Karo Ethnic Experience in Seeking Health Services to Penang Malaysia

The phenomenon of going abroad for medical treatment is something that has come to be attention of the government. The number of Indonesian citizens who went for treatment abroad continues to increase. In 2015 there were 600,000 patients who went abroad for treatment, it is estimated that Indonesia spent around 100 trillion rupiah on medical treatment. The amount of government foreign exchange issued to foreign hospitals is as much as 600 million dollars in one year (Ministry of Tourism, 2015). Data on visits by foreigners to Malaysia in 2012 totaled 671,727 people and in 2013 770,134 people experienced an increase from the previous year (IMTJ International Medical Travel Journal, 2014).


I. Introduction
At present the City District in North Sumatra Province has 213 hospital units consisting of 187 general hospitals and 26 specialty hospitals (Sumutprov, 2018). Each hospital must collaborate with BPJS, so that people who conduct treatment and have a BPJS card do not have to spend treatment funds from their own pockets, but this does not reduce the incidence of treatment to Penang.
The phenomenon of going abroad for medical treatment is something that has come to be attention of the government. The number of Indonesian citizens who went for treatment abroad continues to increase. In 2015 there were 600,000 patients who went abroad for treatment, it is estimated that Indonesia spent around 100 trillion rupiah on medical treatment. The amount of government foreign exchange issued to foreign hospitals is as much as 600 million dollars in one year (Ministry of Tourism, 2015). Data on visits by foreigners to Malaysia in 2012 totaled 671,727 people and in 2013 770,134 people experienced an increase from the previous year (IMTJ International Medical Travel Journal, 2014).
Based on a survey conducted at Polonia immigration office that, 194 people who took care of passports there were 97 people who took care of passports on the grounds of medical treatment and there were 36 Karo people or two point seven percent who intended to seek treatment abroad, there were those who wanted to seek treatment in Singapore and Malaysia. Likewise, when conducting a survey at Kualana Airport out of 35 people who intended to seek treatment, there were six Karo people who wanted to go to Penang for treatment.  Aulia's research results (2016), found that the category of research subjects' trust in foreign doctors and local doctors had differences, the level of trust was higher in foreign doctors. Where the level of satisfaction of the subject to overseas doctors is higher than the local doctor where 155 subjects 97.48 percent expressed satisfaction with the services of overseas doctors and 99 subjects 37.74 percent expressed satisfaction with the services of local doctors.
Obtaining health services is an individual community's authority guaranteed in law, the health service that has the most services and health workers is the hospital. This institution carries out health services by organizing the provision of services in medical services to individuals in a plenary manner consisting of promotive, preventive, curative, and rehabilitative. the hospital provides inpatient, outpatient, and emergency services. Emergency services are clinical conditions of patients who need immediate medical assistance, to save lives and avoid further disability (Permenkes, 2018). Joohyun (2015) explains that the use of health services abroad by patients with different backgrounds is an active health seeking behavior that is formed by a number of factors that are considered to limit access to high quality services in Denmark and that greater and more diverse consequences are a consequence of the search. treatment, and the perspective of health professionals about the use of health services in other areas that are considered better and more quality and each individual will provide information to others about what they are experiencing.
Each individual will look for health facilities that are better and as expected. In the era of globalization, the progress of transportation at this time makes it easy for people to travel with a relatively short time so that distance does not become a barrier for people to determine the choice of treatment, including abroad (Haryanto, 2016).
The Karo community also has facilities in the form of infrastructure that is by direct transportation from Kabanjahe to Kualanamu Airport, so that the Karo community has no difficulty in getting treatment to Penang even many people who travel directly without staying overnight if not recommended by inpatients. This ease will increase the number of people who seek treatment at Penang, this results in losses for the country.

II. Research Method
This research was conducted qualitatively with a phenomenological approach, with data collection techniques are in-depth interviews with participants (Polit&Beck, 2014). For researchers the information provided by one Participant is considered incomplete, then the researcher will look for other Participants who are more expert and can complete the data that has been obtained from a previous Participant. This research was conducted in Kabanjahe Subdistrict of Karo Regency on 8 Participants namely eight main Participants and one key Participant and one doctor who were willing to provide information about the reasons for treatment to Penang Malaysia, aged 30-65 years, had various occupational backgrounds and had income in above the Karo Regency minimum wage. Some participants only did general check-up, MRI (Magnetic Resonance Imaging) examination, while other participants received treatment services to specialists such as cancer, pleural effusion cholecystitis, diabetes mellitus, coronary heart disease (coronary artery disease), stomach, thyroid, kidney dysfunction, cervical cancer and colon cancer.

