Covid-19: A Wake-up Call for Indonesia’s Medical Education System
For the past two years, the Covid-19 pandemic has highlighted the flaws in every country’s healthcare system with no exceptions. Indonesia was one of the top 10 countries with most new daily Covid-19 cases in 2020 and became the epicenter of Delta variant in Asia in 2021. Among all the challenges, lack of doctors is definitely one of the main issues that has gathered a lot of attention as the number of doctors’ mortality due to Covid-19 became the highest number of healthcare professional deaths in Asia. By July 2021, more than 500 doctor Covid-related deaths were recorded, and the number continues to grow as the fight against the pandemic shows no sign of stopping. The limited numbers of doctors have caused them to be overworked, physically exhausted, and mentally burned out, which has increased their risk to contract the virus and decreased their survival rate once infected. Even before the pandemic, Indonesia’s supply of doctors in 2018 was only 0.4 physicians for every 1,000 people, which is far below the 1 to 1,000 physicians to population ratio according to the WHO standard. Overlooking this issue was arguably the main contributor to the high number of physicians’ deaths and patients’ worse health outcomes, which lead to the increase in the Covid-19 general mortality rate in Indonesia.
Undersupply of doctors is a critical healthcare problem that persists to exist in Indonesia without any meaningful adjustment done so far. While the demand for doctors was rapidly growing in a population of more than 270 million people (4th in the world), Indonesia only has 31,073 specialists in 2019. There is also an unequal distribution of specialists across the country, especially in rural areas. For example, in the province of Papua with a population of 3.5 million people, there were only 32 internists and no neurosurgeons available in the area. Imagine living in those rural areas when a lifesaving procedure can only be done by a specialist who lives 4 hours of flight away- concerning is truly an understatement.
This scarcity issue needs to be addressed by assessing the current medical education system as the source of supply. There are two stages of the medical program, the first requires about six to seven years to become a general practitioner (GP), and the second requires about four to six years to become a specialist. The roles of specialist doctors are particularly crucial. They are not only experts on diseases, such as Covid-19 but also lecturers and trainers for the incoming GPs. Some areas might not even have enough specialists to teach in their medical schools, which resulted in poor quality of education for the GPs. Thus, having adequate specialist doctors is key to effectively generating more general doctors, which then would also improve the overall quality of Indonesia’s primary care.
Despite the total required time of education and training to be a specialist doctor is similar to other countries, having only a handful of universities that are permitted to conduct medical specialization programs is the main reason why the number of specialist doctors produced each year has not improved. The government allows medical specialization programs or Program Pendidikan Dokter Spesialis (PPDS) to be conducted exclusively by public medical schools. Up until now, there are only 15 public medical schools, 7 of which are concentrated in Java. The bureaucracy and layers of regulation that put limitations on medical schools to open specialization programs, specifically the private ones, have impeded the progression of growth in a number of specialist doctors. Even though quality control might be the logical reasoning behind the tight regulation around opening a specialization program, the existing policy absolutely does not make it feasible for having equal access to doctors in a country with 33 provinces and more than 17,000 of islands with very disparate resources and infrastructures.
On top of the limited number of medical schools offering PPDS, the admission process is infamously corrupted. The typical admission process for PPDS requires recommendations from senior doctors within the same specializations which often becomes a loophole for corruption. In 2019, the Indonesian anti-corruption commission (KPK) received a significant number of reports on bribery or “Uang pelicin” in the PPDS admission process at multiple universities. A corrupted admission process not only discourages qualified applicants but also lessens the quality of doctors who go into the field, which eventually put the risk on the general public seeking quality healthcare.
Healthcare is barely addressed in political debates, let alone the shortage of specialist doctors. In order for the country to have a fighting chance in the next pandemic and have a strong health system, starting the discussions on opening more medical specialization programs with a transparent and fair admission process in more areas across Indonesia is a necessary step to take in order to increase the number of doctors in Indonesia. Allowing contribution from the private sector in creating more medical specialization programs, especially in provinces outside of Java, could improve the number of specialist doctors produced in those areas and alleviate some of the burdens of medical workers in rural areas. Expanding the coverage of doctors’ licenses for practicing medicine and teaching can also be a good starting point for policy change.
The existing policies are certainly outdated and no longer fit the progression of Indonesia’s healthcare demand. Therefore, this pandemic should be a good enough reason to evaluate the current practices. Indonesia has to move towards more practical and data-informed health policies for a better and more sustainable healthcare system. More doctors are needed—the medical education system should support that.