Problems Related to the Indonesian Medical Authority
The IDI’s development into a large organization should make Indonesian doctors proud. Accusing this large organization of being vulnerable to conflict is an unfounded accusation.
Laksono Trisnantoro's article titled "Pendulum of Indonesian Medical Authority" (Kompas, 14/4/2023) describes at least three things.
First, he describes how after the Medical Practice Law (UU) was passed in 2004, the government did not have strong authority in regulating the world of medicine.
Second, thart the Indonesian Medical Association (IDI) is considered to have great authority in medicine, from upstream to downstream. This authority has created many problems.
Third, that the IDI has developed into a large organization with a complex structure, whose authority is greater than that of the government. The IDI also has large funds without a monitoring system. Because of this, the IDI is prone to conflict and irregularities.
Strong authority
Each law is made with careful consideration and takes into account various relevant aspects. This was the case too with the Medical Practice Law No. 29 of 2004 that was enforced by then president Megawati Soekarnoputri. In this law there are six major pillars that are regulated: the Indonesian Medical Council (KKI), professional education standards, education and training, registration, administration of medical practice and medical discipline.
If you examine these six pillars, Laksono's narrative that the government does not have strong authority after the implementation of the Medical Practice Law becomes unfounded. This is because the six pillars emphasize the vital role of the government.
In the pillar related to the KKI, Article 14 states, KKI membership is determined by the president on the recommendation of the minister. The appointment is regulated by presidential regulations. Article 23 also stipulates that the implementation of KKI’s tasks is carried out in accordance with statutory regulations. It means that the government's authority over KKI membership and processes to obtain it is very strong.
Regarding professional education standards, educational standards are prepared by associations of medical education institutions and collegiums and ratified by the KKI.
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In preparing these standards, medical education institutions or collegiums need to coordinate with other stakeholders, such as professional organizations, hospital association, the Education, Culture, Research and Technology Ministry and the Health Ministry. So, the preparation of these standards is carried out by multiple professions, with the dominant involvement being government institutions.
In the education and training pillar, every doctor must attend continuing education organized by professional organizations or other accredited institutions. So, it is not only dominated by professional organizations.
Regarding registration, Article 29 states that the KKI, which is an arm of the government, has the authority to issue registration certificates. For practicing medicine, a doctor's license to practice (SIP) is issued by the authorized health official in the regency or city where the doctor will practice, namely the health office (Article 37). SIP provisions are further regulated by ministerial regulations.
These pillars clearly show the government's strong and dominant role; that is, the assertion that the government's authority is weakening would be inaccurate.
Is IDI a superpower"?
In the article last week, the IDI was considered to have more comprehensive authority than the government on the grounds that this organization has authority from upstream (education, through collegiums) to downstream (SIP recommendations and becoming a member of KKI). The narrative "from upstream to downstream" describes as if this professional organization has authority in every process. This term is redundant, let alone mentioning that their authority exceeds that of the government.
Medical education and practice in Indonesia is a complex system, involving many stakeholders. Each stakeholder has a relevant role. Undergraduate medical education, for example, is managed by the Education and Culture Ministry, institutional associations, medical faculties, hospital associations and teaching hospitals. The competency test for medical students is overseen by the Education and Culture Ministry, the Committee for Student Competency Test for the Doctor Profession Program (UKMPD) and the medical faculty.
The internship process is overseen by the Health Ministry, the Indonesian Physician Internship Program (PIDI), and the health office. Specialist education is the realm of the Education and Culture Ministry, medical faculties and collegiums. An internship registration certificate and a registration certificate are issued by the KKI. The SIP is issued by the health department.
In this complex system, the IDI's involvement is only in two elements, namely when the competency certificate is issued by the collegium and when the letter of recommendation is issued before the health office issues the SIP.
The IDI professional organization is not involved practically or tactically in the collegium's work processes and decision making.
So, it is much exaggerated to say that professional organizations have a role from upstream to downstream or is more influential than the education ministry, the Health Ministry, the health office, and other institutions, in medical education and practice.
The IDI's involvement in the two elements is justified. The collegium is a body that manages a branch of medical science. For example, the College of Surgery manages the branch of Surgery. Article 1 point 13 of the law on medical practice stipulates that professional organizations form collegiums that are tasked with supporting branches of medical science.
Although the collegium is formed by a professional organization, structurally, the collegium is an autonomous body, which works independently and is responsible for the congress of the association.