Get a Financial Comparison
The results showed that each participant looked at the selection of health services from two sides namely financial advantages and financial losses. Health is an investment for the community, because health is the basic capital that is needed by the entire community to be able to move in accordance with their respective duties and responsibilities, in order to be able to get something useful for themselves and others.
Likewise if health problems are not impossible, all assets and wealth will be used up to obtain that health. Health is a necessity and Karo Ethics who seek treatment in Penang have a modern way of thinking because looking at pain is not personalistic. Karo Ethnics have considered themselves healthy when they are able to do physical activity and are also able to be free from disease. When someone is free from various diseases, thus all activities can be carried out well and provide satisfying results. Likewise when experiencing pain is considered a detrimental condition where if sick then the individual's stamina will decrease and will hinder the implementation of all activities, and when sick then the Participants feel a burden to others.
Soejoeti (2008) said that a person is said to be sick if someone suffers from chronic illness or other health problems that cause work activities / activities to be disrupted. One of the Participants stated that "healthy is whatever well, fresh, delicious we can make our work like usually and we say healthy should be after the doctor said the results of the examination because we don't know where to go, but if it hurts it's hard ahkk, sad we can't do anything and we make other people just bother and get sick is the least I like besides being sick, spending money and also our time ".
The Karo ethnic group also considers that health is right after an examination by a doctor, in the sense that being healthy is already seen medically not only based on what is felt. The ability to carry out these activities is supported by a good functional condition, where a person is able to move his limbs well and with their respective uses, besides being sick is also an expense to undergo treatment statement Participants above in accordance with the definition of sick health according to Purwoastuti (2015).
The Karo ethnic group also know that pain can occur because of a cause. Pain occurs because there is a cause or because there are supporting factors in this case Foster and Anderson (1986) mention there are two causes of disease, namely personalistic and naturalistic interpreted as illness (illness) explained in systematic and non-personal terms.
Thus with the statement of one of the Participants "sickness comes if we don't get enough rest and there is also because there are germs or viruses in our body such as flu, heat, vomiting or itching on the body" Participants mention the cause of pain is due to transmission from one person to person. This is in accordance with the concept of causes of illness that cause naturalistic causes Participants mentioned as diseases caused by transmission can be in the form of viruses or germs. Society defines disease in different ways and accepted symptoms as evidence of disease in a society. The Karo ethnic group has never silenced their illnesses and will quickly seek treatment for their illness, regardless of whether it is expensive or cheap. This statement was justified by a child of Markianu Participant named Metra Ginting, stating that the concept of being sick is very valuable for his family. This child told me that when his father experienced the illness, there was land for sale to cope with his treatment. In the Karo Ethnic family has a strict nature, so if indeed the state of the disease requires immediate treatment, various things will be done.
Service costs are the amount that must be paid by users of health services for what he has obtained while in the health care provider (Dever, 1984). Participant's statement that: "If the cost is cheap, child, compared to the cost that is spent here back and forth but it doesn't heal too, right?" The existence of services in one package so that it is more practical, ways and systems for handling patients are assessed more quickly, with a package system the costs incurred will be cheaper.
Direct medical costs (direct medical costs) direct medical costs are costs incurred by patients associated with medical services, which are used to prevent or detect an illness such as patient visits, prescribed medicines, length of treatment. Likewise, the Karo ethnic group who went to Penang for treatment stated that indeed the cost of the medicine, the cost of the treatment that was incurred was considered cheap, in accordance with the services they received, because with clear services, the Participant's time was shorter in treatment and certainly reduced the cost of expenses. This is in line with the statement of Tjiptono (2015) that the amount of costs incurred by a client who is doing the treatment will lead to perception, the perception in this case is that after treatment the costs used are expensive or cheap. Karo Ethnic Considerations in choosing treatment to Penang, because Penang is able to provide appropriate services from diagnosis to treatment stage, so that the exact time will reduce the cost of treatment. In addition to the costs incurred by the Karo Ethnics, they also consider time very valuable, so if in Penang you can finish treatment in only three days, why should Kabanjahe spend up to a week. Likewise with the research of Ignatius (2012) which states that the driving factors for treating Indonesian patients going abroad are the quality of medical personnel and the quality of hospital services provided by the hospital, this has a significant effect on the intensity of Indonesian patients seeking treatment abroad. Supriadi (2015) states the accuracy, accuracy, accuracy in everything that is done is a very important value. If someone works precisely, quickly, and safely, the reward that will be received is satisfaction at work and increased appreciation.

Select Health Services
The way a person reacts to the symptoms of a disease is called illness behavior (illness behavior). This behavior is influenced by people's belief in the symptoms of the disease and belief in the way they will be treated. This behavior is a manifestation of a human thought concept of the meaning of healthy and sick (Latunji, 2018).
Before choosing health services, Karo Ethnics will first seek out services that meet their needs, namely services that have effectiveness in services, because effectiveness is an achievement of predetermined results and goals (Herlambang, 2013). In terms of Karo Ethnics will choose an efficient health service that is what is issued in accordance with what is obtained and thus effectively that is where what is expected of a person can be obtained and will give satisfaction. Efforts to seek referrals to other parties, both professional and non-professional health workers, are carried out at formal health service centers and outside health care centers (WHO, 2014). Everyone will share the experience they have gained and this will be able to influence someone in making choices.
Based on the results of this study, Karo Ethnics conduct health service searches in order to obtain services that are as expected by:

