Bringing Home Diaspora Doctors

The government has initiated an interesting health program, namely inviting doctors of the Indonesian diaspora back to the country.

Health Minister Budi Gunadi Sadikin initiated it. The reason is that the expertise of diaspora doctors is very much needed in transforming the country’s health programs.

Hundreds of Indonesian doctors currently work in various parts of the world, from Australia to Canada. They have various specializations and super specializations. They hold key positions abroad. Some have become professors, key figures at important institutions or famous clinicians. Their work is recognized in those countries.

The Indonesian government sees their existence as an opportunity to increase health development. Therefore, they have been invited to return home. Of course, this program has its pros and cons.

Poor distribution of doctors

Health Ministry data show that Indonesia currently has 102,000 doctors who serving 274 million people. The ratio is one doctor serves 2,686 people. In fact, the World Health Organization (WHO) recommends a ratio of 1:1,000. This means that Indonesia is still far below the standard.

With the current ratio, Indonesia ranks among the bottom three in ASEAN alone. This is very sad. In fact, the ratio above is the general ratio of doctor per 1,000 population. If you check per specialization, the ratio grows even sadder. For example, the country has only around 600 cardiologists. So, one cardiologist must be prepared to serve 457,000 people.

This is a very poor ratio. What's more, the distribution of cardiologists is uneven and there are more cardiologists in big cities than in rural areas. On the other hand, diseases of the heart and blood vessels are the leading diseases and the No. 1 killer in this country.

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With the limited number of cardiac specialists, it is natural that the morbidity and mortality rates for heart disease are not good. In the last 10 years, cardiovascular disease (including stroke) has remained the top killer in Indonesia. In fact, the fatality rate of cardiovascular disease is now up 25 percent compared to 10 years ago. This is a dilemma.

In developed countries, one cardiologist serves just 100,000 people, far below Indonesia’s ratio.

Considering this poor condition, the government needs a supply of doctors and specialists. To reach a ratio of just 1:1,000, Indonesia needs an additional 173,000 doctors. This is almost double the current number of doctors in the country. This is still a general estimate and does not considering the demand for specialist doctors.

The dozens of medical schools in the country currently produce just 11,000 doctors per year. Given this fact, it will take 10-15 years to reach the standard ratio. This is a very long time.

Therefore, the government is struggling with various efforts to increase the supply of doctors, so it has invited the diaspora doctor to "come home". The government is also discussing the use of foreign doctors.

‘Repatriation program’

Although the invitation to return home is a good innovation, its outcome is still questionable. There are many reasons.

First, some diaspora doctors have settled down in other countries. Many of them have lived there for more than 10 years. They already have permanent jobs and strategic positions, have a large number of regular patients and very adequate income levels.

Some of them even have permanent residence status or are married to citizens there. Inviting them back to Indonesia is the same as asking them to leave their comfort zone. In fact, they achieved this comfort zone after years of hard and relentless struggle. The process is not easy.

Considering this phenomenon, only doctors who possess truly extraordinary commitment and loyalty can be expected to return to Indonesia. Moreover, they certainly have their own considerations for themselves and their families. When they return to Indonesia, how long will they have to work before they have settled down, what will be their income, and how will they and their families adapt to the local environment?

Diaspora doctors are accustomed to working with relatively sophisticated, detailed and fast medical equipment.

Apart from doctors that have settled down, there are also diaspora doctors who are currently training or studying abroad. Members of this group usually haven't been overseas too long and they are relatively young. The offer to return to Indonesia may be more feasible for this group than for doctors that have settled down abroad.

Second is the difference in environments. The training and job environment in developed countries is certainly not the same as that in Indonesia. This relates not only to the system, but also the availability of facilities and infrastructure.

Diaspora doctors are accustomed to working with relatively sophisticated, detailed and fast medical equipment. They use such equipment regularly when serving their patients. They are also supported by an adequate health administration and funding system, as well as a conducive environment.

In such an environment, they can focus on treating patients without being distracted by hassles over equipment, financing or administrative processes.

When they return Indonesia, they would have to deal with a different situation, especially if they work in rural areas. When they need to conduct an MRI or CT scan for immediate diagnosis, the equipment they need may not be available, or their availability may be hampered by funding problems. The different conditions will make it impossible for them to work as effectively and efficiently as they can abroad.

