RESUMO
While Indonesia introduced a national health insurance scheme (JKN) in 2014 and coverage has grown to over 80% of the population, Indonesians still spend significant sums out-of-pocket (OOP) for their healthcare-over 30% of current health expenditure (CHE). This study aims to better understand how JKN is influencing OOP payments, especially among the poor and rural, at the range of health facilities. This study uses data from the National Socio-Economic Survey (SUSENAS) in 2018 and 2019, as these surveys started including a question on how much OOP spending a household incurs on health. The results show that households with JKN membership are far less likely than the uninsured to pay OOP for healthcare, and that if they do incur a cost, the magnitude of this cost is much lower among JKN households than uninsured ones. The results also show that JKN households in the two poorest quintiles have a higher probability to not incur any OOP (37% and 35%, respectively) compared to those in the wealthier quintiles 4 (32%) and 5 (30%). Poorer JKN households living in the eastern part of Indonesia-the less urbanized and developed regions-experienced the most cost-savings, though largely due to supply-side constraints. In fact, JKN members save more at public primary health care facilities vs. private ones (who often do not contract with JKN) and also save significantly more (over 50%) than uninsured households at both public and private hospitals. The study demonstrates the positive influence JKN has on OOP payments, especially among the poor and rural, but also highlights how the scheme needs to better engage with the growing private sector and invest in infrastructure in rural areas to help secure financial protection for its entire population.
RESUMO
Introduction: Globally, there are 370 million children receiving school meals every day. Coverage is least in low-income countries, where the need is greatest and where program costs are viewed as high in comparison with the benefits to public health alone. Here we explore the policy implications of including the returns of school feeding to other sectors in an economic analysis. Methods: We develop an economic evaluation methodology to estimate the costs and benefits of school feeding programs across four sectors: health and nutrition; education; social protection; and the local agricultural economy. We then apply this multi-sectoral benefit-cost analytical framework to school feeding programs in 14 countries (Botswana, Brazil, Cape Verde, Chile, Côte d'Ivoire, Ecuador, Ghana, India, Kenya, Mali, Mexico, Namibia, Nigeria, and South Africa) for which input data are readily available. Results: Across the 14 countries, we estimate that 190 million schoolchildren benefit from school feeding programs, with total program budgets reaching USD11 billion per year. Estimated annual human capital returns are USD180 billion: USD24 billion from health and nutrition gains, and USD156 billion from education. In addition, school feeding programs offer annual social protection benefits of USD7 billion and gains to local agricultural economies worth USD23 billion. Conclusions: This multi-sectoral analysis suggests that the overall benefits of school feeding are several times greater than the returns to public health alone, and that the overall benefit-cost ratio of school feeding programs could vary between 7 and 35, with particular sensitivity to the value of local wages. The scale of the findings suggests that school feeding programs are potentially much more cost-beneficial when viewed from the perspective of their multi-sectoral returns, and that it would be worthwhile following up with more detailed analyses at the national level to enhance the precision of these estimates.
