Out-of-pocket expenditure in Indonesia’s national health insurance: evidence from household survey in Bandar Lampung City, Indonesia

Atika Dalili Akhmad; Irfanianta Arif  Setyawan; Dirga

doi:10.51511/pr.107

Atika Dalili Akhmad Departement of Pharmacy, Faculty of Science, Institut Teknologi Sumatera, South Lampung, Indonesia https://orcid.org/0000-0002-0249-2403
Irfanianta Arif Setyawan Department of Pharmacy, Faculty of Science, Institut Teknologi Sumatera, South Lampung, Indonesia https://orcid.org/0009-0007-4553-059X
Dirga Department of Pharmacy, Faculty of Science, Institut Teknologi Sumatera, South Lampung, Indonesia https://orcid.org/0000-0002-3248-9766

Keywords: health insurance, health coverage, health facilities, out-of-pocket, community pharmacies

Abstract

Indonesia’s National Health Insurance (NHI) was established to promote equitable access to healthcare and protect households from financial hardship. However, out-of-pocket (OOP) payments continue to occur, leading in catastrophic health for many families. This study aimed to measure the incidence and identify the determinants of OOP spending among NHI participants in Bandar Lampung. A cross-sectional survey involving 253 NHI members was conducted in 2020 across clinics, public health centers, and pharmacies. Data were analyzed using chi-square and logistic regression. OOP spending was reported by 31.62% of respondents. Bivariate analysis indicated that the type of health facility (p = 0.004) and membership status (p = 0.040) significantly influenced OOP expenditure, while age, gender, education, occupation, income, and treatment class were not significant. Multivariate analysis confirmed that visits to clinics (p = 0.018) and membership in Mandiri or PBI groups (both p = 0.039) were associated with a higher likelihood of OOP payments. Despite essential health services being covered under NHI, OOP expenditure remains a considerable financial burden. These findings highlight the need for stronger policy interventions to improve benefit coverage and ensure equitable financial protection under Indonesia’s NHI system.

References

Carrin G, Mathauer I, Xu K, Evans DB. Universal coverage of health services: tailoring its implementation. Bull World Health Organ. 2008;86(11):857-63. https://doi.org/10.2471/BLT.07.049387

Gauthfa A, Kuswinarti K, Sunjaya D. Dampak Implementasi Jaminan Kesehatan Nasional terhadap ketersediaan Obat di Apotek Rujukan Wilayah Cibeunying Kotamadya Bandung Tahun 2015. Jurnal Sistem Kesehatan. 2016;1(4):159-64. https://doi.org/10.24198/jsk.v1i4.10374

Aregbeshola BS, Khan SM. Out-of-pocket payments, catastrophic health expenditure and poverty among households in Nigeria 2010. Int J Health Policy Manag. 2018;7(9):798-806. https://doi.org/10.15171/ijhpm.2018.19

Lim MY, Ullah ANZA, Marthias T, Sauerborn R, Hamid AIA, Johar M. Health financing challenges in Southeast Asian countries for universal health coverage: a systematic review. Arch Public Health. 2023;81(1):1-12. https://doi.org/10.1186/s13690-023-01159-3

Lestari TD, Kusumo MP. Universal Health Coverage (UHC): Turning Equitable and Quality Health Care Access for All. Media Penelitian dan Pengembangan Kesehatan. 2025;35(2):420-35. https://doi.org/10.34011/jmp2k.v35i2.2679

Atella V, Brugiavini A, Pace N. The health care system reform in China: Effects on out-of-pocket expenses and saving. China Econ Rev. 2015;34:182-95. https://doi.org/10.1016/j.chieco.2015.02.003

Wang Q, Brenner S, Leppert G, Banda TH, Kalmus O, De Allegri M. Out-of-pocket expenditure on chronic non-communicable diseases in Sub-Saharan Africa: The case of rural Malawi. PLoS One. 2015;10(1):e0116897. https://doi.org/10.1371/journal.pone.0116897

WHO Regional Office for Europe. Can people afford to pay for health care? Regional report. Copenhagen: WHO Regional Office for Europe; 2019. p. 1-116.

