The large number of Indonesian citizens seeking treatment abroad has resulted in Indonesia losing around US$11.5 billion in foreign exchange, or the equivalent of Rp.170 trillion per year. Are our health services still not of high quality?

In terms of medical treatment, our upper middle class includes those who like go abroad for treatment.

It's not just medical treatment to cure serious illnesses, such as cancer, but also for medical check-ups or check-ups, many Indonesian citizens are keen to go abroad. Of course this only applies to those who are financially able because the costs are definitely more expensive than in their own country.

This is what makes President Joko Widodo confused and concerned. A few months ago, the President complained about approximately 2 million Indonesian citizens seeking medical treatment overseas every year. Around 1 million people go to Malaysia, approximately 750,000 go to Singapore, and the rest to Japan, America, Germany, and other countries.

According to the President, around 60 percent of Indonesians who seek medical treatment abroad come from Jakarta, 15 percent from Surabaya, and the rest from Medan, Batam, and other cities. The number of Indonesian citizens seeking medical treatment abroad results in Indonesia losing foreign exchange of approximately 11.5 billion US dollars or equivalent to 170 trillion Rupiahs per year.

The most common treatment undergone by Indonesian citizens abroad is oncology or cancer, followed by orthopedics, joints, dentistry, beauty, and aesthetic surgery.

The President believes that our doctors and hospitals are not less intelligent than their counterparts in neighboring countries. The question arises, is our healthcare still not of good quality that we have to seek treatment abroad?

The President's concern can be interpreted as a push to the Ministry of Health to improve the quality of hospital services, both in terms of doctor and healthcare staff competencies, reliability and friendliness of non-medical staff, as well as hospital management governance.

Patient perception

The perception survey of local patients towards hospitals in Indonesia shows that 70.75 percent of patients feel that communication is the source of the problem. Healthcare services are perceived as inadequate due to lack of empathy and insufficient explanations. More than 60 percent of patients believe that consultation time in Indonesian hospitals is shorter compared to abroad.

Approximately half of all respondents feel that healthcare technology in Indonesia is not advanced enough and its diagnoses are not accurate enough. About 60-70 percent of the respondents feel that medical services overseas are more comprehensive and offer attractive travel packages. Of the patients who have been treated in foreign hospitals, 94 percent said they would return for further medical treatment, and 98 percent would recommend it to their family or others around them.

The results of the perception survey indicate the weakness of three main aspects in our hospital's health services, namely the weak accuracy of diagnoses, which refers to the competency of doctors, the lack of advanced health technology used, and the still poor communication, attention, and empathy of doctors or paramedics to patients. This is certainly a good thing to reflect on and self-correct.

However, comparing the overall quality of hospitals in Indonesia with Singapore is not equivalent. Singapore is a very small country with a population of only 6 million people (equivalent to the population of Bekasi City and Regency), but its per capita income is high, at $82,797 USD (2022). Meanwhile, Indonesia is thousands of times larger than Singapore, with a population of 281 million people, but its per capita income is only $4,783 USD (2022).

Singapore has an area of approximately 720 square kilometers, while Indonesia has an area of approximately 5.2 million square kilometers, consisting of thousands of islands.

A small, wealthy country with few inhabitants naturally has better quality health services and hospitals than Indonesia. However, this does not mean that we do not have good hospitals. In big cities, there are several premium private hospitals with more personalized services, more complete medical equipment, and of course much higher fees.

Is the quality of our nurse services, for example, lower compared to their colleagues in Singapore? It may or may not be, depending on the hospital. In government-owned hospitals that are constantly crowded with patients from the lower economic class, the quality may differ from that of premium private hospitals where the nurse salary standards differ from those of government-owned hospitals.

Even in the care of elderly sector, our nurses are diligent and reliable. Japan has once offered funding to the Indonesian government to establish a special hospital or elderly care center. Elderly people in Japan who feel neglected by their families wish to spend the rest of their lives in Indonesia, where they can enjoy peace and the attention of Indonesian nurses. The Minister of State-Owned Enterprises responded by establishing a special hospital in Bali.

With that description, it can be said that we have competent doctors and a number of quality hospitals with good, even premium services. However, there are very few of these premium quality, while the majority are still of mediocre quality.

If so, is the rush of wealthy patients to hospitals abroad simply because of the bad hospitals here? Here there are other factors that could be the cause, especially not in critical stage patients with chronic diseases, namely medical treatment while traveling. Those who go abroad simply for medical check-ups or check-ups, or minor treatment for a toothache, for example, are basically tourists.

