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.

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.

Supporting dialysis policy for end stage renal disease (ESRD) in Indonesia: an updated cost-effectiveness model.

OBJECTIVE: Continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis (HD) are main modalities for end stage renal disease (ESRD) patients, and those have been covered by National Health Insurance (NHI) scheme since 2014 in Indonesia. This study aims to update the cost-effectiveness model of CAPD versus HD in Indonesia setting. RESULTS: Compared to HD, CAPD provides good value for money among ESRD patients in Indonesia. Using societal perspective, the total costs were IDR 1,348,612,118 (USD 95,504) and IDR 1,368,447,750 (USD 96,908), for CAPD and HD, respectively. The QALY was slightly different between two modalities, 4.79 for CAPD versus 4.22 for HD. The incremental cost-effectiveness ratio (ICER) yields savings of IDR 34,723,527/QALY (USD 2460).

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.

Predicting the cost of COVID-19 treatment and its drivers in Indonesia: analysis of claims data of COVID-19 in 2020-2021.

BACKGROUND: Recent Coronavirus Disease-19 (COVID-19) pandemic shows that health system, particularly hospital care, takes the highest toll on COVID-19. As hospital gets to manage the surge of COVID-19 cases, it is important to standardize treatment standard and package for COVID-19. Until recently, in Indonesia, COVID-19 curative package in hospital is paid using a retrospective payment system (claims system) using a per-diem rate. Quantifying standard cost using an established retrospective claims dataset is important as a basis for standard formulation for COVID-19 package treatment, should COVID-19 be accommodated into the benefit package for Universal Health Coverage (UHC) under the National Health Insurance. METHODS: We estimated a standard cost for COVID-19 treatment using provider's perspective. The analysis was conducted retrospectively using established national COVID-19 claims dataset during January 2020 until 2021. Utilizing individual-or-patient level analysis, claims profile were broken down per-patient, yielding descriptive clinical and care-related profile. Estimate of price and charge were measured in average. Moreover, indicators were regressed to the total charged price (in logarithmic scale) so as to find the predictors of cost. RESULTS: Based on the analysis of 102,065 total claims data received by MOH in 2020-2021, there is an average claim payment for COVID-19 in the amount of IDR 74,52 million (USD$ 5175). Significant difference exists in hospital tariffs or price to the existing claims data, indicating profit for hospital within its role in managing COVID-19 cases. Claim amount predictors were found to be associated with change of claim amount, including high level of severity, hospital class, intensive care room occupancy and ventilator usage, as well as mortality. CONCLUSION: As COVID-19 pandemic shifts towards an endemic, countries including Indonesia need to reflect on the existing payment system and move towards a more sustainable payment mechanism for COVID-19. The COVID-19 payment system needs to be integrated into the existing national health insurance allowing bundled payment to become more sustainable, which can be achieved by comprehensively formulating the bundled payment package for COVID-19.

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.

Utilization patterns of healthcare facility and estimated expenditure of PLHIV care under the Indonesian National Health Insurance Scheme in 2018.

