MULTILEVEL GOVERNANCE IN IMPLEMENTING FREE HEALTH EXAMINATION PROGRAMS (PKG) IN NORTH MALUKU PROVINCE: A CONCEPTUAL FRAMEWORK

Abstract

Drawing upon three complementary theoretical pillars — Multilevel Governance (MLG) theory (Hooghe & Marks, 2003), the Consolidated Framework for Implementation Research (CFIR), and the Health Equity framework — this paper proposes a novel conceptual model termed the Archipelago-Adapted Implementation and Health Equity Framework (AIHEF). The paper argues that conventional linear implementation models are insufficient to capture the multilevel, multi-actor, and multi-context dynamics of PKG implementation in island territories. Situated within Indonesia's decentralized health governance system, PKG faces compounding implementation challenges rooted in geographic fragmentation (1,474 islands with 395 inhabited), critical workforce deficits (doctor-to-population ratio of 13.2 per 100,000 — well below the national average of 24.4), limited digital connectivity (internet penetration of only 23% in outer islands), and vertical-horizontal coordination gaps across governance levels. The paper identifies a 'geographic tax' imposed on archipelagic health policy implementation and demonstrates how this tax systematically widens health equity gaps. The AIHEF framework integrates governance mechanisms, implementation determinants, and equity outcomes into a unified analytical lens, offering both theoretical contributions to implementation science and practical policy implications for health equity in remote island territories. The framework advances the understanding of how governance structures mediate implementation fidelity and health equity in decentralized, geographically complex settings.