The effect of health insurance and socioeconomic status on women’s choice in birth attendant and place of delivery across regions in Indonesia: a multinomial logit analysis

Background: Evidence suggests that women gave birth in diverse types of health facilities and were assisted by various types of health providers. This study examines how these choices are influenced by the Indonesia national health insurance programme (Jaminan Kesehatan Nasional (JKN)), which aimed to provide equitable access to health services, including maternal health. Methods: Using multinomial logit regression models, we examined patterns and determinants of women’s choice for childbirth, focusing on health insurance coverage, geographical location and socioeconomic disparities. We used the 2018 nationally representative household survey dataset consisting of 41 460 women (15–49 years) with a recent live birth. Results: JKN coverage was associated with increased use of higher-level health providers and facilities and reduced the likelihood of deliveries at primary health facilities and attendance by midwives/nurses. Women with JKN coverage were 13.1% and 17.0% (p<0.05) more likely to be attended by OBGYN/general practitioner (GP) and to deliver at hospitals, respectively, compared with uninsured women. We found notable synergistic effects of insurance status, place of residence and economic status on women’s choice of type of birth attendant and place of delivery. Insured women living in Java–Bali and in the richest wealth quintile were 6.4 times more likely to be attended by OBGYN/GP and 4.2 times more likely to deliver at a hospital compared with those without health insurance, living in Eastern Indonesia, and in the poorest income quantile. Conclusion: There are large variations in the choice of birth attendant and place of delivery by population groups in Indonesia. Evaluation of health systems reform initiatives, including the JKN programme and the primary healthcare strengthening, is essential to determine their impact on disparities in maternal health services

The impact of depression and physical multimorbidity on health-related quality of life in China: a national longitudinal quantile regression study

The co-occurrence of mental and physical chronic conditions is a growing concern and a largely unaddressed challenge in low-and-middle-income countries. This study aimed to investigate the independent and multiplicative effects of depression and physical chronic conditions on health-related quality of life (HRQoL) in China, and how it varies by age and gender. We used two waves of the China Health and Retirement Longitudinal Study (2011, 2015), including 9227 participants aged ≥ 45 years, 12 physical chronic conditions and depressive symptoms. We used mixed-effects linear regression to assess the effects of depression and physical multimorbidity on HRQoL, which was measured using a proxy measure of Physical Component Scores (PCS) and Mental Component Scores (MCS) of the matched SF-36 measure. We found that each increased number of physical chronic conditions, and the presence of depression were independently associated with lower proxy PCS and MCS scores. There were multiplicative effects of depression and physical chronic conditions on PCS (− 0.83 points, 95% CI − 1.06, − 0.60) and MCS scores (− 0.50 points, 95% CI − 0.73, − 0.27). The results showed that HRQoL decreased markedly with multimorbidity and was exacerbated by the presence of co-existing physical and mental chronic conditions

