# Disability-based disparities under universal health coverage among chronically ill adults during the COVID-19 pandemic in Indonesia: an interrupted time series analysis

## TL;DR

During the pandemic, people with disabilities in Indonesia faced bigger healthcare access challenges, especially women and those in poor areas.

## Contribution

First study to quantify disability-based healthcare disparities under Indonesia's JKN insurance during a public health crisis.

## Key findings

- PWD had higher curative care use, but disabled women had significantly fewer curative visits than disabled men.
- Residence in underdeveloped districts reduced both preventive and curative healthcare visits for all groups.
- Disability-based disparities worsened during the pandemic, highlighting gender and geographic inequities.

## Abstract

People with disabilities (PWD) face persistent barriers to healthcare, often exacerbated during public health emergencies. In Indonesia, 10.8% of adults with disabilities have chronic disease, yet how the National Health Insurance (JKN) addresses disparities remains unclear.

To assess the COVID-19 pandemic’s impact on disability-based disparities in chronic healthcare utilization under JKN, and whether these were modified by gender or geographic disadvantage.

A panel-based interrupted time series analysis using generalized estimating equations was conducted on the JKN sample dataset (1% of national enrollees). The sample included 108,762 adults aged 19–65 with chronic conditions, with monthly primary care records from September 2019 to August 2020. Outcomes were preventive and curative visits, modeled by disability status, gender, and residence district.

The sample averaged 48.3 years, 61.2% were women, 15.5% had a disability, and 1.2% lived in underdeveloped districts. Preventive visits declined 25.6% and curative visits 40.5% in the first two months of the pandemic. PWD had higher curative care use (IRR = 1.05; 95% CI: 1.02–1.07), but women with disabilities had fewer curative visits than men with disabilities (IRR = 0.92; 95% CI: 0.86–0.98). Residence in underdeveloped districts reduced preventive (IRR = 0.34; 95% CI: 0.19–0.60) and curative (IRR = 0.83; 95% CI: 0.70–0.99) visits.

The pandemic worsened disparities. Gender compounded disability-related inequities in curative use, while geographic disadvantage limited access for all. Future research should examine longer-term trends. Integrating disability- and gender-inclusivetuy approaches is essential for equitable UHC during and beyond crises.

● Main findings: During the COVID-19 pandemic, individuals with disabilities had higher curative care utilization, but women with disabilities faced significantly lower access compared to men. Geographic disadvantage also reduced access for all groups regardless of disability status.

● Added knowledge: Using panel-based interrupted time series analysis, this study is the first to quantify disability-based disparities in healthcare utilization underutilization under Indonesia’s National Health Insurance (JKN) during a public health crisis.

● Global health impact for policy and action: Disability-inclusive and gender-responsive reforms are essential to ensure universal health coverage systems like JKN equitably serve structurally marginalized populations, particularly during systemic disruption.