Budi Gunawan Sadikin, Minister of Health, made a startling statement at the end of 2022: we are experiencing a shortage of specialist doctors. The number of specialist doctors available is insufficient to meet national demands. Furthermore, the distribution of specialist doctors is uneven, with the majority concentrated in major cities. We require the deployment of thousands of specialist doctors to small towns, areas outside of Java, as well as remote and underdeveloped areas. According to the Minister, one regional public hospital requires at least seven specialist doctors.

According to WHO eligibility standards, Indonesia requires at least one doctor for every 1,000 people, or 1 : 1,000. Indonesia, with a population of approximately 275 million people, requires approximately 275,000 doctors. According to data from the Indonesian Medical Council (Konsil Kedokteran Indonesia, KKI), there are 143,900 general practitioners with a registration certificate (surat tanda registrasi, STR) and are actively practicing in October 2022, accounting for approximately 52% of the need. This means that we are short 130,000 doctors, or 48% of the total decent need. (Herry Darwanto, 'Mencukupi Kebutuhan Dokter', kompas.com, 28/10).

Only about 44,700 specialist doctors with STR are currently active, representing 36 different specialties, and their distribution is concentrated in Java-Bali. This figure is still insufficient to meet the needs of all regional public hospitals, which are spread across hundreds of cities and districts.

Inequality in the distribution of health workers can be seen from the 2021 Indonesia Health Profile data quoted by Herry, in which 63% of the total medical personnel or 173,700 people are in Java-Bali, with the following distribution: Jakarta 24,200 people, East Java 24,000 people, and West Java 23,600 people. The provinces with the fewest number of medical personnel were West Sulawesi (485 people), North Kalimantan (558 people), and Gorontalo (627 people). The unequal distribution of doctors can also be inferred from the data on the number of doctors per public health center who are the spearhead of health services for the community.

Out of 10,292 public health center spread across districts/cities (2021), 9.6% of them still do not meet the standards, where there should be one doctor for non-inpatient health center and two doctors for inpatient health center (Ministry of Health Regulation No 75 of 2014) . In fact, there are hundreds of health centers without doctors. Papua is the worst-hit province. Nearly 50% of the health centers in Papua do not have doctors. Other similar areas are Maluku, West Papua, East Nusa Tenggara, Central Kalimantan and West Sulawesi.

Despite the fact that there are many universities with medical faculties, the production rate of doctors and specialists is still slow, and they cannot keep up with the ever-increasing demand. To address this shortage, the Ministry of Health launched an accelerated program to produce specialist doctors, which will include providing scholarships for 2,500 doctors to attend specialist education and efforts to reduce the cost of specialist education.

Interestingly, the Minister of Health said he would make a breakthrough in updating the system to accelerate the production of specialist doctors, with the concept of hospital-based specialist education. Regardless of the advantages and disadvantages, the Minister of Health's plan is a complement to the university-based concept that has been in operation so far, and has proven unable to produce a large number of specialist doctors in large numbers and quickly, while the need in the field is very urgent.

For example, cancer radiotherapy patients currently have to wait 6-12 months for treatment. The risk is that the patient's illness will worsen during the long wait, and the patient may die. As a result, it is critical to accelerate the production of specialist doctors.

University-based specialist medical education

So far, our specialist medical education is university-based and is based on a curriculum jointly developed by several collegiums formed by the Indonesian Medical College Council (MKKI). This MKKI heads 38 specialist medical science colleges and designs a curriculum that will be approved by the Indonesian Medical Council (KKI).

A small proportion of educational material is given in lectures and laboratories, while most of it is in the form of practical work in government-owned hospitals, which are generally central general hospitals, regional public hospitals, and recently there have been several university-owned academic hospitals. The combination of material in lecture theaters and practice in large and well-equipped hospitals under the guidance of senior specialists will produce qualified specialists.

Specialists who graduate from this program are very good at certain skills, for example specialists in surgery, specialists in nephrology, ENT specialists, specialists in obstetrics and gynecology, etc. Each is very proficient in the skill he is taking, but not in the skills of any other type of specialization. An ENT specialist, for example, does not specialize in pregnancy and birth, which is the expertise of obstetrics and gynecology specialists. Likewise, a cardiologist will not handle the problem of birth weight. So, this specialization is more sectoral.

So far, no one has questioned the quality of this specialized education system. However, the issue is not one of quality, but of quantity. This specialist education system is incapable of producing a large number of specialist doctors in a short period of time. This university-based system can only produce approximately 2,000 medical specialists per year. In fact, there is a high demand for specialists. There were approximately 54,000 specialist doctors as of December 2022, while the need was approximately 110,000. There is a significant gap between the needs of medical specialists and their production capabilities.

