Specialist Doctor Education: Investment in Human Resources for Nation's Future

A good healthcare system in a country requires adequate health-service infrastructure, in addition to the procurement of well-grounded human resources.

The education of doctors and specialists is crucial because the procurement of doctors or specialists is not instantaneous, but a time and money-consuming effort. It takes at least six years to produce a doctor, while to become a specialist in various fields of expertise takes an additional four to five years.

If the educational process is unimpeded, one must spend no less than 10 years to become a specialist. The problem is that to take up specialist education, a doctor must pay a very expensive tuition fee, up to hundreds of millions of rupiah, from his or her own pocket. As a result, only a few who have sufficient financial support can continue with a specialist education. Thus, a doctor seeking to become a specialist has to go through “financial” selection, in addition to possessing the requisite academic and professional abilities.

Costly education

A study by Kompas (29/7/2022), which looked into data from 12 medical-study programs in 30 universities in Indonesia, both public and private, shows that Rp 388.8 million (US$26,045) is needed to complete a medical degree (bachelor/S-1), not including fee for professional education. For medical schools at private universities, the required cost is Rp 688.6 million, or Rp 88 million per semester.

Compare this with the tuition fee in civil engineering, informatics, accounting, law and psychology, which is in the range between Rp 100 million and Rp 110 million to attain a bachelor degree.

The management of the Covid-19 pandemic in the last two years has revealed that the number of doctors in Indonesia is only four per 10,000 population (worldbank.org), which appears to be the second lowest in Southeast Asia after Cambodia. Compare this with the Philippines, which has 13 doctors, Malaysia 15 doctors and Singapore 23 doctors for every 10,000 residents. For specialist doctors in Indonesia, the figure is even smaller. Based on the data at the Indonesian Medical Council (KKI) in 2020, there are 41,798 specialist doctors from as many as 35 fields of medical specialization.

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Given Indonesia’s current 270 million population, there are only 1.4 specialists per 10,000 people. This situation has been exacerbated further by unequal distribution of working specialists across the country. For example, out of 400 neurosurgeons in this country, there are 100 who serve residents in Jakarta and its surroundings. Meanwhile, outside Java, there is only one neurosurgeon on average in each province. Five provinces have yet to produce a neurosurgeon specialist.

Accidents or brain injuries and strokes can happen anywhere, with men of productive age being mostly susceptible to the diseases. It would be naive and ironic if an accident victim were to die or become physically impaired just because of the absence of a neurosurgeon specialist in the area. Not to mention the shortage in other specialization fields, such as cardiac, surgery and pediatric. There are only 4,800 pediatricians. In fact, around 15,000 pediatric specialists are needed to serve around 90 million children under the age of 18 across the country (Kompas, 20/2/2021).

It is quite reasonable for Health Minister to bemoan the situation in his recent statement that Indonesia is still falling far short of physicians.

The absence of specialist-medical services is a form of social injustice for the people of this country. Providing social justice for all people, including in receiving good health services, is the state's obligation as mandated in the Preamble to the 1945 Constitution. At this time, these specialist-medical services can only be enjoyed by urban residents, while the services funding is contributed by all citizens, including those living in remote villages in the form of their participation in BPJS national-healthcare security program.

Education system reform

Specialist Doctor Education Program (PPDS) is the only legally institutionalized recruitment mechanism to produce specialist doctors with competency standards required by professional organizations and the government. The educational standards and competence of specialist doctors are ratified by KKI as a government institution.

Producing specialist doctors in large numbers is the government's responsibility in the social justice framework to fulfil the citizens’ rights to specialist-healthcare services. Ironically, many basic problems related to specialist doctor-education programs and systems in Indonesia have not been sufficiently addressed. Among the problems is the very expensive cost for specialist or subspecialist education.

It seems there is hardly a country in the world other than Indonesia where doctors have to pay so much in pursuing their medical-specialist education. In Malaysia, Thailand, Australia and almost all other countries, the participants in the specialist doctor-education program referred to as "residents" deservedly get a decent and sufficient salary because they, in fact, are doctors who already have the competence and "work" to provide services, in addition to receiving guidance and supervision of their seniors as consultants.

It is time to reform the specialist-education system in order to give more citizens more opportunities to receive specialization education in various medical fields. The government should set aside sufficient funds to finance the education of specialist doctors as an investment in human resources for the sake of the nation’s future.

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There are several reasons why reform of the specialization-education system should be carried out immediately. First, the specialization education is expensive, with the tuition fee to be paid ranging between Rp 15 million and Rp 30 million per semester or Rp 150 million to Rp 300 million for four-to-five-year education. Indeed, it is not as costly as academic education to attain a medical bachelor degree, which requires Rp 388 million to Rp 688 million.

These undergraduate-medical students enter university as fresh graduates of senior high school. They are not yet married and still dependent on their parents. However, the PPDS students or apprenticeship residents are 28-35 years old, having medical competence as general practitioners. They generally have just started their family life.

