Health System Performance At District Level In Indonesia: Challenges And Recommendations

Critical challenges in Indonesian healthcare system

Discuss about the Health System Performance at District Level.

The skills, motivation, knowledge and deployment are the factors that define the ability of a country in meeting their health goals. The number of health workers is directly linked to the population health outcomes as outlined in literature. There is also need for formulation of healthcare workforce plans and formulations for meeting the objectives of health development with sound evidence and information. “World Health Statistics Report, 2015” by WHO has segmented the low and lower middle income countries and while analyzing the report, Indonesia face major concerns in terms of shortage of healthcare professionals with uneven distribution in various healthcare settings and management of health workforce in a decentralized healthcare system (Fulton et al., 2011). The rationale for choosing this country is that Indonesia is lacking these building blocks especially in terms of good health facing a critical shortage of healthcare professionals. Indonesia is facing challenges related to human health resources like inequitable health workers distribution, shortage of skilled staffs, absenteeism and lack of motivation. There is also poor supervision lack of support and unsatisfactory working environments in Indonesia. There is need for advocating the human resource issues and situational analysis on the national agenda. Therefore, the following report analyzes the health workforce profile and critical issues witnessed in Indonesia along with recommendations on the shortage and migration of healthcare professionals using WHO framework.

Indonesia faces critical challenges in terms of human resources for health (HRH) that is related to planning and development of HRH (Human Resource for Health) policy with mismatches between production, demand and supply, mal-distribution and remuneration in rural, urban and remote areas. The decentralization of health system in Indonesia is the main reason that the country is facing challenges in terms of healthcare system. The law was enacted in 2001 on local autonomy and that marked the beginning of decentralization, however, its implementation was different at each level of government (Pepinsky & Wihardja, 2011). The transferring of autonomy gave districts more independence in terms of regulation and management of affairs in the health sector. The line of coordination was ignored at the upper level that did not function as command line. Although, the central line wanted to control the main line, however, the HRH situation deteriorated due to decentralization.

As per the 2010 census, Indonesia ranked last among the ten populous countries with respect to physicians density per 1000 population compared to Russia, United States and China ranking first, second and fourth respectively. Similarly, Indonesia ranked fifth in nurse and midwives density (2.04/1000) with United States, Russia, Brazil and Japan occupying the first four positions (Rokx, 2010). During the years 2000-2012, the number of nurses, midwives and physicians increased substantially, however, it was not significant. The increase in health workforce was not enough to meet the needs of the population in terms of health. Moreover, hospital beds per 1000 population were quite low as per 2010 census on the global scale (Hoyler et al., 2014).

Health workforce data profile

Decentralization in Indonesia has given the local governments to take up the direct authority of prioritizing healthcare sectors for development. HRH planning is now in the hands of regional governments that resulted in diverse funding and no attention was given to these challenges in the regions. Critical shortage of HRH due to inadequate resources and understaffing is making Indonesia suffer at every level of healthcare system (Heywood & Choi, 2010). There is acute shortage of health workers in low and middle-income countries and this scenario is witnessed in Indonesia. There is understaffing of healthcare professionals that has led to their inequitable distribution that can be witnessed from the range 10.36 to 53.89 per 100,000 populations as per Indonesia Heath profile, 2008 (Meliala, Hort & Trisnantoro, 2013). Moreover, HRH also face challenges in terms of planning, recruitment and healthcare workers retention in the face of challenging HRH from Indonesia’s neighbouring countries. The quality of care also deteriorated during these years that are related to lack of effective licensing and oversight in HRH. Majority of healthcare professionals in the public sector have opted for second jobs due to lack of adequate wages in this sector.