Until then, we will not be able to meet the shortage of specialist doctors if we only use this university-based education system. If this system is forced to produce specialists in large numbers and in a short period of time, it will undoubtedly become overloaded and the quality will suffer. As a result, a hospital-based system is proposed as an alternative for producing specialist doctors.

Adopting program from the US

A hospital-based specialist medical education program, also known as a community-based specialist residency program, is not a novel concept. Before 2013, a hybrid program that divided university-based and community-based residency was used in Arizona and California, United States of America (USA). This community-based program aims to produce 33,000 primary care physicians by 2035.

Such a system is worth exploring. In the pediatrics residency program, for example, the university-based certification exam has an 85% pass rate, while the hospital/community-based one has a 79% pass rate. The failure rate of surgeon residency exams is also lower than that of community-based programs. In short, the qualifications of specialists produced by university-based programs appear to be slightly higher than those produced by hospital/community-based programs.

On the other hand, educational programs based in hospitals/communities have a positive side effect, i.e. more relevant work experience and more intense clinical exposure. In the United States, community-based pediatric residencies treat more patients than university-based education. Higher clinical experience is highly beneficial when dealing with emergency measures.

It is evident that there is no significant difference in the outcomes of implementing the two specialist education models. Medical education in the US is also added with the educational curriculum for working in rural and remote areas. The hope is that these community specialists will be able to work in areas with few resources, forcing them to think creatively in order to find solutions.

Hospital/community based specialist

The program for producing hospital-based specialists is known as an affirmation program, and it aims to produce specialists in large numbers and quickly in order to address shortages. The students are general practitioners assigned to public health centers located throughout the country. As general practitioners, their knowledge and skills are, by definition, broad, and they lack the in-depth expertise of specialist doctors.

To address the urgent shortage of specialist doctors, general practitioners in these community health centers are enrolled in an educational program known as 'community specialists'. This is a type of upgrading in which they increase their knowledge and skills in the specialization they choose to meet the needs of community assignments. As a result, general practitioners from public health centers will have increased knowledge and skills in a variety of fields that are frequently required, such as the ability to handle simple surgery cases of broken bones due to accidents, simple tropical and infectious diseases, and a variety of other diseases that do not require overly complicated medical treatment.

Even though they are referred to as "community specialists," this does not imply that their education is simple. The educational process remains rigorous, with students required to graduate and master the six major competencies in their field of specialization. These six competencies include mastering a broad range of disease knowledge, being skilled and proficient in treatment procedures and medical procedures, and always adhering to scientific procedures within the framework of evidence-based medicine. Furthermore, the doctors must be capable of communicating with patients, health workers, staff, and stakeholders, as well as maintaining a professional demeanor and adhering to medical ethics. Finally, the doctors must be able to think critically, creatively, and comprehensively about the problems they face.

With the mastery of these six main competencies, graduates of this hospital-based specialist education, which must also be certified by the collegium, will maintain their qualifications and competence. Therefore, this hospital-based special education program can complement the university-based programs.

These hospital-based specialization program graduates can then be assigned to strengthen community health centers. So far, community health centers have been classified as primary health care providers for initial/simple level medical procedures, whereas hospitals have been classified as advanced health care providers for handling advanced/severe medical cases. We will produce 'community specialists' capable of handling a variety of 'intermediate level' medical procedures through a hospital/community-based specialist education program.

If conventional medical specialists are assigned to type A and B hospitals, it is preferable that these "community specialists" be assigned to type B and C hospitals as well as community health centers, with a fairly even distribution across all areas. As a result, community health centers' level will rise from being able to handle only initial-level medical procedures to being able to handle'middle-level' medical procedures, reducing the number of referrals to hospitals. Increasing the capacity of community health centers will help to reduce the long lines of patients at the hospital. The hospital should ideally only manage advanced medical cases or severe stages. Thus, the Minister of Health's affirmative program plan to accelerate the production of specialist doctors can be implemented by combining two models: university-based and hospital-based models. Hopefully, this will allow for greater national distribution of health services.

Djoko Santoso
Professor, Faculty of Medicine, Universitas Airlangga
Chairman of Health Department, Indonesian Council of Ulama, East Java

Translated from:
"Hybrid University-Hospital Based untuk Atasi Krisis Dokter Spesialis"
Djoko Santoso
Media Indonesia, 30 December 2022