BACKGROUND: This study analyzed current patterns of service use, referral, and expenditure regarding HIV care under the National Health Insurance Scheme (JKN) to identify opportunities to improve HIV treatment coverage. As of September 2020, an estimated 543,100 people in Indonesia were living with HIV, but only 352,670 (65%) were aware of their status, and only 139,585 (26%) were on treatment. Furthermore, only 27,917 (4.5%) viral load (VL) tests were performed. Indonesia seeks to broaden its HIV response. In doing so, it intends to replace declining donor-funding through better coverage of HIV/AIDS services by its JKN. Thus, this study aims to assess the current situation about HIV service coverage and expenditure under a domestic health-insurance funded scheme in Indonesia. METHODS: This study employs a quantitative method by way of a cross-sectional approach. The 2018 JKN claims data, drawn from a 1% sample that JKN annually produces, were analyzed. Nine hundred forty-five HIV patients out of 1,971,744 members were identified in the data sample and their claims record data at primary care and hospital levels were analyzed. Using ICD (International Statistical Classification of Diseases and Related Health Problems), 10 codes (i.e., B20, B21, B22, B23, and B24) that fall within the categories of HIV-related disease. For each level, patterns of service utilization by patient-health status, discharge status, severity level, and total cost per claim were analyzed. RESULTS: Most HIV patients (81%) who first seek care at the primary-care level are referred to hospitals. 72.5% of the HIV patients receive antiretroviral treatment (ART) through JKN; 22% at the primary care level; and 78% at hospitals. The referral rate from public primary-care facilities was almost double (45%) that of private providers (24%). The most common referral destination was higher-level hospitals: Class B 48%, and Class C 25%, followed by the lowest Class A at 3%. Because JKN pays hospitals for each inpatient admission, it was possible to estimate the cost of hospital care. Extrapolating the sample of hospital cases to the national level using the available weight score, it was estimated that JKN paid IDR 444 billion a year for HIV hospital services and a portion of capitation payment. CONCLUSION: There was an underrepresentation of PLHIV (People Living with HIV) who had been covered by JKN as 25% of the total PLHIV on ART were able to attain access through other schemes. This study finding is principally aligned with other local research findings regarding a portion of PLHIV access and the preferred delivery channel. Moreover, the issue behind the underutilization of National Health Insurance services in Indonesia among PLHIV is similar to what was experienced in Vietnam in 2015. The 2015 Vietnam study showed that negative perception, the experience of using social health insurance as well as inaccurate information, may lead to the underutilization problem (Vietnam-Administration-HIV/AIDSControl, Social health insurance and people living with HIV in Vietnam: an assessment of enrollment in and use of social health insurance for the care and treatment of people living with HIV, 2015). Furthermore, the current research finding shows that 99% of the total estimated HIV expenditure occurred at the hospital. This indicates a potential inefficiency in the service delivery scheme that needs to be decentralized to a primary-care facility.

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.

Poor quality for the poor? A study of inequalities in service readiness and provider knowledge in Indonesian primary health care facilities.

BACKGROUND: For many low and middle-income countries poor quality health care is now responsible for a greater number of deaths than insufficient access to care. This has in turn raised concerns around the distribution of quality of care in LMICs: do the poor have access to lower quality health care compared to the rich? The aim of this study is to investigate the extent of inequalities in the availability of quality health services across the Indonesian health system with a particular focus on differences between care delivered in the public and private sectors. METHODS: Using the Indonesian Family Life Survey (wave 5, 2015), 15,877 households in 312 communities were linked with a representative sample of both public and private health facilities available in the same communities. Quality of health facilities was assessed using both a facility service readiness score and a knowledge score constructed using clinical vignettes. Ordinary least squares regression models were used to investigate the determinants of quality in public and private health facilities. RESULTS: In both sectors, inequalities in both quality scores existed between major islands. In public facilities, inequalities in readiness scores persisted between rural and urban areas, and to a lesser extent between rich and poor communities. CONCLUSION: In order to reach the ambitious stated goal of reaching Universal Health Coverage in Indonesia, priority should be given to redressing current inequalities in the quality of care.

Economic burden of dengue in Indonesia.

BACKGROUND: Dengue is associated with significant economic expenditure and it is estimated that the Asia Pacific region accounts for >50% of the global cost. Indonesia has one of the world's highest dengue burdens; Aedes aegypti and Aedes albopictus are the primary and secondary vectors. In the absence of local data on disease cost, this study estimated the annual economic burden during 2015 of both hospitalized and ambulatory dengue cases in Indonesia. METHODS: Total 2015 dengue costs were calculated using both prospective and retrospective methods using data from public and private hospitals and health centres in three provinces: Yogyakarta, Bali and Jakarta. Direct costs were extracted from billing systems and claims; a patient survey captured indirect and out-of-pocket costs at discharge and 2 weeks later. Adjustments across sites based on similar clinical practices and healthcare landscapes were performed to fill gaps in cost estimates. The national burden of dengue was extrapolated from provincial data using data from the three sites and applying an empirically-derived epidemiological expansion factor. RESULTS: Total direct and indirect costs per dengue case assessed at Yogyakarta, Bali and Jakarta were US$791, US$1,241 and US$1,250, respectively. Total 2015 economic burden of dengue in Indonesia was estimated at US$381.15 million which comprised US$355.2 million for hospitalized and US$26.2 million for ambulatory care cases. CONCLUSION: Dengue imposes a substantial economic burden for Indonesian public payers and society. Complemented with an appropriate weighting method and by accounting for local specificities and practices, these data may support national level public health decision making for prevention/control of dengue in public health priority lists.

Universal health coverage in Indonesia: concept, progress, and challenges.