There are also deficient information in HRH policy development that is hampering planning and development efforts of policy makers. The average number of HRH in Indonesia per 1000 population is quite below the threshold level that is important to achieve the UHC and health-related MDGs. The Indonesian policy emphasizes on production, recruitment and retention of human resources in various cadres. However, there is less number of healthcare professionals with poor quality of quality services and unequal distribution in rural and remote regions as there is lack of deployment policy in terms of non-financial and financial incentives for the healthcare providers (Efendi, 2012).

These HRH critical shortages impede the progress of Indonesia that can envisage for health system strengthening so that there is equitable access to lifesaving and essential primary healthcare services. Furthermore, this shortage poses obstacles for health-related attainment of Millennium Development Goals (MDGs) and Universal Health Coverage (UHC). Most of the health workforce in Indonesia is concentrated in Java Island that left rural and remote areas underserved (Utomo, Sucahya & Utami, 2011). This is the reason that there is an urgency to develop a national health workforce for Indonesia curbing the HRH program faced by the country.

Although, there are no appropriate norms to calculate the optimum ratio of healthcare workers, however, WHO has identified the threshold doctors density of 2.28 per 1,000 population with nurses and midwives ranging from 2.02 to 2.54 (Short, 2016). Indonesia falls under this threshold and there is lack of 80% coverage of skilled attendance at the time of delivery, measles immunization and reduction of infant and maternal, mortality rate for meeting the goals of health-related MDGs (Grewal, 2016). There is unequal distribution of doctors in Indonesia where there is one doctor for every 3,000 people in urban areas and one doctor for 22,000 people in rural areas as reported by World Bank found in Java-Bali, the most populous Indonesian region (Boyle & Plummer, 2017). According to World Bank 2009, there is only 1 doctor for every 12,000 rural people and one doctor for every 15,000 people residing in remote areas and one doctor per 2,430 people in urban areas (Anderson et al., 2014). The situation is worse outside Bali where nurses are less because of voluntary registration. The people in remote and rural areas rely heavily on health services provided by nurses and were found to be critically short in the underserved areas.

Distribution of Indonesian health workforce

While looking into the health workforce trends in Indonesia as per 2010 data, there is an absolute increment in the number of pharmacy practitioners, nurses, midwives, dental practitioners, medical technologists and public health practitioners. 2010 figures show that there is a major decline in the number from 34,554 to 33, 7336 during the year 2009 to 2010 and during this period, the number of nurses and midwives increased from 194.399 to 266,348 (Anderson et al., 2014).

Considering the distribution of Indonesian health workforce over the region, recruitment was done using the formation of medical doctors, nurses, midwives and civil servants. During the year 2010, there was a significant increase in the number of health providers from 328,044 to 498,590 from 2009 to 2010 with 52% (Anderson et al., 2014). However, despite the increase, there was significant decrease in the supporting staff over these years. Nurse shortages in the rural and remote areas were due to international migration across the country where they are moving from rural to urban areas. The recent data on health workforce showed that international migration remains an issue where they move to urban lands in order to sought employment due to high unemployment in labour market migrating to countries like Japan. Indonesia has become a potential market for migration of international nurses where thousands of them are moving to neighbouring countries for better opportunities.

Figure: Indonesian health workforce (Anderson et al., 2014)

The above statistics illustrates that there is limited workforce management, low production with adequate number of healthcare providers being prevalent in Indonesia. These figures suggests that there is inadequate motivation and retention mechanisms by HRH due to geographical imbalances, inadequate skill mix and mismatches between education and training services results in limited nursing students enrolment, limited medical schools and critical medical educator shortages. Therefore, HRH needs to employ strategies that ensure responsive and competent division of labour with optimum output. Moreover, they should also implement HRH plans that ensure adequate supply of labour with proper balance between production, demand and supply in order to improve distribution and performance of the existing health workforce in Indonesia.

