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

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

Health service coverage and workers density Joint Learning Initiatives, 2004

Higher income more health workers Joint Learning Initiatives, 2004

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

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?

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

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).

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.

Availability WHO, 2013

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

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

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

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

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

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

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

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

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

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.

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

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.

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.

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

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

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

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

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

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.

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