Indonesia is a rapidly growing middle-income country with 262 million inhabitants from more than 300 ethnic and 730 language groups spread over 17 744 islands, and presents unique challenges for health systems and universal health coverage (UHC). From 1960 to 2001, the centralised health system of Indonesia made gains as medical care infrastructure grew from virtually no primary health centres to 20 900 centres. Life expectancy improved from 48 to 69 years, infant mortality decreased from 76 deaths per 1000 livebirths to 23 per 1000, and the total fertility rate decreased from 5·61 to 2·11. However, gains across the country were starkly uneven with major health gaps, such as the stagnant maternal mortality of around 300 deaths per 100 000 livebirths, and minimal change in neonatal mortality. The centralised one size fits all approach did not address the complexity and diversity in population density and dispersion across islands, diets, diseases, local living styles, health beliefs, human development, and community participation. Decentralisation of governance to 354 districts in 2001, and currently 514 districts, further increased health system heterogeneity and exacerbated equity gaps. The novel UHC system introduced in 2014 focused on accommodating diversity with flexible and adaptive implementation features and quick evidence-driven decisions based on changing needs. The UHC system grew rapidly and covers 203 million people, the largest single-payer scheme in the world, and has improved health equity and service access. With early success, challenges have emerged, such as the so-called missing-middle group, a term used to designate the smaller number of people who have enrolled in UHC in wealth quintiles Q2-Q3 than in other quintiles, and the low UHC coverage of children from birth to age 4 years. Moreover, high costs for non-communicable diseases warrant new features for prevention and promotion of healthy lifestyles, and investment in a robust integrated digital health-information system for front-line health workers is crucial for impact and sustainability. This Review describes the innovative UHC initiative of Indonesia along with the future roadmap required to meet sustainable development goals by 2030.

An evaluation of health systems equity in Indonesia: study protocol.

BACKGROUND: Many low and middle income countries are implementing reforms to support Universal Health Coverage (UHC). Perhaps one of the most ambitious examples of this is Indonesia's national health scheme known as the JKN which is designed to make health care available to its entire population of 255 million by end of 2019. If successful, the JKN will be the biggest single payer system in the world. While Indonesia has made steady progress, around a third of its population remains without cover and out of pocket payments for health are widespread even among JKN members. To help close these gaps, especially among the poor, the Indonesian government is currently implementing a set of UHC policy reforms that include the integration of remaining government insurance schemes into the JKN, expansion of provider networks, restructuring of provider payments systems, accreditation of all contracted health facilities and a range of demand side initiatives to increase insurance uptake, especially in the informal sector. This study evaluates the equity impact of this latest set of UHC reforms. METHODS: Using a before and after design, we will evaluate the combined effects of the national UHC reforms at baseline (early 2018) and target of JKN full implementation (end 2019) on: progressivity of the health care financing system; pro-poorness of the health care delivery system; levels of catastrophic and impoverishing health expenditure; and self-reported health outcomes. In-depth interviews with stakeholders to document the context and the process of implementing these reforms, will also be undertaken. DISCUSSION: As countries like Indonesia focus on increasing coverage, it is critically important to ensure that the poor and vulnerable - who are often the most difficult to reach - are not excluded. The results of this study will not only help track Indonesia's progress to universalism but also reveal what the UHC-reforms mean to the poor.

UICC-ARO Symposium at the UICC 2016 World Cancer Congress How Can We Mobilize Action to Realize UHC in Asia?

The 2016 World Cancer Congress, organised by UICC, was held in Paris in November 2016, under the theme "Mobilizing action ­ Inspiring Change." As part of Track 4 presentations on the theme of "Strengthening cancer control: optimizing outcomes of health systems," UICC-Asian Regional Office (UICC-ARO) held a symposium to discuss the issue of mobilizing action to realize UHC in Asia. Introducing the symposium, Hideyuki Akaza noted that universal health coverage (UHC) is included in the Sustainable Development Goals and one of the key issues for achieving UHC will be how to balance patient needs with the economic burden of cancer. Speakers from Japan and Indonesia addressed various issues, including the current status and challenges for medical economic evaluation in Asia, the importance of resource stratification, prospects for precision medicine, and the outlook for cancer control and UHC in developing and emerging countries in Asia. Key issues raised included how to respond to the rising costs of treating cancer as new and increasingly expensive drugs come to the market. Speakers and participants noted that health technology assessment programs are being developed around Asia in order to evaluate the cost-effectiveness of drugs in the face of budgetary constraints within increasingly pressurized national health systems. The importance of screening and early detection was also noted as effective means that have the potential to reduce reliance on expensive drugs for advanced cancers. The symposium was chaired jointly by Hideyuki Akaza and Shinjiro Nozaki (WHO Kobe Centre).

