GIPA's Point of View: Adaptation Process of Overseas-Qualified Indonesian Doctors

GIPA's Point of View Adaptation Process of Overseas-Qualified Indonesian Doctors 1st Edition, October 2020

CONTENTS

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Contents

03

About GIPA

12

Key Challenges

04

Executive Summary

13

Key Recommendations

05

Introduction

14

Conclusions and Next Steps

07

The Indonesia Context

15

Points of Contact and References

10

Peer Comparison

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ABOUT GIPA

About GIPA Global Indonesia Professionals’ Association (GIPA) aims to promote business and investment links overseas through highly talented Indonesian professionals and executives – a true partner for Indonesia’s economic diplomacy and human capital development.

GIPA represents Indonesian professionals and executives in nine key industries across G20 and ASEAN, encompassing 80% of the world’s GDP and 60% of the world’s population. The nine key industries represented are: (1) Financial Services, (2) Technology, (3) Professional Services, (4) Healthcare and Life Sciences, (5) Industrials, Products, and Logistics, (6) Public Sector and International Organisations, (7) Energy, Resources, and Utility, (8) Creative, Communication, and Media, and (9) Capital Projects and Infrastructure.

GIPA champions three Centers of Excellence (CoE) on Professional Development, Public Relations and Advocacy (PRA), and Business and Investment Links (Figure 1). The CoE on PRA exists to advocate the interests of Indonesian professionals and executives abroad by outlining challenges and proposing recommendations – GIPA as an engine for change.

Figure 1: GIPA's operating model

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EXECUTIVE SUMMARY

Executive Summary How can Indonesia reduce its supply gap of doctors, particularly given elevated demand due to the COVID-19 pandemic?

In this report, the question above is explored and addressed through the lens of a global secretariat that represents Indonesian professionals and executives across G20 and ASEAN. GIPA believes that overseas-qualified Indonesian doctors are an ideal stream of supply for bridging the human capital gap. Unfortunately, Indonesia’s adaptation process for overseas-qualified doctors is longer and more convoluted relative to neighbouring countries in Southeast Asia. It is then unsurprising that our survey involving Indonesian doctors and medical students overseas revealed that only 16% of respondents are confident in their understanding of the adaptation process, despite 91% saying that they are interested in returning to practice in Indonesia. To address this longstanding issue, especially in the urgent context of the COVID-19 pandemic, GIPA is advocating for a more streamlined adaptation process that will better enable overseas-qualified Indonesian doctors to serve the nation.

Drawing upon primary interviews and secondary research, GIPA has identified two feasible solutions to address the two key challenges with the existing system. Firstly, following best practices from Malaysia, Singapore, and Thailand, Indonesia can provide a list of recognised universities to expedite the adaptation process, which will in turn reduce job security and financial concerns amongst incoming doctors. Secondly, Indonesia can optimise public disclosures on the adaptation process for an overseas audience to enhance accessibility and transparency, which will in turn improve public awareness and perception. On the back of this report, GIPA is keen to engage and collaborate with relevant stakeholders in Indonesia to progress this crucial agenda into a green paper with tangible action plans.

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INTRODUCTION

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Introduction As a global secretariat, GIPA has heard and captured the common sentiment from many Indonesian doctors working abroad that the adaptation process for practicing back home is notoriously lengthy and complex. Additionally, the COVID-19 pandemic has also highlighted the pressing need for a consistent supply of well-qualified doctors in Indonesia. Taken together, GIPA believes that overseas-qualified Indonesian doctors are an ideal stream of supply for bridging this human capital gap.

Ultimately, through this Point of View (PoV) report, the CoE on PRA is advocating for a more streamlined adaptation process that will better enable overseasqualified Indonesian doctors to serve the nation (Figure 2). GIPA believes that this is in line with Indonesia’s human capital development agenda, one of President Joko Widodo’s strategic priorities during his second term (2019-2024).