Their peers, who engage in other professions, such as business and technology, are mostly already pursuing careers with sufficient income to support a household. This PPDS program runs full time, meaning that it is not possible for students to spare time to work as general practitioners.

Being already married, PPDS students have the responsibility to sustain their families with financial needs. It requires a minimum financial support ranging from Rp 500 million to Rp 1 billion for a PPDS student to complete the educational program while supporting a family. Without strong financial ground, it is not possible to enter or stay in a specialization course.

There are several reasons why reform of the specialization-education system should be carried out immediately.

Most of them receive financial support from their families (parents/in-laws). The opportunity to complete a PPDS program is closed to those who do not have financial support despite their academic eligibility.

Moreover, the PPDS program is a professional-education program based entirely on apprenticeship under the supervision of specialist doctors as mentors (clinical educators). While their status as students obliges them to pay tuition fees, they become voluntary workers who are not entitled to wages because their occupational status is not as hospital employees.

These PPDS residents assume prominent roles in serving inpatient treatment at the hospital of their apprenticeship base. The residing doctors treat and evaluate the progress of patients around-the-clock for the whole week, with an apprentice status placing them as the serving arms of the supervising-specialist doctors occupationally in charge of hospital patients.

The status as students of the “internship program” places these PPDS residents as the most vulnerable working group to labor exploitation under cover of education. Such a situation was rife in the United States some 70 years ago, but now a specialist-education student gets an incentive of US$5,000 per month, $1,000 in Brazil and South Africa and $500-700 in India and the Philippines (@pandemictalks, 9/8/2020).

Why can this not be implemented in Indonesia? Residents being entitled to incentives is stipulated in Law No. 20/2013 on medical education, but it has been hardly realized.

On the one hand, we need to accelerate the impact of specialist doctors, who will be willing to be placed anywhere across the country in order to fulfill the people's rights to social justice in the form of specialist-medical services. On the other hand, the specialist-doctor education is held back by problems of affordability in the households, while the government turns its back on funding aid. This situation has contributed to the uneven distribution of specialist doctors. They opt to operate around big cities, leaving remote and outermost-rural areas struggling in dire need.

The Medical Education Law, which is currently under process of revision, stipulates in Article 8-1 that only medical-education institutions with A accreditation are allowed to hold PPDS program. Out of 95 medical schools, there are 17 state universities that have PPDS programs, with a total of 13,355 students (MKKI, 2020).

As the only legal mechanism for the recruitment of specialist doctors, PPDS is a professional-education program jointly administered by three institutions, namely university (medical school) as the organizer of medical-academic study, hospital as educational facilitator and professional organization (medical education law, paragraph 11, articles 1 and 2). The professional organization represented by the collegium in the field of science regulates the requirements for opening-study programs and student academic eligibility, draws up educational curriculum and determines the standard competence of PPDS graduates.

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Article 31 of the law explicitly states the rights of PPDS students, such as the right to legal protection in the teaching and learning process, sufficient rest time between work and incentives entitlement and other facilities from the apprenticeship-facilitating hospital.

In practice, regarding incentives for PPDS students, it is more easily said than done. Some apprenticeship-facilitating hospitals have interpreted that the provision of incentives does not have to be in the form of money, but hospital facilities, such as duty rooms/rest rooms, and catered food during working hours.

All stakeholders -- the Education, Culture, Research and Technology Ministry as the patron of the PPDS program, the Health Ministry as the administrator of apprenticeship hospitals and the Indonesian Doctors Association (IDI) as the professional organization, must sit together and push those at the House of Representatives (DPR) to draw the implementing statutory regarding the rights of PPDS students to incentives as stated in Article 31 of Law No. 20/2013, which is currently undergoing revision.

It is time for the medical-education system, especially specialist doctors, to be reformed in this country.

The sum of financial incentives may not be the same as the salary that specialist residents receive, as it applies globally in the world. However, it will help improve the fate of specialist residents in this country. Otherwise, the besetting condition would be an "anomaly" taken for granted in Indonesia’s medical education.

In the consumption sector, among the known forms of direct subsidies are fuel and electricity for various levels of society. It is time to provide financial subsidies apportioned from the state budget for specialist-doctor education as an investment in future human resources. The end result will be none other than the realization of one of the main goals of the founding of this country, which is social justice for all Indonesian people, especially related to specialist-healthcare services.

It is time for the medical-education system, especially specialist doctors, to be reformed in this country. It has been far too long that this protracted situation has been taken for granted. The exploitation of specialist residents in the name of education must stop if we are to be on par with other countries in the world. Without reform, we do not deserve entry to compete in this era of globalization.

KOMPAS/DEONISIA ARLINTA

Zainal Muttaqin

Zainal Muttaqin, Medicine School, Diponegoro University, Neurosurgery Department, Dr Kariadi Hospital, Semarang, Central Java

This article was translated by Musthofid.