Factors Associated With Working in Remote Indonesia: A National Cross-Sectional Study of Early-Career Doctors

Identifying Physician Public Health Competencies to Address Healthcare Needs in Underserved, Border, and Outer Island Areas of Indonesia: A Rapid Assessment

Phenomenon: Most medical schools in Indonesia have developed innovations to integrate public health content into the curricula. However, ensuring that all schools meet appropriate standards regarding the quality of subjects, content relevancy, and course delivery takes time and effort. Approach: This study employed a rapid assessment procedure to identify the current knowledge and competencies required to practice medicine effectively in underserved, border, and outer island areas of Indonesia. Ninety-three participants from six remote districts were involved in 12 focus group discussions. Qualitative data were analyzed using content analysis using the social determinants of health as a guiding framework. Findings: Under decentralized health system governance, the local socio-geographical context is critical to understanding the current public health landscape. Medical education with respect to public health must emphasize physicians' ability to advocate and encourage the coordination of healthcare services in responding to disasters, as well as community-based surveillance and other relevant data for synergistic disease control. As part of a healthcare facility management team, prospective doctors should be able to apply systems thinking and provide critical input to improve service delivery at local health facilities. Also, recognizing underlying factors is essential to realizing effective interprofessional collaboration practices and aligning them with leadership skills. Insights: This study outlines recommendations for medical schools and relevant colleges in formulating compulsory block or integrated public health curricula. It also provides a public health learning topic that may aid medical schools in training their students to be competent for practice in underserved, border, and outer island areas. Medical schools should offer initiatives for students to acquire the necessary public health competencies merited by the population's health needs.

Social accountability in a medical school: is it sufficient? A regional medical school curriculum and approaches to equip graduates for rural and remote medical services

BACKGROUND

Social accountability is increasingly integral to medical education, aligning health systems with community needs. Universitas Pattimura's Faculty of Medicine (FMUP) enhances this through a curriculum that prepares graduates for rural and remote (RR) medical practice, exceeding national standards. The impact of this curriculum on graduate readiness in actual work settings remains unassessed.

OBJECTIVE

This study was conducted to capture the perspectives of FMUP medical graduates in a rural-centric curriculum, focusing on the teaching and learning opportunities afforded to them during their medical education. These insights are crucial for evaluating the accountability of regional medical schools in delivering quality service, particularly in underserved areas.

METHODS

Semistructured interviews were conducted with nine FMUP graduates employed in the RR areas of Maluku Province. A qualitative analysis was employed to examine graduates' views on the curriculum concerning medical school accountability.

RESULTS

The FMUP curriculum, informed by social accountability principles, partially prepares graduates to work under Maluku's RR conditions. However, it was reported by participants that their skills and preparedness often fall short in the face of substandard working environments.

CONCLUSIONS

The FMUP curriculum supports the government's aim to develop an RR medical workforce. However, the curriculum's social accountability and rural emphasis fall short of addressing community health needs amid inadequate practice conditions. Political investment in standardizing medical facilities and equipment is essential for enhancing graduates' effectiveness and health outcomes in RR communities.

Teledermatology to Improve Access to and Quality of Skin Care in Eastern Indonesia

Skin diseases are a major public health concern in Indonesia, although access to specialized care in remote areas is limited. We initiated a low-cost teledermatology service in Sumba, a remote island in eastern Indonesia. Eighteen healthcare workers (HCWs) at five primary healthcare centers received training to manage common skin diseases and submit clinical cases beyond their expertise to an online platform. Submitted cases were reviewed by at least one dermatologist. Diagnostic agreement between HCWs and dermatologists was calculated. The HCWs participated in a satisfaction survey 2 years after project initiation. Since October 2020, of 10,384 patients presenting with skin complaints in a 24-month period, 307 (3%) were submitted for a teledermatology consultation. The most frequent skin diseases were infections and infestations (n = 162, 52.8%) and eczematous (85, 27.7%) and inflammatory (17, 5.5%) conditions. Fifty-three patients (17.3%) were diagnosed with a neglected tropical skin disease, including leprosy and scabies. Dermatologist advice was provided within a median of 50 minutes (interquartile range, 18-255 minutes), with 91.9% of consultations occurring within 24 hours. The diagnostic agreement level between HCWs and dermatologists significantly improved over time, from 46.9% in the first 6-month period (κ = 0.45; 95% CI, 0.37-0.54) to 77.2% in the last 6-month period (κ = 0.76; 95% CI, 0.67-0.86; global P < 0.001). The HCWs reported that the teledermatology service was extremely/very useful in supporting daily practice (100%) and improved their knowledge of skin diseases tremendously/a lot (92%). Teledermatology can improve accessibility and quality of skin services in medically underserved areas, providing opportunities for scalability and knowledge transfer to frontline HCWs.

