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Cost of illness of hemodialysis in Indonesia: A survey from eight hospitals in

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DOI: 10.31838/ijpr/2021.13.01.375

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 ISSN 0975-2366
DOI:https://doi.org/10.31838/ijpr/2021.13.01.375
Research Article

Cost of illness of hemodialysis in Indonesia: A survey

from eight hospitals in Indonesia
SUSI ARI KRISTINA1*, DWI ENDARTI1, TRI MURTI ANDAYANI2, HARDIKA ADITAMA3
1
Department of Pharmaceutics, Faculty of Pharmacy, Universitas Gadjah Mada
2
Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Gadjah Mada
3
Research Assistant, Faculty of Pharmacy, Universitas Gadjah Mada
*Corresponding Author
Email ID: susiari_k@ugm.ac.id
Received: 21.10.20, Revised: 03.11.20, Accepted: 20.12.20

ABSTRACT
Background: End-stage renal disease (ESRD) in Indonesia has a major impact on the economic burden,
particularly hemodialysis treatment. The objective of this study was to estimate the cost-of-illness of
hemodialysis and to examine its associated factors in Indonesia.
Methods: A cross-sectional study was conducted in 2019 and 1,365 participants with end-stage renal disease
were recruited from eight hospitals representative of the western, central, and eastern regions of Indonesia.
Medical records of patients have been reviewed for clinical data, and hospital administrative records were
reviewed for cost data. Costs of illness were measured from a patient perspective using a bottom-up
approach. The direct costs for each patient and indirect costs for each patient and their attendants have been
calculated. Multiple regression analysis was performed to identify the determinants of the average annual cost.
Results: The vast majority of the patients were male (57.14%), 45-60 years of age (55.46%), and employed
(57.58%). The average annual cost per patient was US$ 7845.6. The cost of hemodialysis (US$ 4217.2) was the
largest proportion of the total direct cost, followed by the cost of the medicine (US$ 1286.1). Long duration
of hemodialysis, comorbidity, and poor health status were significantly associated with the highest average of
annual cost.
Conclusion: Since the costs of the HD procedure are all covered by country finance, it is crucial to minimize
costs by developing interventions to control the prevalence of ESRD.
Keywords: hemodialysis, cost of illness, direct cost, indirect cost

INTRODUCTION followed by Continuous Ambulatory Peritoneal

Chronic kidney disease (CKD) is a public health
concern in developed and developing countries.
The progression of CKD to end-stage renal
disease (ESRD) is unavoidable at a certain stage
of renal function (Prodjosudjadi & Suhardjono,
2009). Not only increased in the incidence, but
ESRD also has a major impact on the financial
burden (Kontodimopoulos & Niakas, 2008;
Ranasinghe et al., 2011; US Renal Data System
(USRDS), 2011; Kristina et al., 2018). In
Indonesia, the prevalence of CKD increases with
increasing age in the 35-44 year age group, in
men, rural communities, non-school, and self-
employed or workers (Indonesian Health Ministry,
2013). Hemodialysis is the common type of ESRD
therapy compared to other types of therapy, such
as peritoneal dialysis and renal transplantation
(Abbasi et al., 2010; Karopadi et al., 2013).
Medical expenditure on hemodialysis places a
significant burden on the national health system
(Kerr et al., 2012; Mushi et al., 2015; Kristina et
al., 2020). Based on the Indonesian Renal
Registry, the majority of services provided at
dialysis facilities were hemodialysis (82%),
Dialysis (CAPD) (12.8%), transplantation (2.6%)
and Continuous Renal Replacement Therapy
(CRRT) (2.3%) (Indonesian Renal Registry, 2014).
Jaminan Kesehatan Nasional (JKN) is one of
several types of funding used by patients with
hemodialysis therapy in Indonesia. JKN's funding
increased to 86%, consisting of 71% of PBI
(recipients of contribution assistance) and 15% of
non-PBI (Data and Information Center of the
Ministry of Health Indonesia (InfoDATIN), 2017).
The total cost of 2012 hemodialysis covered by PT
Askes and other insurance coverage amounted to
IDR 227 billion (US$ 15 million) and was a
medical procedure that absorbed the largest
portion of health costs (Data and Information
Center of the Ministry of Health Indonesia
(InfoDATIN), 2017; Indonesian Health Ministry,
2017). Since daily hemodialysis typically results in
financial pressure in national health system, the
therapy needs to be assessed by evaluating the
cost of treatment. This study was conducted to
estimate the average annual cost of hemodialysis
and to assess its determinants. The findings of this
study will provide up-to-date information on the