The health workforce plan in Indonesia is aimed challenging the decentralization as it has hindered human resources development in the health workforce. There is improvement needed for dividing tasks and for the sound functioning between central and local government. This health workforce plan is aimed at improving the HRH condition, rural services through community approach that focuses on offering quality healthcare services and extension of healthcare workers to outreach to the rural and remote areas. This HRH plan would be beneficial in scaling up healthcare providers in offering clinical services to the regional and zonal levels. Most importantly, this plan is aimed at increasing the health workforce as the current statistics shows that there is a rising demand for them in the health services. Concisely, this plan aims to improve the healthcare staffs including, physicians, nurses, midwives and other medical officials. Therefore, the following recommendations would be helpful in curbing the problem of international migration entailing a road map for the avenues in a way where the Indonesian health workforce can address the problems.

Recommendations for strengthening the health workforce in Indonesia

Indonesia is at risk for international migration especially to Japan and they need to do more in prioritizing investments in education and training. Education models need to shift away from specializations and move towards building of lifelong relevant competencies at the local level. Geographical inequalities need to be addressed and provide opportunities for strengthening youth education for successful employment in the health sector. For this, the government needs to scale up high quality, transformative and lifelong learning for skilled workers who match the needs of the population and work to their best potential (Kurniati et al., 2015).

There is an urgency to develop the current Indonesian labor market for fostering the demand for a sustainable and population-centered health workforce. There is need for government policies that address the issues in labor market. The right mix of skills is required for fulfilling the health needs of the population. The government should stimulate investments for the creation of decent jobs in the health sector especially for women and youth with right skills at right places in right numbers.

The health sector is a growing platform for women employment and gender equality. In the healthcare sector, women are the main care providers including conflict settings and humanitarian crises. However, there are prevailing gender biases in this sector that remains a big challenge that need to be addressed. To curb the problem of gender inequality, there should be maximization of women participation in the economy and fostering empowerment. This can be achieved through leadership that addressed education inequalities, gender biases in the health labor market, and tackle concerns regarding gender in the reform processes. 

The rapidly changing phase of technology is already changing the nature of healthcare services. Information and communication technology (ICT) is changing and there is emergence of new cadres of healthcare providers. In such cases, digital technologies can offer opportunities for enhancing the access to healthcare services and in improving the responsiveness of system towards health needs of the communities and populations. The delivery of healthcare can be improved and therefore, there should be harnessing of cost-effective ICT that enhances health education, offer client-centered care and health-related information systems (Agarwal et al., 2015).

The healthcare systems are organized around hospitals and clinical specialties and therefore, there is a need for shifting towards primary care and prevention. There is lack of perfect mix of private and public healthcare professionals and so, the government should adopt healthcare policies that cover overall performance of the health sector. For serving the underserved, social business, models in private sector can be socially oriented solution where regulatory bodies and public policies should protect the public interests ensuring that there is no domination from professional interests (Carruth & Valle, 2013). Therefore, service models need to be reformed that concentrates on hospital care and focus on prevention with efficient-provision of affordable, high-quality, community-based, integrated and patient-centered ambulatory and primary care especially offering services to the underserved and remote areas.

The recruitment and selection of healthcare personnel should be fair and conducted in each central units and local government levels coordinated and selected by a single body. The deployment and distribution mechanisms should be based on available staff and recruitment plans. Unequal distribution and placement of health personnel can be tackled through contractual employee and civil servant scheme. To attract interest for health providers towards working in underserved and remote areas, financial incentives through national budget can be helpful and encouraging local governments to pay for additional incentives. The shortening of service period with scholarship for higher education and workplace safety can also attract more health workers. Foreign investment in health sector can help to increase the private health workers in the future. Development of HRH plans and policies is an important task that comprises of main functions like HR policy and strategy, HR planning and distribution, coordination of in-service and pre-service training with proper evaluation and training that can produce equitable distribution of medical staffs, HR personnel and service quality improvement (World Health Organization, 2016).