Tourism is a trend that continues to increase along with economic progress, such as fashion, apparel, automotive, and culinary. For pass-class Indonesian citizens, traveling to Yogyakarta or Bali is enough to make them happy. However, for the middle class, being able to travel abroad will add happiness and pride.

Check-up to Mount Elizabeth Hospital only takes one hour, followed by shopping and culinary snacks in the Jalan Bugis area in Singapore, and the photos are posted on the Instagram account, of course an attractive choice for the middle class in the digital era .

”Medical tourism”

So, we shouldn't worry too much about the phenomenon seeking medical treatment abroad. The explanation above illustrates that those who seek treatment abroad are basically those who are financially able.

Now, can we do something similar, building premium quality hospitals to attract wealthy foreign consumers to seek medical treatment in Indonesia? As explained above, we already have several premium quality hospitals. However, in terms of perception, we are still losing to Singapore, Japan, and even compared to Thailand and Malaysia. Moreover, seeing long queues is still commonplace in our premium class hospitals.

In mid-July, the Minister of Tourism and Creative Economy Sandiaga Uno determined two special economic zones (KEK) in Bali to be developed as centers for medical tourism, namely Sanur and the Bali Turtles. Investment will be boosted in this area. Last April, Sandiaga also approved Medan, Malang and North Sulawesi as one of the prime health service areas in Indonesia.

Certainly this is a good start as long as we don't just stop at the slogan as we have been accustomed to doing so far.

Healthcare services are a tradable service industry, which is regulated by the General Agreement on Trade in Services (GATS) under the World Trade Organization (WTO). One of the elements that is regulated is the flow of cross-border patients in seeking medical treatment and care.

This is a phenomenon known as medical tourism, which may be more suitable for types of medical services that are relatively not very urgent or not life threatening. For example, dental care, facial reconstruction, plastic surgery, silicone breast injections, liposuction or liposuction, and fertility treatment, general check-ups, and the like. Types of treatment that are not very urgent need to be done.

Apart from that, there are also people who seek treatment abroad because it is very urgent and their lives are threatened, not for cosmetic purposes, for example, for cancer treatment, kidney transplant surgery, ring insertion and by-pass for heart disease, and other types of disease. other weight. Many of our hospitals are already of good quality in treating serious illnesses like earlier, but generally the lines are very long. So, the decision to immediately seek treatment abroad is a rational choice for those who can afford it. Because delaying treatment can be fatal.

Actors of medical tourism are not only rich people in developing countries. It is interesting to observe the trend of British people seeking medical treatment in India, its former colony. Data for 2011 showed that the cost for hip surgery for elderly patients in England was 8,800 pounds (about Rp. 160 million), while in India it was only 3,400 pounds (Rp. 65 million). If flight and accommodation costs are added, the total cost is around IDR 85 million.

There is a saving of IDR 75 million if you seek medical treatment in India and this amount can be used to continue touring the remote areas of this former British colony.

According to Hospital Episode Statistics data in 2007-2008, there were around 28,000 patients in England who waited in line, providing a potential market for the healthcare industry in India. In this example, British people seek medical treatment abroad which is cheaper.

India has been depicted as a country with a billion population, mostly poor, with chaotic and squalid cities. However, in terms of technology, including medical technology and healthcare services, India is considered advanced.

Regulatory support

Nowadays, many countries offer high-quality healthcare services for a lower cost compared to the patient's home country. This makes medical tourism an attractive option for those seeking more affordable care without sacrificing quality. Patients must ensure that the hospital they choose has high quality standards and competent doctors.

We must emulate the ability of India, Singapore, Thailand and Malaysia in building medical tourism. To build medical tourism, the government and professional institutions must ensure that health facilities meet the standards set, doctors and nurses have sufficient expertise, technology and medical devices are complete and modern, nurses are reliable and friendly, and patients receive protection. law.

We can follow Malaysia's example in terms of being serious about promoting medical tourism. In 1998, Malaysia formed a national committee to promote medical tourism. One of the breakthroughs is the provision of tax incentives for buildings, medical equipment, training, and promotions while pursuing quality accreditation for each hospital. As a result, Malaysia is now one of the destinations for Indonesians to seek treatment.

Neighboring countries that have previously succeeded in this sector such as Malaysia, Thailand, and Singapore took 15-25 years to develop as they are now. A broad-minded approach is necessary to be willing to learn and collaborate with developed countries in order to develop this health industry sector.

Djoko Santoso
Professor of Medicine at Airlangga University
Head of East Java MUI Health Agency