Beogo I, Huang N, Gagnon MP, Amendah DD. Out-of-pocket expenditure and its determinants in the context of private healthcare sector expansion in sub-Saharan Africa urban cities: Evidence from household survey in Ouagadougou, Burkina Faso. BMC Res Notes. 2016;9(1):34. https://doi.org/10.1186/s13104-016-1846-4

Han SM, Rahman MM, Rahman MS, Swe KT, Palmer M, Sakamoto H, et al. Progress towards universal health coverage in Myanmar: a national and subnational assessment. Lancet Glob Health. 2018;6(9):e989-e997. https://doi.org/10.1016/S2214-109X(18)30318-8

Maulana N, Dzakiyullah NR, Daud A, Abdullah MT, Idris H, Dachlan DM, et al. How Jaminan Kesehatan Nasional (JKN) coverage influences out-of-pocket (OOP) payments by vulnerable populations in Indonesia. PLOS Glob Public Health. 2022;2(7):e0000203. https://doi.org/10.1371/journal.pgph.0000203

Alves JC, Law MR, Luz TCB. Prevalence and Factors Associated With Out-of-Pocket Pharmaceutical Expenditure Among Primary Healthcare Patients: Evidence From the Prover Project. Value Health Reg Issues. 2022;30:83-90. https://doi.org/10.1016/j.vhri.2022.01.006

Rokx C, Schieber G, Harimurti P, Tandon A, Somanathan A. Health Financing in Indonesia. Washington DC: World Bank; 2009. https://doi.org/10.1596/978-0-8213-8006-2

Tangcharoensathien V, Patcharanarumol W, Ir P, Aljunid SM, Mukti AG, Akkhavong K, et al. Health-financing reforms in southeast Asia: Challenges in achieving universal coverage. Lancet. 2011;377(9768):863-73. https://doi.org/10.1016/S0140-6736(10)61890-9

Wiseman V, Thabrany H, Asante A, Haemmerli M, Kosen S, Gilson L, et al. An evaluation of health systems equity in Indonesia: Study protocol. Int J Equity Health. 2018;17(1):138. https://doi.org/10.1186/s12939-018-0822-0

Fattah RA, Salami R, Wulandari RD, Besral B. Incidence of catastrophic health spending in Indonesia: insights from a Household Panel Study 2018-2019. Int J Equity Health. 2023;22(1):187. https://doi.org/10.1186/s12939-023-01980-w

Akhmad AD, Satibi, Puspandari DA. Analisis Persepsi Dan Faktor Yang Mempengaruhi Persepsi Terhadap Penerapan Sistem Pembiayaan JKN Pada Fasilitas Kesehatan [Analysis of Perception and Factors Affecting the Perception on Implementation of JKN Payment System in Health Facilities]. Jurnal Manajemen dan Pelayanan Farmasi. 2015;5(4):267-74.

Ja B, Wm N, Apuzzo D. Medicaid Payer Status Is Associated with In-Hospital Morbidity and Resource Utilization Following Vaginal Deliveries. Am J Perinatol. 2014;31(7):635-42.

Courtney PM, Boniello AJ, Berger RA. Complications Following Outpatient Total Joint Arthroplasty: An Analysis of a National Database. J Arthroplasty. 2017;32(5):1426-30. https://doi.org/10.1016/j.arth.2016.11.055

Singh JA, Cleveland JD. Insurance Payer Type and Patient Income Are Associated with Outcomes after Total Shoulder Arthroplasty. J Rheumatol. 2020;47(4):589-96. https://doi.org/10.3899/jrheum.190287

Quick JD, Rankin JR, Laing RO, O'Connor RW, Hogerzeil HV, Dukes MNG, et al. Managing Drug Supply: The Selection, Procurement, Distribution, and Use of Pharmaceuticals. 2nd ed. West Hartford: Kumarian Press; 2012.

Zhou G, Chen R, Chen M. Equity in health-care financing in China during the progression toward universal health coverage. China Econ Rev. 2020;61:101427. https://doi.org/10.1016/j.chieco.2020.101427

Courtney PM, Froimson MI, Meneghini RM, Lee GC, Della Valle CJ. Can Bundled Payments Be Successful in the Medicaid Population for Primary Joint Arthroplasty? J Arthroplasty. 2017;32(11):3263-7. https://doi.org/10.1016/j.arth.2017.05.035

Republic of Indonesia. Peraturan Presiden Nomor 82 Tahun 2018 Tentang Jaminan Kesehatan [Presidential Regulation No. 82 of 2018 on Health Insurance]. Jakarta: Republic of Indonesia; 2018.

