Aims: Indonesia’s Universal Health Coverage (UHC) agenda continues to face enrolment and implementation challenges despite the expansion of the JKN program. This study explores stakeholder perspectives on the PESIAR Program, a community-based initiative program that designed to support UHC through outreach and enrolment.

Methods: A qualitative case study was conducted in West Sumatra, Indonesia, between March and July 2026. Semi-structured interviews were conducted with 30 purposively selected participants, including branch management, membership managers, membership officers, and community outreach agents. Additional data were obtained through non-participant observation and document review. Data were analyzed using reflexive thematic analysis informed by combining the Systems Approach (Input-Process-Output-Outcome) and interpreted through the Lean Six Sigma Define–Measure–Analyze–Improve–Control (DMAIC) framework.

Results: This study shows input readiness relies on local government commitment and resources. DMAIC analysis redefines low enrollment as a systemic issue involving data accuracy, coordination, community understanding, and affordability. Growth mainly results from reactivating inactive members and promoting sub-district collaboration. Member activeness, not total enrollment, is a bigger challenge for long-term sustainability.

Conclusion: The findings highlight the importance of collaboration, data quality, and local implementation capacity in achieving sustainable program outcomes. Lean Six Sigma, particularly the DMAIC framework, provided a useful lens for understanding implementation processes and identifying opportunities for continuous improvement.