Experiences
and Roles of Community Health Cadres in the Implementation of Integrated
Service Posts for Non-Communicable Diseases in Indonesia: A Qualitative Study
Irhamni Rahmatillah1, Said Usman1*, Nurjannah1, Teuku
Maulana1, Marthoenis2
1Master of Public Health, Faculty of
Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia
2Department of Psychiatry and Mental
Health Nursing, Universitas Syiah Kuala, Banda Aceh, Indonesia
*Corresponding
author: saidusman@usk.ac.id
Submitted: 05.06.2025 Revised: 17.06.2025 Accepted: 19.06.2025 Published: 30.06.2025
Keywords:
Health Cadres, Non-Communicable Diseases, Community Health, Qualitative Study
Introduction
Non-Communicable Diseases (NCDs) contribute to over 75%
of global mortality, presenting a substantial burden on health systems
worldwide. In 2021, an estimated 18 million individuals died from
non-communicable diseases (NCDs) before reaching the age of 70, with
approximately 82% of these premature deaths occurring in low- and middle-income
countries (World Health Organization [WHO], 2023). Cardiovascular diseases were the leading cause, responsible for at least
19 million deaths, followed by cancers (10 million), chronic respiratory
diseases (4 million), and diabetes, which accounted for over 2 million deaths,
including those linked to diabetic-related kidney complications (World Health Organization [WHO], 2021). In Indonesia, the prevalence of these conditions continues to rise, with
the 2018 National Basic Health Research (Riskesdas) reporting that 34.1% of
adults suffer from hypertension and 8.5% from diabetes mellitus (Riset Kesehatan Dasar (Riskesdas), 2018). This epidemiological trend imposes increasing demands on the healthcare
infrastructure, necessitating sustainable, community-based responses (Indrawati L , Mahendra A, 2021)
In light of the shifting epidemiological landscape,
recent studies underscore the urgency of adopting localized, data-driven
strategies to mitigate the rising burden of NCDs in Indonesia (Prasetya et al., 2020). Urbanization, sedentary lifestyles, dietary transitions, and
environmental pollution are increasingly recognized as contributory factors to
the surge in NCD prevalence, particularly among working-age adults and
adolescents (Adani et al., 2022). In response, the Indonesian Ministry of Health initiated the Pos Pembinaan Terpadu Penyakit Tidak Menular
(Posbindu PTM) program—Integrated Service Posts for Non-Communicable
Diseases—as a preventative health initiative centered on community
participation (Nugroho & Astuti, 2022). These posts are designed to deliver early screening, health education,
and behavior change interventions, particularly for individuals aged 15 to 59
years (Nuraini & Wahyuningsih, 2023). Central to the implementation of Posbindu PTM are community health
cadres, who serve multifaceted roles as educators, facilitators, and
intermediaries between health institutions and the public (Oktavia & Lestari, 2023).
Moreover,
the evolution of NCD risk profiles—now increasingly affecting younger
populations—demands a recalibration of health promotion strategies that go
beyond traditional models and leverage digital literacy, behavioral economics,
and intersectoral partnerships (Dewi et
al., 2024). In this
regard, the empowerment and resilience of cadres become central not only to
screening and prevention, but also to the sociocultural transmission of health
norms (Yuliana
& Handayani, 2021). The
sustainability of such programs hinges on recognizing the psychosocial dynamics
of volunteerism, wherein intrinsic motivation must be matched with tangible
institutional support (Rosanti et
al., 2022). Finally,
integrated monitoring and evaluation frameworks that include qualitative
perspectives of health workers can provide richer insights for adaptive policy
reforms (Kok et
al., 2020).
Banda Aceh was selected as the study location owing to
its high incidence of non communicable
disease, active Posbindu PTM programs, documented urban health challenges,
and the municipality’s policy focus on community-based healthcare strategies (Rahmadana et al., 2023). recent data highlights persistent challenges in program engagement and
outreach, particularly in sub-districts like Ulee Kareng where community
participation rates remain suboptimal. (Profil Kesehatan Kota Banda Aceh, 2024)
In the context of Banda Aceh, where urbanization and
shifting health behaviors converge, the role of Posbindu PTM has become
increasingly significant (Putri & Ardi, 2022). These discrepancies indicate a critical need to explore not only
institutional and community-level constraints but also the intrinsic dynamics
shaping cadre engagement (Fahlevi et al., 2023). Despite the established structure of Posbindu PTM, its overall
effectiveness remains constrained by several systemic issues, including limited
infrastructure, low public participation, insufficient cadre training, and weak
cross-sector collaboration (Arifin et al., 2022).