There are two main objectives to this PoV: 1. To advocate for the aspirations of Indonesian professionals and executives globally and for the advancement of Indonesia’s human capital development agenda 2. To provide thought leadership that clearly outlines context, key challenges, and potential solutions, which can be used as a reference by: a. Relevant stakeholders in Indonesia who are able to incite considerations on the matter and influence change b. Future change-makers within our affiliated Professional Hubs across G20 and ASEAN, particularly overseas-qualified Indonesian doctors and Indonesians currently studying to qualify as doctors overseas

Figure 2: GIPA's PoV in a nutshell

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In investigating this matter, the scope of this PoV is defined as follows: “Overseas-qualified Indonesian doctors”: current and former Indonesian nationals (i.e. Warga Negara Indonesia) who received a Doctor of Medicine degree and/or practiced as physicians in countries other than Indonesia “Adaptation process”: the procedure that overseasqualified Indonesian doctors are mandated to complete prior to practicing back home in Indonesia, as prescribed by the Indonesian Medical Council’s (INAMC) Regulation No.41 of 2016 (Peraturan Konsil Kedokteran Indonesia No.41 Tahun 2016 – Penyelenggaraan Program Adaptasi Dokter dan Dokter Gigi Warga Negara Indonesia Lulusan Luar Negeri) To address the objectives and scope laid out above, this PoV drew upon: Primary interviews with 58 overseas-qualified Indonesian doctors and Indonesians currently studying to qualify as doctors across the United Kingdom, United States, Canada, Australia, United Arab Emirates, China, and Hong Kong Secondary research on best practices in other emerging markets in the region

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INTRODUCTION

THE INDONESIA CONTEXT

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The Indonesia Context Human resources for health is one of the key hurdles to strengthening Indonesia's national health system

In "The Consolidated Report on Indonesia Health Sector Review 2018", Indonesia’s Ministry of National Development Planning (Kementrian PPN/Bappenas) highlighted human resources for health as one of the key hurdles to strengthening Indonesia’s national health system. For too long, the supply and demand gap in the quantity and quality of healthcare workers in Indonesia has constrained progress in public health. In 2019 alone, the number of healthcare workers fell below the national target, with 7.7% of community health centres (puskesmas) still without physicians, and 40% of centres in Eastern Indonesia (Papua, Maluku, West Papua) without both physicians and dentists (Gani and Budiharsana, 2019).

Relative to other countries, Indonesia has the second lowest number of physicians in Southeast Asia, with approximately 4 physicians serving every 10,000 residents. This is in stark contrast to neighbouring countries Singapore and Malaysia, where approximately 2 physicians serve 1,000 residents (Figure 3) (WHO, 2018).

Coupled with the current COVID-19 pandemic, it has become more paramount than ever to address the human capital challenge faced by Indonesia’s national health system. As of 5th October 2020, Indonesia has reported over 300,000 cases, and was named the 17th most at-risk economy in the face of COVID-19 (Worldometer; Deep Knowledge Group, 2020).

According to the Indonesian Chamber of Commerce and Industry (KADIN), there are “less than 200,000 doctors, 36,000 specialist doctors, and 2,000 pulmonologists in the country” (Hamdani, 2020).

Increasing the number of doctors is not only critical for tackling this global health emergency at the national level, but also for laying out the foundation to a more robust system for years to come.

The supply of doctors in Indonesia can be segmented into four streams (Figure 4): (1) Indonesian nationals who qualified locally, (2) Indonesian nationals who qualified overseas, (3) foreign nationals who qualified locally, and (4) foreign nationals who qualified overseas. As GIPA’s constituents are primarily Indonesians abroad, this PoV focuses on stream 2.

Figure 3: Physicians to residents ratio in Indonesia, Singapore, and Malaysia

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THE INDONESIA CONTEXT

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Figure 4: Supply streams of doctors in Indonesia

At present, the large majority of physicians in Indonesia qualified locally after up to nine years of education (stream 1), which include four years of academic medical studies (six years for primary care medical education), two years of clinical training (KOAS), and one year of internship. Medical students are also required to sit a national competency exam (Uji Kompetensi Mahasiswa Program Profesi Dokter or UKMPPD for short) between their clinical studies and internship (internsip). For overseas-qualified Indonesian doctors (stream 2), in addition to up to seven years of medical education in a foreign country, they are also required to complete an adaptation process that could last between one to four years should they wish to return to and practice in Indonesia (Anugrah, 2018).

