Bridging the gap between policy and practice: challenges and strategies in implementing universal health coverage in rural Indonesia

Background: Universal health coverage (UHC) aims to ensure access to quality health services without financial hardship. In Indonesia, the Jaminan Kesehatan Nasional (JKN, National Health Insurance) has achieved high enrollment (>90%), yet implementation gaps persist—particularly in rural areas. This study aims to evaluate the implementation of UHC in Tanah Laut Regency, identify the key facilitating and constraining factors, and propose context-sensitive strategies to strengthen its effectiveness and equity.

Methods: This qualitative case study examines UHC implementation in Tanah Laut Regency, South Kalimantan, a semi-rural setting with relatively high JKN enrollment (>92%) and low claim rejection rates. Data were collected between January and March 2024 through in-depth interviews with five key informants (two health officials and three UHC beneficiaries selected via purposive sampling), direct field observation at two Puskesmas and the regency health office, and document analysis of regional health reports, budget records, and Badan Penyelenggara Jaminan Sosial (BPJS, Social Security Administering Body) Kesehatan coordination minutes.

Results: We identified four persistent barriers: critical health workforce shortages, inequitable budget allocation, low public awareness of entitlements, and fragmented data systems relying on manual reporting. Despite these challenges, Tanah Laut demonstrates notable strengths: sustained political commitment (15% annual increase in local health budgets), regular inter-agency coordination, and effective use of national digital platforms (E-Dabu) linked to social services for real-time beneficiary verification.

Conclusions: UHC success in decentralized contexts hinges less on new technology and more on governance arrangements that optimize existing systems. We propose context-sensitive strategies: needs-based budgeting, interoperable health information systems, community health worker-led education, and contractual recruitment schemes for remote facilities. Without such adaptations, high enrollment risks becoming a “coverage illusion” masking low utilization and persistent inequity. The Tanah Laut experience offers a scalable model for other semi-rural districts seeking to transform UHC from policy promise into tangible health justice.