Inequalities in mental healthcare utilisation and out-of-pocket expenditure among adults in Indonesia: evidence from a large community-based cross-sectional survey

Equitable access to mental healthcare remains a critical challenge in low- and middle-income countries, where inequalities in service utilisation and financial burden are poorly quantified at the population level. Furthermore, outpatient psychological therapies for common mental disorders often fall outside national insurance benefit packages, leaving patients to pay out of pocket. This study examined patterns, determinants, and inequalities in mental healthcare utilisation and out-of-pocket payments among adults with symptoms of depression and anxiety in Indonesia. We analysed data from a community-based cross-sectional survey conducted in 2023 across urban and rural areas in four provinces on Java, Indonesia ( n = 19,236 adults aged ≥ 18 years). Mental healthcare utilisation was defined as any outpatient mental health service use in the past 90 days or inpatient mental health admission in the past 12 months. Depression and anxiety symptoms were assessed using validated screening scales. Logistic regression models were used to examine associations between sociodemographic characteristics, health-related need factors, and mental healthcare utilisation, adjusting for age, sex, marital status, education, and household wealth. Multinomial logistic regression was used to explore the type of facility used among service users. Depressive symptoms were reported by 4.4% of respondents and anxiety symptoms by 8.5%. Overall, only 2.96% of respondents reported using mental healthcare services. Among individuals with depressive or anxiety symptoms, utilisation remained low (11.9% and 9.0%, respectively). Service use was strongly associated with depressive symptoms (odds ratio 5.13, 95% confidence interval 3.32, 7.92), anxiety (3.94, 2.65–5.86), perceived mental health problems (6.91, 3.80, 12.57), poor self-rated health (14.39, 4.43 to 46.68), high exposure to stressful life events (5.41, 3.75 to 7.81), physical comorbidity (5.81, 4.20 to 8.03) and lower health-related quality of life (0.08, 0.05 to 0.11). Marked inequalities were observed: women and those with higher household asset ownership were more likely to access care. Most service users (61.7%) paid out of pocket, although per-visit amounts were modest for most. Mental healthcare utilisation in Indonesia remains low and deeply socially patterned, with clear inequalities by wealth and sex. Health insurance ownership was not associated with greater service use, and most service users paid out of pocket, indicating that insurance coverage alone has not translated into effective access to mental healthcare. Achieving equitable access requires strengthening primary care-based mental health services, expanding the effective coverage of the JKN benefit package to include mental health care, and addressing stigma and financial barriers among the most vulnerable populations.