ABSTRACT
Introduction Ensuring health equity, especially for vulnerable populations in less developed settings with poor health system is essential for the current and future global health threats. This study examined the heterogeneity of COVID-19 mortality and its association with population health characteristics, health care capacity in responding pandemic, and socio-economic characteristics across 514 districts in Indonesia. Methods This nationwide ecological study included aggregated COVID-19 cases data from all 514 districts in Indonesia, recorded in the National COVID-19 Task Force database, during the first two years of the epidemic, from 1 March 2020 to 27 February 2022. We calculated incidence and mortality rate by time, sex, and age. We extracted district-level socio-demographics, population health, and health care capacity data from government official sources. We used multivariable linear regression to examine factors associated with higher mortality rate. Results Of total 5,539,333 reported cases, 148,034 (2.7%) died, and 5,391,299 (97.4%) were recovered. The national mortality rate was 55 per 100,000 population, ranged from 13 per 100,000 population in Papua to 156 per 100,000 population in East Kalimantan province. At district-level, higher mortality rate was associated with higher COVID-19 incidence (p<0.0001), higher proportion of >60 years old population (p<0.0001), higher prevalence of diabetes mellitus (p<0.0001), lower prevalence of obesity (p=0.019), lower number of doctors per population (p=0.001), higher life expectancy at birth (p=0.035), and lower formal education (p=0.021). There was no association between COVID-19 mortality rate with expenditure, prevalence of hypertension and pneumonia, vaccine coverage for >60 years old population, number of nurses, midwives, and hospitals per population (p>0.05 each). Conclusion COVID-19 mortality rate in Indonesia was highly heterogeneous and associated with different prevalence of pre-existing comorbidity, healthcare capacity in responding the pandemic, and socio-economic characteristics. This study revealed the need of health capacity strengthening and better resource allocation to ensure optimal health outcomes for vulnerable population.