Menurunkan Angka Kematian Ibu dan Anak: Pembelajaran dari Nepal dan Sri Langka

Saat ini pencapaian Millennium Development Goals (MDGs) 4 dan 5, yakni penurunan angka kematian Balita (AKABA) dan angka kematian ibu (AKI) di Indonesia masih jauh dari target 2015 yaitu 102 AKI per-100.000 kelahiran hidup dan 34 AKABA per 1.000 kelahiran. Meskipun terjadi penurunan AKABA dari 97 (1991) menjadi 44 (2007) dan AKI menurun dari 390 (1991) menjadi 228 (2007), pencapaian ini masih jauh dari target yang harus dicapai. Selain itu, pencapaian tersebut masih di bawah negara-negara lain di Asia seperti: Vietnam, Nepal, Sri Lanka, dan Malaysia. AKI di Vietnam pencapaiannya lebih bagus dari Indonesia, padahal gross domestic product (GDP) Vietnam hanya US$141 miliar dan jauh berada di bawah Indonesia US$ 878 miliar (2012). Sri Lanka dengan GDP-nya hanya US$59,4 miliar dan Nepal US$ 19,4 miliar capaian AKI dan AKABA-nya melesat jauh di atas Indonesia. Berbagai strategi telah dicanangkan untuk menurunkan AKI dan AKABA antara lain: peningkatan kualitas dan kuantitas tenaga kesehatan, peningkatan infrastruktur dan kapasitas fasilitas kesehatan seperti Rumah Sakit PONEK (Pelayanan Obstetri Neonatal Emergensi Komprehensif) dan Puskesmas PONED (Pelayanan Obstetri Neonatal Emergensi Dasar) serta memperbanyak jumlah Polindes (Pondok Bersalin Desa), pemberdayaan masyarakat melalui ambulan siaga dan tabungan bersalin (tabulin), serta pembebasan biaya persalinan melalui Jampersal (Jaminan Persalinan). Namun demikian, penurunan AKI dan AKABA masih jauh dari yang diharapkan. Dua tahun menuju tahun 2015 merupakan kesempatan emas untuk mengejar ketertinggalan dari target AKI 102 dan AKABA 34. Berbagai kendala bermunculan mulai dari belum dipenuhinya alokasi anggaran kesehatan 5% dari total APBN di luar gaji pegawai, masih minimnya fasilitas dan tenaga kesehatan, rendahnya akses ke fasilitas PONED dan PONEK, rendahnya pemanfaatan Jampersal, tidak berfungsinya Polindes sebagaimana mestinya dan pergantian petugas-pejabat yang sangat cepat dan lainnya. Permasalahan ini mengindikasikan bahwa Pemerintah Indonesia perlu memperhatikan dan menelaah dengan seksama kebijakan kesehatan ibu dan anak yang saat ini berlaku untuk diperbaiki dan dikembangkan di kemudian hari. Di samping itu, pemerintah perlu menata kebijakan kesehatan secara lebih baik. Untuk mencapai target MDGs ini selain mengevaluasi langkah-langkah yang telah ditempuh Indonesia sampai saat ini, kita juga perlu menilik ke upaya-upaya yang telah dilakukan oleh negara-negara berkembang lain di Asia yang telah berhasil mencapai penurunan tajam AKI dan AKABA. Nepal dan Sri Lanka merupakan contoh negara yang mengalami penurunan AKI dan AKABA yang sangat signifikan dalam 10 tahun terakhir. Pembelajaran mengenai hal-hal yang berdayaguna dan berdayaungkit tinggi bagi Indonesia untuk mengidentifikasi peluang yang ada demi mencapai target MDGs dalam 2 tahun mendatang. Lalu, dengan mengetahui kebijakan AKI dan AKBA di dua negara tersebut, kita akan dapat belajar atas tantangan dan hambatan yang dihadapi dalam mencapai target penurunan AKI dan AKABA

Effect of multimorbidity on utilisation and out-of-pocket expenditure in Indonesia: quantile regression analysis

Background Multimorbidity (the presence of two or more non-communicable diseases) is a major growing challenge for many low-income and middle-income countries (LMICs). Yet, its effects on health care costs and financial burden for patients have not been adequately studied. This study investigates the effect of multimorbidity across the different percentiles of healthcare utilisation and out-of-pocket expenditure (OOPE). Methods We conducted a secondary data analysis of the 2014/2015 Indonesian Family Life Survey (IFLS-5), which included 13,798 respondents aged ≥40 years. Poisson regression was used to assess the association between sociodemographic characteristics and the total number of non-communicable diseases (NCDs), while multivariate logistic regression and quantile regression analysis was used to estimate the associations between multimorbidity, health service use and OOPE. Results Overall, 20.8% of total participants had two or more NCDs in 2014/2015. The number of NCDs was associated with higher healthcare utilisation (coefficient 0.11, 95% CI 0.07–0.14 for outpatient care and coefficient 0.09 (95% CI 0.02–0.16 for inpatient care) and higher four-weekly OOPE (coefficient 27.0, 95% CI 11.4–42.7). The quantile regression results indicated that the marginal effect of having three or more NCDs on the absolute amount of four-weekly OOPE was smaller for the lower percentiles (at the 25th percentile, coefficient 1.0, 95% CI 0.5–1.5) but more pronounced for the higher percentile of out-of-pocket spending distribution (at the 90th percentile, coefficient 31.0, 95% CI 15.9–46.2). Conclusion Multimorbidity is positively correlated with health service utilisation and OOPE and has a significant effect, especially among those in the upper tail of the utilisation/costs distribution. Health financing strategies are urgently required to meet the needs of patients with multimorbidity, particularly for vulnerable groups that have a higher level of health care utilisation

Out-of-pocket expenditure associated with physical inactivity, excessive weight and obesity in China: quantile regression approach

