In recent years, Indonesia’s National Health Insurance (NHI) program has been a pivotal force shaping the country’s healthcare landscape, promising universal coverage and equitable access regardless of socioeconomic status. However, emerging research highlights substantial disparities in health service delivery and patient outcomes among different membership categories within this system. A groundbreaking study analyzing claims data from 2017 to 2022 sheds new light on these inequalities, particularly focusing on ischemic heart disease (IHD) and stroke—two leading causes of morbidity and mortality globally and in Indonesia. This comprehensive investigation uncovers how, despite broader health reforms, significant gaps persist that influence patient prognosis and challenge the objectives of universal health coverage.
At the core of this study is an intricate comparison of health service utilization and outcomes based on NHI membership types, which include the subsidized membership funded by the government for the poor and near-poor, and the contributory membership, paid by formal sector workers and individuals in informal employment who pay insurance premiums. This classification creates a natural experiment to examine whether financial and administrative frameworks within a unified insurance system translate into disparities in clinical care and outcomes for critical cardiovascular conditions. By meticulously analyzing claims data encompassing millions of patients, the research team provides robust quantitative insights, revealing that membership type remains a determinant of healthcare quality and survival rates even within a nominally equitable system.
Ischemic heart disease and stroke represent pathologies characterized by acute vascular events typically requiring timely, specialized intervention to prevent irreversible tissue damage and fatal complications. The study delves deeply into treatment modalities accessed by patients, ranging from diagnostic procedures such as angiography and neuroimaging to interventional therapies including percutaneous coronary interventions and thrombolysis. Findings indicate that members subscribing to the contributory scheme demonstrate higher rates of advanced diagnostic utilization and procedural treatments, suggesting superior access to specialized care. In contrast, subsidized members show lower rates of such interventions, highlighting structural barriers that limit the delivery of guideline-recommended therapies despite insurance coverage.
Beyond procedural access, the research evaluates health outcomes measured in terms of mortality rates, readmission frequencies, and long-term disability markers. The analysis reveals a stark contrast in survival odds, with subsidized members experiencing significantly higher mortality following hospitalization for ischemic heart disease and stroke. This discrepancy likely stems from delayed care seeking, differences in comorbidity burdens, or disparities in hospital quality where patients receive care. These findings underscore not only systemic inequities embedded within healthcare financing models but also emphasize the multifactorial nature of cardiovascular care outcomes in resource-limited settings.
A critical technical dimension explored relates to the administrative aspects of claims processing and reimbursement under the NHI framework. The study uncovers that bureaucratic complexities disproportionately affect subsidized members, with delayed claims approval and limited provider incentives potentially reducing the availability and timeliness of services. Moreover, the reimbursement rates for procedures and medications under the subsidized program are often lower than for contributory schemes, which may disincentivize healthcare providers from offering cutting-edge interventions or investing in care infrastructure in facilities frequented by subsidized patients.
The policy implications arising from this comprehensive claims analysis are profound. They challenge the existing narrative that universal health insurance coverage alone suffices to eliminate healthcare disparities. Instead, the data suggest a need for nuanced reform approaches targeting the design of benefits packages, provider payment models, and quality assurance mechanisms to ensure equitable care delivery. For instance, enhancing infrastructure and clinical capacity in hospitals serving subsidized members, alongside incentivizing provider performance through adjusted reimbursement strategies, could substantially mitigate current inequities in cardiovascular care outcomes.
This research further draws attention to the intersection of social determinants of health and insurance status. It posits that subsidized membership eligibility correlates strongly with lower socioeconomic status, higher prevalence of risk factors such as hypertension and diabetes, and limited health literacy, all of which amplify vulnerability to adverse cardiovascular events. The resultant clinical disparities thus reflect not only health system inefficiencies but also broader context-driven inequities requiring integrated public health strategies alongside insurance reform.
On the methodological front, the study utilizes an unprecedentedly large and detailed administrative claims database to perform longitudinal analyses, allowing for temporal trend assessment over six years. This design facilitates evaluation of the impact of recent NHI policy changes and health system reforms on service utilization patterns and outcomes. Advanced statistical techniques control for confounders such as age, sex, comorbidity indices, and regional healthcare infrastructure, reinforcing the causal inference strength regarding membership type disparities and patient trajectories.
From a global health perspective, the findings resonate with concerns voiced across low- and middle-income countries attempting to implement universal health coverage amidst fragmented financing and service delivery ecosystems. Indonesia’s experience provides a critical case study elucidating how insurance stratification can inadvertently create tiers of healthcare access and quality, thus undermining equity goals. Insights gained from this analysis have implications for international policy dialogues seeking to optimize health insurance schemes to serve vulnerable populations better while maintaining financial sustainability.
Clinicians and healthcare administrators may find the study’s granular data on treatment patterns particularly valuable. It highlights areas where clinical guideline adherence is suboptimal, notably among subsidized members, including underutilization of life-saving reperfusion therapies and secondary prevention medications. Addressing these gaps through targeted provider education, adherence monitoring, and integration of quality improvement initiatives could improve patient outcomes and reduce readmissions and complications over time.
Moreover, the research underscores the necessity of patient-centered approaches that recognize the socioeconomic challenges faced by subsidized members. Strategies such as enhanced patient navigation services, community health worker engagement, and culturally tailored education programs could help overcome barriers in timely care seeking and medication adherence. These interventions would complement system-level reforms and contribute to closing the outcome gap in ischemic heart disease and stroke management.
Importantly, the ethical dimensions of insurance-linked health disparities illuminated by this study invite deeper discourse on justice and fairness in healthcare systems undergoing rapid transformation. Policymakers must grapple with balancing cost containment and equitable access, recognizing that gaps pronounced in critical conditions like cardiovascular diseases signal failures to uphold social protection principles foundational to universal health coverage.
The comprehensive nature of this claims analysis also opens pathways for future research, including qualitative studies exploring patient and provider perspectives on barriers within the NHI system. Further investigation into regional variability and differences in hospital capabilities can elucidate contextual factors contributing to observed disparities, guiding tailored interventions aligned with local needs.
This work, situated within the broader movement to leverage big data analytics in health systems research, exemplifies the potential of claims databases to inform evidence-based policy-making. By systematically dissecting financial and clinical dimensions of health inequities, such studies provide actionable intelligence necessary for designing insurance models that truly deliver universal and equitable healthcare access.
In conclusion, the elucidation of disparities in health service use and outcomes by NHI membership type for ischemic heart disease and stroke in Indonesia calls for urgent and coordinated policy responses. The findings demonstrate that nominal insurance coverage is insufficient to guarantee equitable care without addressing systemic, socioeconomic, and administrative challenges. As Indonesia continues to advance toward its universal health coverage ambitions, integrating structural reforms, equity-focused strategies, and patient-centered care innovations will be indispensable to reducing the burden of cardiovascular diseases and improving population health outcomes.
Subject of Research: Disparities in health services and outcomes by National Health Insurance membership type for ischemic heart disease and stroke in Indonesia.
Article Title: Disparities in health services and outcomes by National Health Insurance membership type for ischemic heart disease and stroke in Indonesia: analysis of claims, 2017–2022.
Article References:
Darmawan, E.S., Hasibuan, S.R., Permanasari, V.Y. et al. Disparities in health services and outcomes by National Health Insurance membership type for ischemic heart disease and stroke in Indonesia: analysis of claims, 2017–2022. glob health res policy 10, 33 (2025). https://doi.org/10.1186/s41256-025-00432-y
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