Universal Health Coverage and Geographical Barriers in Island and Remote Settings: A PRISMA-Guided Systematic Review (2010–2025)

Abstract

Distance and travel time remain major barriers to healthcare use in island/remote settings despite financial protection under UHC/NHI; evidence from Indonesia’s JKN and small island nations shows financial coverage does not guarantee equitable spatial access or service readiness (Fanda et al., 2024; Banks et al., 2022). To map (i) reported associations between distance/travel time/remoteness and utilization; (ii) supply-side readiness indicators under UHC/NHI; and (iii) documented mitigation strategies (transport, telehealth, workforce). Following PRISMA 2020, we searched Scopus, PubMed, ScienceDirect, and Oxford Academic (2010–2025) for observational and qualitative studies in English/Indonesian linking geographical access to utilization within UHC/NHI. Quality was appraised using QualSyst and NHMRC; “poor” studies were excluded. Given heterogeneity of exposure/outcome measures, we conducted no meta-analysis or narrative synthesis; findings are presented as study-level characteristics and effect-direction indications (↑/↓/0). Twenty-two studies met inclusion. Most reported inverse associations between distance/travel time (and inter-island fragmentation) and utilization, with uneven readiness in peripheral areas (Fanda et al., 2024; Nundoochan, 2020). Spatial analyses showed consistent distance–decay effects (e.g., older adults beyond primary-care catchments in rural Java) and limited proportions of Pacific populations within two hours of surgical care (Bratanegara et al., 2025; Cooper et al., 2016). Transport barriers and indirect costs persisted despite coverage (Banks et al., 2022). Several reports described mitigation such as VSAT-enabled telehealth and referral-transport arrangements (Borgelt et al., 2022; Cooper et al., 2016). Financial coverage coexists with spatial barriers. Heterogeneous definitions/metrics preclude pooled or narrative conclusions. Standardized travel-time thresholds, readiness indicators, and adjusted estimates are needed to assess whether geography-aware interventions—transport infrastructure, regionalization, telehealth—improve utilization (Fanda et al., 2024; Cooper et al., 2016; Borgelt et al., 2022).