Across the world, it is commonplace for doctors who intend to practice in a country other than where they qualified to undergo adaptation programs. These programs generally have two primary aims: 1. To equip overseas-qualified doctors with countryspecific knowledge, including but not limited to the national healthcare system, language skills, medical laws, epidemiology, and general customs 2. To benchmark and ensure that overseas-qualified doctors have similar experience and competencies relative to locally-qualified doctors. For Indonesia, it seems particularly important that doctors have experienced both academic medical studies and clinical training as part of their Doctor of Medicine (MD) degree

Given the significance of these aims, GIPA acknowledges the importance of an adaptation process for overseas-qualified doctors, and is not looking to neither abolish nor discredit the system currently in place. However, it believes that there is scope to streamline the existing program for the benefit of both overseas-qualified doctors and the Indonesian Government.

The adaptation program for overseas-qualified Indonesian doctors is regulated by the INAMC as per INAMC Regulations No. 41 Year 2016 ("Peraturan Konsil Kedokteran Indonesia No.41 Tahun 2016 Penyelenggaraan Program Adaptasi Dokter dan Dokter Gigi Warga Negara Indonesia Lulusan Luar Negeri"), the key stages of which are illustrated in Figure 5. This program consists of two primary stages, Competency Benchmarking (Penyetaraan Kompetensi) and Capability Adjustment (Penyesuaian Kemampuan), each of which is assessed by graded examinations. Following the two stages, if a doctor has yet to complete an internship or is considered lacking in clinical training, he/she is then prescribed to complete a year-long internship.

Collectively, the entire adaptation process could take between one to four years to complete, depending on level of experience and whether a certain stage or examination needs to be redone.

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THE INDONESIA CONTEXT

Figure 5: Stages of the adaptation process for overseas-qualified Indonesian doctors

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PEER COMPARISON

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Peer Comparison Compared to neighbouring countries in Southeast Asia (Table 1), Malaysia and Singapore are similar to Indonesia in that they also run two primary stages, Provisional/Conditional Registration and Full Registration. To progress from provisional/conditional to full registration, doctors are required to undertake general clinical training. Additionally, Thailand’s three Licensing Examinations are also similar to Indonesia’s two examinations.

With regards to duration, adaptation processes in Thailand and Malaysia are considerably shorter than in Indonesia and Singapore. However, Singapore’s process includes either two or four years of supervised practice, whereby these doctors are already licensed to practice in the country, but are simply under tighter supervision. Thus, with up to four years, Indonesia runs the longest pre-licensed adaptation period across peers.

Contrarily, in Singapore and Thailand, overseasqualified doctors are only able to adapt if they graduate from one of the c.100 institutions on the list of recognised universities. Alternatively in Malaysia, overseas-qualified doctors can adapt regardless of their alma mater, but those who graduated from one of the c.200 institutions on the list are exempted from the Examination for Provisional Registration. In the context of Indonesia, this peer analysis suggests that having a list of recognised universities provides a credible benchmark that can at least partially waive the Capability Adjustment stage and accelerate the Competency Benchmarking stage.

Notably, two striking differences between Indonesia and the three other countries are the lack of a list of recognised universities and the need for re-education at a INAMC-prescribed institution. GIPA sees these discrepancies as interconnected: the lack of a list of recognised universities feeds into the need for reeducation. As part of the Capability Adjustment stage, INAMC determines the duration, content, and institution at which an overseas-qualified doctor must undergo re-education on a case-by-case basis based on results from the Competency Benchmarking stage. This materially contributes to the lengthiness and complexity of the process, as INAMC has to assess doctors individually and liaise with the relevant collegium (e.g. Indonesian Medical Association or Ikatan Dokter Indonesia) where applicable.

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PEER COMPARISON

Table 1: Peer analysis across neighbouring countries in the region (Malaysian Medical Council; Singapore Medical Council; The Medical Council of Thailand)

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KEY CHALLENGES

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Key Challenges Given the context set by the previous section, this section looks to distill key challenges with the existing adaptation process, as evidenced by both primary interviews and secondary research conducted for this PoV. 1.) Lengthy process and delays fuelling job security and financial concerns

As illustrated previously, Indonesia’s adaptation process can take between one to four years depending on experience level, making it the longest compared to Malaysia, Singapore, and Thailand due to the need for a case-by-case assessment. Not only has secondary research uncovered a degree of systematic inefficiency, but primary interviews also revealed that the lengthy process fuels job security concerns amongst overseasqualified Indonesian doctors.

Two Indonesian doctors who qualified and are currently pursuing further doctoral studies in the UK claimed that the range of duration is “unsettling due to de-skilling risk” and “source of concern, because as you go through the adaptation process, you will not know for certain just how long you will be unable to practice.”

