Journal of Biomedical Advancement Scientific Research

Abstract

Background: Cardiac rehabilitation (CR) constitutes a cornerstone of secondary prevention in cardiovascular disease (CVD) management. Yet, its incorporation into National Health Insurance (NHI) schemes within low- and middle-income countries (LMICs) remains fragmented and inconsistent. Despite robust evidence supporting its cost-effectiveness and capacity to lower mortality, patient participation and referral rates remain critically limited.

Objective: This review aims to synthesize evidence on the constraints and opportunities of implementing CR services under NHI or Universal Health Coverage (UHC) frameworks in LMIC hospitals

Methods: A systematic review was conducted following the PRISMA 2020 framework. Searches were performed through PubMed, Scopus, Web of Science, and Google Scholar for studies published between 2010 and 2025 addressing CR availability, utilization, or financing in LMICs under NHI or UHC contexts. Eligible studies were analyzed thematically across system-level, facility-level, and patient-level domains.

Results: A total of six studies fulfilled the inclusion criteria. The principal barriers identified were inadequate reimbursement mechanisms, weak referral networks, shortages in specialized human resources, and limited patient awareness of cardiac rehabilitation (CR). Opportunities centered on incorporating CR within National Health Insurance (NHI) benefit packages, expanding tele-rehabilitation services, and adopting bundled-payment systems. Evidence from Asia, Africa, and Latin America revealed similar challenges, notably insufficient insurance coverage, fragmented referral pathways, workforce deficits, and high out-of-pocket expenses. Countries such as Indonesia, India, and China reported pronounced geographical and financial disparities in CR access. In contrast, emerging policy innovations were associated with greater cost-effectiveness and improved patient adherence.

Conclusion: To achieve equitable cardiovascular care, LMICs must integrate CR into NHI benefit packages as a core service, supported by digital health innovation and primary-care empowerment. Sustainable policy reform should emphasize bundled or outcome-based reimbursement models, workforce training, and patient-centered delivery systems.