Expenditure on obstetric care and the protective effect of insurance on the poor: lessons from two Indonesian districts.

Objective: The Indonesian Government recently introduced a health insurance scheme to improve access to care for the poor. We investigated the payments made by households for different types of obstetric care, the economic consequences of payments and the effects of the new insurance on that expenditure.

Methods: Expenditures on obstetric care for women were collected from three main hospitals in the Serang and Pandeglang districts of Banten Province for all 'near-miss' cases (372), a sample of normal deliveries (146) and deliveries with Caesarean section (98) over a 6-month period. Women were also interviewed after they were discharged to collect information on economic status, household expenditure and source of payment for care.

Findings: Average expenditure by the mothers for near-miss cases was found to be Rp 2.6m (US$279) and Rp 1.9m (US$205) in Serang and Pandeglang Hospitals, respectively. Caesarean section was found to be the most expensive intervention. Insurance for the poor covered 51% of women at Serang Hospital and 73% of women at Pandeglang. Around 68% of households in the poorest quintiles would have made catastrophic payments. Insurance for the poor appears to have some positive association with the hospitals' expenditure for treatment of different types of maternal care.

Conclusion: Insurance for the poor appeared to be relatively effective in protecting households from catastrophic payments. However, it is not sufficient only to cover the very poor; the non-poor can also suffer catastrophic payments and they are only protected because hospital rules over who qualifies have been relaxed. Although the association between insurance and expenditure for obstetric care was important, it was not clear that this represents over-provision of services but rather that it reflected previously inadequate treatment given to those unable to pay.