a. Looking for a Hospital in the Country
The search for health services is very closely related to how one's perceptions of health and the level of individual perceived need for a treatment (Soekanto, 2012). In accordance with the Participant's statement: "... the general hospital is similar to Efarina, so at first the doctor said that I had high blood pressure and cholesterol, but after a long time the family and the family were amazed why often dizzy and sometimes difficult to move the body, then brought to the hospital Elisabeth is said to be a doctor that there is a nervous breakdown and the sphere is said to have a mild stroke.
Ethnical Karo makes choices of health services starting from existing health services in the area, namely in health centers, private and government hospitals and even doctor's practice, and then Ethnic Karo will choose to seek treatment in Medan, namely to private hospitals. Transfer of treatment from one place to another is an action taken by the community in order to meet their needs to get maximum treatment.
Everyone is different in their willingness to seek help from health care services. Some people will look for health services when they are in a state of severe illness one is no longer detained. When choosing health services, a person will focus on what he suffers, and will compare what he has received before, because dissatisfaction ranging from establishing a diagnosis to administering a drug that has no effect is a trigger to always seek service from one another with various alternatives, relationship looking for health services that are able to provide treatment in accordance with the expectations of the sick with the decision to choose the right health service that is what can get the situation better. Participants said that: "... and I have also tried to practice it right away so that I mean better treatment, but it remains just the same often I think ..." This statement is in accordance with Suchman's (1965) theory which states that a person seeking health services based on social and cultural factors influences the sequence from pain symptoms to treatment processes, using an anthropological approach, using qualitative investigative methods. This concerns the social patterns of sick behavior that can be seen in people who seek and find medical care.

b. Obtaining Health Service Information
When you want to make a choice of health services, Ethnic Karo will collect various information about the treatment it can get. Ethnic Karo sought health services to Penang Malaysia, with various encouragement and information obtained from senina, anakberu and also friends from the profession. Provides information if treatment in Penang is able to provide good treatment. Participants stated that: "... I told you about my illness with friends from one local head and it happened to be a friend of mine who was as sick as I was, so that's how he recovered after he went to Penang and then he wanted me ..." In accordance with the statement of each Participant stating that Participants received information about treatment to Penang from various sources, some came from one pemulungen friend or was called a church friend, and there were those who obtained information from a colleague's wife and also had information. From his brother or in the Karo language called turang. In accordance with Rothman's statement (2012) that the role of health information sources includes knowledge about health and health care.
Health seeking behavior has developed over time. The search for health services has become a tool to see how a person is involved with the treatment system in various sociocultural, economic, and demographic circumstances. To be healthy a variety of efforts will be made by individuals as well as the Karo Ethnic will do the same thing that is looking for information for the treatment of the disease he suffers.
The Karo ethnic group also conducts a bronze before treatment, especially in the selection of health services, all families will gather to give opinions to one another. When doing the bronze discussed not only the place of service but also discussed the cost of treatment. These costs will be helped together for families who need financial assistance, especially children will provide financial assistance because for them it is a "pasu-pasu" or blessing especially those who are sick are kalimbubu or God seen, often also called a bearer of blessings (Sitepu, 1996).

Obtaining Satisfactory Health Services
Satisfaction (satisfaction) is a feeling of pleasure or disappointment someone who appears after comparing the performance (results) of the product thought to the performance (or results) expected. If the performance is below expectations, the customer is not satisfied, and if the performance exceeds expectations, the customer is very satisfied or happy (Kotler 2006). So, satisfaction is a function of perception or impression of performance and expectations.
Based on this research, Karo Ethnic has satisfaction when conducting treatment, such satisfaction includes matters relating to providers, in this case regarding the ability of service providers to provide services to clients by providing needed services, can be seen through the characteristics of hospital quality, service provider quality health services which include doctors, paramedics and also related to communication with clients and also the ease of obtaining service information

a. Hospital Facilities
Infrastructure is a dimension that is able to describe the physical appearance of service facilities. Clients are not so concerned with the physical building of a hospital, but rather pay attention to the completeness of these facilities, especially in medicine and also cleanliness. The capacity of a hospital is important in the infrastructure dimension (Bowling, 2012). In this research Ethnic Karo illustrates that the Penang hospital is a comfortable hospital with sophisticated and modern equipment, providing one-stop service, clean and has no drug smell. With the sense that hospitals in Penang have complete facilities and infrastructure so that services in hospitals meet the needs of patients who come for treatment.
In line with Aprilia's research (2013), it is stated that good quality of service is the availability of adequate facilities and short patient waiting times, which will provide high interest by the community in the utilization of health services. "The results also come out fast and we are treated quickly. Good times, the inspection tools, the results are not slow," he said. The availability of good services in Penang makes the Karo Ethnics choose treatment to Penang because health services in Kabanjahe and Medan have not been able to provide good services, seen from the experience of Participants who said that "the waiting time in treatment is long and also the results of the laboratory can last for days. Different from in Penang the results of the laboratory quickly came out because the medical equipment used was sophisticated and had good and high quality.