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.