There is a need to have a sustainable health financing to assume continuous growth in public revenue and necessary prioritization in the health workforce. Political commitment and societal dialogue are the critical factors that drive health finance policies and macroeconomic reforms. However, there is insufficient market demand to create jobs and in fulfilling the Sustainable Developmental Goals (SDG) in fragile and middle-income countries like Indonesia. Collective action is demanded on financing by raising adequate funds from national and international sources, appropriate privatization and health financing. Health financing reforms can be undertaken through investment in right skills, proper working conditions and having an appropriate number of healthcare professionals.

In Indonesia, there is an urgency to achieve fit-for-purpose healthcare workforce across all health sectors in the labor market. Inter-sectoral collaboration promotion at regional, national and international levels can help in supporting effective partnership in health sector. There is also requirement of aligning with international bodies that can be helpful in supporting health workforce investments as a part of educational strategies and national health plans. The processes must engage private and public sectors, trade unions, civil society, workers associations and non-governmental organizations, training organizations and regulatory bodies (World Health Organization, 2014).

Analysis of data through institutional capacity is much need for health labor market. The strengthening of health workforce depends on the active engagement of health workers, communities, training institutions, employers and regulatory bodies. Organizations like WHO and OECD play a key role in the establishment of harmonized metrics for monitoring trends in the Indonesian health labor market.

Every country should have health system and workforce that has the capacity to identify and respond to the health risks prevailing in the population and emergencies. Public health crisis in conflict and fragile settings can exacerbate existing shortcomings of the countries for providing health care to their populations. To achieve this, ensure investment in places with right mix of skills including domestic and international workers in humanitarian aid and emergencies. The country should also ensure security and protection of all health workers in all settings.

Conclusion

Health workforce is one of the important pillars and interacting blocks in the healthcare system that has an impact on the strengthening of the systems. However, many countries face lack of human resources that is required to fulfill the healthcare needs and deliver healthcare interventions due to shortage of healthcare professionals, migration, and poor mix of skills, limited capacity and demographic imbalances. The current health personnel shortages in service delivery greatly affect the quality of care including diagnosis and treatment provided to the people of the country. In low-middle income country like Indonesia, health workforce is experiencing critical staff shortages with imbalances in production, demand and supply especially in underserved and remote areas.  Quality of healthcare is also deteriorated that depend on the policies where the healthcare providers are capable of delivering care as per the demand. There are loopholes in the HRH strategies and its implementation in terms of planning recruitment and selection that is resulting in international migration experiencing shortage of nurses and midwives in the underserved and remote areas. As a result, there is urgency for a health workforce plan that ensures to fulfill the challenges in Indonesian health sector. Therefore, the above report mentioned recommendations that are aimed at curbing the critical shortage and addressing health workforce issues faced by the country.

The plan comprises of HRH development as one of the main priorities in Indonesian health workforce that includes planning, management, registration, training, certification and technical support.

The five-year plan can act as a catalytic support for Indonesia to report a well functioning HRH information system through stakeholders’ engagement. By implementing this strategy, the country can make a substantial move towards strengthening health workforce and foreign investment. Moreover, the country can mobilize additional resources for the HRH development.

Stakeholder analysis will be done for identifying constituencies with development of close links. The HR committee should have adequate representation and inclusive having defined roles and responsibilities.

HRH situational analysis includes pre and during service training and professional development, current utilization of existing healthcare workforce and determinants, health trends and analysis of retention strategies, responsiveness and migration trends with respect to population health needs.

HRH planning should be comprehensive, evidence-based and cost-effective that engages all stakeholders from every health sector aligning with the national strategy, aims and objectives that are measurable, achievable, realistic and time-bound.

Resource mobilization for HRH investments will happen in the fourth year that requires resource mobilization plan and advocates for additional resources from national budget and exploring funds from bilateral and multilateral partners.

Implementation, monitoring and evaluation of the HRH plan at the committee can be implemented through stakeholders’ collaboration employing in framework of indicators in a unified manner with dissemination of transparent and accurate information.

References

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