Strengthening integrated noncommunicable disease care through implementation research in Indonesia

On a weekday morning in Yogyakarta, Indonesia, a primary health care team prepares its monthly report. Among the indicators they must complete is a column requiring the use of the WHO cardiovascular disease (CVD) risk chart, a requirement tied to the district’s free health screening programme. In some facilities, the chart has become a routine part of consultations; in others, it is less used, set aside when trained staff rotate out, or workloads intensify. This uneven use reflects how national priorities, district incentives, staffing practices and everyday clinical realities intersect.

Such dynamics sit at the heart of Indonesia’s efforts to strengthen integrated care for noncommunicable diseases (NCDs). NCDs account for around three quarters of all deaths in Indonesia, with cardiovascular diseases and diabetes among the major contributors. Delivering consistent, high-quality services is particularly challenging in a country spanning more than 17 000 islands and diverse terrains, from dense jungles to remote mountainous regions, over 5000 kilometres from west to east. In response, the Ministry of Health has introduced major reforms, including Pandu PTM FKTP, adapted from WHO’s Package of Essential NCD Interventions (WHO PEN), and a new Integrated Primary Health Care model. The ambition is to ensure continuous, person-centred and coordinated NCD care delivered close to communities. Translating this ambition into practice across Indonesia’s highly diverse settings, however, remains a complex task.

Learning by doing across diverse contexts

Since March 2025, the Center for Indonesia’s Strategic Development Initiatives (CISDI), with support from the Alliance – through funding from the National Institute for Health and Care Research (NIHR) – and in close collaboration with WHO headquarters and the WHO Country Office for Indonesia, has been embedding implementation research in six districts ranging from urban Medan to remote island settings such as Tojo Una-Una. Using diabetes and hypertension as tracer conditions, the 30-month project examines how integrated NCD care is organized, delivered and experienced at primary care level. 

Early insights from the field

Although the study is ongoing, several early insights are surfacing.

Despite implementation constraints, current momentum from the national screening programme and community-based platforms, including posyandu and pustu, creates opportunities for integration. From these early findings, it is clear that integration is a question of service availability, and, similarly important, of incentives, routines, beliefs and relationships operating across the health system.

Building capacity, trust and shared ownership

Rather than treating data collection as a technical exercise, these efforts have prioritized building the relational and institutional conditions needed for learning and change. Field officers based in the study districts have played a central role in this process, acting as trusted intermediaries between communities, facilities and district authorities, and helping to surface everyday constraints that are often invisible in national-level planning.

Early engagement revealed divergent expectations among policy-makers, managers and frontline providers about what integrated NCD care should look like in practice. Working through these differences required time and negotiation, but it also helped align research more closely with local priorities and decision-making processes. In this sense, the pace of the work has been a deliberate investment in relevance, credibility and future uptake, rather than a delay to be minimized.

From analysis to action

The next phase of this work is designed to shift from sense-making to action. A joint analysis workshop with CISDI, WHO and the Ministry of Health has provided a structured space to interpret findings from the inception phase together and identify leverage points for change. This was followed by validation sessions with participants, ensuring that emerging conclusions resonate with lived experience and are grounded in operational realities.

In 2026, the focus will move toward supporting implementation in selected districts. Using the qualitative findings, the team will develop a shortlist of feasible implementation strategies (for example, training and supportive supervision, task-shifting, patient follow-up systems, referral pathways, and data/monitoring improvements). These will be refined through co-design sessions with local actors, district managers, frontline providers, and community representatives, and translated into a district-level implementation plan. Clinical and regulatory experts will then review the plan to ensure it aligns with national guidance and to support any practical system adjustments needed for rollout. The aim is not simply to generate evidence, but to help translate it into practical improvements to how integrated NCD care is organized, delivered and sustained through Indonesia’s evolving primary health care approach.

Broader significance

Indonesia’s experience highlights that integrated NCD care cannot be delivered through a single blueprint. Urban clinics, rural Puskesmas and remote island health posts face distinct constraints and opportunities. Implementation research provides a way to navigate this complexity, linking national policy intent with the lived realities of providers and communities.

Early lessons from Indonesia are already informing discussions and reflections among local and national stakeholders, while also raising awareness of the implementation of Pandu PTM and future guideline updates. They also offer practical insights for other countries grappling with the challenge of embedding integrated NCD care within primary health care systems shaped by diversity, decentralization and rapid change.