The availability of health care professionals in Indonesia Health care professional migration The right to health

1. The availability of health care
professionals in Indonesia, its
migration and the right to
health
Ahmad Fuady
Faculty of Medicine Universitas Indonesia
Indonesia

2. Introduction
• The right to health = the right to be healthy?
• An obligation to the State to secure progressively health care
access and any underlying determinants of health.
• Right to the highest attainable standard of health. Four
interrelated elements:
– Availability
– Accessibility
– Acceptability
– Quality

3. Health service coverage
and workers density
Joint Learning Initiatives, 2004

4. Higher income – more health workers
Joint Learning Initiatives, 2004

5. • Availability of health care
professionals  one of
fundamental elements to
provide the highest attainable
standard of health.
• Shortage of health care
professionals  health care
professionals migration
(import).
• Health care professional
migration (export)  lacking
of health care professionals.
Stocks and flows
Joint Learning Initiatives, 2004

6. • How is the availability of health care professionals in Indonesia?
• Would health care professional migration improve the fulfillment of
the right to the highest attainable standard of health?

7. Theoretical framework
• Health is a fundamental human right.
• Article 12.1 of the International Covenant on Economic, Social
and Cultural Rights: the rights to the enjoyment of the highest
attainable standard of health.
• International and local legal instruments.
Four interrelated and essential
elements:
1.Availability
2.Accessibility
a. Non discrimination
b. Physical accessibility
c. Economic accessibility
d. Information accessibility
3.Acceptability
4.Quality
The glue of health system

8. Method
• Literature review of studies with time framework of 1998 to 2013.
• Sources :
– Indonesian databases.
– Scientific databases (Google Scholar, PubMed, and
WebScience).
– International databases WHO, World Bank and the Joint
Learning Network (JLN) for Universal Health Coverage.
– local and/or international case law.
• Analysis using guideline assessment of four important elements,
adapted from Hunt (2006).

9. Availability
Availability of (functioning) health care facilities.
• Increasing number of facilities, but remains insufficient.
• Puskesmas with inpatient service has grown mainly in the urban
area while the remainings have shown a significant growth in the
rural area. Puskesmas ‘without doctors’.
Pustu  poor
quality of care, do
not operate
regularly, and lack
of drugs and
diagnostic kits.

10. Availability
WHO, 2013

11. Availability
Availability of trained health care professionals and their salaries.
• Problem of data validity and reliability
• Lack of health care professionals, unequal distribution
• Problem of deployment policy and unclear decentralization policy
• Without domestically competitive salary

12. Availability of general physicians
• National: 13.8 GPs
per 100,000
population
• The ratios within eight
provinces are lower
than national rate.
Indonesian Health Profile, 2011

13. Availability of specialists
• National: 7.13 specialists
per 100,000 population
• The ratios within only
nine provinces are
higher than national rate.
Indonesian Health Profile, 2011

14. Doctor production
• Recently, there are 73
medical schools in
Indonesia
– 53 have graduated
GPs, 20 have not
graduated yet (2013)
– 18 with very good level
(Accreditation A), 21
with Accreditation B,
and 34 with
Accreditation C
– 31 public owned, 42
private owned
1 med school
9
1
2
2
Fig. Ratio of GPs and available med schools
5
4
2
2
2
Indonesian Medical Council, 2013

15. Availability of dentists
• National: 4.3 dentists per 100,000 population
• The ratios within almost half of all provinces are higher than
national rate.
Indonesian Health Profile, 2011

16. Availability of nurses
• National: 93.43 nurses per 100,000 population
• The ratios within seven provinces are lower than national rate.
Indonesian Health Profile, 2011

17. Availability of midwives
• National: 52.55 midwives per 100,000 population
• The ratios within nine provinces are lower than national rate.
Indonesian Health Profile, 2011

18. Accessibility
• Physical constraints to facilities along with financial constraints
because of transportation cost  poor utilization of those existing
public health facilities despite the free access.
• Access gap between rich and poor has remained high.
• Problems:
– Subsidy distribution is more pro-rich rather than pro-poor
– Leakage
– Considerable illegal fees, buying the card
– Illegal up-front payments

19. Acceptability
• …have to be respectful of medical ethics including the
requirement of informed consent and confidentiality of personal
health information, as well as culturally appropriate.
• Ethical violation increases. From 182 reported cases, MKDKI has
decided that 29 (15.9%) doctors have been proven guilty, and
their licenses have been revoked.
• Legal case  unclear informed consent and incomplete
information.
• Foreign doctor  Different culture
• How to deliver medical services with a high respect to local
culture for acceptable service?
• (Cross) Cultural competence

20. Quality
• Health providers in outer Java-Bali have worse quality than those
practicing in Java-Bali because of limited facilities.
• Private-solo practices worsen the quality of public health care
service in a rural area.
The quality in terms
of structural
indicators
has improved.

21. Health care professional migration?
Motivation to migrate:
• Personal values
• Professional ethics
• High rate of remuneration
• The good work environment
• The support of the health system

22. Patient migration
• Malaysia: among 150,000 patients admissions originated from
ASEAN countries, 65-70% are from Indonesia. Favored
destinations are Penang, Malacca, and Johor Baru.
• Singapore: 52% of foreign medical tourist are from Indonesia,
roughly 12,000 people annually.
Doctor migration to Indonesia?
• Good market for foreign doctor to practice.
• Concentrated in big cities; good remuneration, good facilities,
wide access, high level of income
• Specialists are more likely to migrate than GPs
• Foreign medical students in Indonesia
Rad et al, 2010; UNESCAP, 2007; Ormond, 2011;Connell and Burgess,2006; Khalik, 2006.

23. • Is the migration inclines the achievement of the right to health?
• The migration does not necessarily enhance the achievement of
rights to the highest standard of health.
• Some policies are required to improve the process.

24. What should we do?
The goal for every community is access to
a motivated and competent health worker,
backed by sustainable national health systems.
Joint Learning Initiatives, 2004

25. Recommendation
Increasing availability
• Improving health care professional database. The MoH, KKI, and
IMA have to develop a better method in registering and reviewing
the health care professional.
• Maldistribution  Mandatory placement for fresh graduated
doctors in rural and remote area, but high turn over rate.
• Incentives?
Sending health care professionals in teams, better payment
• Setting national design and dividing the clear authorities between
central and local government
– To recruit health care professionals, civil workers
– To improve number and quality of health care facilities

26. Recommendation
• Doctor migration?
– Temporary licensing
– Directed to public health care facilities
– Directed to rural and remote area

27. Recommendation
Widening accessibility
• Improving supporting infrastructure; access
• Preventing the leakages
• Eliminating illegal upfront payment and rejection.

28. Recommendation
Making it more acceptable
• Regarding to respect of medical ethics, the MKDKI and the IMA
should develop preventive measures instead of merely
accommodate people’s complaints of medical services.
• Developing (cross) culture competence

29. Recommendation
Improving quality
• Licensing and periodical review.
– National examination for physicians, nurses and midwifes.
– Limiting the recruitment for new civil workers to those who
have been certified and reviewed periodically.
• Moratorium of new development of health and medical schools
– If required, new medical school should be only developed in
province with low ratio of doctors per population.
• Limiting enrolment for those poor-accredited schools or programs.
• Establishing competency and education standards.

30. Thank You