Heterogeneity and district-level factors associated with COVID-19 mortality during three epidemic waves in Indonesia: a nationwide ecological study

IntroductionEnsuring 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. MethodsThis 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. ResultsOf total 5,539,333 reported cases, 148,034 (2{middle dot}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 [&ge;]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 [&ge;]60 years old population, number of nurses, midwives, and hospitals per population (p>0.05 each). ConclusionCOVID-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. What is already known on this topicO_LIThe severity of COVID-19 illness and clinical outcomes can be affected by the concentration of comorbidities in susceptible groups in communities, and through disparities of access to health care for preventive measures or prompt diagnosis and treatment. C_LIO_LIHowever, evidence on the heterogeneity of COVID-19 impact from low- and middle-income country (LMIC) where differences in age distribution, comorbidities, access to quality health services, and other factors, may greatly influence mortality risk, are limited. C_LI What this study addsO_LIThis study affirmed that COVID-19 disproportionately affected areas with high proportion of elder population, high prevalence of diabetes mellitus, lower doctor to population ratio, higher life expectancy at birth, and lower level of formal education. C_LIO_LIThese findings indicate that vulnerability to death associated with COVID-19 in LMIC includes not only elder and comorbid, but also males and communities living in area with lower health care capacity and with lower level of education. C_LI How this study might affect research, practice and/or policyO_LIThese findings may inform decisions on health resource allocation against COVID-19 delivering the greatest possible health dividends by prioritising interventions, including even distribution of essential health care need such as doctors, and a tailored risk communication and community engagement for the most vulnerable communities in LMIC, especially with decentralised health systems like in Indonesia. C_LI