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 Susi Ari Kristina et al / Cost of illness of hemodialysis in Indonesia: A survey from eight hospitals in
Indonesia

economic burden of health insurance in
Indonesia, which will serve as an important aid in
the planning and allocation of funding for the
country’s healthcare needs.
METHODS
Study design and population
A cross-sectional study was conducted using a
prevalence-based approach. Data was collected
from eight hospitals located in the western,
central, and eastern regions of Indonesia. The
participants in the study were ESRD patients with
or without comorbidity. Of about 1365
participants were included for the period of
January to December 2019. Data were collected
from hospital registries, such as gender, age,
working status, educational level, distance from
hospital, comorbidity, family history, duration of
hemodialysis, and health status.
Calculation of costs
The total cost of hemodialysis was calculated on
the basis of the annual cost per patient for the
year 2019, taking direct and indirect costs as the
main components. Direct costs were divided into
two sub-categories: direct medical costs (e.g. GP
visit, hemodialysis procedure, medicine,
laboratory tests, bed and other services) and
direct non-medical costs (e.g. food and
transport). The indirect cost was calculated for
both patients and their en-route attendants to the
hospital on the basis of time lost in hospital
admissions and outpatient visits. Total costs were
calculated by adding together all total direct and
total indirect costs. All costs were calculated in
Indonesian currency (IDR) and then converted to
US$ for the international perspective using the
2019 currency conversion rate (US$ 1 = IDR
15,000).
Statistical analysis
Data were analyzed using descriptive statistics in
the form of mean with standard deviation for
numerical data and frequency with percentage for
categorical data. Multiple regression analysis was
used to examine the determinants of the average
annual cost. The statistical software package SPSS
version 13.0 was used for data analysis and p
value of 0.05 or less was considered to be
statistically significant.
RESULTS
Socio-demographic and clinical characteristics
The socio-demographic and clinical
characteristics of the study participants are shown
in Table 1. Out of 1365 ESRD patients, 57.14%
were male, 55.46% were between 45 and 60
years of age, 57.58% were employed, and
46.30% were secondary level of education.
Approximately half (46.45%) of the participants
were 5-10 km away from the hospital. In
addition, about one-fifth (17.73%) of ESRD
patients had no comorbidity, one-third had
diabetes mellitus (31.87%) and hypertension
(34.21%), and one-fifth (16.19%) had coronary
heart disease. The majority of participants had no
family history of kidney disease (86.15%), 5-10
years duration of hemodialysis (46.23%) and
good health status (46.74%).

Table 1: Details of annual cost in US$ by socio-demographic and clinical characteristics of the
study participants (N=1365)
Variable N %
Gender Male 780 57.14
Female 585 42.86
Age 18-45 432 31.65
45-60 757 55.46
>60 176 12.89
Working status Employed 786 57.58
Unemployed 356 26.08
Retired 223 16.34
Education level Primary 532 38.97
Secondary 632 46.30
University 201 14.73
Distance from <5 km 245 17.95
hospital 5-10 km 634 46.45
>10 km 486 35.60
Comorbidities None 242 17.73

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 Susi Ari Kristina et al / Cost of illness of hemodialysis in Indonesia: A survey from eight hospitals in
Indonesia

Diabetes mellitus 435 31.87

Hypertension 467 34.21
Coronary heart 221 16.19
disease
Family history Yes 189 13.85
of kidney No 1176 86.15
disease
Duration of <1 year 226 16.56
HD 1-5 years 348 25.49
5-10 years 631 46.23
>10 years 160 11.72
Health status Good 245 17.95
Fair 638 46.74
Poor 482 35.31

Costs of Hemodialysis
Table 2 presents the total annual direct costs of
hemodialysis from 8 hospitals in Indonesia. The
average annual hemodialysis cost was US$
7845.6, of which the direct cost was 94.20% with
an average value of US$ 7390.5 and the indirect
cost was 5.80% with an average value of US$
455.1. Of the total direct costs, the direct medical
and non-medical costs amounted to 91.22% and
2.98% respectively. The cost of the hemodialysis
procedure was the largest share (US$ 4217.2) of
the total direct cost, followed by the cost of the
medicine (US$ 1286.1) and the cost of the
laboratory tests (US$ 672.3).

Table 2: The values of total direct costs in US$ related to hemodialysis in Indonesia in 2019
Cost category Types of cost Mean SD Percentage
(US$) (US$) of total
cost
Direct cost
Direct medical cost 7156.4 210.7 91.22
GP visit 573.2 98.3
HD procedure 4217.2 218.4
Medicine 1286.1 226.4
Laboratory tests 672.3 68.3
Bed cost 310.9 108.2
Other services 96.7 56.4
Direct non-medical 234.1 78.3 2.98
cost Meal 98.5 67.4
Transportation 135.6 78.6
Total direct cost 7390.5 458.2 94.20
Indirect cost Productivity loss of 352.1 217.2
patient
Productivity loss of 103 96.3
accompanied person
Total indirect cost 455.1 67.3 5.80

Total cost 7845.6 563.2

Determinants of Cost-of-Illness than 10 years of hemodialysis (US$ 7532.1,

Details of annual costs based on socio- p<0.001), comorbidity such as diabetes (US$
demographic and clinical characteristics are 7435.2), hypertension (US$ 7120.2), coronary
summarized in Table 3. Multiple regression heart disease (US$ 7631.2) (p<0.001), and poor
analysis showed that ESRD patients with more

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 Susi Ari Kristina et al / Cost of illness of hemodialysis in Indonesia: A survey from eight hospitals in
Indonesia

health status (US$ 7085.8, p<0.001) were significantly associated with higher costs.