Within the IDI organization, there are four bodies that work autonomously, including the collegium, which is part of the Indonesian Medical Collegium Council (MKKI). In their duties and authorities, the MKKI and other autonomous bodies are not interfered with by the IDI. The IDI professional organization is not involved practically or tactically in the collegium's work processes and decision making.
In several countries, collegiums as academics are formed earlier than professional organizations. Therefore, collegiums are separate from professional organizations. In Indonesia, the IDI professional organization was born in 1950. The first collegium (collegium of surgery) was formed in 1955, followed by the collegium of pediatrics in 1966. So, it is only natural that the professional organization is also a large collegium house.
The IDI is mandated by law to issue recommendation letters for doctors who will practice. This recommendation is taken into consideration for the health office to issue an SIP. The mandate of this letter of recommendation also belongs to other professional organizations, such as the Indonesian National Nurses Association and the Indonesian Midwives Association.
Recommendation letters provide information about the administrative status of credentials and ethics from doctors and health workers who will practice. The goal is that doctors or health workers who will practice do not become entangled in issues of credentialing and ethical administration.
Recommendation letters are documents that are often required to apply for a job or to continue education. In other countries, the issuance of letters of recommendation, whether from superiors, supervisors or colleagues, is a common practice for doctors who want to work or to continue their education. So, there's nothing strange about recommendation letters.
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Professional organizations are appointed as recommendation providers because professional organizations are indeed the most relevant institutions in screening the credentials and ethical aspects of their members. In addition, because the name is a recommendation, there are no absolutes. The health office can issue a SIP even without a letter of recommendation.
Regarding the representation of professional organizations in the KKI, this is also regulated in the law. Two out of 17 KKI members (12 percent) must represent medical professional organizations. The rest come from other elements, including the Health Ministry (two people), the education and culture ministry (two people) and community leaders (three people).
The two representations of professional organizations are a reflection of the representation of 200,000 doctors in this country.
Their presence at the KKI allows the doctor's perspective to be represented/taken into account in decision making.
For example, medical professional organizations can provide input on the ethical standards and quality of health care needed to protect patients’ interests and ensure safe and effective medical practice. Of course, the presence of representatives from professional organizations does not dominate the KKI because decisions are taken collegially, where the proportion of organizational representation is only around 12 percent.
Moreover, the function of the KKI is not limited to being a regulator. Another function is fostering the implementation of ethics as determined by professional organizations.
This function cannot be taken and carried out by elements or groups of other professions. This means that the existence of representation of professional organizations is to respond to specific tasks at the KKI. Nothing is wrong.
Excess of authority
The IDI’s development into a large organization should make Indonesian doctors proud. Accusing this large organization of being vulnerable to conflict and irregularities due to large funding and the lack of a supervisory system is an unfounded accusation.
As the only medical professional organization recognized by the government, which has so far contributed significantly to health services, the IDI should have received funding from the government. Unfortunately, until now, the IDI has not received any allocation of funds or financing from the government.
The IDI also does not carry out profit-taking cooperation with other industries and institutions. It also has not become part of a political organization or a mass organization that allows obtaining disbursement of funds or incentives.
The IDI’s development into a large organization should make Indonesian doctors proud.
The organization's regular source of funds comes from the original membership fee of Rp 15,000 (US$1.01) per month, which was increased several years ago to Rp 30,000 per month. The largest portion of this fee goes to IDI branches (80 percent) and IDI regions (15 percent) to run the organization and activities. The remaining 5 percent goes to the central IDI.
With the number of active doctors, ranging from 150,000-200,000, the annual contribution rate is not large for a single professional organization. Compare that to a nurse's organization whose annual contributions are Rp 200,000 and the number of members exceeds 1 million. Because of this, nurse organizations can develop various businesses, including the establishment of nursing schools.
Based on this data, Laksono's statement regarding the amount of IDI funds is surprising. It is even more surprising that he claims it is an unaudited fund. IDI funds are regularly audited by external parties. The audit results are also internally conveyed to all members openly in branch or regional meetings or at congresses.
There was nothing wrong when Laksono expressed his views regarding IDI. However, in order for the context and content of the views to be objective and not partial, these views should be supported by valid and objective evidence; and not based solely on prejudice or inadequate evidence. This is important so that his views do not stutter in narration, but stutter in substance.
Iqbal Mochtar
Iqbal Mochtar, executive of the Indonesian Medical Association (IDI), the Indonesian Public Health Association (AKMI) and chairman of the Association of Indonesian Doctors in Middle East .
This article was translated by Hendarsyah Tarmizi