Joint Symposium of Korean Cancer Association & UICC-ARO-Cross-boundary cancer studies: cancer and Universal Health Coverage (UHC) in Asia.

On 16 June 2016, the Korean Cancer Association (KCA) and Union for International Cancer Control-Asia Regional Office (UICC-ARO) organized a joint symposium as part of the official program of the 42nd Annual Meeting of the Korean Cancer Association to discuss the topic 'Cross-boundary Cancer Studies: Cancer and Universal Health Coverage (UHC) in Asia.' Universal Health Coverage is included in the Sustainable Development Goals adopted by the United Nations as part of the 2030 Agenda for Sustainable Development. The objectives of UHC are to ensure that all people can receive high-quality medical services, are protected from public health risks, and are prevented from falling into poverty due to medical costs or loss of income arising from illness. The participants discussed the growing cost of cancer in the Asian region and the challenges that this poses to the establishment and deployment of UHC in the countries of Asia, all of which face budgetary and other systemic constraints in controlling cancer in the region. Representatives from Korea, Japan and Indonesia reported on the status of UHC in their countries and the challenges that are being faced, many of which are common to other countries in Asia. In addition to country-specific presentations about the progress of and challenges facing UHC, there were also presentations from WHO Kobe Centre concerning advancing UHC in non-communicable diseases and prospects for further collaboration and research on UHC. A presentation from the University of Tokyo also highlighted the need to focus on multidisciplinary studies in an age of globalization and digitization.

Health facility and skilled birth deliveries among poor women with Jamkesmas health insurance in Indonesia: a mixed-methods study.

BACKGROUND: The growing momentum for quality and affordable health care for all has given rise to the recent global universal health coverage (UHC) movement. As part of Indonesia's strategy to achieve the goal of UHC, large investments have been made to increase health access for the poor, resulting in the implementation of various health insurance schemes targeted towards the poor and near-poor, including the Jamkesmas program. In the backdrop of Indonesia's aspiration to reach UHC is the high rate of maternal mortality that disproportionally affects poor women. The objective of this study was to evaluate the association of health facility and skilled birth deliveries among poor women with and without Jamkesmas and explore perceived barriers to health insurance membership and maternal health service utilization. METHODS: We used a mixed-methods design. Utilizing data from the 2012 Indonesian Demographic and Health Survey (n = 45,607), secondary analysis using propensity score matching was performed on key outcomes of interest: health facility delivery (HFD) and skilled birth delivery (SBD). In-depth interviews (n = 51) were conducted in the provinces of Jakarta and Banten among poor women, midwives, and government representatives. Thematic framework analysis was performed on qualitative data to explore perceived barriers. RESULTS: In 2012, 63.0% of women did not have health insurance; 19.1% had Jamkesmas. Poor women with Jamkesmas were 19% (OR = 1.19 [1.03-1.37]) more likely to have HFD and 17% (OR = 1.17 [1.01-1.35]) more likely to have SBD compared to poor women without insurance. Qualitative interviews highlighted key issues, including: lack of proper documentation for health insurance registration; the preference of pregnant women to deliver in their parents' village; the use of traditional birth attendants; distance to health facilities; shortage of qualified health providers; overcrowded health facilities; and lack of health facility accreditation. CONCLUSIONS: Poor women with Jamkesmas membership had a modest increase in HFD and SBD. These findings are consistent with economic theory that health insurance coverage can reduce financial barriers to care and increase service uptake. However, factors such as socio-cultural beliefs, accessibility, and quality of care are important elements that need to be addressed as part of the national UHC agenda to improve maternal health services in Indonesia.

Catastrophic health expenditure and 12-month mortality associated with cancer in Southeast Asia: results from a longitudinal study in eight countries.

