Changes in Smoking Status and Behaviors After the First 10 Months of COVID-19 Pandemic in Indonesia.

INTRODUCTION: There remains inconclusive evidence on potential changes in smoking status and behaviors during the coronavirus disease 2019 (COVID-9) pandemic, especially in developing countries. AIMS AND METHODS: This study explores the direction of changes in smoking status and behaviors after 10 months of the COVID-19 pandemic in Indonesia as well as examining the association between economic shocks and changes in smoking behaviors. Primary data were gathered through a phone survey targeting productive-age mobile-phone users in Indonesia (n = 1082). Descriptive analysis was employed to determine changes in smoking status and behaviors 10 months into the pandemic, while logistic regression analysis was used to investigate how employment shocks, financial strain, COVID-19-related indicators, and demographic characteristics were associated with smoking behaviors of people who continue smoking. RESULTS: Respondents experiencing changes in smoking status were dominated by people who persistently smoked during the pandemic, while those who quit, relapsed, and started smoking, was extremely small. Nevertheless, a considerable portion of people who continue smoking adjusted their smoking behaviors: 40.3% reduced smoking intensity and 25.3% switched to lower-price cigarettes. Multivariable regression analysis revealed that, among people who continue smoking, those who experienced financial strain during the pandemic had higher odds of reducing smoking intensity, while those who switched to lower job status had higher odds of switching to cheaper cigarettes. CONCLUSIONS: The research has shown that smoking status and behaviors of people who continue smoking mostly remained unchanged after 10 months of the COVID-19 pandemic. Changes in employment and financial conditions during the pandemic were associated with modified smoking behaviors. IMPLICATIONS: This study is the first to determine the direction and analyze the factors of changes in smoking during the COVID-19 pandemic in Indonesia. This new understanding should help improve predicting the trends in smoking in future crises or pandemics in developing countries, specifically Indonesia. The discovered patterns on smokers' reaction to an exogenous shock may provide evidence to support tobacco control policies in Indonesia.

Macroeconomic impact of tobacco taxation in Indonesia.

BACKGROUND: A significant tobacco tax increase has long been advocated to reduce Indonesia's high smoking prevalence. However, implementing such a policy remains challenging due to the tobacco industry's argument that it would negatively impact the economy. OBJECTIVE: This study aims to provide a comprehensive estimate of the net impact of tobacco taxation on Indonesia's economy. METHOD: The impact of the tax hike on the economy is simulated through a change in cigarette demand and reallocation of household's budget and allocation government spending from additional tobacco tax revenue. Input-output analysis is employed to estimate the net effect of the tobacco tax rise on the total economic output, income and employment in Indonesia. FINDING: Increasing the tobacco tax would generate a net positive impact on the economy as it would increase economic output, household income and employment. The positive impact is mainly driven by government spending from additional revenue from increased tobacco taxes. Spending tax revenue using the current structure of government spending has the potential to generate the optimal economic effect. Increasing tobacco tax by 45% from the 2019 tax level would increase economic output, household income and employment by Rp84.2 trillion, Rp24.1 trillion and 400.3 thousand jobs, respectively.

The 2019 economic cost of smoking-attributable diseases in Indonesia.

BACKGROUND: In 2019, ever-smoking prevalence among adults in Indonesia was 32.8%, which may correlate with a high burden on the economy. Therefore, there is an urgent need to estimate the economic costs of tobacco use, which are crucial for policymakers in planning healthcare provisions and other public expenditures. METHODS: We follow the WHO standard approach, multiplying the sum of the direct and indirect costs with the smoking-attributable fraction. Direct costs include healthcare and non-healthcare costs. Indirect costs include the loss of productivity resulting from absence from work and premature death due to smoking-related illnesses. FINDINGS: We found that the 2019 economic cost of smoking ranges from Rp 184.36 trillion to Rp 410.76 trillion (1.16%-2.59% of the gross domestic product). This research found a similar economic cost of smoking compared with a previous estimate conducted by Kosen et al of Rp 438.5 trillion. However, the estimated direct cost of smoking ranges from Rp 17.9 trillion to Rp 27.7 trillion, which is higher than the estimate of Rp 15.5 trillion by Kosen et al. Badan Penyelenggara Jaminan Sosial Kesehatan allocated between Rp 10.4 trillion and Rp 15.6 trillion to cover the healthcare costs attributable to smoking, representing between 61.2% and 91.8% of the 2019 deficit. CONCLUSIONS: The vast economic cost of smoking is a waste of resources and a burden on Indonesia's National Health Insurance System. Therefore, the government must increase cigarette taxes to correct the negative externalities of smoking consumption.

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.

Revisiting the Energy-Happiness Paradox: A Quasi-Experimental Evidence of Electricity Access in Indonesia.

This study revisits the energy-happiness paradox hypothesis using the context of a developing nation. We used Indonesia as a case study, a unique archipelagic country with sparse subnational energy infrastructure, leading to the persistent regional energy access gap. We employed an instrumental variable technique to obviate conventional bias in the happiness regression. The model utilised a newly available national-level household survey on life satisfaction and historical data on digital maps of Indonesia's electricity infrastructure conditions in 1985. Unlike the phenomena known as the energy-happiness paradox found mainly in the developed countries that suggest the null relationship between having energy access and people's happiness, our finding reveals a positive effect of electricity access on people's happiness. We also show that the mechanism in which the effect operates is through individuals' satisfaction with housing conditions. The heterogeneity analysis shows that the impact of electricity access on happiness is more prominent in the lagging region. It justifies the placed-based policy strategy by the government in developing countries for expanding electricity access in favour of disadvantaged areas.

