<![CDATA[Healthcare institutions operating in resource-constrained rural settings face distinct challenges in building durable patient relationships, particularly when serving predominantly public insurance beneficiaries. This study aims to examine the direct and indirect effects of service quality on patient loyalty through patient satisfaction as a mediator, focusing on the national health insurance scheme (BPJS) outpatients at a private rural hospital in Brebes, Indonesia. A descriptive-verificative approach with quantitative methods was employed, drawing on purposive sampling to recruit 374 eligible outpatients who had attended the facility on at least two separate occasions. Structured questionnaires served as the primary data collection instrument, and path analysis was applied to examine both direct and mediated relationships among the three constructs. The findings reveal that service quality significantly impacts patient satisfaction (path coefficient = 0.837, p < 0.05) and patient loyalty (path coefficient = 0.693, p < 0.05). Satisfaction additionally influences loyalty (path coefficient = 0.178, p < 0.05) and acts as a partial mediator. These results suggest that service quality serves as a primary driver for institutional sustainability in rural healthcare networks. Management should prioritize empathetic and responsive service to secure patient commitment within insurance-based systems. This study provides a specific framework for improving patient retention in underserved healthcare sectors.]]>
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