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 healthfinancing 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 center dot 0 [pro-poor] to 1 center dot 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 center dot 5% and men constituted 49 center dot 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 center dot 9% of the participants for each year, whereas men constituted 51 center dot 1%. The distribution of health-care benefits in the public sector was marginally propoor; people with low income received a greater proportion of benefits from health services than people with high income between 2018 (concentration index -0 center dot 008, 95% CI -0 center dot 075 to 0 center dot 059) and 2019 (-0 center dot 060, -0 center dot 139 to 0 center dot 019). The benefit incidence in the private health sector was significantly pro-rich in 2018 (0 center dot 134, 0 center dot 065 to 0 center dot 203, p=0 center dot 0010) and 2019 (0 center dot 190, -0 center dot 192 to 0 center dot 572, p=0 center dot 0070). Health-financing incidence changed from being moderately progressive in 2018 (Kakwani index 0 center dot 034, 95% CI 0 center dot 030 to 0 center dot 038) to mildly regressive in 2019 (-0 center dot 030, -0 center dot 034 to -0 center dot 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-ofpocket spending and allocating more funding to primary care would improve access to health-care services for people with low income.