Endometriosis healthcare access in Indonesia based on the Indonesian national health insurance data in 2020-2023

This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.

This is a cross-sectional secondary data analysis study focusing on visitation data from BPJS Kesehatan Indonesia for 2020–2023. We used the dataset of Advanced Referral Health Facilities (FKRTL), catering to secondary and tertiary healthcare services. This subset was derived from the broader national healthcare visitation data, governed by Indonesia’s universal health coverage framework, and employed stratified random sampling by visitation type and family unit. List-wise deletion is applied to missing values with a frequency of less than 10% in the analyzed dataset. Participants in the study were identified based on their primary diagnosis of endometriosis, as classified under N.80 in the International Classification of Diseases (ICD-10). The accuracy of this diagnosis was further confirmed through validation using the INA-CBG description variable for procedures in relation to endometriosis, available in the dataset. Several variables were considered during the analysis. The number of visits per participant was monitored using each participant’s unique sample identification code. The geographical location of the healthcare facility attended was classified by the province and further categorized into five regions: i) Java and Bali; ii) Sumatra; iii) Kalimantan; iv) Sulawesi; and v) Nusa Tenggara, Maluku, and Papua. The data selection process is summarized in a flow chart ( Fig. 2 ). Data selection flowchart and analytical process. We used logistic regression to examine associations between predictor variables and the outcome of endometriosis management. Our primary predictor was the region with the outcome of endometriosis management categorized into i) diagnostic-only, ii) laparoscopy, iii) non-laparoscopy surgery, and iv) non-surgical treatment. We considered these outcomes regarding our hypothesis that, due to disparities in healthcare infrastructure across regions, patients outside Java, Bali, and Sumatra might have less access to specialized endometriosis care, including laparoscopy. We also adjusted the outcome for other predictors, including age, marital status, class of service, and NHI participation type (subsidized and non-subsidized group). Age and marital status (as part of cultural belief) were considered as patient-related factors that affect time to diagnosis, as well as laparoscopy uptake among women with endometriosis ( Al-Jafari et al. 2024 , Peruzzo et al. 2025 ). We still considered class of service and NHI participation type, regardless of NHI implementation, given documented evidence of disparities in healthcare services stemming from these factors ( Darmawan et al. 2025 ). All analyses were performed using STATA 18.

We identified 1,974 visits from patients with a primary diagnosis of endometriosis between 2020 and 2023. To effectively delineate patterns in follow-up care, the patient cohort was categorized into two distinct groups: those with a single visit and those with multiple visits. Our final analytical focus was placed on the multi-visit group, comprising 306 individual patients with complete data, as this subset provides a more nuanced understanding of the continuum of care ( Fig. 2 ). We conducted a preliminary comparison of these two groups on demographic and clinical characteristics, including age, marital status, class of service, NHI participation, and endometriosis care received at the referral hospital. We found no significant difference between the single- and multi-visit groups ( Table 1 ). A key geographical disparity was observed in follow-up care. Our logistic regression analysis indicated that patients residing in Kalimantan had 93% higher odds of being in multi-visit groups than their counterparts in Java and Bali ( Table 2 ). Characteristics of endometriosis patients under Indonesia NHI in 2020–2023 according to their number of visits ( n = 1,371). Data are presented as mean (min–max) or as n (%). NHI, national health insurance. Number of visits and the odds of having multiple visits among endometriosis patients under Indonesia NHI in 2020–2023 according to the region ( n = 1,371). P ≤ 0.05 (statistically significant). OR, odds ratio; CI, confidence interval; NHI, national health insurance. The core objective of this study was to evaluate access to various endometriosis care, categorized as diagnostic-only, laparoscopy, non-laparoscopy surgery, and non-surgical treatment. The most significant predictor for care received was the patient’s class of service within the NHI system. Those in the lowest class of service, including both fully subsidized and lowest-premium contributors, were significantly less likely to access any form of therapeutic management, such as laparoscopy, non-laparoscopy surgery, or non-surgical treatment. Consequently, a disproportionately large number of these patients were limited to diagnostic-only care throughout their follow-up visits ( Table 3 ). Procedure of endometriosis patients who had multiple visits under Indonesia NHI in 2020–2023 according to their age, marital status, NHI participation, and class of service ( n = 259). LAP, laparoscopy; NHI, national health insurance. P ≤ 0.05 (statistically significant). Analysis of data for patients who received treatment beyond diagnostic also revealed pronounced regional inequity in surgical access. For the odds of undergoing surgery, Sulawesi was excluded because no patients were identified in the non-surgical treatment group. Despite more frequent visits, patients from Kalimantan had a significantly lower likelihood of undergoing any surgery than patients in the reference populations of Java and Bali. In contrast, patients from Nusa Tenggara, Maluku, and Papua had a non-significantly lower likelihood of undergoing any surgery than the reference population in Java and Bali ( Table 4 ). In addition, patients from Sumatra, Nusa Tenggara, Maluku, and Papua had non-significantly lower odds of undergoing laparoscopy than those from Java and Bali ( Table 5 ). Relative odds ratio of having certain procedures among endometriosis patients who had multiple visits under Indonesia NHI in 2020–2023 according to their class of service ( n = 259). In this multinomial regression, ‘highest (class I)’ was the base predictor for class of service, and ‘diagnostic only’ was the base outcome for procedure. LAP, laparoscopy; NHI, national health insurance. P ≤ 0.05 (statistically significant). Odds of having surgery and laparoscopy among endometriosis patients who had multiple visits under Indonesia NHI in 2020–2023. There was no laparoscopy identified in Nusa Tenggara, Maluku, and Papua. NHI, national health insurance.

