioral illustration of the overall pattern of health service utilization which can describe the level of knowledge and trust of the community in health service facilities.The conditions of mountain communities are of course very different from urban communities.Based on the Regulation of the Minister of Health of the Republic of Indonesia Number 6 of 2013, especially in article 4, mountainous areas are one of the areas with remote criteria based on geographical location.The priority situation based on these conditions is the emergence of health problems such as unclear standards of health services provided by health providers along mountainous areas.
Based on the research results, the Community Health Center in Ilaga District is very useful for them in terms of community health services so that they can help the community in treatment for public health so that the community is enthusiastic about utilizing the community health center's services.
Respondents' knowledge about seeking treatment may be influenced by many factors, for example through experience and information tools.
Respondents' ignorance about community health centers caused respondents not to want to use health services.Most respondents knew about the existence of the Community Health Center.
Health services are an important part of implementing health efforts.Use of health services is related to access to health facilities, both Community Health Centers (FKTP) and Hospitals (FKRTL).Equal access to the use of health services is also the goal of the JKN program.With this program, it is hoped that the entire community can utilize health services without any inequality (Su'udi & Hendarwan, 2018).FKTP and FKRTL play a role in providing good and quality health services that enable people to make optimal use of health services.

Service AvailabilityHealth
The working area of the Ilaga District health center is quite large, geographically some parts are difficult to reach, the population is small, spread out in small groups that are far from each other.Apart from that, there are limited buildings, infrastructure, medical equipment, pharmaceutical supplies and human resources.In addition, the challenges of geography, transportation, communication and local cultural tools also become health service problems in mountainous area health centers (Nurlinawati & Putranto, 2020).
Based on the research results, it was found that the availability of health services was adequate, including the number of existing health workers.The large number of health workers means that it does not become an obstacle for the community in getting health services.Apart from that, staffing at the Puskesmas (Public health center) in Ilaga District is still lacking due to health workers returning home or not coming in, resulting in a shortage of staff at the Puskesmas (Public health center).
The problem with the availability of health services that the public complains about is the lack of staff due to health workers going home or not coming in, resulting in a shortage of staff.Availability of health workers in this case is the presence of health workers at the Puskesmas (Public health center) when serving patients, because even though all the health workers at the Puskesmas (Public health center) are there, sometimes they are not there when the patient needs them, this is due to various activities, including; training, meetings and so on, so it is necessary to further evaluate the duties and functions of existing personnel and take wise steps to overcome this.Apart from that, there are still many people who do not know the profession of each health worker so they do not know their main duties at the health center.

Officer Attitude
Attitude is a person's reaction or response that is still closed to a stimulus or object.The officer's attitude is related to the interaction between the officer and the patient.Good relationships instill trust and credibility by showing respect which can be seen in acceptance, trust, empathy, keeping secrets, respecting and being responsive as well as providing attention to patients (Aswar, 2013).
Based on the research results, it was found that the attitude of health officers or workers in Ilaga District was very good so that there were no obstacles felt by the community in obtaining health services for the community.
Utilization of health services is influenced by the attitude of health workers when providing services to patients.This can be shown in the friendliness of staff in serving patients, smooth communication between staff and patients through providing extensive information to patients, as well as the responsiveness of staff in serving patients (Azwar, 2013).
The actions or way the staff perform services is something that greatly influences the patient regarding the recovery of their illness.Having good and attentive treatment is a special attraction in providing services to patients.This provides psychological strength for patients and fosters motivation to utilize the services provided (Rumengan, Umboh, & Kandou, 2015).
Good human relations will play a big role in effective counseling.Poor human relations will affect the effectiveness and technical competence of health services (Konsareh & Wijono, 2018).

Access to Health Services
Barriers to accessing health services can affect a person's health condition.Access to health services is divided into several aspects, namely geographical, economic and social conditions.Geographic access includes ease of reaching health facilities, types of transportation, and road infrastructure.Economic access is seen from financial ability to reach health facilities.Social access includes issues of communication, culture, friendliness, and the level of satisfaction with the services provided by health facilities (Laksono, 2016).
Research result obtained we obtained an overview of the factors that hinder the community from accessing health services, especially the Ilaga District Health Center, so that we can understand the difficulties experienced by the community in visiting the Community Health Center.Access to health services at the Ilaga District Health Center can be reached if you use a vehicle and takes a short time if you use a motorbike (ojek) or vehicle, whereas if there is no vehicle, people walk to reach the health center which takes 1-3 hours depending on the distance from home to the health center. .Travel distance and geographical conditions cause some people not to utilize health services properly.
Access to health services is a form of health service with various types of services that can be reached by the community (Language Development and Development Agency, 2020).Improving quality in terms of access to health services is needed to improve the level of public health.Every individual has the right to gain access to resources in the sector.This access includes geographical, social and economic.Ease of access to health services is very crucial for the community.Access to health services can include service availability, physical access, economic access, and social access (Megatsari et al., 2019).
Health services are obtained from health facilities that are accessible to the general public.One of the health service facilities is the community health center which is a FKTP or what is called a first level health facility.Barriers to accessing health services can be influenced by several factors such as economic level, geographic location and social culture (Halim et al., 2020).Research conducted by Su'udi et al., (2022) shows that geographical factors and the availability of minimum standard equipment can hinder access to health services, thereby reducing the quality of services.Factor of adequate health personnel in facilitiesserviceHealth, especially community health centers, also influences the quality of services so that there is a need for equality aimed at optimizing the services received by the community (Nurlinawati and Putranto, 2020).

