Building Foundation and Bridging Lives: Three Years’ Experience and Future Plan from the Indonesian Stroke Care Transformation Initiatives
Muhammad Kusdiansah MD1, Arnau Benet MD PhD2., Muhammad Hafif MD1, Abrar Arham MD1, Reza Aditya Arpandy MD1, Asra Al Fauzi MD, PhD3, Joni Wahyuhadi MD PhD4 1 National Brain Center Hospital, Mahar Mardjono, Jakarta. 2Barrow Neurological Institute, USA. 3Indonesian College of Neurosurgery 4Indonesian Neurosurgical Society
Background
Stroke is the leading cause of death in Indonesia, surpassing other major diseases in both mortality and disability. The Global Burden of Disease Study 2019 and the National Healthcare Basic Research 2018 estimate that 2.5 out of every 1,000 Indonesians suffer a stroke annually, with 15% at risk of death and over 60% at risk of permanent disability.
The Starting Point
When the Stroke Care Transformation Initiatives began in 2021, capacity was alarmingly limited: seven hospitals capable of thrombolysis, twelve hospitals thrombectomy-ready, and ten comprehensive centers able to perform clipping. These comprehensive centers were the only facilities providing the full spectrum of acute stroke care: thrombolysis, Thrombectomy, and microsurgical clipping, highlighting the urgency of systemic reform.
Figure 1. Initial mapping of the Indonesian Stroke Network in 2021
Summary of Strategies
To address these gaps, the Ministry of Health, professional societies, and the National Brain Center introduced several strategies: Tiered System and Regionalization — creating a structured referral network, local Manpower Development — training specialists within provinces, facility Upgrades and Local Commitment — improving infrastructure with government support, expanded Education and Fellowships — increasing specialist training quotas, proctorship and Hands-On Training — supervised experience in coiling and clipping.
The Four-Tier Stroke Hospital System
The program established a clear four-tier hierarchy:
•
Figure 2. Diagram showing the proctoring scheme for each tier system.
Stroke Proctoring Scheme
Beyond infrastructure, the initiative emphasizes capacity transfer through structured proctoring. The 10 Paripurna Hospitals serve as national mentors, training 34 provincial hospitals to reach Utama status. Utama hospitals then guide district hospitals to Madya, while Madya hospitals support the transition of Dasar hospitals upward. The ultimate vision is to upgrade every city hospital (514 in total) to at least Madya, all provincial hospitals (34 in total) to at least Utama, and to have Paripurna hospitals anchor regional networks, thereby elevating Utama and Madya centers.
Acceleration Strategies
Because neurosurgeons remain limited, accelerated programs were designed:
Figure 3. Several 3D printed models have been developed for the initiatives, including a full-scale head model created at the Barrow Neurological Institute.
Progress to Date
We have increased the annual national fellowship quota for dual-trained neurosurgeons from two in 2022 to 26 in 2025, producing 17 fellows in 2024 and 26 fellows in 2025. We have also trained 20 neurosurgeons from 16 provinces in our intensive 6-month hands-on training program. By these strategies, clipping-ready provinces increased to 31 in 2025. Moreover, we managed to help increase the number of thrombectomy- and coiling-ready cities, along with the neurology and radiology fellowship programs, to 94 cities in 2025, marking a substantial improvement. In three years, we have done 24 proctoring events, 31 supervised procedures, and trained 1,090 health workers in 162 hospitals, including 251 nurses from 88 hospitals. It is important, however, to understand what "ready" means in this context. The designations "clipping-ready" and "thrombectomy- and coiling-ready" are based on national surveys of equipment and staffing. For thrombectomy and coiling, readiness requires a cath and at least one endovascular specialist, either an interventional neuroradiologist, a neurointerventionist, or a vascular neurosurgeon. For clipping, readiness requires a microscope and high-speed drill, plus neurosurgeons who have undergone baseline training in case selection and technique through workshops, live surgeries, and webinars. The "ready" status does not necessarily mean that hospitals are already performing procedures independently or that they have complete instrument sets. In practice, many services still rely on proctoring, instrument sharing, mentorship, or tele-proctoring to deliver care. The readiness designation, therefore, reflects that the infrastructure and human resources are in place to provide services under guided support, while hospitals move toward complete independence in the future.
Figure 4. Clipping-ready provinces (dark green), with three provinces under equipment and specialist development. Hospitals in four provinces are planned or being built. Red dots indicate newly trained hybrid cerebrovascular fellows, while yellow dots denote upcoming fellows scheduled for training this year.
Future Directives
Looking forward, Indonesia aims to:
including hospital-based programs under ACGME accreditation, to sustainably produce neurosurgeons for all 514 districts.
Conclusion
Indonesia’s stroke care transformation is a global first: a nationwide protocol tailored not only to medical guidelines but also to geographic, socio-economic, and cultural realities. The greatest challenge is not equipment, but human resources. Machines can be purchased, but building skilled neurosurgeons, neurologists, and interventional neuroradiologists requires years of structured training and collaboration. The message is clear: this is not us competing with other specialties, but us together against the disease. By uniting across specialties, Indonesia is laying the foundation for a stroke care system that bridges lives across its vast archipelago, a model that could inspire global health systems. The journey is far from over, but the foundation has been laid. With continued commitment, innovation, and collaboration, Indonesia is on its way to transforming stroke care into a model for the world.
References
[All News]