Interconnected barriers to mental health service provision in Indonesia’s tiered referral system: a qualitative study

Despite increasing attention to mental health, access to quality mental health services in Indonesia remains constrained by health-system, workforce, and patient/family-level factors. This study explored barriers to mental health service provision within Indonesia’s tiered referral system from the perspectives of health professionals. We conducted individual semi-structured interviews with 23 participants (pharmacists, psychiatrists, and nurses) working in psychiatric and general hospitals (Types A–D) across multiple provinces. Interviews were audio-recorded, transcribed verbatim, and analysed using inductive thematic analysis supported by NVivo 12. Participants described three interconnected barrier domains. At the healthcare-system and access level, complex insurance and administrative requirements, intermittent psychotropic medicine stock-outs, inadequate infrastructure, and geographic distance disrupted referral flow and continuity of treatment. At the health-professional level, staff shortages and limited time for counselling and follow-up impeded comprehensive assessment and coordinated care. At the perceived patient, family, and caregiver level, financial constraints, limited understanding of the role of medicines and the need for adherence, weak family or social support, denial of illness, stigma, and challenges with long-term medication adherence delayed help-seeking and undermined retention in care. Participants’ accounts also indicated interaction across levels: system constraints increased operational burden on health professionals, while reduced counselling and follow-up capacity could amplify patient and family difficulties in sustaining treatment. Strengthening mental health services in Indonesia will require simplifying insurance and referral procedures, improving the reliability of psychotropic medicine supply chains and service infrastructure, investing in workforce capacity, and implementing community- and family-oriented strategies to support adherence and reduce stigma.