Addressing the Shortage of Medical Doctors
What are they doing? According to this year’s data from the Health Ministry, Indonesia has 10,260 Puskesmas (community health centers) across the archipelago number.
Kudos must be given to Health Minister Budi Gunadi Sadikin for his sincerity in openly acknowledging that Indonesia is short of doctors and specialists.
Based on the standards of the World Health Organization (WHO), which is one doctor for every 1,000 people, Indonesia appears to be languishing at the bottom among Southeast Asian nations, according to the WHO’s 2018 report.
It has become a major concern that the decades-long problem of Indonesia’s doctor shortage has remained unsolved until now. Regarding the exact number of doctors, no institution is able to provide an accurate figure because government agencies at the central and regional levels, and even professional associations, have different data.
The latest available figure is provided by the Indonesian Medical Council (KKI). As of 22 Aug. 2022, the KKI website shows 161,663 registered doctors. However, only 142,127 doctors are still in active practice, as indicated by their valid registration certificate (STR) listed on the site. This means that there are 19,536 doctors who are not practicing.
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What are they doing? According to this year’s data from the Health Ministry, Indonesia has 10,260 Puskesmas (community health centers) across the archipelago number. This means that one Puskesmas serves around 26,315 residents.
This means that if each Puskesmas has one or two doctors recruited by the regency/municipal administration, at most 30,000 doctors should be serving at Puskesmas.
In fact, Health Minister’s Regulation No. 75/2014 on the provision of Puskesmas health workers recommends at least one on-duty doctor at outpatient Puskesmas. For inpatient Puskesmas, the minimum number of doctors is two, not only for health facilities in urban areas, but also for health facilities in rural, remote and extremely remote areas. This means that if each Puskesmas has one or two doctors recruited by the regency/municipal administration, at most 30,000 doctors should be serving at Puskesmas.
For some 110,000 doctors who still hold a valid STR, where are they working? During a webinar hosted by the Health Ministry a few months ago, it was revealed that as many as 508 Puskesmas (4.95 percent) did not have doctors, while 50 percent of akk Puskesmas in Maluku and Papua had zero doctors, even though universities in those provinces have medical schools.
Among the available datasets, none gives detailed figures on who is serving where regarding the 142,127 doctors with a valid STR. On the other hand, the most pressing demand for primary healthcare services comes from Puskesmas.
A colleague on duty at a community health center has said that the doctors assigned to Puskesmas were often overworked because they had to serve so many patients. Fulfilling the ratio of one doctor per 1,000 population would require at least 20 doctors at each Puskesmas.
Can regency/municipal administrations afford to recruit 20 doctors for each Puskesmas in their region? The financial capacity varies for each regency/municipality, as well as between provinces. Will the massive increase in the number of medical graduates guarantee that 20 doctors will be immediately distributed to each Puskesmas?
Low occupational retention has exacerbated the current situation, the Health Ministry has noted. It has been reported that doctors serving in the regions are prone to abandoning their posts, claiming unattractive incentives and unpromising career development prospects. The Eight-point Health System Transformation 2021-2024 does not touch on the basic problems at Puskesmas.
This problem is likely to persist without a change in mindset and in the absence of a comprehensive health policy. Here are some policy options to consider in resolving this pathetic condition.
Increase retention
This is like pouring water into a punctured vessel. No matter how much water we pour in, it will never be filled. The same goes for doctors at community health centers. No matter how many doctors we place at Puskesmas, if retention is low, Puskesmas will always find it difficult to provide health services to the local community.
Meanwhile, replacing doctors at Puskesmas too quickly will threaten the sustainability and continuity of the health center’s existing programs.
They are expected to continue services, instead of being tempted to leave their workplace to pursue further education or seek career opportunities elsewhere.
In 2010, the world health body issued the “WHO guideline on health workforce development, attraction, recruitment and retention in rural and remote areas”. It provides several policy options that can be implemented to retain on-duty doctors. They are expected to continue services, instead of being tempted to leave their workplace to pursue further education or seek career opportunities elsewhere.
First is to develop a career advancement system for Puskesmas doctors. For instance, hospitals have a career advancement system for nurses through the provision of four hierarchical positions, namely clinical nurse (PK), nurse manager (PM), nurse educator (PP), and nurse researcher (PR).
