Incidence of catastrophic health spending in Indonesia: insights from a Household Panel Study 2018-2019.

BACKGROUND: Indonesia implemented one of the world's largest single-payer national health insurance schemes (the Jaminan Kesehatan Nasional or JKN) in 2014. This study aims to assess the incidence of catastrophic health spending (CHS) and its determinants and trends between 2018 and 2019 by which time JKN enrolment coverage exceeded 80%. METHODS: This study analysed data collected from a two-round cross-sectional household survey conducted in ten provinces of Indonesia in February-April 2018 and August-October 2019. The incidence of CHS was defined as the proportion of households with out-of-pocket (OOP) health spending exceeding 10% of household consumption expenditure. Chi-squared tests were used to compare the incidences of CHS across subgroups for each household characteristic. Logistic regression models were used to investigate factors associated with incurring CHS and the trend over time. Sensitivity analyses assessing the incidence of CHS based on a higher threshold of 25% of total household expenditure were conducted. RESULTS: The overall incidence of CHS at the 10% threshold fell from 7.9% to 2018 to 4.4% in 2019. The logistic regression models showed that households with JKN membership experienced significantly lower incidence of CHS compared to households without insurance coverage in both years. The poorest households were more likely to incur CHS compared to households in other wealth quintiles. Other predictors of incurring CHS included living in rural areas and visiting private health facilities. CONCLUSIONS: This study demonstrated that the overall incidence of CHS decreased in Indonesia between 2018 and 2019. OOP payments for health care and the risk of CHS still loom high among JKN members and among the lowest income households. More needs to be done to further contain OOP payments and further research is needed to investigate whether CHS pushes households below the poverty line.

Public support for cigarette price increase in Indonesia.

BACKGROUND: The current tobacco control policies in Indonesia are known to be ineffective in reducing tobacco consumption. Therefore, increasing cigarette prices is one of the effective instruments that should be supported by governments and society. This study aims to assess public support for cigarette price increases as well as to generate scientific evidence for the government and policymakers. METHOD: This cross-sectional survey obtained data through telephone interviews with 1000 respondents aged ≥18 years old in Indonesia. The interviews started from 1 May 2018 to 31 May 2018. RESULT: Respondents were varied in terms of age, gender, level of education, income, occupation, area of living and smoking status. This study found that 87.9% of the respondents including 80% of smokers support cigarette price increase to prevent children from buying cigarettes. Approximately 74.0% of smokers said they would stop smoking if cigarette prices were Rp70 000 (US$5) per package. The multivariate analysis revealed that age, income, money spent on cigarettes per day and the perception of current cigarette prices are the factors influencing support for higher cigarette prices. CONCLUSION: The increase in cigarette prices is supported by society at large, including active smokers. The government must consistently adjust cigarette prices through an excise taxing and cigarette retail price mechanism. Governments, academicians, non-governmental organisations and tobacco control activists should generate a unified understanding that increasing cigarette prices will improve overall life quality.

Using measures of quality of care to assess equity in health care funding for primary care: analysis of Indonesian household data.

BACKGROUND: Many countries implementing pro-poor reforms to expand subsidized health care, especially for the poor, recognize that high-quality healthcare, and not just access alone, is necessary to meet the Sustainable Development Goals. As the poor are more likely to use low quality health services, measures to improve access to health care need to emphasise quality as the cornerstone to achieving equity goals. Current methods to evaluate health systems financing equity fail to take into account measures of quality. This paper aims to provide a worked example of how to adapt a popular quantitative approach, Benefit Incidence Analysis (BIA), to incorporate a quality weighting into the computation of public subsidies for health care. METHODS: We used a dataset consisting of a sample of households surveyed in 10 provinces of Indonesia in early-2018. In parallel, a survey of public health facilities was conducted in the same geographical areas, and information about health facility infrastructure and basic equipment was collected. In each facility, an index of service readiness was computed as a measure of quality. Individuals who reported visiting a primary health care facility in the month before the interview were matched to their chosen facility. Standard BIA and an extended BIA that adjusts for service quality were conducted. RESULTS: Quality scores were relatively high across all facilities, with an average of 82%. Scores for basic equipment were highest, with an average score of 99% compared to essential medicines with an average score of 60%. Our findings from the quality-weighted BIA show that the distribution of subsidies for public primary health care facilities became less 'pro-poor' while private clinics became more 'pro-rich' after accounting for quality of care. Overall the distribution of subsidies became significantly pro-rich (CI = 0.037). CONCLUSIONS: Routine collection of quality indicators that can be linked to individuals is needed to enable a comprehensive understanding of individuals' pathways of care. From a policy perspective, accounting for quality of care in health financing assessment is crucial in a context where quality of care is a nationwide issue. In such a context, any health financing performance assessment is likely to be biased if quality is not accounted for.