While the role of health cadres is pivotal in the
success of these programs, there is a notable lack of empirical research
examining their day-to-day experiences and operational challenges. (Widya & Sari, 2023). Capturing these lived experiences is vital to identifying programmatic
bottlenecks and informing targeted strategies for improvement (Lestari et al.,
2023). Additionally, many cadres operate
under constrained resources, limited digital literacy, and modest financial
incentives—factors that may affect both service delivery and personal
well-being (Suryani & Lestari, 2023) (Chanda et al., 2021). Recognizing these contextual elements is essential to crafting
responsive policy interventions that elevate both the sustainability and impact
of community health initiatives (Nasution & Siregar, 2021).
Methods
The research employed a qualitative phenomenological
design, which is well-suited to capturing and interpreting individual
experiences within a particular context. This method allows for an in-depth
examination of the subjective realities and nuanced challenges encountered by
health cadres as they perform their roles.
Participants
The study was conducted in Ulee Kareng, a sub-district
in Banda Aceh known for its large population and high prevalence of
non-communicable diseases, which then correspond to its active Posbindu PTM
programs. According to data from the Aceh Provincial Health Office in 2020, the
prevalence of hypertension in the province reached 32%, while diabetes mellitus
was reported at approximately 10%. In Banda Aceh City specifically, the
prevalence of hypertension among individuals aged over 40 was even higher, reaching
around 30%. Twelve female health cadres were selected using purposive sampling
to ensure varied representation in terms of age, experience, and educational
background. All participants had at least one year of continuous involvement in
Posbindu PTM operations and had completed formal training modules provided by
the local health office.
Data Collection
Data collection took place in January 2025 through
face-to-face, Semi-structured interviews were conducted in Bahasa Indonesia
using open-ended prompts such as: "Can you describe a typical day at
Posbindu PTM?" and "What challenges do you encounter when engaging
the community?". Each interview lasted 30–45 minutes and was
audio-recorded with consent.
Trustworthiness of Data
To ensure trustworthiness, researchers used
triangulation, member-checking, and prolonged engagement with participants.
Verbatim transcription and peer debriefing strengthened data reliability. The
cadres were approached at the Posbindu PTM-Community-Based NCD Posts event
location while the activity was taking place. This was done at the same time to
conduct field observations.
Ethical Considerations
The study received ethical approval from the Ethics
Committee of the Faculty of Medicine at Universitas Syiah Kuala. All
participants provided informed consent and were assured of their anonymity and
the confidentiality of their responses. The ethical framework emphasized
voluntary participation, non-maleficence, and transparency.
Data Analysis
Data analysis was conducted using the Miles and Huberman
framework. The first stage involved data reduction through the identification
and extraction of significant statements. These data were then categorized and
displayed to reveal patterns, relationships, and emerging themes. The final
step involved interpreting the data to draw meaningful conclusions.
Triangulation and member checking were employed to ensure data credibility and
reliability.
Results
A total of 12 informants participated in this study, all
of whom were female Posbindu cadres with varying ages and years of experience.
The majority of the informants were between 22 and 53 years old, with their
length of service ranging from 3 to 35 years. Notably, all respondents had
received some form of training related to their roles, such as non-communicable
disease (NCD) prevention, child health, maternal health, and the use of
health-related applications like ASIK. This indicates that the cadres not only
possess diverse experience levels but also demonstrate a consistent engagement
in capacity-building efforts, which is crucial in supporting the implementation
of community-based health programs. Detail of characteristics of study
respondents is presented in Table 1.
Based on the interview findings with informants in this
study, a range of perceptions emerged regarding the challenges they faced in
fulfilling their roles as health cadres in the Ulee Kareng District, Banda Aceh
Regency. The analysis produced two main themes and five subthemes, which will
be further explored and discussed as follows:
Theme 1: Cadre Experiences and Perceived
Benefits
The experiences of Posbindu PTM cadres highlight a
delicate balance between dedication and adversity. While the role provides
personal fulfillment, learning opportunities, and social recognition, it also
demands resilience in the face of logistical, motivational, and community-
related challenges. Health cadres involved in the Posbindu PTM program reported
profound satisfaction in their roles, particularly in contributing to the
well-being of their communities. They expressed joy in the opportunity to interact
with fellow residents, participate in social activities, and gain new health
knowledge.