Health Costs and Insurance Ownership
Based on the research results, it was found that the services provided at the Ilaga District Health Center were free for treatment.Of the six informants, they stated that they had national health insurance from the Social Security Administering Body (BPJS) as health insurance when accessing health center health services, while 1 informant stated that they did not have health insurance from BPJS, but if they were sick, there was a letter of introduction from the Village Head to get free health care treatment.
Previous research at the Haji General Hospital in Surabaya stated that the variables access to additional costs and access to referrals were statistically related to the utilization of health services for people participating in the National Health Insurance (JKN) group receiving contribution assistance (PBI) (Rachmawati & Chalidyanto, 2014).
As a community health service center, the Community Health Center has an obligation to provide outreach services to the community.Some people still do not know what services the Community Health Center provides, one of which is access to JKN and better facilities for participants, such as completeness of medicines., doubling chairs in patient waiting rooms, and directions for each room, as well as optimizing the performance of service officers in handling complaints expressed by BPJS Health Puskesmas (Public health center) participants.
One of the factors causing low JKN participation is the public's lack of knowledge about National Health Insurance (JKN).People do not understand and realize the importance of JKN.There are several causes of low public knowledge about JKN, namely the lack of socialization regarding registration procedures, use of contributions, JKN benefits, thus making people passive (Kurniawati and Rachmayanti, 2018).
Furthermore, Kurniawati and Rachmayanti, (2018) said that apart from that, community knowledge was lacking so that respondents were still very passive, such as for JKN registration they only relied on the village head or village head or the Social Service if one of their family members was seriously ill.The reason people don't understand JKN is because there is a lack of information regarding registration and how to use it.The solution to this problem is to increase outreach regarding the benefits and procedures of National Health Insurance (JKN) so that the public receives correct information.Apart from focusing on increasing knowledge, the socialization carried out is expected to increase community participation in JKN.
In the health system in Indonesia, community health centers and National Health Insurance (JKN) have an intertwined relationship and cannot be separated.Community Health Centers have a big role for JKN participants, where Community Health Centers are the first level health facilities that carry out promotive and preventive efforts to improve the level of public health as high as possible (Ministry of Health, 2019).
The National Health Insurance (JKN) program is still not running smoothly and there are still many shortcomings, facing many challenges and obstacles.The perception of upper class people regarding poor service quality and uniform service for all participants as well as long waiting times is one of the reasons that middle and upper class people lack pride.JKN participant satisfaction tends to be low, contact with health facilities results in limited choices of health facilities, this has the potential to cause complaints and dissatisfaction among participants, especially upper class participants.If a health service is declared good, then JKN participants can also access that health service, just as if medical services are poorly served or under-served, it will have the opposite effect.As a result, JKN participants do not often use health services.
Based on the findings from the research results, it was found that there were people who did not want to take care of National Health Insurance (JKN) membership even though they would be assisted by the Community Health Center but did not complete the administrative requirements.This is in line with research by Laturrakhmi, et al., (2019) that the public's attitude towards JKN is simply receiving information without any desire to make changes in behavior regarding the use of JKN.
This shows that the existence of socialization regarding participation in National Health Insurance (JKN) will not necessarily change the community towards the JKN program even though the communityhave a positive perception of health services.Therefore, if the perception of a program is not good, it can increase behavior not to use community health centers or other health services (Rumengan, 2015).

Security Disruption
Based on the results of the research, informants stated that there were no security disturbances in the health center services and that the public health center was able to operate in serving public health.In contrast, 1 informant stated that it would not be safe if there was war or interference from the Armed Criminal Group (KKB) so they handled health services.
The threat of security problems from armed criminal groups which vandalized government buildings including the Community Health Center building and also attacked civilians and health workers which recently occurred around August and October 2023 (Katingka, 2023).
The location of health services in Ilaga District, which is the capital of Puncak Regency, Central Papua Province, is not free from security disturbances, so that health workers are more focused on hospitals or health centers located in the city center.Even in several districts, the number of health workers, including medical personnel, is very minimal.Many regional hospitals and community health centers do not have specialist doctors or even general practitioners.One of the factors that contributes to the lack of doctors in remote locations is security and safety factors (Sumule et al., 2022).
According to the research results, it was found that security disturbances that occurred temporarily disrupted accessibility for 1-3 days to ensure the safety of health workers and that services continued to run.The impact of the security disturbances that occurred did not dampen people's interest in utilizing health services in Ilaga District.The community has enthusiasm and hopes for the use of health services in Ilaga District.

CONCLUSIONS AND RECOMMENDATIONS
People seeking treatment in the Ilaga District utilize the Community Health Center as a place for good treatment and as a referral place to other health service institutions (referrals) so that the community is enthusiastic about utilizing the services of the Community Health Center.Availability of Health Services is adequate in terms of the number of health workers and health services available according to community health center standards.The obstacle is if there are officers who are not present, which becomes an obstacle in other health services.The attitude of the officers or health workers in Ilaga District is very good, which is felt by the community to obtain health services.Access to health services is still an obstacle, especially in terms of transportation, due to demographic conditions and the low economy of the community in terms of transportation costs.The health costs provided by the puskesmas (Public health center) are free and help the community with treatment.Not all people have health insurance due to low knowledge and lack of support from health workers in assisting health services in arranging membership for the National Health Insurance Social Security Administering Body (BPJS).Security disturbances disrupt the accessibility of community health services in the event of conflict, especially from armed criminal groups.

FURTHER STUDY
It is hoped that there will be similar research in the same location using other approaches, as well as other implementation theories.Where the study that has been carried out uses the theory introduced by Edward III.

Table 1 . Staffing at Ilaga Community Health Center No Type of Employment Type Sex CertificateFinal
Type power There are 63 people at the Ilaga Community Health Center who are mostly women.The education level is dominated by D-III and the largest number are midwives with 46 people and 34 nurses.