Management of Type 2 Diabetes Mellitus (T2DM) requires integrated and continuous care across levels of the health system. Despite the goals of universal health coverage (UHC), health service fragmentation persists and can undermine chronic disease outcomes. This study investigated how governance arrangements influence service integration and patient-reported experiences in T2DM care in Indonesia, with the aim of developing strategic recommendations to strengthen integrated governance.
The study sought to: evaluate governance factors that affect integration of T2DM services in an Indonesian UHC setting; measure patient-reported outcomes including knowledge, medication adherence, service quality perceptions, and health-related quality of life; and translate integrated qualitative and quantitative findings into strategic recommendations to support integrated governance.
A concurrent mixed-methods design was used, with qualitative data driving the inquiry. Qualitative data were collected through in-depth interviews with stakeholders across the health system, including policymakers, insurance representatives, hospital managers, clinicians, and primary care providers. Quantitative data were collected from 107 adults with T2DM using structured questionnaires that assessed patient knowledge, medication adherence, perceived service quality (SERVQUAL domains), and health-related quality of life (SF-36). Integration of findings was performed using a joint display guided by Green's PRECEDE framework. Strategic positioning employed SWOT and Internal-External (IE) matrix analyses, and a TOWS matrix was used to formulate recommendations.
Qualitative analysis identified four main governance barriers to integrated T2DM care:
Fragmented primary-to-referral care pathways, which hinder continuity and coordination of chronic care across levels.
Misaligned financing arrangements that do not adequately support the sustained needs of chronic disease management under current purchasing mechanisms.
Uneven facility and workforce capacity, reflecting variation in infrastructure and human resources across facilities and levels of care.
Weak coordination and monitoring mechanisms, limiting the ability of the system to track, evaluate, and adjust integrated care processes effectively.
These governance barriers collectively impede service integration and the consistent delivery of chronic care for people living with T2DM.
Quantitative measures among the 107 adult participants highlighted several findings:
Patient knowledge about T2DM was high, with a reported median score of 86.7%.
Medication adherence was high overall: 76.6% of respondents were classified as highly adherent.
Perceptions of service quality were generally positive across SERVQUAL domains; however, the reliability domain showed the largest gap between expectations and experience.
Health-related quality of life, measured with SF-36, revealed suboptimal physical quality of life indicators. Domains particularly affected included energy and general health, indicating persistent physical burden despite positive perceptions of services and high self-reported adherence.
These quantitative findings demonstrate a disconnect between patient-reported process measures (knowledge, adherence, perceived quality) and outcome measures (physical quality of life), suggesting system-level constraints that limit translation of good process into improved health status.
Using SWOT, Internal-External matrix analyses, and a TOWS matrix to integrate qualitative and quantitative findings, the study placed current T2DM governance in a grow-and-build quadrant. This strategic positioning indicates that the system shows sufficient internal capability and favorable external conditions to pursue proactive reforms focused on integration and capacity building.
The TOWS-informed recommendations prioritize leveraging strengths (for example, high patient knowledge and adherence) to address weaknesses (fragmented pathways, financing misalignment, workforce variability) and to exploit opportunities (policy windows within UHC) while mitigating threats (system fragmentation and weak HIT interoperability).
The study concludes that strengthening integrated governance for T2DM in Indonesia requires focused, system-level reforms. Key recommended actions reported include:
Development and institutionalization of structured referral pathways to reduce fragmentation between primary and referral care.
Aligning financing and purchasing arrangements with the long-term needs of chronic disease management under universal health coverage so that payments support continuity and multidisciplinary services.
Strengthening facility and workforce capacity, including formalizing diabetes educator roles within institutions to support self-management and team-based care.
Accelerating interoperability of health information systems to support coordination, monitoring, and data-driven governance decisions.
These recommendations are presented as actionable lessons for UHC systems in low- and middle-income countries seeking to improve chronic disease outcomes by integrating governance, strategic purchasing, stronger primary care, multidisciplinary coordination, and interoperable digital health architectures.
Main findings reported: integrated governance of T2DM care in Indonesia remains limited by fragmented referral coordination, constrained primary care authority, misaligned financing, and non-interoperable health information systems. Despite these system-level barriers, patients reported relatively high knowledge, high medication adherence, and generally positive service quality perceptions. The gap between perceived service processes and suboptimal physical quality of life highlights the need for system reforms rather than sole focus on patient-level interventions.
Policy implications emphasized: combine patient-reported outcomes, service quality assessment, and multistakeholder governance analysis to identify priorities; use strategic purchasing and financing reform to support chronic care; institutionalize educator roles and strengthen primary care capacity; and prioritize interoperable health information systems and coordinated monitoring to support integrated governance under UHC. These steps offer practical, system-level guidance for improving T2DM care within Indonesia and for other low- and middle-income settings.
Note: All findings, metrics, and recommendations above are taken from the source article. Specific numerical details and methodological nuances are reported as presented in the source.