Moreover, an Indonesian student currently pursuing her MD at Hong Kong University also pointed out that the adaptation process, including the cost of re-education at an INAMC-prescribed institution, is fully funded by applicants. Taken together, this means that incoming overseas-qualified Indonesian doctors will lose their income from practicing for an uncertain duration, yet have to pay for the cost of the adaptation process.

Even more worryingly, 13 interviewees (c.22%) shared that they have heard of stories whereby applicants faced delays either due to late certificate issuances or longer than expected processing times between INAMC and the relevant collegium. Overall, the complexity of the adaptation process leads to both a lengthy baseline in the first place and rooms for delay between stages.

2.) Subpar availability and quality of relevant information leading to poor public perception

Out of 58 overseas-qualified Indonesian doctors and Indonesians currently studying to qualify as doctors overseas interviewed, only 9 (c.16%) were confident in their understanding of the adaptation process, despite 53 respondents (c.91%) saying that they are interested in returning to practice in Indonesia. The overwhelming majority of interviewees stated that they have heard from relatives and colleagues that the process is extremely convoluted, and that they are only vaguely aware of the different stages.

“There is a lot of ambiguity around coming back to Indonesia as doctors - there seems to be no job security or support system. Who can we contact and rely on to guide us through the process? The resources online are nowhere near comprehensive or clear enough,” said an Indonesian doctor who qualified and has been practicing in China for the past seven years. Browser searches on this topic using a combination of different keywords reveal that top search results are typically news articles and blog entries, many of which are relatively outdated or released by unofficial authors, and further emphasise the discouragingly complicated nature of Indonesia’s adaptation process. INAMC’s website seldom appears on the first page of results, let alone the relevant regulation itself.

When asked about what kind of information is required in addition to the official regulation, all 58 interviewees mentioned evaluation/assessment criteria and 50 interviewees (c.86%) mentioned success rates/stories.

Respondents assert that clarity on the criteria against which they are assessed across the different stages of the adaptation process is critical in informing their decision to return. Furthermore, given the notoriously negative sentiment around the process, respondents call for enhanced disclosure on success rates/stories and points of contact for inquiries. At present, all of these are not seemingly available on the websites of INAMC, relevant collegium or the Ministry of Health.

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KEY RECOMMENDATIONS

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Key Recommendations To address the two challenges identified, this PoV is proposing two feasible solutions: one targeted at the systemic inefficiency and another at the less favourable public perception.

1.) Provide a list of recognised universities to expedite the adaptation process

As seen in Malaysia, Singapore, and Thailand, prebenchmarking and recognising the medical programmes run by 100-250 universities worldwide can help streamline the adaptation process. There are two approaches to implementing this strategy: a. If the list is made into a non-negotiable prerequisite similar to Singapore and Thailand, it will provide binary clarity on the prospects of practicing in Indonesia even before Indonesians leave the country to qualify overseas, thus tackling the issue of ambiguity around evaluation/assessment criteria to some extent b. If the list is made into a negotiable prerequisite similar to Malaysia, then it can at least partially waive the Capability Adjustment stage and accelerate the Competency Benchmarking stage, which would address both concerns around ambiguity and the length of the process Implementing this prerequisite could reduce the duration of the adaptation process by up to two years or 50%, a significant amount considering that overseasqualified Indonesian doctors have typically completed around seven years of medical education in a foreign country. Additionally, the human capital freed up from a more streamlined adaptation process can be dedicated to maintain/grow the list of recognised universities or support the second recommendation as per below.

2.) Enhance the accessibility and transparency of public disclosures to improve awareness and perception

Ultimately, there is an underlying public perception and communications issue around the adaptation process, exacerbated by the lack of information online.

Information on the adaptation process must be made readily available and accessible online for an overseas audience, given the aim of supporting Indonesian doctors overseas. This entails ensuring actions such as but not limited to: a. Designing websites containing the relevant information professionally and credibly b. Optimising the appearance of these websites for browser searches (i.e. search engine optimisation) c. Clearly signposting essential information and actively monitored points of contact for inquiries In addition to availability, the quality of information disclosed must also be pertinent and easily understandable. Not only does this mean that the process is ideally outlined with limited legal jargon, but also that the information includes details around evaluation criteria and success rates, two areas of high interest/relevance as shown by GIPA’s survey.

