Doctors Not Main Source of Health Service Problem
The health service crisis occurring up to the present is once again not only due to the limited number of doctors.
Heryunanto
A total of 598 doctors have perished since the COVID-19 pandemic began in Indonesia (kompas.com, 28/7/2021). The deaths of these heroes of health is described as a loss and at the same time, a forewarning that the state will get bogged down in a protracted pandemic crisis.
Healthcare workers’ exhaustion and their exposure to COVID-19 are regarded as causing the high mortality rate among doctors. The country’s health services have collapsed. The number of doctors is no longer sufficient to meet the need for health services. Various solutions are being offered. The recruitment of prospective health personnel as a solution is also being carried out.
The question arises, is the health emergency in the COVID-19 pandemic period an sich due to the limited number of doctor? Or is it due to the muddled health service system now ill-equipped to face the pandemic? An emergency condition demands a way of thinking beyond what’s “normal”.
However, comprehensive and systematic mapping of the problem remains important in order to avoid haphazard actions that will just increase anxiety.
Doctors in figures
Data from the Indonesian Medical Council (KKI) of 2019 indicates that Indonesia has 89 medical schools made up of 38 state higher educational institutes and 51 private higher educational institutes. The number of general-practitioner graduates in Indonesia is approximately 13,000 per year. In 2025, Indonesia is even predicted to graduate more than 14,000 new doctors annually.
The large number of doctors elicits a major question. Where will they be assigned to for their devotion to the state? On the distribution of doctors in Indonesia, it’s still hard to find “single data” harmony. KKI data comes from the total of registration letters (STR) of doctors who are going to practice.
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Meanwhile, data from the Health and Human Resources Development and Empowerment Agency (BPPSDMK) of the Health Ministry tends to show the number of doctors engaged in clinical practice in hospitals and community health centers (Puskesmas). Data on doctors with clinical practice is not yet covered.
The Health Ministry’s BPPSDMK data of 2020 reveals that in 2019, Indonesia had 188,868 doctors. With the annual growth of 13,650 medical graduates (KKI, 2020), the BPPSDMK is optimistic that in 2030, Indonesia will turn out 325,368 doctors at the rate of 2.5 percent per year. This position will make Indonesia register a surplus of 43,783 doctors within the 10-year target of the Sustainable Development Goals (SDGs) of 281,585 doctors (75 percent). This means Indonesia will achieve the SDG target in seven to eight years.
Data on the sufficient number of health workers in Indonesia should be calculated from the beginning. The government is optimistic about increasing the number of graduates and the availability of doctors. But data on the distribution of doctors in Indonesia still escapes attention. It’s high time that the distribution of doctors is no longer about figures or ratio-based sufficiency, but should take into account the mapping of health problems in the various regions so that their communities will enjoy health service as needed.
The 2013 Medical Education Law affirms that the production of medical personnel should be in the context of necessity. Besides, the number of doctors produced by educational institutes needs to allow for the positions to which they will be assigned so that cooperation between the Health Ministry as the user and the Education, Culture, Research and Technology Ministry should be solid. The production of doctors should be watched out against any surplus or minus because it will have an undesirable impact on the state.
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The government has issued the Health Ministerial Regulation No.26/2019 on the implementation of Law No.38/2014 on treatment, stipulating that in an emergency situation, the state allows the delegation of authority. This delegation must be based on competence because competent human resources constitute the dignity of health service. All attempts to annul this competence requirement amount to violations of human rights.
Health system’s response
The World Health Organization in 2020 in its Operational Planning Guidelines to Support Country Preparedness and Response outlined nine preventive aspects of how countries have to respond to the pandemic.
Of the nine aspects, the state has attempted many things, such as coordination with the National Disaster Mitigation Agency (BNPB) or the COVID-19 task force as the “conductor” in building up and strengthening surveillance and laboratories. Everything is undertaken and set up rapidly because the pandemic prompts all parties to think hard in order to survive.
The communication of risks and involvement of the public should be thoroughly designed. The absence of centralized communication confuses people when accessing valid information, so they become trapped in disinformation and misinformation of health. The distortion of information and communication harms the public. It’s at this point that the role of the state is need to control health information.
The behavior of health protocol disobedience, suggestions on consuming concoctions or doing certain activities will just increase exposure to infection, induce case surges and heighten the risk faced by doctors in the frontline of health services.
Social restrictions like the stigmatization and isolation of residents infected with COVID-19 have begun to be practiced by the public. Such acts will just prevent surveillance from being fully conducted. Transparency is the key to the success of surveillance. But the rapid response of different regions in Indonesia varies according to their preparedness. There’s a region still fearful of being labeled a “red zone”.
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When the preventive aspects have been consistently observed, case spikes in health facilities can be anticipated, such as by expanding the capacity of field wards and the health system’s monitoring. Practices violating the preventive aspects have the consequence of many health workers’ demise while on duty. The situation gets even worse as some health workers decide to withdraw from their duties.
The nine aspects offered by the WHO indicate that doctors are not the single source of the health service crisis. There are multifactor causes that can be reflected upon together. The declining number of doctors is only the effect of the health service system’s unpreparedness rather than the main source of the problem.
Health promotion
The complexity of the health service crisis should be comprehensively understood so we can propose the right solutions. First, the COVID-19 pandemic does not only constitute a medical personnel crisis. Transsectorial cooperation is, therefore, necessary to enable all parties to play a role, covering the public, educational institutes, infrastructure, logistics, various resources, political, economic and even cultural sectors to overcome the COVID-19 pandemic.
Second, the mapping of doctors’ distribution by the government is urgent. This is important in order to obtain real data on the activation of health services based on public needs. Third, Puskesmas or primary level health facilities (FKTP) should be strengthened with competent doctors, and the competence of primary service doctors should be formally promoted so that they have excellent profession status. Ignoring the quality of competence will only put public safety at risk and at the same time, violate citizens’ right to health.
Ova Emilia
The health service crisis occurring up to the present is once again not only due to the limited number of doctors. The offer of the solution to utilize health workers who are not yet competent is a form of hastiness that endangers patients because doctors’ competence is of primary significance in executing the mandate of humanitarian service.
Ova Emilia, Professor of Medical Education, dean of School of Medicine, Public Health and Treatment (FK-KMK), Gadjah Mada University
This article was translated by Aris Prawira