Participants consistently reported that their
involvement in Posbindu PTM fostered both personal and professional growth.
Many shared that they had developed greater confidence in public speaking,
facilitating discussions, and managing health screening procedures. This
empowerment extended to an increased sense of self-efficacy in addressing
health issues, both within their families and the broader community. One
participant stated, “I feel more confident speaking in public after being
involved in Posbindu activities.” This empowerment extended to an increased
sense of self-efficacy in addressing health issues, both within their families
and the broader community.
Table 1. Characteristics of Informants
|
Respondent No. |
Age (years) |
Gender |
Years of Service as Posbindu
Cadre |
|
1 |
53 |
Female |
12
years |
|
2 |
30 |
Female |
3
years |
|
3 |
35 |
Female |
8
years |
|
4 |
27 |
Female |
3
years |
|
5 |
49 |
Female |
3
years |
|
6 |
48 |
Female |
5
years |
|
7 |
40 |
Female |
7
years |
|
8 |
28 |
Female |
2
years |
|
9 |
29 |
Female |
6
years |
|
10 |
48 |
Female |
3
years |
|
11 |
30 |
Female |
4
years |
|
12 |
22 |
Female |
2
years |
Knowledge acquisition was another prominent benefit.
Cadres indicated that their understanding of NCDs, risk factors, dietary
habits, and physical activity recommendations had significantly improved.
Several mentioned applying this knowledge in their daily lives and encouraging
neighbors and relatives to adopt healthier lifestyles. This accumulation of
expertise not only elevated their self-esteem but also positioned them as
trusted figures within their communities. “At first I didn’t know the normal
range for each disease or any detail things about it, but as I became part of
the health cadres, I slowly grew my knowledge, and my neighbor now often comes
to me for health advice.” This quote illustrates how cadres gain personal
and social value from their roles.
Despite these positive experiences, cadres also faced
significant challenges. A frequently cited concern was the limited community
engagement. Many residents were hesitant to participate in Posbindu activities,
often due to low health literacy or fear of receiving a medical diagnosis. As a
result, cadres had to repeatedly motivate community members to attend sessions
and emphasize the importance of early detection and adopting healthy
lifestyles. This effort proved both time- consuming and emotionally demanding.
Theme 2: Challenges in Program
Implementation
Despite these positive outcomes, cadres encountered
numerous challenges. A recurring issue was the place where the event was held
tended to be small and the limit of essential resources. The findings from this
study reveal that health cadres operating within the Posbindu PTM program
encounter multifaceted challenges that significantly affect their performance
and overall program implementation. These challenges include systemic barriers
such as the inadequacy of medical equipment and facilities which limit the
effectiveness of service delivery and compromise community trust in the
program. Cadres also report insufficient financial incentives that do not
reflect the breadth of their responsibilities, leading to a sense of
undervaluation.
Currently, Posbindu activities are conducted under the
ILP (Primary Service Integration) system, which has generated both support and
criticism. One of the main advantages is the increased number of participants,
as health screenings for both toddlers and the elderly can be carried out
simultaneously. However, this system also presents challenges, including
extended working hours and a less conducive environment due to limited space in
the facility where the activities are held.
Collectively, these obstacles highlight structural
deficiencies in program design and implementation. While the implementation of
the ILP system in Posbindu PTM activities has led to a higher turnout of
participants by enabling simultaneous health screenings for various age groups,
it also introduces significant operational challenges. These include extended
working hours, inadequate facilities, and insufficient resources, which
collectively hinder the efficiency and effectiveness of health service delivery.
Furthermore, the lack of appropriate financial incentives contributes to the
demotivation of cadres, despite their critical role in the program. To enhance
the sustainability and impact of the Posbindu PTM program, it is recommended
that relevant stakeholders improve infrastructural support, ensure the availability
of essential medical equipment, and provide fair and structured financial
compensation for health cadres. Strengthening these aspects is crucial to
maintaining the trust of the community and optimizing the quality of integrated
primary health services. Inadequate financial incentives were also cited as a
major concern. Most cadres received minimal stipends, which did not reflect the
time, energy, and emotional labor invested in their roles. This lack of
compensation contributed to feelings of undervaluation and, in some cases,
demotivation.
