Medical Doctors in Indonesia: Unknown Story about Struggling Healers
People tend to like some things unknown or clouded in secret. Many tries to find out about aliens, North Korea, ancient Egypt, or the mystery of Jack the Ripper. Of course, this article is nothing as spectacular as those examples, but it can be quite surprising for many people.
We know that doctors complaining about salary is something happening all over the world. But how badly can a doctor be treated? Sometimes, some part of the world is much worse than the rest.
Let's start by showing a picture of an actual salary of a general practitioner in Yogyakarta, Indonesia. The attached picture is the total amount of money received after 12 working shifts. Each shift is about 7-10 hours. Convert it into US $ or whatever currency you're familiar with. Rp 10,000.00 is slightly less than US $ 1.00. Surprised? It doesn't even reach 120 US $ for a total of 108 working hours. Of course daily necessities cost much less in Indonesia than in countries with higher average income. But even in Indonesia, the average monthly salary is about 3 million rupiahs.
Different from how it is in Europe and US, all doctors in Indonesia start their career as general practitioner. Doctors will only become a specialist if they have money for further education. So basically, general practice is not one of the specialism. It might be more fitting to consider it an "unspecialized state". This is an important issue to mention as this causes general care physician to become a lesser profession compared to specialist.
To become a doctor, someone needs to complete about 4 years of education and 1-2 years of clinical rotation. There is no pre-medical school or any preceding education. After legally acquiring the title of doctor, someone needs to do an internship for one year to get "document of registered physician", which is a necessity to process a practice license.
Here,the first problem awaits. Internship program is managed by government and institutions ready to accept these new doctors are limited. The limitation causes the new doctors at present days need to wait up to six months for internship. Note that during such period, any practice license is denied, that obtaining legal job is impossible. During such period, someone with doctor title is literally "not in employment, education, or training" purely caused by government errors. After waiting pointlessly for months and work as an intern for a year, someone can finally get his license.
After getting licensed, a GP is just like any other worker, left out in the wide world while needing to find a job. The shorter length of education also makes Indonesian general care physician to have less standard than physician in developed countries. It also implies that general care physician is cheaper human resource, as they are "just physician and not specialist".
There has never been a guarantee that a GP will definitely get a job. Some doctors I personally know are jobless for months. It doesn't mean that there are enough GP to give optimal care to the population. It's just that medical institutions are "getting used to" the high burden of it's physicians and do not intend to increase the amount of it's worker. For example, small district hospital called Puskesmas may need to handle a hundred patients a day with only one or two doctors. While hundreds of doctors applying as civil servants, which is a category of job including Puskesmas doctors, are rejected in every recruitment season. Many hospitals even choose not to open recruitment at all. Many newly graduated physician will give their CV to various hospitals despite the lack of job vacancy. The hospitals will keep the CVs to use later when one or more of it's doctor resigns. The waiting time can vary for 6 months to years, depending on when the hospital needs a replacement doctor.
As mentioned earlier in this article, payment for general care physician can be less than average income of Indonesian. For example, in Yogyakarta, where I live, it's perfectly natural for a clinic to pay about 15000 rupiahs per hour, or even less, for it's GPs. Hospitals pay more, around Rp20000 per hour. As the average income of Indonesian is 3 million rupiahs a months, a general practitioner may need to work 200 hours a month, just to reach the average. Some people go for the extreme and cases where a physician works for two to three days straight (6 to 9 shifts without a break, except for sleep and rest when no patient is present) is not a rarity. Of course, there are places that gives more salary, but those are quite a rarity.
There is an enforced rule in Indonesia that a physician can only work in at most three different places. It might not make much sense in other countries as a single work place should give enough to the physician. The reason this rule was enforced was that there were physicians working in 5 different institutions or more to get more salary. There were still some, despite the rule, and this implies that doctors in Indonesia has less hourly salary, but always has the chance to multiply his working hours to increase the earnings. Some doctors overwork to support his children's education or to save for further education, which is a terrifying quicksand that drowns money very quickly.
A Puskesmas doctor having a modest house is not a rare sight. It's kind of saddening to see that there are doctor's private practices with a worn-down sign and building while a massage service often have a more modern and clean building.
A general practitioner having more than twice average salary of Indonesian is quite rare. Usually, those that do are:
- Someone lucky enough to work in a very good institution
- Someone with successful side jobs, like selling clothes online (not a rarity although it's not the norm either) or managing a large clinic
- Someone who overworks in multiple places
- Someone in big cities where daily necessities are also twice as expensive
- Someone working in remote area with minimum facilities, where even water is hard to get. They are highly valued, but the payment can reach them several months late.
- Someone with illicit agreement with large pharmaceutical companies.
Chance for Further Education
As previously mentioned, every doctor has a chance to take up residency to become a specialist. However, it's an even thornier road. They need to save a large amount of money to prepare for the education. The reason why residency can be such a black hole for money will be mentioned later.
