Fit for growing old? Financial protection before and after Indonesia's national health insurance scheme - a repeated cross-section study

The world is ageing with unprecedented momentum, and large global south nations are ageing at higher speed than their northern peers. They have grown old while they have not grown rich, straining their health systems' ability to deliver financial protection. This work aimed to assess whether Indonesia's health insurance scheme, seven years on, has delivered equal protection for families with older members (over 60 years) as for other families. Methods Before-and-after observation study is designed to estimate how much difference the Scheme made to probabilities of catastrophic payment and financial impoverishment for the two family types. As in recent assessments, two national socioeconomic surveys were used (2013, 2021). Two level observations came from 622,125 families residing in 514 districts across the archipelago. Financial protection indicators against catastrophic payment and impoverishment were constructed following recent works. I estimated two level probit models, then plotted marginal probabilities of financial protection. A sensitivity analysis was conducted with the standard financial protection indicator. Findings After the Scheme, financial hardship for all family types has reduced by 19%. But families with older members (compared to other families) have an additional 0.7% risk of incurring catastrophic payment or financial impoverishment. And social and spatial inequalities in health persist. Discussion While the Scheme has markedly improved financial protection for all, families with older members remain at higher risk of being unprotected. The global south can prepare for an ageing world by monitoring financial protection and its social determinants and systematically distinguishing families with older members.