To our knowledge, this is the first study to evaluate NHI claims for endometriosis in Indonesia. The mean age of endometriosis patients in this study is in the late thirties and is comparable to previously reported ages in the United States, Hungary, and South Korea ( Estes et al. 2019 , Csákvári et al. 2023 , Kim et al. 2023 ). Although endometriosis can affect all women throughout their reproductive age, this later age of diagnosis might be related to the chronicity of the disease and the delay in diagnosis in terms of the duration between the onset of symptoms and the first contact with healthcare providers. As in the past ten years, the delayed duration of endometriosis diagnosis has not changed much, ranging from six to seven years, starting at the onset of the first symptoms ( Moradi et al. 2022 , Nnoaham et al. 2011 ). In our study, we also found that most of the endometriosis patients in Indonesia are married. This finding might resonate with the documented evidence that many unmarried women, specifically in Asia, hesitate to seek care related to their sexual lives ( Ryu & Pratt 2025 ). This study categorized endometriosis care into four groups: diagnostic-only, laparoscopy, non-laparoscopy surgery, and non-surgical care. The diagnostic-only group relied primarily on ultrasound, while only a few patients received other imaging modalities, such as MRI. Recent guidelines recommend that a definitive diagnosis of endometriosis be made using non-invasive imaging techniques, such as transvaginal ultrasound by experienced clinicians or MRI, replacing laparoscopy as the gold standard ( Becker et al. 2022 ). While ultrasound has good sensitivity and specificity for detecting endometriomas and deep-infiltrating endometriosis, its ability to diagnose superficial endometriosis is limited, and negative ultrasound findings do not rule out endometriosis ( Pascoal et al. 2022 ). In addition, imaging accuracy, including ultrasound, varies significantly with operator expertise, and subtle lesions (e.g. superficial peritoneal endometriosis) are often missed, leading to an underestimation of the true prevalence. Currently, there are no data on the diagnostic accuracy of USG compared to laparoscopy in the country. Given the limited use of laparoscopy and the lack of local evidence on the diagnostic accuracy of less invasive modalities, the underdiagnosis of endometriosis in Indonesia is still a significant concern. In this study, most patients were from the lowest service class and the non-subsidized group, a pattern also observed among patients with chronic kidney disease and diabetes mellitus ( Sunariyanti et al. 2023 , Darmawan et al. 2024 ). However, despite having the insurance, those who are in the lowest class of service, subsidized and non-subsidized ones, had the least access to the endometriosis treatment. Similar findings are also present in ischemic heart disease, in which those who belong to the lowest class of service had the least access to percutaneous coronary intervention and thus had the highest mortality rate compared to the other classes ( Darmawan et al. 2025 ). This highlights the discrepancy between UHC as a NHI program and its implementation, in which those in the lowest socioeconomic groups may not receive the same benefits as those in higher socioeconomic groups. Studies in the Netherlands, which also implemented UHC, showed the opposite, patients in the lowest socioeconomic group accessed more specialist care before adjustment for general health. They had higher expenditure on them than patients in higher socioeconomic groups ( Loef et al. 2021 ), showing the effectiveness of UHC implementation to support those who need it the most. In general, disparities in UHC outcomes among different socioeconomic groups in low- and middle-income countries are common. For example, regarding infant mortality, the decline was mostly pronounced among those who are generally better off than the less well off ( Hone et al. 2024 ). Notable regional disparities in endometriosis care were observed. Those living in areas with the highest number of OB/GYN and referral hospitals have significantly greater access to surgical treatment. Patients in Kalimantan, despite having more visits than in other regions, had significantly lower odds of undergoing surgery than those in Java and Bali, suggesting that these visits were likely for non-surgical treatment, such as oral medication and blood transfusions. This finding showed the implications of having unequal healthcare resource distribution across the country ( Kemenkes 2023 , Darmawan et al. 2024 ). Not only the number of specialists and hospitals but the infrastructure gap between regions is also equally severe, as advanced medical technologies are only available in the highest level referral healthcare facilities. We noticed that, although not significant, patients from Sumatra, Nusa Tenggara, Maluku, and Papua were less likely to undergo laparoscopy than those in Java and Bali, perhaps suggesting that the distribution of laparoscopy facilities is even scarcer than that of OB/GYN specialists. In Kalimantan, despite fewer surgeries, and in Sulawesi, there were higher odds of laparoscopy than in Java and Bali, following the recent establishment of referral hospitals in these regions that are more likely to have advanced technology than older referral hospitals in other regions. Nonetheless, this maldistribution of healthcare infrastructure creates a persistent care gap for endometriosis and other specific women’s health conditions in general. Some limitations we identified in our study include the nature of our data, which is secondary and limited in clinical information, and the lack of longitudinal data after 2023, which is necessary to better understand each patient’s dynamics throughout their care. However, our findings remain relevant for uncovering disparities in endometriosis healthcare access across Indonesia, with significant differences in care accessibility between regions, conveying the urgent need to improve these disparities by providing more healthcare providers and better infrastructure, especially in the eastern part of Indonesia.