Relieving or aggravating the burden: Non-communicable diseases of dual users of electronic and conventional cigarette in Indonesia.

INTRODUCTION: Conventional (tobacco) and e-cigarette smoking prevalence is a growing concern in Indonesia. It has worsened as e-cigarettes complement conventional cigarettes, resulting in dual users, potentially causing an additional burden in terms of health. METHODS: Our study is a secondary data analysis of the 2018 National Basic Health (Riskesdas) Survey. The sample is limited to respondents aged 15-64 years who either only used e-cigarettes (e-cigarette single users), only used conventional cigarettes (conventional cigarette single users) or used both e-cigarettes and conventional cigarettes (dual users) in the last month. The sample size of the data was 174917 individuals. Our analysis utilized the logit and negative binomial regression to test whether the type of smoking behavior was associated with reporting to have a non-communicable diseases (NCDs) and multimorbidity, respectively. RESULTS: We found that: 1) dual users are positively associated to report having NCDs, such as liver failure (AOR=2.38; 95% CI: 2.32-2.44), diabetes (AOR=1.53; 95% CI: 1.50-1.57), hypertension (AOR=1.49; 95% CI: 1.48-1.51), and gum diseases (AOR=1.74; 95% CI: 1.73-1.74) compared to single users; and 2) e-cigarette single users are positively associated with reporting to have NCDs such as asthma (AOR=3.11; 95% CI: 3.01-3.22) and diabetes (AOR=16.01; 95% CI: 14.57-17.59), and dental problems such as broken teeth (AOR=1.04; 95% CI: 1.03-1.06), and they have disease multimorbidity compared to conventional cigarette single users. CONCLUSIONS: Simultaneous control of the consumption of e-cigarettes and conventional cigarettes is essential. In addition, it is important to promote policies to increase the price of e-cigarettes and conventional cigarettes to reduce smoking prevalence and prevent dual users. Moreover, as there are negative health consequences for conventional and e-cigarette single users or dual users, the most effective alternative is to stop smoking, not switching products.

Retailer's Density and Single Stick Cigarette's Accessibility among School-Age Children in Indonesia.

OBJECTIVE: The density of single-stick cigarette sales is related to the increase in tobacco epidemic-related diseases. This study aims to provide evidence of retailers' density and radius around the school location, accessibility of single-stick cigarette selling among school-age children, and retailers' response regarding the restriction policy options in urban areas in Indonesia. METHODS: It is a cross-sectional study. The retailers' spatial density and the radius around schools in Daerah Khusus Ibukota (DKI) Jakarta Province were investigated using Google Maps and Google Street View (GSV). The coordinates of retailers and schools were geo-coded to Kernel Density Map. The accessibility of single-stick cigarettes among children and restriction policy options for cigarette selling were derived from random sampling using surveys of 64 retailers based on Google Data results. RESULT: Virtually walking using google maps and GSV found 8,371 retailers in DKI Jakarta. There were ± 15 cigarette retailers every 1 km2, and an average of ± one cigarette retailer in every 1,000 residents. There were 456 (21.67%) retailers with a radius ≤ 100 meters around elementary schools, even an increase around junior high school locations of 167 (26.05%) retailers. The accessibility of cigarettes among children is easy because the price is relatively low, at Rp1,500/ $0.11 per stick. In addition, 58.1% of retailers allowed customers to buy on debt. Eleven percent of cigarette retailers intended to reduce the sale of cigarettes if the prohibition of single-stick cigarette sales were applied. CONCLUSION: Cigarette retailers were very dense and single-stick cigarettes were still accessible to children in Indonesia. The implementation of the prohibition on single-stick cigarette sales should be added for future tobacco control in developing countries such as Indonesia.

The benefits and burden of health financing in Indonesia: analyses of nationally representative cross-sectional data.