Table 3: Details of annual cost in US$ by socio-demographic and clinical characteristics of the
study participants
Variable Direct Indirect Total cost
p-value
cost (US$) cost (US$) (US$)
<5 years 6954.2 322.1 7276.3 <0.001
Duration of HD 5-10 years 7121.2 435.2 7556.4
>10 years 7532.1 478.4 8010.5
None 6943.7 218.9 7162.6 <0.001
diabetes 7435.2 245.4 7680.6
Comorbidity hypertension 7120.2 232.2 7352.4
coronary heart
7631.2 463.4 8094.6
disease
Good 6890.4 195.4 7085.8 <0.001
Health status Fair 7328.2 245.4 7573.6
Poor 7632.1 465.3 8097.4

DISCUSSION trillion were spent in 2014 (US$ 1=IDR 13,500),

Hemodialysis is widely used to treat ESRD and is
one of the most intensive and expensive clinical
procedures. The need for hemodialysis is rising as
the prevalence of ESRD continues to increase
(Jain et al., 2012; Jha et al., 2013). The present
study highlighted the largest share of direct costs
(94.20%) of total costs. Among the different direct
medical cost components, the average cost was
found to be the highest for hemodialysis (US$
4217.2) followed by the cost of medicine (US$
1286.1). Similar results have been reported in
both developed (Icks et al., 2010; Naoum et al.,
2016) and developing countries (Fathima et al.,
2018; Rizk et al., 2016) studies.
This study also found that higher costs associated
with long duration of hemodialysis, comorbidity,
and poor health status. The duration of
hemodialysis was proportional to the age of the
patient. As age increases by year, hemodialysis
treatment costs have increased (Grün et al.,
2003; Mendes de Abreau et al., 2011; Okafor &
Kankam, 2012; Zambrowski, 2016). Our findings
were corroborated by studies conducted in
Ethiopia (Kassa et al., 2020), France
(Zambrowski, 2016) and Calgary (Manns et al.,
2003), which reported that comorbidity
significantly increased the cost of hemodialysis
treatment. Patient’s choice on dialysis is
influenced by age, physical condition,
comorbidities and lifestyle (Chanouzas et al.,
2012; de Wit et al., 2002).
Hemodialysis treatment in Indonesia are
reimbursed under Jaminan Kesehatan Nasional
(JKN) scheme that managed by the Health Social
Security Institution (BPJS). More than IDR 1.5
the second largest cost to BPJS (National
Healthcare Security Agency, 2015). Therefore, the
results of the study will play a significant role in
evaluating and quantifying the costs related to
hemodialysis in Indonesia for both patients and
providers. It would be useful for policy makers to
prepare for future healthcare needs. This study
examined all possible cost components of both
direct and indirect cost from the patients’
perspective, and the cost was calculated on the
basis of primary data. However, our study was
limited to some intangible costs such as pain,
suffering and loss of quality of life that were not
estimated in this study. In addition, this study did
not provide information on resource efficiency as
it was a descriptive cost-of-illness study.
CONCLUSION
The economic burden of hemodialysis is high in
Indonesia, the second largest cost spent by BPJS.
The cost of hemodialysis was mainly driven by the
HD procedure followed by the cost of medicine
and laboratory tests. In order to reduce costs, it is
necessary to develop interventions to control the
progression of CKD to ESRD.
ACKNOWLEDGEMENTS
The authors would like to thank the Ministry of
Research, Technology, and Higher Education
Republic of Indonesia, for financial support of this
study, contract number 1673/UN1/DITLIT/DIT-
LIT/PT/2020, board of directors and hospital staff
of 8 hospitals in the western, central, and eastern
regions of Indonesia, and also the participants of

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 Susi Ari Kristina et al / Cost of illness of hemodialysis in Indonesia: A survey from eight hospitals in
Indonesia
this study. We also thank the pharmacists in
Universitas Gadjah Mada, Yogyakarta.
CONFLICT OF INTEREST
Authors declared no conflict of interest in this
study
FINANCIAL STATEMENT
This study was supported by Ministry of Research,
Technology, and Higher Education Republic of
Indonesia.
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