Cheng Q, Hidayat B, Parmar D, Irava W, Dashzeveg C, Theint MM, et al. Equity of health financing in Indonesia: A 5-year financing incidence analysis (2015-2019). Lancet Reg Health West Pac. 2022;21:100400. https://doi.org/10.1016/j.lanwpc.2022.100400

Asante A, Hayen A, Eagar K, Woelke A, Longman J, Phommahaxay P, et al. The benefits and burden of health financing in Indonesia: analyses of nationally representative cross-sectional data. Lancet Glob Health. 2023;11(5):e770-e780. https://doi.org/10.1016/S2214-109X(23)00064-5

O'Donnell O, van Doorslaer E, Rannan-Eliya RP, Somanathan A, Adhikari SR, Akkazieva B, et al. Who pays for health care in Asia? J Health Econ. 2008;27(2):460-75. https://doi.org/10.1016/j.jhealeco.2007.08.005

Wagner N, Quimbo S, Shimkhada R, Peabody J. Does health insurance coverage or improved quality protect better against out-of-pocket payments? Experimental evidence from the Philippines. Soc Sci Med. 2018;204:51-8. https://doi.org/10.1016/j.socscimed.2018.03.024

Hu FB, Liu Y, Willett WC. Preventing chronic diseases by promoting healthy diet and lifestyle: Public policy implications for China. Obes Rev. 2011;12(7):552-9. https://doi.org/10.1111/j.1467-789X.2011.00863.x

Patel V, Chatterji S, Chisholm D, Ebrahim S, Gopalakrishna G, Mathers C, et al. Chronic diseases and injuries in India. Lancet. 2011;377(9763):413-28. https://doi.org/10.1016/S0140-6736(10)61188-9

Pallegedara A. Impacts of chronic non-communicable diseases on households' out-of-pocket healthcare expenditures in Sri Lanka. Int J Health Econ Manag. 2018;18(3):301-19. https://doi.org/10.1007/s10754-018-9235-2

Sisira Kumara A, Samaratunge R. Relationship between healthcare utilization and household out-of-pocket healthcare expenditure: Evidence from an emerging economy with a free healthcare policy. Soc Sci Med. 2019;235:112364. https://doi.org/10.1016/j.socscimed.2019.112364

Yip W, Hsiao W. China's health care reform: A tentative assessment. China Econ Rev. 2009;20(4):613-9. https://doi.org/10.1016/j.chieco.2009.08.003

Husain MJ, Dutta M, Zaghloul MS. Use of hospital services and socio-economic status in urban India: Does health insurance ensure equitable outcomes? Munich Pers RePEc Arch. 2012;40055:1-28.

Rathish D, Bahini S, Sivakumar T, Thiranagama T, Abarajithan T, Wijerathne B, et al. Drug utilization, prescription errors and potential drug-drug interactions: An experience in rural Sri Lanka. BMC Pharmacol Toxicol. 2016;17(1):27. https://doi.org/10.1186/s40360-016-0071-z

Tuti SRID, Athiyah UMI, Utami W. Faktor yang Mempengaruhi Ketersediaan Obat Program Rujuk Balik (PRB) di Fasilitas Pelayanan Obat PRB Wilayah Eks Karesidenan Kediri [Factors Affecting The Drugs Availability on Referral Back Program (PRB) at Health Service Facilities in Ex-Residency Kediri]. Jurnal Ilmu Kefarmasian Indonesia. 2018;16(1):30-5. https://doi.org/10.35814/jifi.v16i1.437

Anggriani Y, Amrin MS, van Asselt ADI, Setiati TE, Postma MJ. The Impact of Pharmaceutical Policies on Medicine Procurement Pricing in Indonesia Under the Implementation of Indonesia's Social Health Insurance System. Value Health Reg Issues. 2020;21:1-8. https://doi.org/10.1016/j.vhri.2019.05.005

Kristina SA, Wiedyaningsih C, Cahyadi A, Ridwan AB. Evaluating accessibility of essential medicines in indonesia: A survey on availability and prices in public and private health sectors. Int J Pharm Res. 2020;12(2):692-9. https://doi.org/10.1016/j.vhri.2020.07.204

Maulana N, Dzakiyullah NR, Daud A, Abdullah MT, Idris H, Dachlan DM, et al. How Jaminan Kesehatan Nasional (JKN) coverage influences out-of-pocket (OOP) payments by vulnerable populations in Indonesia. PLOS Glob Public Health. 2022;2(7):e0000203. https://doi.org/10.1371/journal.pgph.0000203