A doctor’s skills in diagnosis and treatment are highly dependent on the availability of facilities and infrastructure. Their performance is not only determined by their knowledge and skills, but also the equipment they use. In this regard, the concept of “who has the gun and who pulls the trigger” applies.

Third, the entry requirements to Indonesia, especially the transition process, are considered burdensome. Indonesian Medical Council Regulation (Perkonsil) No. 41/2016 contains a rule stipulating that every foreign doctor who provides clinical services or whose expertise is to be recognized in Indonesia must undergo a process of transition lasting 6-12 months for general physicians and 6-24 months for specialist doctors.

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In practice, the time of transition can be sometimes prolonged by more than two years. The transition process requires them to participate in a training program or clinical residency similar to programs for Indonesian doctors in training.

After the transition program, they usually have to take another competency exam. The transition and exam requirement is universal, no matter what country they came from or how highly skilled they are.

Actually, the transition process is indeed a substantial stage that is required whenever a doctor relocates to another territory. Before they start providing clinical services, doctors must have adapted to the system and conditions of the country they have entered. This is also true in a number of other countries.

However, the issue is the duration of the transition process. Two years of transition for a specialist doctor is considered too long. Moreover, their status is “trainee” for these two years and they are not allowed to practice independently. This means that they will not have a steady source of income.

In fact, they have undergone years of training and passed various difficult exams abroad. Practically and psychologically, the transition process and duration is inconvenient for them.

Starting a career from scratch over a relatively long time is highly inconvenient for doctors that have years of experience. In comparison, the average specialization program in Indonesia takes four years. This means that diaspora doctors must undergo a period transition equivalent to half the duration of a specialization program.

Simplify the process

To accelerate Indonesia's health transformation program, inviting diaspora doctors to return is a good program. This is more feasible than inviting foreign doctors to open practices in Indonesia. However, to better realize it, the program must be adjusted so it will be more acceptable to diaspora doctors.

Another thing: The invitation to return home is certainly not the only model under which diaspora doctors can contribute to develop public health.

To make the “repatriation program” more acceptable, the government needs to cut the length of the transition process. Two years is too long. The transition process can be reduced to a fixed period of one year. During the transition process, they also need to be remunerated properly so they can support their families.

If there is a very urgent need for specialized health workers, the government can even create a special program, like a course. In this special program, the government and diaspora doctors cooperate under certain terms and obligations. On the one hand, the government makes the process easier, but on the other, diaspora doctors are willing to work with the government for a certain period. This resembles the scholarship model.

A diaspora doctor is also a “child of the nation”. They may work abroad, but not because they do not love their country. They have passion to contribute to developing their country.

In this special program, the transition period can even be reduced to six months. Six months is not a "magic number", because the transition period in several countries is, in fact, around six months.

During this transition process, they are paid an appropriate salary and if necessary, the facilities to help their transition. Is this too much? Certainly not. Because here there is an urgent need for additional health workers and therefore, an extraordinary pathway is needed. The pathway must match the need.

However, this special program should not be general and aimed only at doctors whose knowledge and skills are urgently needed.

The government can also empower diaspora doctors to apply their expertise in other ways, not only limited to bringing them home. They can be asked to help realize cooperation between domestic and foreign institutions or be remote teachers, involved in joint social services, visiting doctors for a certain period, conduct joint research, and other activities that can help transform Indonesian health care.

They can also be invited to participate regularly in certain cases via telemedicine, cross-border clinical workshops, and other innovative programs. Developing intellectual activities like these seems more feasible and acceptable than inviting them to repatriate, at least for now. So, even if they do not physically return to Indonesia, their minds, knowledge and skills can be used in Indonesia.

A diaspora doctor is also a “child of the nation”. They may work abroad, but not because they do not love their country. They have passion to contribute to developing their country. The government can use this opportunity wisely by, among other means, making a more conducive and fair climate for their repatriation and giving them the chance to take part in various health and education events here.

ARSIP PRIBADI

Iqbal Mochtar

Iqbal Mochtar, Chairman, Middle East Indonesian Doctors’ Association; central board member, Indonesian Association of Public Health Experts (IAKMI); member, Indonesian Occupational Medicine Association (IOMA)

This article was translated by Kurniawan Siswo.