Each role consists of five professional levels that a nurse can reach (Health Minister’s Regulation No. 40/2017 on Professional Career Development for Clinical Nurses).
As Puskesmas doctors are recruited by regency/municipal administrations, the Home Ministry needs to develop new nomenclature to accommodate the career paths of Puskesmas doctors. The following is a model of a career path that deserves consideration: junior doctor, middle-rank doctor, high-rank doctor, and senior doctor.
Of course, every career ladder has implications. Improved competence deserves recognition that can be converted into greater incentives.
In addition to vertical career development, it is also possible to allow Puskesmas doctors to pursue horizontal career development by, among other things, diversifying services.
The following are some services that Puskesmas doctors can pursue: haj medicine, occupational health and safety, blood transfusion, anti-aging medicine, wellness, esthetic and regenerative medicine, and sports medicine.
This will help develop competence, recognition, and subsequently, additional incentives.
It is also possible for a Puskesmas doctor to study herbal medicine or other forms of alternative medicine. Outside their duties as a doctor, they can run a private clinic in the afternoon, even a fitness center or a beauty clinic. This will help develop competence, recognition, and subsequently, additional incentives.
For thet some 100,000 doctors who do not work at Puskesmas, their services are actually spread across various fields. This needs to be regulated in order to guarantee the delivery of public healthcare services. In recognition of increased competence, doctors’ associations can establish a Professional Certification Agency to issue competency certificates, following the mechanism of the National Professional Certification Agency.
Second is to improve the welfare of Puskesmas doctors and guarantee security for healthcare facilities. Regency/municipal administrations need to see Puskesmas as an investment in human resources to create healthy and productive residents in their regions.
Puskesmas should not be seen as a source of income for local administrations. It is possible for financially well-off local administrations to allocate general allocation funds (DAU) to improve Puskesmas facilities and the welfare of doctors as well as other health workers. They should remain committed to increasing the number of doctors so as to achieve the recommended ratio of one doctor per 1,000 population.
Less financially well-off regions should be supported with financial assistance from the central government. Without adequate facilities at Puskesmas, doctors will not be able to provide the best health services, which will result in many patients being referred to other facilities for secondary services.
Such events usually take place in big cities.
Third is to bring sustainable professional development closer to Puskesmas. Every doctor is obliged to maintain and improve their knowledge in line with developments in science and technology through seminars, courses, and workshops organized by professional associations. Such events usually take place in big cities.
Sustained professional development should be a requisite for recertifying competence.
The use of distance learning technology, which has been widely used during the Covid-19 pandemic, can encourage a variety of online scientific activities. The internet network has expanded rapidly across the country, which will enable Puskesmas doctors in all corners of the country to access online events. This will save both time and money.
Social Accountability
University medical schools, even if their number grows, will not have a significant impact on regional healthcare problems if they medical schools do not implement social accountability, which has become a global movement. Called the Global Consensus on Social Accountability for Medical Schools, the movement was first declared in 2010 and is supported by around 170 world organizations.
After graduation, the student must serve for his or her region in a binding agreement under the scholarship program.
The movement sends out the message that medical schools are not a socially segregated educational institution, but together with hospital and health centers, they constitute a healthcare ecosystem in a specific area. For medical schools in a particular region, new students should come from that region and the local administration should provide them with scholarships. After graduation, the student must serve for his or her region in a binding agreement under the scholarship program.
If this policy is implemented consistently, it can help guarantee the availability of doctors and ensure the delivery of health access for the local community.
In order to mobilize government agencies in various sectors as well as funds from either the central or regional administration, an accommodative law is needed. The House of Representatives proposed a revision to the Medical Education Law in 2018 and has incorporated the above policy issues as provisional articles.
President Joko Widodo has also issued three instructions to the Health Ministry and the Education Ministry to submit a list of problems as topics to be discussed, so the bill can be ratified into law and implemented immediately to address Indonesia’s problem of the shortage of doctors.
Titi Savitri Prihatiningsih
Titi Savitri Prihatiningsih,Associate Professor of Medical Education at the Gadjah Mada University (UGM) Medical School and President of the South East Asia Regional Association for Medical Education (SEARAME)
(This article was translated by Musthofid)
