HEALTHCARE UTILIZATION AND LONG-TERM CARE IN INDONESIA’S AGEING POPULATION

Abstract

Background: Noncommunicable diseases (NCDs) are the leading cause of death worldwide, with cardiovascular diseases (CVDs) being the largest contributor. Seventy-three percent of NCD deaths occur in low- and middle-income countries (LMICs), where the population aged ≥60 years is projected to nearly double by mid-century. In Indonesia, rapid demographic and epidemiological transitions have intensified healthcare and long-term care (LTC) demands, yet evidence linking these changes to system responses remains limited. Objective: This thesis examines healthcare utilization and LTC among older adults in Indonesia, focusing on individuals with CVDs. It aims to assess healthcare costs, evaluate the impact of the COVID-19 pandemic on service utilization, project future LTC expenditure, and explore policymaker perspectives on Indonesia’s transition from informal to formal LTC systems. Methods: A mixed-methods design was employed, integrating quantitative and qualitative components. Study I used National Health Insurance (NHI) claims data from 2016–2018 (N = 271,065) and applied a three-level linear mixed-effects model (individual, household, and district levels) to examine associations between CVDs, with or without other chronic disease comorbidities, and healthcare costs. Study II analyzed longitudinal NHI data from 2016–2020 (N = 378,495) using interrupted time-series analysis to evaluate the impact of COVID-19 on healthcare utilization. Study III employed a macro-simulation model to project LTC costs for adults aged ≥60 years (N ≈ 35 million in 2025). Study IV conducted in-depth interviews with nine policymakers and analyzed them using inductive qualitative content analysis. Results: Adults with CVDs and multimorbidity incurred nearly twice the healthcare costs of those with CVD alone. Among higher-income groups, mean outpatient costs were USD 119.5 (SD 264.1) for CVDs and multimorbidity versus USD 49.1 (SD 153.6) for CVD alone; among lower-income groups, USD 79.9 (SD 202.4) versus USD 36.7 (SD 127.5). Healthcare utilization declined markedly during the COVID-19 pandemic: hospital outpatient visits decreased 32% (95% CI 0.55–0.85), inpatient visits 18% (95% CI 0.71–0.95), and primary-care visits 23% (95% CI 0.63–0.94). LTC expenditure is projected to increase from USD 3.2 billion in 2025 to USD 19.2 billion in 2045—equivalent to a rise from 0.94% to 2.06% of GDP—driven primarily by home-based care. Stakeholders emphasized the need to balance family, community, and state responsibilities in developing equitable and sustainable LTC systems. Conclusion: Cardiovascular disease and multimorbidity were associated with substantially higher healthcare costs and resource utilization among Indonesian adults, with subsidized households showing lower healthcare use and spending reflecting socioeconomic barriers to access. Beyond healthcare utilization, LTC needs and costs are projected to rise sharply, highlighting a central policy challenge: defining the respective roles of the state, families, and communities in future care provision. As Indonesia remains a relatively young nation, investments in population health and NCD prevention will be critical, as these will strongly influence both healthcare utilization and future LTC demand. Preventive strategies and prioritizing the development of public facilities that promote healthy aging and inclusivity are essential to building a resilient, equitable, and sustainable LTC system aligned with Indonesia’s broader development and social protection goals.