2009年-世界发展银行全球_Indonesias_Doctors_Midwives_and_Nurses___Current_Stock_Increasing_Needs_Future_Challenges_and_Options_98页_7mb

Summary of Indonesia's Doctors, Midwives and Nurses: Current Stock, Increasing Needs, Future Challenges and Options

Core Content

This document is a comprehensive review of Indonesia's health workforce, including doctors, midwives, and nurses, as part of the Government of Indonesia's broader Health Sector Review. It aims to inform the development of the next five-year National Development Strategic Plan and provides insights for future health workforce policies.

Main Objectives

• To assess the current supply and distribution of health workers in Indonesia.
• To evaluate the impact of private and public health service providers.
• To analyze the effectiveness of health workforce policies and the challenges they face.
• To identify future needs and suggest strategies to address them.

Current Health Workforce Status

• The number of medical doctors and specialists, midwives, and nurses in Indonesia has increased significantly from 1995 to 2006.
• As of 2006, Indonesia had nearly 80,000 midwives, with a better ratio and distribution in rural areas compared to urban ones.
• There are approximately 70,000 medical doctors, including 15,000 specialists and 55,000 general practitioners.
• Nurses and midwives are in greater numbers than doctors, but their distribution is also inequitable, especially in remote areas.
• A substantial portion of public health expenditures is allocated to personnel salaries and allowances, with personnel costs making up over 50% of the total public health budget.

Dual Practice and Its Impact

• About 60–70% of publicly employed health service providers have second jobs or operate private practices after hours.
• Dual practice was initially introduced as an incentive to attract workers to remote areas, but it has led to several negative consequences, such as absenteeism, resource misallocation, and diversion of public patients to private services.
• Health facility utilization has declined since the 1997 economic and political crisis, with a shift from private to public providers in recent years.

Health Workforce Production

• Indonesia has expanded its capacity to produce health workers over the past two decades.
• There are now 682 nursing schools, producing about 34,000 nurses annually.
• 52 medical schools produce an average of 5,000 new doctors each year.
• 465 midwifery schools produce 10,000 midwives annually.
• However, the expansion has focused more on quantity than quality, leading to concerns about the standard of education and subsequent certification.

Regulatory and Policy Framework

• The regulatory framework for health workforce education and certification is weak, with many schools lacking proper accreditation and standards.
• There are no consistent standards for evaluating the quality of health professionals, leading to wide variations in service provision.
• Health workforce policies have evolved over time, with a focus on maintaining numbers and improving distribution, especially to remote areas.
• Decentralization has introduced new challenges, including unclear responsibilities and poor data collection on health worker locations and activities.

Increasing Demand for Health Workers

• Demographic and epidemiological changes are expected to drive increasing demand for health services.
• These include an aging population, higher prevalence of non-communicable diseases (NCDs), and increased utilization due to expanding health insurance coverage.
• The current health workforce planning methods rely heavily on ratios rather than on actual demand and need projections, which is an outdated and insufficient approach.

Challenges and Options

The paper identifies four main challenges:

1. Shortage and Inequitable Distribution: Medical doctors and specialists are in short supply, especially in remote and underserved areas.
2. Poor Quality of Education and Weak Certification Systems: Many schools, particularly private ones, lack accreditation and quality assurance.
3. Ineffective Policy Development and Planning: Policies are not based on evidence or demand but on standard norms, and have not adapted to the decentralized system.
4. Growing and Changing Demand: Demographic and epidemiological shifts are increasing the burden on an already strained health system.

To address these challenges, the paper proposes nine alternative options, including:

• Strengthening the accreditation and certification system.
• Improving the quality of health professional education.
• Enhancing the distribution and retention of health workers in remote areas.
• Revising the dual practice model to reduce its negative impacts.
• Introducing performance-based incentives and better monitoring systems.
• Increasing investment in training and development programs.
• Expanding the role of nurse practitioners in underserved areas.
• Improving data collection and management for better workforce planning.
• Aligning health workforce policies with the broader goals of the health system, including MDGs and universal health coverage.

Key Information

• Doctor Ratios: The ratio of doctors per 100,000 population has improved, but remains below regional averages.
• Midwife Ratios: Midwives are more prevalent in rural areas, but data on nurse distribution is limited.
• Utilization Trends: Utilization of health services has declined since 1997, with a recent shift toward public providers.
• Dual Practice: Dual practice is widespread among public health workers, leading to inefficiencies and inequities in service delivery.
• Private Sector Growth: The private health sector has grown significantly, especially with the liberalization of hospital ownership and the introduction of the dual practice model.
• Health Insurance: The introduction of Jamkesmas has increased access to health services for the poor, but further policy analysis is needed to assess its impact on the health workforce.
• Education and Training: There are concerns about the quality of education and training, particularly in new and private institutions.
• Decentralization: Decentralization has introduced new challenges in policy implementation and data collection.

Conclusion

This review highlights the need for a more evidence-based, demand-driven, and quality-focused approach to health workforce management in Indonesia. It outlines the current situation, identifies the key challenges, and proposes nine strategic options to improve the health system's capacity and efficiency in the face of growing and changing demand.