Assessing the magnitude and factors contributing to socioeconomic and geographical inequalities in maternal and child health care utilisation in Indonesia

Abstract

Significant progress has been made in reducing maternal and child mortality at the global level. However, the burden of maternal and child mortality remains high. Indonesia, home to over 270 million population, has one of the highest burden of maternal and child mortality in the world. One of the main challenges in reducing maternal and child health burden in Indonesia, and other LMICs, is inequitable access to essential maternal and child health (MCH) interventions, particularly among the poorest population and those living in remote areas with poor access to health services. It is crucial to understand the influence of health systems on MCH to inform the design and implementation of health interventions. Furthermore, there is also limited evidence on the impact of health insurance on effective MCH service coverage, disparities of health care, and health outcomes. The four objectives in this thesis addressed these issues.

First, I described the geographical inequalities in skilled birth attendance (SBA) coverage across Indonesia regions and quantified the contributions of socioeconomic and health supply-side factors towards the geographical variations. Geographical inequality in SBA coverage was mainly driven by disparities in the availability of health supply-side, i.e. the number of skilled birth attendants and hospitals. Interestingly, the number of primary health centres did not influence the uptake of SBA.

Second, I assessed the trends and inequalities in the RMCH effective coverage from 2002-2017 to examine gaps in the RMCH care cascade, and investigate variations of these cascade indicators among regions and socio-demographic groups over time. The study revealed that while significant improvement has been made in the levels of crude coverage for all MCH services, the quality of care is still low. The user adherence in following the standards of antenatal care and childhood immunisation was also found to be a challenge. Antenatal care and maternal delivery services were the least equitable interventions compared to family planning and childhood immunisation services. Provinces with similar levels of overall coverage had varying degrees of inequity. This indicates different pathways towards high coverage in relation to the distribution of the services.

Next, I evaluated the association of the Indonesia national health insurance (JKN program), the largest single-payer health insurance program in the world, on access to maternal health service and child mortality. Findings from my thesis clearly indicated that JKN was associated with increased coverage of antenatal care, SBA and facility-based delivery. However, JKN was not associated with the reduction in neonatal or infant mortality. This study supports WHO call for universal health coverage through the expansion of social health insurance in LMICs. Quality improvement initiatives must place greater emphasis on the vulnerable population, less developed regions, and geographically remote areas. Finally, the JKN influenced women’s choice of the type of birth attendant and place of delivery. JKN could reduce unsafe deliveries by increasing the SBA use and facility-based deliveries. However, JKN also promoted the use of high-level maternal care, particularly among the richer population and women living in more developed regions in Indonesia. Hence, the main lesson from this study for the healthcare system in Indonesia and other countries is that health insurance coverage by itself may not be sufficient to address challenges in the quality and appropriateness of care. Consequently, future health system reform must place greater emphasis on strengthening integrated primary health care to achieve universal health coverage in Indonesia.