Integration is not only about the service as one, but also how the place is safe and the officers are friendly, especially female drug users — Community member, Jakarta

Integration can work if the community is involved. We know the conditions of the field and can help accompany patients- Community member Jakarta

Harm Reduction International in collaborations with Karisma Foundation and Rumah Cemara (Indonesian civil society and community-led organisations working on HIV preventions, harm reductions, policy advocacy) publish two reports on Harm Reduction Integration into Primary Health Care Centers in Indonesia.

The report published in collaboration with the Karisma Foundation is a summary of their comprehensive report on integration.

The Indonesia Ministry of Health issued guidelines in 2021 saying that primary health centres—called Puskesmas should be the main place for integrated HIV, drug use, mental health, tuberculosis, and hepatitis services. In 2023, a reform called the Integrated Primary Health Care policy (ILP) tried to reorganise Puskesmas into coordinated clusters.

These two studies assessed whether integrated harm reduction services are effective and implemented as envisioned by their integration policies. Karisma Foundation study was conducted in Jakarta, Surabaya, Medan and Makassar; while Rumah Cemara study was conducted in Bandung.

Both reports have different findings reflecting on how city and provincial context, history of harm reduction activism, supportive government, multi-stakeholder engagement make a difference to deliver integrated services.

One common theme throughout both studies is

Communities play an important role as companions, educators, and links between service users and healthcare facilities. However, their contributions have not yet been formally recognised within the service system. They do this for free, without official recognition and under constant risk of arrest.

The high-level functional working group in Bandung: providing district-level stewardship for harm reduction programmes. The Working Group consisted of communities of people who inject drugs, NGOs, and government agencies such as the Health Office, hospitals, the Police, and the BNN (National Narcotics Board). In particular, the engagement of the Police and BNN was crucial in ensuring safer passage for people who inject drugs to access integrated services at public facilities, amidst harsh criminal laws in the country.

Collaborations between community and health workers: The Puskesmas selected for harm reduction integration joined hands with community leaders and civil society organisations in encouraging people who inject drugs to access integrated services. Community and civil society outreach workers were also trained to ensure increased access for people who inject drugs to integrated.  Referral systems were functional and effective where formal and informal collaboration between providers and community actors already exists.

Trained and sensitised health workers: Puskesmas who prepared themselves by training healthcare workers in harm reduction, alongside various other training programmes, provided stigma-free services to people who inject drugs.

Reorganising primary healthcare services into functional clusters: In Jakarta, Puskesmas was emphasized as the primary entry points and offers integrated services with coordinated service structures to connect clients with other specialised services. They scrapped disease specific siloed services.

Community leadership and monitoring: Community leadership was critical throughout all studied cities to ensure integrated services are accessed by people who use drugs, no-one is left behind, reduced loss to follow up, bridged the coordination between different sectors and stakeholders and many more. Feedback managed even changed practices such as requiring ID documents to access services, where health centers provided services without requiring ID after advocacy.

Good laws but weak action: Still fragmented services: The Integrated Primary Care Policy (ILP) has not been translated into clear instructions that health workers and service centers can actually follow in many cities. Inspite policies, HIV drug use and mental health programmes sit in different parts of Ministry of Health without robust coordination mechanism. Each unit works separately. When coordination does happen, it is because specific individuals make the When those individuals are transferred, the coordination stops.

The digital data of HIV, mental health and drug programmes are stored in separate systems that cannot talk to each other. Workers have to enter the same patient’s information multiple times, in multiple systems.

“The ILP (Integrated Primary Health Care Policy) has only been in the last two years, but the technical guidelines are not yet clear, so we are still confused about what kind of integration it will take in the field.” Health stakeholder, Makassar

The harm reduction services are unevenly distributed across PHCs and patients are frequently referred elsewhere, increasing out-of-pocket costs and risk of loss to follow up.

Not enough staff, not enough training, Too much turn over: In many Puskesmas across all all cities, often one health officer is responsible for HIV, drug use, and mental health programmes all at once. Health centres have asked for more staff but the requests have been denied.

