Modelling the coverage gap in percutaneous coronary intervention in LMIC: a geospatial analysis of cath lab coverage in Indonesia

BACKGROUND: International guidelines recommend percutaneous coronary intervention within 120 min for high-risk acute coronary syndrome. In Indonesia, a sprawling archipelago with a rising cardiovascular burden, the ministry of health is expanding catheterisation laboratory (cath lab) infrastructure. This study aims to evaluate the current distribution, population coverage and 'effective access' to cath labs to inform equitable infrastructure planning. METHODS: We conducted a cross-sectional geospatial analysis using a primary hospital survey (January-June 2024) to identify 335 functional cath labs. Travel times were estimated from the midpoints of all inhabited subdistricts (kecamatan) to the nearest facility using road network modelling. Primary outcomes included cath lab density per million population and the proportion of the population within successive 30 min travel thresholds. Secondary outcomes assessed 'effective coverage' by adjusting for National Health Insurance (BPJS) credentialing. RESULTS: Nationally, cath lab density is 1.23 per million population, with a median travel time of 54 min. While 73.0% of the total population can reach a facility within 120 min, stark disparities exist: 95% of urban residents have 2-hour access compared with 66.9% in rural areas. Regionally, Java (92.3%) and Bali (91.5%) show high coverage, while Papua and Maluku face critical gaps, with >80% of the population requiring more than 3 hours of travel. 46.3% of cath labs are covered by BPJS, and only 5.1% offer documented 24/7 service. When accounting for insurance status, national 2-hour coverage drops from 73.0% to 63.5%. CONCLUSION: Although geographical access appears moderate at a national level, Indonesia's cardiovascular infrastructure is highly inequitable and operationally constrained. Many provinces meet density benchmarks but lack geographical coverage or financial/operational readiness. Beyond Indonesia, this approach offers a practical tool for other low- and middle-income countries to align scarce cardiac care resources with population need.