GIPA is keen to work together with INAMC, relevant collegium, Ministry of Health, and other suitable stakeholders to devise a more concerted effort in encouraging and welcoming overseas-qualified Indonesian doctors home. This could be in the form of a campaign highlighting success stories of those who have successfully completed the adaptation process or simply being more vocal about how overseas-qualified talents could benefit the supply gap. Collectively, this recommendation could improve public awareness and perception.

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CONCLUSIONS AND NEXT STEPS

Conclusions and Next Steps Overseas-qualified Indonesian doctors are currently being pulled by two opposing forces. On the one hand, the COVID-19 pandemic has amplified the urgent need for a consistent supply of well-qualified doctors in Indonesia. On the other hand, a notoriously lengthy and complex adaptation process prevents the very doctors that the country needs from returning to practice back home. Noting that the number of healthcare workers fell below the national target in 2019 and more than 300,000 COVID-19 cases have been recorded as of 5th October 2020, it has become more crucial than ever for Indonesia to progress its human capital development agenda in the healthcare sector.

As the first edition of this survey, there are still limitations to this investigation, including the relatively small sample size of 58 interviewees and subsequent lack of statistical analysis. Consequently, for potential future iterations of this PoV, GIPA hopes to connect with more overseasqualified Indonesian doctors who are willing to provide further insights, as well as collaborate with relevant stakeholders to develop the PoV into a green paper with tangible action plans.

Having laid out the context around and evaluated the adaptation process for overseas-qualified Indonesian doctors, this PoV recommends two distinct solutions to address the two key challenges identified through primary interviews and secondary research (Figure 6).

Ultimately, GIPA is advocating for a more streamlined adaptation process that will better enable overseasqualified Indonesian doctors to serve the nation.

Figure 6: Summary of challenges and recommendations identified by this PoV

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POINTS OF CONTACT AND REFERENCES

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Points of Contact Global Indonesia Professionals’ Association (GIPA) gipa.co | council@gipa.co

Christy Zakarias Head of Europe and Public Advocacy christy.zakarias@gipa.co

Viancqa Kurniawan Centres of Excellence Manager viancqa.kurniawan@gipa.co

References Anugrah, B.A.H., 2018. Menristek Dikti Tanggapi soal Agen "Nakal" dan Dokter Lulusan Luar Negeri.

Kompasiana. Available at: https://www.kompasiana.com/aryoo/5ad0e782dd0fa823 7c2cb7b2/tanggapan-menristek-dikti-terhadap-agennakal-dan-dokter-lulusan-luar-negeri [Accessed August 2020].

Deep Knowledge Group, 2020. Available at: https://www.dkv.global/covid-safety-assessment-200regions [Accessed October 2020].

Gani, A.P. & Budiharsana, M.P., 2019. P. B. Ali, R. G. M. Siahaan, & Ardhiantie, eds., Indonesia's Ministry of National Development Planning (Kementrian PPN/Bappenas). Available at: https://www.unicef.org/indonesia/reports/consolidatedreport-indonesia-health-sector-review-2018 [Accessed September 2020].

Hamdani, T., 2020. RI Kekurangan Dokter di Tengah Gempuran Corona, Ini Datanya. Detik Finance.

Available at: https://finance.detik.com/berita-ekonomibisnis/d-5127451/ri-kekurangan-dokter-di-tengahgempuran-corona-ini-datanya [Accessed September 2020].

Singapore Medical Council. Register of Medical Practitioners. Singapore Medical Council. Available at: https://www.healthprofessionals.gov.sg/smc/becominga-registered-doctor/register-of-medicalpractitioners/conditional-registration [Accessed August 2020].

The Medical Council of Thailand. How Foreign doctors to register to practice medicine in Thailand. The Medical Council of Thailand. Available at: https://tmc.or.th/En/how-foreign_en.php [Accessed August 2020].

WHO, 2018. The 2018 Update, WHO Global Health Workforce Statistics. Available at: https://apps.who.int/gho/data/node.main.HWFGRP_00 20?lang=en [Accessed September 2020].

Worldometer, Coronavirus Updates. Available at: https://www.worldometers.info/coronavirus/country/ind onesia/ [Accessed October 2020].

Malaysian Medical Council. Registration. Malaysian Medical Council. Available at: https://mmc.gov.my/registration/ [Accessed August 2020].

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