Implementation of Newborn Pulse Oximetry Screening for Critical Congenital Heart Disease in Indonesia: Province-Level Coverage, Outcomes, and Geographic Disparities

Background: Indonesia introduced nationwide pulse oximetry screening for critical congenital heart disease (CCHD) in 2022. However, the implementation and the performance of the program across provinces have not been systematically evaluated. Objectives: To assess provincial CCHD screening performance, examine the association between provincial training coverage and screening outcomes, and identify geographic disparities and health system gaps in the national screening program. Methods: A cross-sectional provincial-level analysis was conducted using national newborn screening data (January–December 2024 and January–May 2025) and healthcare worker training records. Screening coverage, abnormal screening results, referral completion, diagnostic confirmation, early management, mortality, and loss to follow-up were evaluated. Geographic disparities were assessed using regional comparisons and geospatial mapping, while associations between training coverage and screening outcomes were analyzed using multivariable regression. Results and Discussion: Thirty-eight provinces reported screening data. National screening coverage remained low and highly variable, with most provinces screening fewer than one-third of newborns. Major losses occurred after positive screening, particularly during referral, diagnostic confirmation, and initiation of treatment. Marked geographic disparities were observed, with relatively higher performance in Java, Sumatra, and Bali–Nusa Tenggara, whereas most Papuan provinces reported minimal screening activity. Training coverage averaged 28% but was not independently associated with screening performance. Provinces with higher screening coverage identified more infants with CCHD but also reported higher mortality, indicating delays in diagnosis and limited access to definitive care. Conclusion: Early implementation of Indonesia’s national CCHD screening program is characterized by low and uneven coverage, substantial geographic disparities. Expanding training alone is unlikely to improve program performance. Strengthening diagnostic capacity, referral systems, access to pediatric cardiac services, and data quality, is essential to maximize the effectiveness and equity of nationwide CCHD screening.