The insufficient ratio of healthcare workers to patients means people who inject drugs are often served only by designated HIV staff. This is compounded by a lack of formal harm reduction training, with workers relying on on-the-job learning from previously trained

“If there are drug patients or mental disorders, we are often confused about where to start. We have never been taught how to handle it.” Health stakeholder, Surabaya

No adequate and reliable funding for integrated work: Special Allocation Funds (DAK), which are central government transfers to regional governments, and regional budgets (APBD). Neither currently has a dedicated line for harm reduction integration. As the result there were no budget lines for integration activities in any of the health offices studied, both in the Strategic Plan and in the Activity Plan and Budget (RKA). The budget is still sectoral and separate between programmes.

“The drug programme is still considered not a favourite programme, so when submitting a budget, it is often not approved.” Health stakeholder, Jakarta

Bandung however provided relatively better financing outlook where local/city level funding contributes 70% of total funding for harm reduction, HIV prevention and diagnostic sets. However, their funding on outreach workers across Bandung city was insufficient- partly due to reliance on external funding for such outreach activities.

Lack of adequate infrastructures at integrated sites: Most of the health centres studied have no private room for drug use or mental health consultations. Patients with stigmatised conditions are seen in shared spaces where anyone can overhear. This is not just a comfort issue. When people cannot speak privately, they do not disclose what is really happening. They do not ask for help:

“Integration is important, but there must be a comfortable and safe space. Many female patients don’t want to come if the place is open.” Community member, Jakarta

Unable to instutionalise or fund community contribution to integrated services: One of the most striking findings of this study is not what the formal health system is failing to do. It is what communities are already doing, every day, without pay and without official recognition. Communities function as peer navigators, treatment supporters, case trackers, and linkage facilitators within community systems strengthening approaches. These are roles the formal health system has not funded or filled. The social contracting was only documented in Bandung- though it had quite a limited funding available.

“We often help follow up patients who have lost contact. So if there is a name from the health centre, we will help find it in the field.” Community member, Jakarta

Health and criminal justice are pulling in opposite directions: The two systems—health and criminal justice—are working against each other. Between October 2024 and May 2025, police recorded nearly 19,000 drug cases and over 26,000 suspects. This is happening at the same time as the government is trying to build a health-based approach to drug use. These two things contradict each other. Health workers reported feeling unsafe doing outreach in areas where police were active. Some were summoned by police for doing their jobs:

“There was once an officer who was called by the police for participating in a field rehabilitation programme. They don’t understand that this is part of health.” Health stakeholder, Makassar

For National Governments and Health Ministries

• Turn integration policy into enforceable rules and implementation and comprehensive technical guidelines.
• Create dedicated earmarked budget line for integration
• Formally include communities and civil society organisations in service delivery and health planning and provide funding for their work through social contracting mechanism.
• Design sustainability and transition planning into the integration process from the

For Local Governments and Health Facilities

• Invest and retain competent human resource.
• Invest in the physical environment- and spaces that feel safe and welcoming key populations, women, LGBTQ+ people, and people with mental health conditions.
• Strengthen internal and external coordination bodies to ensure coordinated services and referral mechanism.
• Build a shared commitment with community, civil society and peer support groups to strengthen community outreach.
• Conduct regular and accurate mapping of healthcare facilities and their proximity for key populations.
• Conduct stakeholder mapping at the outset of planning in collaborations with communities.

For Civil Society Organisations and Communities

• Push for formal agreements with health centres and importantly access to social contracting fund to ensure consistent advocacy and support.
• Build community monitoring tools- and aim connecting the tool to official programme monitoring to create accountability.
• Advocate for stable and multi-year funding for community organisations with both donors and governments.

For Donor and Development Partners

• Fund the conditions for sustainability, not just the services- to ensure reliable and adequate domestic funding for integrated services.
• Fund integrated data systems that protect privacy.
• Fund inclusion explicitly to ensure all marginalised populations such as women who use drugs, key populations are part of integrated services.