Stroke team workforce maldistribution in indonesia: a burden-based policy analysis
Abstract
Background Stroke is Indonesia's leading cause of disability, yet workforce planning relies on population-based norms, risking territorial inequities in access to essential services. Objective To examine the ecological alignment between provincial stroke burden and key stroke team workforce availability, and to test the robustness of a proposed burden-based planning indicator. Methods Cross-sectional ecological policy analysis across 34 provinces combining Global Burden of Disease Study 2023 DALYs with 2025 administrative data on neurologists, neurosurgeons, and physiotherapists. Burden-to-workforce ratios assessed service pressure; robustness was tested against an alternative indicator specification, alternative statistical classification methods, and formal comparison with population-based fulfillment metrics. Results Substantial geographic mismatches exist between need and availability. Eight provinces (23.5%) were classified High Pressure for each cadre (neurologists, neurosurgeons, physiotherapists) individually, while the overall bottleneck classification (worst cadre per province) flagged 11 provinces (32.4%) as High Pressure. Four provinces (North Kalimantan, West Sulawesi, Gorontalo, West Papua) reported zero practicing neurosurgeons. Provinces with comparable stroke burden displayed up to 26.3-fold differences in neurologist workforce capacity. Burden-based classification correlated weakly with population-based fulfillment metrics (Spearman's ρ = 0.35, p = 0.044) and showed only 41.2% categorical agreement, indicating the two approaches frequently identify different priority provinces. Conclusions Indonesia's stroke workforce distribution shows a structural, ecologically observed mismatch with subnational disease burden. Cautious integration of burden-based indicators such as DALYs alongside conventional population-based metrics may support more equitable workforce planning; prospective validation and multi-country testing are warranted before broader adoption.