Discussion
Cadre Experiences and Perceived Benefits
The findings of this study affirm that health cadres
involved in the Posbindu PTM program derive significant personal and
professional benefits from their roles. The sense of empowerment reported by
the participants aligns with existing literature that highlights the
transformative potential of community health work in fostering self-efficacy
and identity development among volunteers. Cadres in this study gained
increased confidence in communication, public speaking, and technical
competencies such as health screening and counseling. These developments
contribute not only to the success of the Posbindu program but also to the
enhancement of individual cadre capacity for broader health advocacy roles.
The acquisition of knowledge related to non-communicable
diseases, including their risk factors and preventive strategies, further
enhanced the cadres’ credibility and functionality within their communities. By
serving as sources of health information and behavioral models, cadres
positioned themselves as trusted intermediaries between formal health systems
and local populations. The recognition and appreciation they received from
community members and local authorities reinforced their motivation and sustained
their commitment to voluntary health promotion work.
These results mirror global findings from similar
community-based interventions Studies from South Asia and Sub-Saharan Africa
also reflect similar outcomes, where community health volunteers experience
both empowerment and institutional neglect (e.g., Akintola & Chikoko, 2016;
Smith & Hall, 2021)., where health volunteers reported psychosocial
benefits, social capital, and enhanced status as key motivators. However, it is
important to note that such intrinsic benefits, while impactful, may not be
sufficient to sustain long-term participation in the absence of structural
support.
Challenges in Program Implementation
In contrast to the positive personal outcomes, the study
also reveals persistent systemic and contextual challenges that hinder the
optimal implementation of the Posbindu PTM program. The most pressing issues
identified include lack of public interest in undergoing health checks and the
facilities that support the running of the event which restrict cadres from
conducting proper screenings and reduce the community’s trust in the quality of
the services provided. The physical space for Posbindu activities was often
limited, compromising privacy and accessibility for participants.
Another central concern is the insufficient financial
remuneration provided to cadres. The minimal or inconsistent stipends do not
adequately reflect the scope of responsibilities, or the time invested by
cadres. These findings are consistent with broader literature on community
health workers, which emphasizes the need for fair compensation to maintain
workforce stability and prevent attrition.
Cadres are required to input all data online within the
specified time which leads to fatigue and time constraints. While some cadres
reported receiving digital literacy training, others noted inconsistent access
to such support, suggesting variability in administrative assistance or digital
literacy training. Moreover, community engagement remains a persistent and
complex challenge. Despite the cadres’ active efforts, attendance at Posbindu
sessions was generally low. An unexpected finding was the high intrinsic
motivation of some cadres, who continued volunteering without expecting
financial compensation. This was attributed to poor health literacy, irregular
scheduling, insufficient awareness campaigns, and socio-economic factors that
caused health promotion to be deprioritized in daily life. This challenge
underscores the importance of a coordinated approach involving local
leadership, culturally sensitive messaging, and sustained outreach strategies.
Collectively, these barriers reflect critical weaknesses
in the institutional and operational frameworks that underpin the Posbindu PTM
program. Addressing them will require a multifaceted response that includes
resource allocation, technical training, financial investment, and cross-sector
collaboration.
Conclusion
Health cadres represent a vital link between formal
health systems and community members, especially in the context of NCD
prevention. Their lived experiences illustrate both the potential and the
limitations of community-based health initiatives. While personal growth and
communal respect are notable outcomes, systemic challenges such as inadequate
facilities, limited incentives, and insufficient public engagement hinder the
full realization of Posbindu PTM's objectives.
Therefore, policymakers and health authorities must
recognize the critical importance of cadres Specifically, the Ministry of
Health should institutionalize periodic cadre training, while local governments
are advised to allocate dedicated resources for infrastructure and
remuneration. and commit to strengthening the institutional frameworks that
support them. By addressing these challenges, Indonesia can better leverage the
Posbindu PTM program to combat the growing threat of NCDs and promote a healthier,
more resilient population.
Conflicts of interest
The authors declare that they have no competing
interests.
Funding
This research received no specific grant from any
funding agency.
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