A dialogue-informed analysis of programmatic assessment implementation in an LMIC: The Indonesian experience

Programmatic assessment (PA) is a longitudinal, learner-centered approach that integrates multiple low-stakes assessments, continuous feedback, and collective decision-making to support competency-based medical education. Although PA has been largely developed in high-income Western contexts, there is growing interest in its implementation in low- and middle-income countries (LMICs), where sociocultural and institutional conditions differ substantially. This article examines a national effort to introduce PA in an LMIC medical education system, using Indonesia as an illustrative case. Drawing on a dialogue-informed analysis and guided by selected elements of the Consolidated Framework for Implementation Research (CFIR) and Hofstede's cultural dimensions, we explore how culture, leadership dynamics, and policy environments shaped PA implementation. Our analysis highlights key challenges, including hierarchical educational traditions, reliance on high-stakes examinations, leadership instability, and limited faculty readiness, alongside enabling factors such as grassroots faculty development, distributed leadership, and locally adapted implementation strategies. We argue that successful PA implementation requires cultural alignment rather than direct transfer of existing models. This case offers transferable insights for educators leading large-scale assessment reform in culturally diverse and resource-variable contexts.