Original Research
Health Systems & Universal Coverage
Key Takeaways
- Primary health centres (Puskesmas) in Tidore faced multiple barriers in implementing Indonesia’s national health insurance scheme (JKN), including insufficient staffing, inadequate infrastructure, limited medication supplies, and complex administrative requirements.
- The gap between policy ambition (universal health coverage) and ground-level capacity (what primary health centres can actually deliver) is a fundamental challenge that affects the quality of care patients receive.
- Capitation-based payment — where primary health centres receive a fixed amount per enrolled patient regardless of services provided — created both opportunities (predictable funding) and challenges (insufficient funding for actual service needs in some facilities).
- These findings resonate across Southeast Asia, where many countries are pursuing universal health coverage but face similar capacity constraints at the primary care level.
The Promise of Universal Health Coverage
Universal health coverage (UHC) — the principle that all people should have access to the health services they need without suffering financial hardship — has become the defining health policy goal of the 21st century. The United Nations Sustainable Development Goals include UHC as Target 3.8, and countries across the world are pursuing various strategies to achieve it.
Indonesia launched one of the world’s most ambitious UHC programmes in 2014: the Jaminan Kesehatan Nasional (JKN), or National Health Insurance, operated by the social security agency BPJS Kesehatan. The programme aimed to cover the entire Indonesian population of over 260 million people — making it potentially the largest single-payer health insurance system in the world.
The backbone of JKN’s service delivery model is the primary health centre — known as Puskesmas in Indonesian. These government-run facilities serve as the first point of contact for patients and as the gatekeepers of the health system, with referrals to hospitals required for most specialist care. The theory is sound: a strong primary care system that manages common conditions effectively, provides preventive services, and refers complex cases appropriately is the most efficient and equitable foundation for any health system.
But the theory only works if primary health centres have the capacity to deliver on these expectations. Research in Tidore — a small island city in the Maluku Islands of eastern Indonesia — documented the reality of JKN implementation at the primary care level, and the findings highlight challenges that extend far beyond this single location.
The Challenges on the Ground
Staffing Shortages
Primary health centres in Tidore struggled with insufficient numbers of healthcare workers, particularly doctors. Remote and island locations face persistent difficulty attracting and retaining medical professionals, who tend to prefer urban postings with better facilities, social amenities, and career development opportunities. The result is that some Puskesmas operate with fewer staff than required to meet the demands of their enrolled population, leading to long waiting times, rushed consultations, and inability to provide the full range of primary care services.
Infrastructure and Equipment Limitations
Physical infrastructure at some primary health centres was inadequate for the range of services expected under JKN. Diagnostic equipment — including basic laboratory testing capability — was limited or non-functional in some facilities. This meant that conditions that should be diagnosed and managed at the primary care level had to be referred to hospitals, increasing costs and inconvenience for patients and defeating the purpose of the primary care gatekeeping model.
Medication Supply Challenges
The availability of essential medications at primary health centres was inconsistent. JKN includes a national formulary of medicines that should be available at primary care facilities, but procurement and distribution systems did not always deliver these medications reliably to remote locations. Patients who could not obtain their prescribed medications at the Puskesmas had to travel to pharmacies or hospitals, creating additional costs and barriers to treatment adherence.
Administrative Burden
The administrative requirements of JKN — patient registration, claims processing, reporting, and data management — added workload to already stretched staff. Healthcare workers reported spending significant time on paperwork and computer systems that took them away from direct patient care. In facilities with limited IT infrastructure and staff who had not received adequate training on the new systems, administrative tasks became a source of frustration and inefficiency.
The Bigger Picture: Lessons for Southeast Asia
Indonesia’s experience with JKN implementation at the primary care level mirrors challenges reported across Southeast Asian countries pursuing universal health coverage. The Philippines’ PhilHealth programme, Thailand’s Universal Coverage Scheme, Vietnam’s social health insurance, and Malaysia’s own public healthcare system all face, to varying degrees, the tension between ambitious coverage goals and primary care capacity constraints.
Several common themes emerge from these experiences. First, expanding insurance coverage without simultaneously strengthening service delivery capacity creates a gap between entitlement and access — patients have insurance cards but cannot actually access quality care. Second, primary care workforce development requires sustained investment over years and decades, not short-term fixes. Third, supply chain systems for medications and equipment must be as robust as the clinical systems they support. And fourth, payment mechanisms (such as capitation) must be designed with sufficient understanding of actual costs and workload at the facility level to avoid underfunding the very services they are meant to support.
Implications for Health Policy
Countries pursuing UHC must invest in primary care infrastructure and workforce in parallel with expanding insurance coverage — one without the other creates expectations that cannot be met. Payment levels under capitation or other primary care payment models should be based on realistic assessments of service costs, not arbitrary budget ceilings. Remote and underserved areas require targeted strategies for workforce attraction and retention, including financial incentives, career development pathways, and improved living conditions. Administrative systems should be designed to minimise burden on clinical staff, with investment in training and IT infrastructure to support efficient operations. And the experiences of frontline health workers should be systematically collected and used to inform policy refinement — they are the people who see firsthand what works and what doesn’t.