In a groundbreaking study published in 2025, researchers have uncovered significant discrepancies in health services and outcomes linked to the type of National Health Insurance (NHI) membership for patients suffering from ischemic heart disease (IHD) and stroke in Indonesia. This analysis, spanning five years of claims data from 2017 to 2022, sheds light on the deep-rooted inequalities within the country’s health system, offering a critical lens through which policymakers can evaluate and potentially reform Indonesia’s health insurance framework.
Indonesia’s National Health Insurance system, established to provide equitable healthcare access to its vast population, operates with various membership categories, primarily categorized into subsidized and non-subsidized memberships. These classifications inherently influence the quality and extent of healthcare services members can access, a factor that profoundly impacts patient outcomes, particularly for chronic and acute cardiovascular diseases such as ischemic heart disease and stroke. The study utilized a comprehensive dataset of insurance claims to analyze how these different membership types correlate with patterns in service utilization, treatment quality, and survival rates.
One of the most striking findings of the study is the stark disparity in hospital admission rates for IHD and stroke patients across the two primary NHI membership types. Patients under the subsidized scheme – often representing lower socioeconomic groups – had significantly lower hospital admission rates than their non-subsidized counterparts. Given the acute nature of ischemic cardiovascular events, delayed or reduced hospitalization may critically worsen prognosis, underscoring a systemic inequality that exacerbates health outcomes based on financial or social status within the insurance framework.
Beyond hospital admissions, the research revealed important differences in the timeliness and intensity of rehabilitation services received post-discharge by different membership groups. Rehabilitation is pivotal in reducing disability and improving long-term functionality following stroke and IHD incidents. The subsidized NHI members consistently received fewer rehabilitation sessions, signaling a gap not merely in acute care but extending into long-term recovery and quality of life—a gap likely perpetuating cycles of disability and dependence in already vulnerable populations.
Pharmacological treatment patterns also varied notably. The study found that subsidized members were less likely to be prescribed or adhere to optimal secondary prevention medications like antiplatelets, statins, and antihypertensives. This difference may stem from accessibility issues, affordability constraints, or systemic biases in healthcare delivery, contributing to higher risks of recurrent cardiovascular events and mortality among subsidized patients. The implications for chronic disease management within large-scale public health programs are profound, calling for targeted interventions to ensure equity in medication access and adherence support.
Mortality outcomes further emphasized the gravity of these disparities. Mortality rates for ischemic heart disease and stroke were consistently higher among subsidized NHI members across the study period. This alarming finding not only highlights the immediate human cost of insurance-based healthcare inequality but also portends escalating burdens on Indonesia’s healthcare system, economy, and social fabric if left unaddressed. The study contextualizes mortality trends within broader social determinants of health, emphasizing systemic obstacles beyond clinical care.
Regional variability within Indonesia’s vast archipelago also emerged as a critical factor. The research demonstrated that disparities were more pronounced in rural and less-developed regions where healthcare infrastructure is less robust, compounding the disadvantages faced by subsidized insurance members. Geographic disparities introduce an additional layer of complexity for health policymakers, indicating that insurance reforms alone may be insufficient without concurrent investments in regional healthcare capacity.
Methodologically, the research employed rigorous quantitative analyses of insurance claims, integrating advanced statistical models to control for confounding factors such as age, sex, comorbidities, and socioeconomic status. This robust approach allowed for a nuanced understanding of the interplay between insurance status and health outcomes, providing a credible evidence base for stakeholders aiming to reform Indonesia’s health insurance policies and clinical care pathways for cardiovascular diseases.
Importantly, the study offers crucial insights into potential systemic interventions that could bridge these disparities. Suggestions include revising subsidy frameworks to expand access to comprehensive care, enhancing patient education regarding chronic disease management, and improving the availability of essential medications and rehabilitation services especially in underserved rural areas. Implementing such measures could reduce mortality, improve quality of life, and alleviate the socioeconomic toll of ischemic heart disease and stroke.
The timing of this research is particularly pertinent given Indonesia’s ongoing efforts to achieve Universal Health Coverage (UHC). While the National Health Insurance scheme has succeeded in expanding coverage, this study underscores that coverage alone is insufficient without equitable service provision. Addressing these disparities aligns with global priorities set by the World Health Organization and the Sustainable Development Goals, particularly those focused on reducing premature mortality from non-communicable diseases.
Beyond Indonesia, the findings have broader relevance for low- and middle-income countries (LMICs) grappling with similar dual burdens of expanding insurance coverage while ensuring equitable healthcare quality. The study provides a cautionary tale illustrating how differences in insurance design and implementation can engender unintended inequalities, urging that equity must be a central pillar in health financing reforms globally.
The study further highlights the crucial role of data infrastructure and health information systems in identifying and monitoring disparities. Indonesia’s capacity to leverage insurance claims data for health system research demonstrates a growing maturity in data-driven policymaking, serving as a model for other countries aiming to tailor interventions based on empirical evidence rather than anecdote.
From a clinical perspective, the research draws attention to the necessity for tailored care pathways that account for insurance and socioeconomic status. Healthcare providers must be sensitized to disparities in resource availability and patient adherence risks, integrating multidisciplinary approaches to optimize outcomes. This may involve stronger linkages between hospital care, community health workers, and social support services to create resilient patient-centered care models.
In summary, this extensive investigation into the inequities associated with Indonesia’s National Health Insurance types provides a foundational understanding of how financial and systemic factors shape cardiovascular health outcomes. The implications ripple far beyond Indonesia, pressing health policymakers worldwide to critically examine how insurance schemes are structured and delivered. Equitable access to not only coverage but timely, high-quality care and rehabilitation remains the keystone to combating the growing global burden of ischemic heart disease and stroke.
As cardiovascular disease remains a leading cause of mortality and morbidity worldwide, studies like this illuminate the pathways through which health systems can either entrench or alleviate disparities. The evidence presented calls for urgent action, blending policy reform with innovative care delivery to bridge gaps and save lives in Indonesia and comparable contexts facing the challenge of equitable health service provision.
Subject of Research: Disparities in health services and outcomes associated with National Health Insurance membership types among ischemic heart disease and stroke patients 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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