Introduction: Previous studies exploring associations of physical inactivity, obesity and out-of-pocket expenditure (OOPE) mainly used traditional linear regression, little is known about the effect of both physical inactivity and obesity on OOPE across the percentile distribution. This study aims to assess the effects of physical inactivity and obesity on OOPE in China using a quantile regression approach. Methods: Study participants included 10,687 respondents aged 45 years and older from the recent wave of the China Health and Retirement Longitudinal Study in 2015. Linear regression and quantile regression models were used to examine the association of physical activity, body weight with annual OOPE. Results: Overall, the proportion of overweight and obesity was 33.2% and 5.8%, respectively. The proportion of individuals performing high-level, moderate-level and low-level physical activity was 55.2%, 12.7% and 32.1%, respectively. The effects of low-level physical activity on annual OOPE was small at the bottom quantiles but more pronounced at higher quantiles. Respondents with low-level activity had an increased annual OOPE of 26.9 US$, 150.3 US$, 1534.4 US$, at the 10th, 50th, and 90th percentiles, respectively, compared with those with high-level activity. The effects of overweight and obesity on OOPE were also small at the bottom quantiles but more pronounced at higher quantiles. Conclusion: Interventions that improve the lifestyles and unhealthy behaviours among people with obesity and physical inactivity are likely to yield substantial financial gains for the individual and health systems in China

Evidence-Based Planning in Improving the Health Service and Insurance Utilization in Addressing Child Survival

To identify bottlenecks in health system that hinders the scaling up of important health intervention, particular for vulnerable population including poor families. To identify health system environment' that' would' support' the utilization of' health' insurance scheme for important interventions in child health survival

Medical costs and out-of-pocket expenditures associated with multimorbidity in China: quantile regression analysis

Objective Multimorbidity is a growing challenge in low-income and middle-income countries. This study investigates the effects of multimorbidity on annual medical costs and the out-of-pocket expenditures (OOPEs) along the cost distribution. Methods Data from the nationally representative China Health and Retirement Longitudinal Study (CHARLS 2015), including 10 592 participants aged ≥45 years and 15 physical and mental chronic diseases, were used for this nationally representative cross-sectional study. Quantile multivariable regressions were employed to understand variations in the association of chronic disease multimorbidity with medical cost and OOPE. Results Overall, 69.5% of middle-aged and elderly Chinese had multimorbidity in 2015. Increased number of chronic diseases was significantly associated with greater health expenditures across every cost quantile groups. The effect of chronic diseases on total medical cost was found to be larger among the upper tail than those in the lower tail of the cost distributions (coefficients 12, 95% CI 6 to 17 for 10th percentile; coefficients 296, 95% CI 71 to 522 for 90th percentile). Annual OOPE also increased with chronic diseases from the 10th percentile to the 90th percentile. Multimorbidity had larger effects on OOPE and was more pronounced at the upper tail of the health expenditure distribution (regression coefficients of 8 and 84 at the 10th percentile and 75th percentile, respectively). Conclusion Multimorbidity is associated with escalating healthcare costs in China. Further research is required to understand the impact of multimorbidity across different population groups

Perencanaan Berbasis Bukti Untuk Menjawab Kebutuhan Kesehatan Anak Dan Jaminan Sosial Bidang Kesehatan: Studi Kasus Tasikmalaya Dan Jayawijaya

Millennium Development Goal acceleration has called for innovations in health. One of the innovations is the Evidence-Based Planning (EBP) for maternal, neonatal and child health (MNCH). The Evidence-Based planning and budgeting approach is a rational approach, and put forward the scale-up of interventions that have been proven to be effective in reducing women and children deaths globally. The evidence- based interventions package for MNCH was published based on systematic review of over than 190 health interventions (Kerber, 2007) and is part of the Lancet series in maternal and child survival. The EBP was designed to improve sub-national MNCH planning and to be used at the district level, by the district health office and District hospital, as well as other healthrelevant offices/departments. In terms of social protection and health insurance, the regulation No. 24/2011 on BPJS (Social Security Managing Organization) and the President decree No. 12/2011 on Health Insurance have instructed that health care providers, including hospitals, have to provide comprehensive health services for poor and near-poor population

Trends and inequities in use of maternal health care services in Indonesia, 1986-2012