Household financial vulnerability in Indonesia: Measurement and determinants.

This study assesses the level of financial vulnerability of Indonesian households using data from the Household's Balance Sheet Survey (Survei Neraca Rumah Tangga/SNRT) 2016 and 2017. The SNRT are micro-unit of household data that contains information on preferences and behavior. Through both objective and subjective measurements of the Household Financial Vulnerability Index (FVI), we find that the financial vulnerability of Indonesian households is not only strongly influenced by income factors, but also by finance-related behavioral characteristics and several socio-economic factors. As a consistency and robustness check, we also estimate econometric models using the Indonesian Family Life Survey (IFLS) panel data for the periods 1993, 1997, 2000, 2007 and 2014. Our study then conclude that the level of household financial vulnerability decreased in 2017. Moreover, the study suggests that we should carefully monitor the behaviour of middle income group as they contribute significantly to the household financial vulnerability in Indonesia.

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.

COVID-19 in Indonesia: Challenges and Multidisciplinary Perspectives for a Safe and Productive New Normal.

The COVID-19 pandemic has caused disruption in all aspects of life, and countries around the world have been combating this pandemic using multiple approaches. Success in one country does not guarantee a transferable approach to other countries with different contexts. This review describes the challenges of COVID-19 management in Indonesia as a populous, socially and culturally diverse, and archipelagic country. It aims to provide multidisciplinary perspectives for a safe, evidence-based, and productive new normal as well as a comprehensive and integrated actionable policy for COVID-19 control.

The role of the 30% threshold for Islamic parties: A fast-growing middle class and religion-based political preferences in Indonesia.

Recently, Indonesia's middle-class Muslims have come under suspicion for strengthening the religious foundation of their political preferences. However, while this suspicion has been triggered by their increasingly confident expressions of Islamic identity in political, social and economic spheres, these public expressions do not consistently translate into electoral outcomes. Despite the significant growth of the middle class, the proportion of votes cast for Islamic parties, encompassing both pro-shari'a or Islamist and Islam-inclusive parties, has declined from 37% in 1999 to 30% in 2019. Utilising panel data from 397 districts and cities spanning three recent general elections (2009, 2014 and 2019), this study examines the association between the middle class's proportion of the total population and the vote share of Islamic parties. Our fixed-effect estimations validate an inverted U-curve relationship between the middle class's share and the vote share of pro-shari'a or Islamist parties, with the turning point occurring at approximately 29% of the middle class's total population. In regions with a lower percentage of the middle class, the vote share of Islamist parties rises in parallel with middle-class growth. Conversely, at a higher level, a growing middle class curtails the vote share of Islamist parties. This suggests that Indonesia's contemporary social structure is undergoing desecularisation in various ways, contingent on levels of modernisation. Notably, this desecularisation process does not imply a movement towards establishing an Islamic state. Indonesia's Muslims are moderate and more inclined to support secular, national or Pancasila-based parties, which tend to be inclusive and secular in their approach.

Factors associated with skilled birth attendance in 37 low-income and middle-income countries: a secondary analysis of nationally representative, individual-level data.

BACKGROUND: Progress on skilled birth attendance (SBA) has been very uneven across low-income and middle-income countries (LMICs). There is scant empirical evidence on the role of fundamental development processes in explaining differences in SBA outcomes across world regions over time in these settings. We therefore aimed to estimate how these processes have contributed to observed changes in SBA across Latin America and the Caribbean, South Asia, Southeast Asia, and sub-Saharan Africa. METHODS: We pooled all available Demographic and Health Survey (DHS) rounds that contained detailed birth attendance information. The compiled data covers about 1·1 million births (1·1 million female individuals) from 103 DHS rounds in 37 countries. We estimated the determinants of SBA using multivariable regression techniques and Oaxaca-Blinder decompositions for different world regions and time periods (1990s, 2000s, and 2010s). FINDINGS: We show that progress in SBA is associated with improvements in terms of household-level wealth, mothers' education, urbanisation, contraceptive knowledge, and proxies of female empowerment. Furthermore, we show that changes in the underlying relationship between SBA and specific development indicators (wealth, education, and rural residence status) have further contributed to the observed rise in SBA across LMICs. Our findings further suggest that certain determinants of improvements in SBA are region-specific (eg, importance of rural residence status in sub-Saharan Africa), whereas some of the studied processes (eg, poverty, maternal education, and urbanisation) have become less predictive for the uptake of SBA over time. INTERPRETATION: Although substantial progress has been made in increasing SBA rates over the past three decades across LMICs, further efforts for continued progress are still needed to achieve international targets on SBA as part of the Sustainable Development Goals, the Every Newborn Action Plan, and the Ending Preventable Maternal Mortality initiative. According to our findings, these efforts can include general policies (eg, female empowerment) and region-specific policies (eg, poverty reduction programmes in Southeast Asia). FUNDING: Bernhard Nocht Institute for Tropical Medicine. TRANSLATIONS: For the French and Indonesian translations of the abstract see Supplementary Materials section.