LAUSR

Background: Patients' loyalty to visit and use the services provided by the primary health centers (PHCs) is an important requirement of a patient referral system in many countries. The aim of this study was to examine the influence of internal service factors (service provider, service process, and service environment) on service quality and behavioural loyalty of patients in Indonesian PHCs ( Puskesmas). Methods: A cross-sectional study was conducted in 14 districts in Aceh Province, Indonesia between September and December 2020. Data were collected in 102 PHCs that were selected randomly from 137 PHCs that have an Inpatient Unit in the province. The demographic data, three components of internal service factors (service provider, service process, and service environment), the service quality and behavioural loyalty were assessed using a validated questionnaire. Hypothesis testing was conducted by using the structural equation model (SEM). Results: Our data suggested that two elements of internal service factors (service provider and service environment) had a positive and significant influence on service quality of the PHCs with p<0.001 and p=0.021, respectively. Service quality had a positive and significant influence of behavioural loyalty of patients to the PHCs (p=0.003). Service quality however did not serve as an intervening variable between internal service factors (service provider, service process, and service environment) and behavioural loyalty of patients, with p=0.091, p=0.230 and p=0.260, respectively.  Conclusions: Service provider and service environment are two main factors that influence the service quality and the service quality directly influence the behavioural loyalty on PHC users. Therefore, to increase the patients' loyalty to use the PHC services, the quality of the services should be improved by levelling up the quality of providers and both physical and social environments in the PHCs.