Background 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 geographical variations 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 data of COVID-19 cases and deaths 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. The dependent variable was district-level COVID-19 mortality rate per 100,000 populations. The independent variables include district-level COVID-19 incidence rate, population health, health care capacity, and socio-demographics data from government official sources. We used multivariable ordinal logistic regression to examine factors associated with higher mortality rate. Results Of total 5,539,333 reported COVID-19 cases, 148,034 (2.7%) died, and 5,391,299 (97.4%) were recovered. The district-level mortality rate ranged from 0 to 284 deaths per 100,000 populations. The top five districts with the highest mortality rate were Balikpapan (284 deaths per 100,000 populations), Semarang (263), Madiun (254), Magelang (250), and Yogyakarta (247). A higher COVID-19 incidence (coefficient 1.64, 95% CI 1.22 to 1.75), a higher proportion of ≥ 60 years old population (coefficient 0.26, 95% CI 0.06 to 0.46), a higher prevalence of diabetes mellitus (coefficient 0.60, 95% CI 0.37 to 0.84), a lower prevalence of obesity (coefficient -0.32, 95% CI -0.56 to -0.08), a lower number of nurses per population (coefficient -0.27, 95% CI -0.50 to -0.04), a higher number of midwives per population (coefficient 0.32, 95% CI 0.13 to 0.50), and a higher expenditure (coefficient 0.34, 95% CI 0.10 to 0.57) was associated with a higher COVID-19 mortality rate. Conclusion COVID-19 mortality rate in Indonesia was highly heterogeneous and associated with higher COVID-19 incidence, different prevalence of pre-existing comorbidity, healthcare capacity in responding the pandemic, and socio-economic characteristics. This study revealed the need of controlling both COVID-19 and those known comorbidities, health capacity strengthening, and better resource allocation to ensure optimal health outcomes for vulnerable population.

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.

No abstract

Background There are limited measures of the impact of the COVID-19 pandemic on tuberculosis (TB) control in high-burden countries like Indonesia. Methods We analysed district-level data of reported TB cases, treatment and deaths, COVID-19 incidence and mortality, health care capacity, economic status, education level, and public health development index from all 514 districts in Indonesia. We compared data before (2016-2019) and during (2020-2021) the pandemic. Findings Compared to the preceding year (2019), in the first pandemic year (2020) the TB case notification declined by 31% (from median 172 [IQR 129-244] in 2019 to 119 [IQR 87-170] in 2020 per 100,000 population; 565,669 vs 393,323 cases, respectively); mortality increased by 8% (from median 4.2 [IQR 2.0-7.4] to 5.0 (IQR 3.1-7.5) per 100,000 population; 13,059 vs 14,148 deaths, respectively); and the overall proportion of cases who started treatment declined by 7% (from 98% to 91%). The second pandemic year (2021) saw a partial recovery of case notifications (median 142 [IQR 99-204]; 473,006) and deaths (4.1 [IQR 2.5-6.8]; 12,016), but a persistently reduced treatment coverage (84%). Reductions in TB notifications between districts were associated with higher COVID-19 incidence and fewer per capita GeneXpert machines for TB diagnosis. Likewise, reduced TB treatment coverage was associated with fewer per capita doctors, and increased reported TB deaths was associated with fewer per capita primary health centres, lower per capita domestic expenditure and higher education. Interpretation The COVID-19 pandemic significantly, yet unevenly, impacted the national TB control programme across Indonesia, with the greatest impacts in districts with the least resilient health systems.