BACKGROUND: Indonesia has committed to deliver universal health coverage by 2024. Reforming the country's health-financing system is key to achieving this commitment. We aimed to evaluate how the benefits and burden of health financing are distributed across income groups and the extent to which Indonesia has achieved equity in the funding and delivery of health care after financing reforms. METHODS: We conducted benefit incidence analyses (BIA) and financing incidence analyses (FIA) using cross-sectional nationally representative data from several datasets. Two waves (Feb 1 to April 30, 2018, and Aug 1 to Oct 31, 2019) of the Equity and Health Care Financing in Indonesia (ENHANCE) study household survey involving 7500 households from ten of the 34 provinces in Indonesia were used to obtain health and socioeconomic status data for the BIA. Two waves (2018 and 2019) of the National Socioeconomic Survey (SUSENAS), the most recent wave (2014) of the Indonesian Family Life Survey, and the 2017 and 2018 National Health Accounts were used to obtain data for the FIA. In the BIA, we calculated a concentration index to assess the distribution of health-care benefits (-1·0 [pro-poor] to 1·0 [pro-rich]), considering potential differences in health-care need. In the FIA, we evaluated the equity of health-financing contributions by socioeconomic quintiles by calculating the Kakwani index to assess the relative progressivity of each financing source. Both the BIA and FIA compared results from early 2018 (baseline) with results from late 2019. FINDINGS: There were 31 864 participants in the ENHANCE survey in 2018 compared with 31 215 in 2019. Women constituted 50·5% and men constituted 49·5% of the total participants for each year. SUSENAS had 1 131 825 participants in 2018 compared with 1 204 466 in 2019. Women constituted 49·9% of the participants for each year, whereas men constituted 51·1%. The distribution of health-care benefits in the public sector was marginally pro-poor; people with low income received a greater proportion of benefits from health services than people with high income between 2018 (concentration index -0·008, 95% CI -0·075 to 0·059) and 2019 (-0·060, -0·139 to 0·019). The benefit incidence in the private health sector was significantly pro-rich in 2018 (0·134, 0·065 to 0·203, p=0·0010) and 2019 (0·190, -0·192 to 0·572, p=0·0070). Health-financing incidence changed from being moderately progressive in 2018 (Kakwani index 0·034, 95% CI 0·030 to 0·038) to mildly regressive in 2019 (-0·030, -0·034 to -0·025). INTERPRETATION: Although Indonesia has made substantial progress in expanding health-care coverage, a lot remains to be done to improve equity in financing and spending. Improving comprehensiveness of benefits will reduce out-of-pocket spending and allocating more funding to primary care would improve access to health-care services for people with low income. FUNDING: UK Health Systems Research Initiative, UK Department of International Development, UK Economic and Social Research Council, UK Medical Research Council, and Wellcome Trust.

Equity of health financing in Indonesia: A 5-year financing incidence analysis (2015-2019).

BACKGROUND: In 2014, Indonesia launched a single payer national health insurance scheme with the aim of covering the entire population by 2024. The objective of this paper is to assess the equity with which contributions to the health financing system were distributed in Indonesia over 2015 - 2019. METHODS: This study is a secondary analysis of nationally representative data from the National Socioeconomic Survey of Indonesia (2015 - 2019). The relative progressivity of each health financing source and overall health financing was determined using a summary score, the Kakwani index. FINDINGS: Around a third of health financing was sourced from out-of-pocket (OOP) payments each year, with direct taxes, indirect taxes and social health insurance (SHI) each taking up 15 - 20%. Direct taxes and OOP payments were progressive sources of health financing, and indirect tax payments regressive, for all of 2015 - 2019. SHI contributions were regressive except in 2017 and 2018. The overall health financing system was progressive from 2015 to 2018, but this declined year by year and became mildly regressive in 2019. INTERPRETATION: The declining progressivity of the overall health financing system between 2015 - 2019 suggests that Indonesia still has a way to go in developing a fair and equitable health financing system that ensures the poor are financially protected. FUNDING: This study is supported through the Health Systems Research Initiative in the UK, and is jointly funded by the Department of International Development, the Economic and Social Research Council, the Medical Research Council and the Wellcome Trust.

Good intentions, unintended outcomes: Impact of social assistance on tobacco consumption in Indonesia.

INTRODUCTION: Social assistance programs create an income effect that allows low-income groups to raise their consumption to improve their well-being. However, this may unintentionally induce an increase in their consumption of temptation goods, including tobacco. By analyzing five massive social assistance programs distributed by the government since 2007, we explore whether those programs may induce increased smoking intensity in Indonesia. METHODS: This study is a quantitative study that applies a Tobit regression, Difference-in-Differences (DiD) regression, Difference regression, and two-sample t-test, using the 2017 Susenas (National Socioeconomic Survey) and the 2007 and 2014 Indonesia Family Life Survey. Estimations using sociodemographic, regional, and social assistance dummy variables are used to explore the impact of the programs on the intensity of cigarette consumption in Indonesia, simultaneously assessing the relationship between cigarette consumption and socioeconomic conditions. RESULTS: Our estimations using Tobit regressions confirm that social assistance recipients consume 3.39 cigarettes per capita per week more than non-recipients. The DiD regressions on IFLS panel data show that social assistance programs significantly increase cigarette consumption by 2.8 cigarettes per capita per week. We also find that: 1) smokers have lower socioeconomic indicators than non-smokers in terms of nutrition and health and education expenditures, and 2) younger household members living with smokers have less educational attainment and higher average sick days. CONCLUSIONS: There is reasonable evidence to support the hypothesis that social assistance programs in Indonesia have contributed to the greater intensity of tobacco consumption among the recipients. The findings call for policy reforms in social assistance programs to be warier with the eligibility conditions for social assistance recipients. Adding new conditions related to smoking behaviors might reduce the smoking intensity of those in low-income groups and, in the long run, might improve the effectiveness of social assistance programs in raising the socioeconomic welfare of the low-income population.