BACKGROUND: One of the biggest obstacles to developing policies in cancer care in Southeast Asia is lack of reliable data on disease burden and economic consequences. In 2012, we instigated a study of new cancer patients in the Association of Southeast Asian Nations (ASEAN) region - the Asean CosTs In ONcology (ACTION) study - to assess the economic impact of cancer. METHODS: The ACTION study is a prospective longitudinal study of 9,513 consecutively recruited adult patients with an initial diagnosis of cancer. Twelve months after diagnosis, we recorded death and household financial catastrophe (out-of-pocket medical costs exceeding 30% of annual household income). We assessed the effect on these two outcomes of a range of socio-demographic, clinical, and economic predictors using a multinomial regression model. RESULTS: The mean age of participants was 52 years; 64% were women. A year after diagnosis, 29% had died, 48% experienced financial catastrophe, and just 23% were alive with no financial catastrophe. The risk of dying from cancer and facing catastrophic payments was associated with clinical variables, such as a more advanced disease stage at diagnosis, and socioeconomic status pre-diagnosis. Participants in the low income category within each country had significantly higher odds of financial catastrophe (odds ratio, 5.86; 95% confidence interval, 4.76-7.23) and death (5.52; 4.34-7.02) than participants with high income. Those without insurance were also more likely to experience financial catastrophe (1.27; 1.05-1.52) and die (1.51; 1.21-1.88) than participants with insurance. CONCLUSIONS: A cancer diagnosis in Southeast Asia is potentially disastrous, with over 75% of patients experiencing death or financial catastrophe within one year. This study adds compelling evidence to the argument for policies that improve access to care and provide adequate financial protection from the costs of illness.

Socioeconomic impact of cancer in member countries of the Association of Southeast Asian Nations (ASEAN): the ACTION study protocol.

Cancer can be a major cause of poverty. This may be due either to the costs of treating and managing the illness as well as its impact upon people's ability to work. This is a concern that particularly affects countries that lack comprehensive social health insurance systems and other types of social safety nets. The ACTION study is a longitudinal cohort study of 10,000 hospital patients with a first time diagnosis of cancer. It aims to assess the impact of cancer on the economic circumstances of patients and their households, patients' quality of life, costs of treatment and survival. Patients will be followed throughout the first year after their cancer diagnosis, with interviews conducted at baseline (after diagnosis), three and 12 months. A cross-section of public and private hospitals as well as cancer centers across eight member countries of the Association of Southeast Asian Nations (ASEAN) will invite patients to participate. The primary outcome is incidence of financial catastrophe following treatment for cancer, defined as out-of-pocket health care expenditure at 12 months exceeding 30% of household income. Secondary outcomes include illness induced poverty, quality of life, psychological distress, economic hardship, survival and disease status. The findings can raise awareness of the extent of the cancer problem in South East Asia and its breadth in terms of its implications for households and the communities in which cancer patients live, identify priorities for further research and catalyze political action to put in place effective cancer control policies.

Health-financing reforms in southeast Asia: challenges in achieving universal coverage.

In this sixth paper of the Series, we review health-financing reforms in seven countries in southeast Asia that have sought to reduce dependence on out-of-pocket payments, increase pooled health finance, and expand service use as steps towards universal coverage. Laos and Cambodia, both resource-poor countries, have mostly relied on donor-supported health equity funds to reach the poor, and reliable funding and appropriate identification of the eligible poor are two major challenges for nationwide expansion. For Thailand, the Philippines, Indonesia, and Vietnam, social health insurance financed by payroll tax is commonly used for formal sector employees (excluding Malaysia), with varying outcomes in terms of financial protection. Alternative payment methods have different implications for provider behaviour and financial protection. Two alternative approaches for financial protection of the non-poor outside the formal sector have emerged-contributory arrangements and tax-financed schemes-with different abilities to achieve high population coverage rapidly. Fiscal space and mobilisation of payroll contributions are both important in accelerating financial protection. Expanding coverage of good-quality services and ensuring adequate human resources are also important to achieve universal coverage. As health-financing reform is complex, institutional capacity to generate evidence and inform policy is essential and should be strengthened.

Cigarette smoking in Indonesia: examination of a myopic model of addictive behaviour.

Using aggregated panel data taken from three waves of the Indonesian Family Life Survey (1993-2000), this article tests the myopic addiction behaviour of cigarette demand. Sensitivity analysis is done by examining a rational addiction behavior of cigarette demand. The results provide support for myopic addiction. The short- and long-run price elasticities of cigarette demand are estimated at -0.28 and -0.73 respectively. Excise taxes are more likely to act as an effective tobacco control in the long-run rather than a major source of government revenue.