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