The global prevalence of endometriosis is currently at 18%, and it is significantly higher in women with infertility (31%) and chronic pelvic pain (42%) ( Moradi et al. 2021 ). Endometriosis is internationally defined as the ectopic endometrium-like epithelium and/or stroma occurring outside the endometrium and myometrium and is frequently associated with inflammatory processes ( Tomassetti et al. 2021 ). This condition not only brings physical discomfort due to chronic pain but also impairs mental health, as women with endometriosis commonly experience anxiety and depression, leading to a diminished quality of life across various aspects, including emotional, social, and relational well-being ( Mori et al. 2024 , Silva et al. 2024 ). Moreover, endometriosis also holds an economic burden. Patients incur substantial financial costs, with annual expenses soaring to $ 9,000. In addition, the condition leads to productivity loss due to impaired activity and absenteeism from work, further exacerbating the economic strain on individuals affected by endometriosis ( Swift et al. 2024 ). Diagnostic delays compound the challenges associated with endometriosis. On average, there is a significant gap between symptom onset and seeking medical attention, ranging from 3.7 to 8.7 years before receiving a formal diagnosis. These delays prolong suffering and contribute to the progression and severity of the disease, making effective management more challenging ( Tewhaiti-Smith et al. 2022 , Requadt et al. 2023 ). These delays might constitute many aspects, from patient-related factors, in which they tend to normalize the symptoms, to stigma and lack of advocacy toward women’s health in cultural beliefs, to provider-related factors, such as misdiagnosis, symptom dismissal, and reliance on non-specific diagnostic ( Li et al. 2025 ). Meanwhile, within the health system, the barrier affecting endometriosis might occur due to the difficulty in finding a specialist, as well as socioeconomic factors, in which those who have no health insurance are less likely to have access to care than those who are insured ( Peruzzo et al. 2025 ). Indonesia has implemented universal health coverage (UHC) through the national health insurance (NHI) system, delivered by the Social Security Agency for Health (BPJS Kesehatan), which covers the entire population. In its implementation, BPJS Kesehatan pooled the funding from both the government and individual participants through monthly premiums. This scheme ensures that the government subsidizes those who cannot afford the premium; hence, the system can provide access to healthcare for all ( Agustina et al. 2019 ). Under this scheme, participants in the subsidized group have access to the third (lowest) class of service, while those in the non-subsidized group have access to the first (highest) to third classes of service, depending on the monthly premium they pay ( Agustina et al. 2019 ). These NHI systems operate through a structured multilevel referral network, where specialized obstetrics/gynecology (OB/GYN) services, including specialized endometriosis management, are exclusively accessible after referral from a primary care provider. However, due to Indonesia’s expansive archipelago, the distribution of OB/GYN and referral hospitals across geographical regions is highly unequal. More than 80% of OB/GYN and referral hospitals are concentrated in Java, Bali, and Sumatra. In comparison, the remaining 20% are spread across the vast regions of Kalimantan, Sulawesi, Nusa Tenggara, Maluku, and Papua ( Fig. 1 ). OB/GYN and referral hospital distribution in Indonesia in 2025. Despite the critical issue of healthcare access distribution across regions in Indonesia, studies evaluating healthcare access to endometriosis care are scarce. Therefore, this study aims to assess the disparities of healthcare access for endometriosis in Indonesia by identifying the number of visits and the type of procedure performed at each visit across regions, using NHI data from 2020 to 2023.

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the work reported.

Raw data may be accessed by request to the authors.

SM contributed to research design, data acquisition and analysis, and manuscript drafting. RYP contributed to research supervision and manuscript verification.

This study was approved by the Health Research Ethics Committee of the Faculty of Medicine, Airlangga University (70/EC/KEPK/FKUA/2024).