not enough here, too many there

Scenario: Medical Doctors and Specialists Distribution in Indonesia.

There is a huge gap between the DISTRIBUTION of medical doctors and specialists in REMOTE and NON-REMOTE areas, not only in Indonesia but all over the world.


Facts:

1. There is a positive correlation between the availability of health workers and better health outcomes, as well as increased coverage of essential health interventions.

2. The World Health Report 2006 estimated that the world lacks about 4 million health workers, if a minimum level of health outcomes is to be achieved (WHO 2006).

3. Health worker shortages are currently reported by many other countries, both developed and developing. Such shortages are symptoms of a poorly managed health workforce and health care system. The causes of the crisis are complex, and have to do with insufficient production capacity, but also with an inability to keep the workers that are being produced in the
places where they are most needed. (WHO: Increasing access to health workers in remote and rural areas through improved retention,2009)

4. In the majority of countries, rural and remote areas are usually lacking sufficient numbers
of health workers. Approximately one half of the global population lives in rural areas, but these areas are served by only 38% of the total nursing workforce and by less than a quarter of the total physicians’ workforce. (WHO: Increasing access to health workers in remote and rural areas through improved retention,2009)

Thus, we can assume that most of health workers are more attracted to serve in urban rather than remote areas. But why?


Most physicians prefer to settle in urban areas offering opportunities for professional development, education and other amenities for their families, and attractive employment opportunities.

There are many things that had been done by Indonesia's laws and regulations in governing the health sector of Indonesia. I chose a few that have correlations to improve the gap difference, which are:
- 1974 by Presidental Instruction (Inpres) : Mandates that all new medical graduates serve in
under-served rural districts for 1–3 years.
- 1991 by Presidential Regulation No. 37 : Regulates the recruitment of doctors as
temporary employees.
- 2002 Ministry of Health Regulation No. 1540 : Regulates the placement of doctors during service period.
- 2004 Local Government Authority Act No. 32 : With decentralisation each local government has authority to recruit their own medical personnel as local government employees.


*notes: Not all laws and regulations remain until now. For example, after the Indonesia crisis of 1997 the policy of mandatory service was challenged as violating the rights of doctors to choose their jobs. Most doctors who finished their period of mandatory service sought to become civil servants to ensure lifetime job security. Eventually, the mandatory service program was replaced by a voluntary contract arrangement.


Problems:

Although there is an existing acts and regulations for the governance
of the medical profession in Indonesia, its implementation was not consistent, with significant arbitrariness in the application of regulations by governments at all levels. The biggest constraint in devising and implementing measures to address the weaknesses discussed below is that the Government of Indonesia, in the last three decades, has allocated less than two per cent of its national budget for health care.

Solutions:
How can we persuade doctors to serve in remote areas?

Offer a fine tune incentive packages that the physician wont say no to. The types of incentives (can be cash, housing, career development etc) can be decided after a simple survey technique is done to assess
doctors' reactions to potential incentive packages together with policy analysis.

Ministry of Health is developing initiatives to provide placement-related fellowships for young doctors to pursue specialist training. Under this program, a doctor can apply for a fellowship (covering educational costs and living allowances during 4-5 years of specialist training), conditional on the doctor signing a contract that commits him or her to a given number of years service in a smaller district after graduation.

The more remote and less developed the district, the shorter the period of mandatory service. Past evidence from the placement of general practitioners shows that doctors are more likely to consider remote postings when an adequate incentive system is in place, indicating that financial incentives can be an effective mechanism for achieving a more even distribution of health workers.


just giving an exaggerated comparison:


VS


References:
1. Lecture note: International health and decentralization, dr. Yodi Mahendradhata M.Sc,PhD
2. Research at the World Bank: Attracting Doctors to Rural Areas (Indonesia
)
3.
WHO: Increasing access to health workers in remote and rural areas through improved retention,2009
4. Viewing Decentralization as an Opportunity: In Improving Availability of Health Workers in Underserved Areas, Anna Kurniati, Ferry Efendi, 2009

the choice is yours. :)
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