To get into the program, GPs need to compete with many others by taking the entrance exam. Around 5-20 GPs will be accepted per department in a university. The competition depends on the popularity of the department. Most-wanted department like Cardiology may accept only 15% of the applicants.
After getting accepted, those residents are simply considered a student. They need to pay for education fee, and gets no money for taking care of patients. Yes, those licensed doctors are now students, and their services are considered part of education.
The harshest part regarding money is that residency took most of their time and they aren't allowed to practice medicine for money, as it may distract them from the study. Note that those residents have families, no longer have a job, and need to work hard while paying for around five years. The reason I compare it to black hole is not because of the education fee, but because of the need to sustain themselves without income for years. If you read up to this part, I know some would stop reading thinking that it might just be a complete lie. But I assure you that it's all real.
There are exceptions for those who take up residency under orders from the institution they worked for. Those institutions may give them salary with an agreement that the doctor will work in the institution again after graduating as specialist. But most aren't that lucky.
Some GPs need to work hard for years to save a lot of money so that they can survive those years without income. While many others with ambition and parental support relies on their parent's money to become a specialist as fast as they can. Americans may call them "failure to launch". But many need to swallow their pride as it's pretty much the best way to be a specialist at young age.
Because of the hardship and competition for residency, many general practitioners choose not to become a specialist at all. Actually, most of them will never become a specialist.
Government Attention and Weird Insurance System
Despite being the one with the most information, the government is also the one that preserves the tradition. Most of what it does is to provide a good sparkly package to make the citizens believe that Indonesian Health System is fine. So far, government only allocates about 3% of national budget for health. The promise of increasing it to 5% is yet to be realized.
Tracing back to around 1-2 decades ago, the government launched an insurance system covering for poor individuals. The insurance is called Jamkesmas, and it has ridiculously low premium paid by the nation. The premium is about Rp 6000.00 per individual, which is less than 60 cents US dollar.
The reason this insurance is weird is because it decided the prices for all services. It was possible because it was created by the government, and it's practice was supported by law. It would cover a certain amount and decided how much is enough. As the premium was minimum, so was the amount given for medical services and necessary drugs. The participant is allowed to pay for extra services not included in jamkesmas, for example if they want better-branded drugs, but as long as they accepted the basic services as mentioned by jamkesmas, the patient is forbidden to pay a single cent, and the hospital directors needed to scratch their head to find idea to minimize expense so that they didn't go bankrupt.
Fast forward to now and here comes the age of Universal Health Care. As previously mentioned, our government has a hobby of designing sparkly package to show off. Despite the mess that was Jamkesmas, they want to be among the first that applies Universal Health Care. Borrowing the concept of Jamkesmas, they launch JKN, which is the current insurance system we have. They increase the premium to about Rp19,000.00 for poor individuals covered by the nation, to Rp60,000.00 for individuals who paid on their own.
However, they continue on with the proud slogan of "the insurance that decides the cost". Every single participant of JKN is forbidden to pay, unless they want to move to better room than what JKN standardized. What's worse than Jamkesmas is that JKN decides the cost per diagnosis for patients needing to stay in hospital. It didn't care how long the patient needed to stay, which differed it from Jamkesmas, which allowed claims based on service (although it decided the cost). There are some ridiculous costs like around 5 million rupiahs for fractured femur (from admittance until dismissal, plating, drugs, and surgery included) or around 10 million rupiahs for PCI for type C hospital. Note that those are done by specialists, and that the materials for ORIF surgery for femoral fracture is more expensive than the whole "designated cost" itself. Smaller hospitals tend to refer the patients needlessly to larger facility, as JKN gives more the larger the facility is. It causes needless spilling of patients to larger facilities.
The worst part about JKN is that it intended to be universal, taking in citizens in higher economic group and giving them Jamkesmas-based service. Civil servants working for the nation needed to have their salary cut by 2% for JKN, but will receive similar service to the rest of JKN participants. Even a minister would have 2% of their salary cut and no more facilities than everyone else. It has a plan to eventually force every citizen to join although such rule is not yet enforced.
Insurance system is actually beyond the scope of this article. It was briefed just to mention the government's willingness to worsen the situation. After all, one of the factor that lower the price of physician service is the low cost set by government insurance. Many clinics and hospital eventually adjust accordingly.
Chance for Recovery
This article is not intended to depreciate or grieve over Indonesian health system and it's treatment toward GPs. I personally believe that improvement can be done, and that this system needs to change as fast as possible before it causes unrepairable damage. But Indonesia is quite a closed off country, in a certain sense. Anything foreign is often considered unachievable and luxury, so we rarely compare with other nations other than to witness their magnificence. A hard slap might be needed to wake us up.
Indonesia needs to treat science, knowledge, and professionals more than it does today. Hopefully, if it appreciates knowledge and yearns for improvement, the future might be brighter than I imagine.