Barriers and enablers in implementing integrated primary health care: A qualitative assessment in West Sumbawa District, Indonesia

In 2023, Indonesia introduced an integrated primary health care (IPHC) model called Integrasi Pelayanan Kesehatan Primer (ILP) as part of the national primary care transformation agenda. ILP seeks to strengthen the network of public primary care providers across sub-district, village, and community levels with a five-cluster model organized around a life-cycle approach, replacing the previously fragmented, program-based model. West Sumbawa District (WSD) in West Nusa Tenggara Province was chosen as a national pilot district by the Ministry of Health (MOH), with ILP implementation expanding from one to all ten public primary care clinics (Puskesmas) in 2024. Using a qualitative design, this study aims to evaluate the implementation process, barriers, and facilitators of ILP in WSD. Data were collected through focus group discussions, small group interviews, and individual interviews with health workers, community health workers, and district-level stakeholders across multiple time points between 2023 and 2025. The study found that health system barriers, namely limited human resources availability and capacity across all levels of primary care network, fragmented governance, leadership, and management practices, insufficient financing attributable to limited cross-sectoral support, inadequate physical resources, and a fragmented information system constrained ILP implementation. Despite these barriers, support from local government, community health workers, and the MOH were identified as key enablers. The results demonstrate that establishing IPHC in decentralized settings requires structural and operational redesign as well as recognizing the social, political, and organizational dynamics of the local units where reforms take place. These findings are applicable to broader primary health care (PHC) strengthening initiatives across decentralized contexts.