Purpose: Overall health status indicators have improved significantly over the past three decades in Indonesia. However, the country's maternal mortality ratio remains high with a stark inequality by region. Fewer studies have explored access inequity in maternal health care service over time using multiple inequality markers. In this study, we analyzed Indonesian Demographic and Health Survey (DHS) data to explore trends and inequities in use of any antenatal care (ANC), four or more ANC (ANC4+), institutional birth, and cesarean section (c-section) birth in Indonesia during 1986-2012 to inform policy for future strategies ending preventable maternal deaths. Methods: Indonesian DHS data from 1991, 1994, 1997, 2002/3, 2007, and 2012 surveys were downloaded, merged, and analyzed. Inequity was measured in terms of variation in use by asset quintile, parental education, urban-rural location, religion, and region. Trends in use inequities were assessed plotting changes in rich:poor ratio, rich:poor difference, and concentration indices over period based on asset quintiles. Sociodemographic determinants for service use were explored using multivariable logistic regression analysis. Findings: Between 1986 and 2012, institutional birth rate increased from 22% to 73% and c-section rate from 2% to 16%. Private sector was increasingly contributing in maternal health. There were significant access inequities by asset quintile, parental education, area of residence, and geographical region. The richest women were 5.45 times (95% CI: 4.75-6.25) more likely to give birth in a health facility and 2.83 times (95% CI: 2.23-3.60) more likely to give birth by c-section than their poorest counterparts. Urban women were 3 times more likely to use institutional birth and 1.45 times more likely to give birth by c-section than rural women. Use of all services was higher in Java and Bali than in other regions. Access inequity was narrowing over time for use of ANC and institutional birth but not for c-section birth. Conclusion: Ongoing pro-poor health-financing strategies should be strengthened with introduction of innovative ways to monitor access, equity, and quality of care in maternal health

Trends and inequities in use of maternal health care services in Indonesia, 1986&minus;2012

Herfina Y Nababan,1 Md Hasan,2 Tiara Marthias,1,3 Rolina Dhital,4 Aminur Rahman,2 Iqbal Anwar2 1Nossal Institute for Global Health, Melbourne School of Population and Global Health, the University of Melbourne, Parkville, Melbourne, VIC, Australia; 2Health Systems and Population Studies Division, icddr,b, Mohakhali, Dhaka, Bangladesh; 3Center for Health Policy and Management, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia; 4FIGO Post-Partum IUD Initiative &ndash; Nepal, Nepal Society of Obstetrician and Gynaecologists (NESOG), Kathmandu, Nepal Purpose: Overall health status indicators have improved significantly over the past three decades in Indonesia. However, the country&rsquo;s maternal mortality ratio remains high with a stark inequality by region. Fewer studies have explored access inequity in maternal health care service over time using multiple inequality markers. In this study, we analyzed Indonesian Demographic and Health Survey (DHS) data to explore trends and inequities in use of any antenatal care (ANC), four or more ANC (ANC4+), institutional birth, and cesarean section (c-section) birth in Indonesia during 1986-2012 to inform policy for future strategies ending preventable maternal deaths.Methods: Indonesian DHS data from 1991, 1994, 1997, 2002/3, 2007, and 2012 surveys were downloaded, merged, and analyzed. Inequity was measured in terms of variation in use by asset quintile, parental education, urban&ndash;rural location, religion, and region. Trends in use inequities were assessed plotting changes in rich:poor ratio, rich:poor difference, and concentration indices over period based on asset quintiles. Sociodemographic determinants for service use were explored using multivariable logistic regression analysis.Findings: Between 1986 and 2012, institutional birth rate increased from 22% to 73% and c-section rate from 2% to 16%. Private sector was increasingly contributing in maternal health. There were significant access inequities by asset quintile, parental education, area of residence, and geographical region. The richest women were 5.45 times (95% CI: 4.75-6.25) more likely to give birth in a health facility and 2.83 times (95% CI: 2.23-3.60) more likely to give birth by c-section than their poorest counterparts. Urban women were 3 times more likely to use institutional birth and 1.45 times more likely to give birth by c-section than rural women. Use of all services was higher in Java and Bali than in other regions. Access inequity was narrowing over time for use of ANC and institutional birth but not for c-section birth.Conclusion: Ongoing pro-poor health-financing strategies should be strengthened with introduction of innovative ways to monitor access, equity, and quality of care in maternal health. Keywords: health inequity, health inequality, maternal health, health service utilization, universal health coverage, sustainable development goa