Determinants of Household Health Expenditure in Indonesia: A Systematic Literature Review and Evidence Synthesis

Abstract

Universal health coverage (UHC) requires not only access to essential services but also effective financial protection against out-of-pocket (OOP) payments and catastrophic health expenditure (CHE). This review aims to synthesize empirical evidence on the determinants of household health expenditure in Indonesia and to identify the factors most consistently associated with higher OOP and CHE. A systematic literature review was undertaken using PRISMA-oriented procedures and targeted searches across PubMed, SpringerLink, PLOS, Frontiers, Wiley Online Library, BMJ Open, and indexed Indonesian journals for studies published from 2015 to 2025. Fourteen eligible studies were included in the final narrative synthesis. The evidence indicates that household health expenditure in Indonesia is shaped by five interacting domains: socioeconomic status and capacity to pay, insurance coverage and benefit design, morbidity burden and multimorbidity, healthcare utilization and provider choice, and residential-contextual factors. Poor households were more likely to experience CHE, whereas better-off households often incurred higher absolute OOP because of greater service use and stronger reliance on private providers. National Health Insurance (JKN) generally reduces direct payments, but its protective effect remains incomplete in settings marked by medicine stock-outs, private provider use, limited contracting, and supply-side constraints. Chronic disease, hospitalization, multimorbidity, and the presence of elderly members further increased financial vulnerability. The findings suggest that household health expenditure in Indonesia reflects the interaction between health need, health system design, and unequal service availability rather than income alone. Policy responses should therefore prioritize high-need households, strengthen financial protection under JKN, improve medicine availability, and expand equitable primary care capacity across regions.