Attracting, Recruiting, and Retaining Medical Workforce: A Case Study in a Remote Province of Indonesia

Indonesia, one of the Asia Pacific low-and middle-income countries (LMICs), has suffered from a chronic medical workforce shortage. However, there are limited published studies describing the approaches implemented by the Indonesian government regarding the recruitment and retention of the medical workforce. This case study aimed to understand the current practices for recruitment and retention of the medical workforce in Indonesian rural and remote provinces. We conducted a case study of the Maluku Province of Indonesia with a document analysis and key informant interviews with officials responsible for medical workforce recruitment and retention. We used the World Health Organization's (WHO) guidelines as an analytical matrix to examine the recruitment and retention practices under the four domains of (i) educational, (ii) regulatory, (iii) financial, and (iv) professional and personal development and classified them into either University/Medical School level or Government/Non-government level. Our findings suggest that Indonesia implemented most of the WHO-recommended medical workforce recruitment and retention strategies. However, implementation is still problematic; hence, the aim of establishing an adequate, sustainable medical workforce has not been reached. Nationwide government intervention in educational aspects is important to magnify the impact of regional medical school initiatives. Relevant programmes must be re-evaluated and re-enforced concerning significance, comprehensiveness, and effectiveness for a sustainable rural and remote medical workforce.

Commitments, Conditions and Corruption: An Interpretative Phenomenological Analysis of Physician Recruitment and Retention Experiences in Indonesia

Complex factors influence physicians’ decisions to remain in rural and remote (RR) practice. Indonesia, particularly, has various degrees of poor governance contributing to physicians’ decisions to stay or leave RR practice. However, there is a paucity of literature exploring the phenomenon from the perspective of Indonesian RR physicians. This study explores physicians’ lived experiences working and living in Indonesian RR areas and the motivations that underpin their decisions to remain in the RR settings. An interpretative phenomenological analysis was utilised to explore the experiences of 26 consenting voluntary participants currently working in the RR areas of Maluku Province. A focus group discussion was undertaken with post-interns (n = 7), and semi-structured interviews were undertaken with junior (n = 9) and senior physicians (n = 10) working in district hospitals and RR health centres. Corruption was identified as an overarching theme that was referred to in all of the derived themes. Corruption adversely affected physicians’ lives, work and careers and influenced their motivation to remain working in Indonesia’s RR districts. Addressing the RR workforce shortage requires political action to reduce corruptive practice in the districts’ governance. Establishing a partnership with regional medical schools could assist in implementing evidence-based strategies to improve workforce recruitment, development, and retention of the RR medical workforce.

Doctor Placement’s Policy and Its Implications in Indonesia: Legal Qualitative Study

BACKGROUND: Remote, Underdeveloped Areas, Frontiers, and Islands (RUAFI) in Indonesia have a less equal distribution of doctors compared to other more developed areas, causing a decline in healthcare service quality in RUAFI and the health degree of the overall population. AIM: This research aims to describe the policy and the implication of doctor distribution in Indonesia and to provide a proportional justice-based doctor distribution policy concept. METHODS: This is a mixed qualitative research of juridical-normative and literature review. The laws that regulate the distribution of doctors in Indonesia are the 1945 Constitution, Law No. 36 of 2009, Law No. 26 of 2014, Governmental Decree No. 67 of 2019, Presidential Decree No. 72 of 2012, and the Decree of the Minister of Health No. 16 of 2017. RESULTS: The unequal doctor distribution is mainly caused by the low motivation for recruitment and retention in RUAFI. The affecting factors include disparity of incentives between doctors, low regional government involvement in the healthcare system in RUAFI, and the lack of career development for doctors being placed in RUAFI. CONCLUSION: The concept of proportional justicebased policy proposed is as follows: (a) Intensive proportionality between doctors and other types of health workers, (b) a direct regional government function of control, and (c) providing career and educational prospects.

Factors associated with the rural and remote practice of medical workforce in Maluku Islands of Indonesia: a cross-sectional study

BACKGROUND

Many factors contribute to engagement in rural and remote (RR) medical practice, but little is known about the factors associated with rural and remote medical practice in such remote locations as the Maluku Province of Indonesia. This study describes factors associated with actual RR practice, preferred RR practice, and intention to remain practice in Maluku Province.

METHODS

An online survey of work-related experience and intentions for future rural work was administered to 410 doctors working in the Maluku province of Indonesia. Participant characteristics were described using descriptive statistics, associations between the independent variables with the location of the workforce, intention to remain practice in Maluku, preference for future RR practice in Maluku were analysed using Chi-square tests and logistic regression.

RESULTS

A total of 324 responses (79% response rate) were recorded, comprising 70% females and 30% Pattimura University graduates of doctors employed in Maluku. Doctors working in RR areas were more likely to be a GP (OR 3.49, CI 1.03-11.8), have a monthly salary of more than IDR 6 million (OR 11.5, CI 4.24-31.1), and have no additional practice (OR 2.78, CI 1.34-5.78). Doctors intended to stay practice in Maluku were more likely to be born in Maluku (OR 7.77, CI 3.42-17.7) and have graduated from Pattimura University (OR 3.06, CI 1.09-8.54), and less likely to be a temporary employee (OR 0.24, CI 0.10-0.57). Doctors who prefer future RR practice in Maluku were more likely to experience rural living (OR 2.05 CI 1.05-3.99), have a positive indication of the impact of community exposure during medical schools on their current practice (OR 2.08, CI 1.06-4.09), currently practising in RR Maluku (OR 8.23, CI 3.27-20.8); and less likely to have bigger take-home pay (OR 0.30, CI 0.13-0.70).

CONCLUSION

This study indicates that special attention should be given to recruiting doctors with a rural background and ongoing support through attractive opportunities to build a sustainable RR workforce. Since a regional medical school helps supply doctors to the RR areas in its region, a sustained collaboration between medical schools and local government implementing relevant strategies are needed to widen participation and improve the recruitment and retention of RR doctors.