Integrated primary healthcare reform in Indonesia: Lessons learned from early community-level implementation

ObjectivesIn many low- and middle-income countries, comprehensive, first contact primary health care is fragmented by the delivery of centralized programs focused on specific health conditions. Indonesia's 2023 primary health care reform restructured community health services to provide integrated rather than condition-specific services, representing one of the broadest primary health care integration efforts in a middle-income country to date. We sought to understand the outcomes, barriers, and facilitators of early implementation of this reform.MethodsWe conducted a convergent mixed-method study in one of the first areas to implement primary health care reform. We used descriptive statistics to quantify service delivery outcomes from a survey of 14 village health facilities and data extracted from monthly reports from two village health facilities and 11 community health posts. We sought to understand barriers and facilitators to implementation via 24 patient interviews, seven key informant interviews, and four focus group discussions with healthcare providers. We used deductive-inductive qualitative analysis guided by the Consolidated Framework for Implementation Research. Findings were integrated to understand factors that impacted service delivery outcomes.ResultsIn the initial months of implementation, both health facilities and health posts offered integrated services to all patients simultaneously, but neither introduced new screening services (e.g., mental health) immediately. At health facilities, patient visits substantially increased across all age groups, with more modest changes seen at health posts. The convenience of getting services at community health posts increased patient visits, but scheduling incompatibility and a low sense of belonging were barriers to attendance for teenagers and working adults. Insufficient training, staff, and resources posed barriers to introducing new services.ConclusionsIt is possible for a middle-income country to move from condition-specific community health programs toward integrated primary health care. Doing so requires investment in human resources, intersectoral collaboration, and outreach to less engaged segments of the population.