NURSE ‘SURPLUS’ IN INDONESIA: THREAT OR OPPORTUNITY?

By: Agus Suwandono, Muharso, Anhari Achadi and Ketut Aryastami
Human resources on health (HRH) in Indonesia include all persons engaged in healing and rehabilitation of peoples suffering of illnesses as well as promoting and maintenance of peoples’ health status. They can be the communities who support those with disease problems (informal) to professionals that provide health cares (formal). HRH is considered as one of the important component in the 1982 National Health System in Indonesia (NHSI), and it is placed significantly as a major sub-system and one of the most pertinent health policies in the 2003 New National Health System in Indonesia (NNHSI). In this particular paper, the general discussion will be merely concentrated at the nurses in Indonesia, and it will be focused at the nurses in Indonesia for foreign countries. This concentration is selected due to the subject is considered as one of the most complicated and complex effort in improving the effectiveness and efficiency of HRH in Indonesia.
The total academic of nurses and health poly-technique for nurses in Indonesia is 409 schools; with the total prediction of nurse production are approximately 22,000 persons per year (reported about 18,000 nurses in 2004). The total absorptive capacity by public health sector within this five year of health development period is in exceed of 2000-3000 persons per year, while the total absorptive capacity by private health sector is vary and depend on situation with approximately 1000 – 2000 persons per year.
Unequal distribution of nurses in Indonesia is still a serious problem in Indonesia. Concentration of nurses is in the big cities and surrounding areas of Java and other big islands. Difficulties of geographic with lack of transportation and infrastructure facilities in most areas outside of Java, Bali and Sumatra islands cause rejection of nurses to be placement in those areas Decentralization policy in health and other sectors has been started since 2001. This sudden and new policy of the Government of Indonesia has caused some uncertainty of local HRH policies including to the placement of nurses. While low salary, lack of facilities and uncertainty of future carrier of nurses are also considered as other importance factors for unequal distribution of nurses in Indonesia.
The above conditions have created a discrepancy of nurse production and placements with approximately more than 15,000 nurses do not get proper placements. Or, in other words, there has been a ‘surplus’ of roughly 15,000 nurses per year in Indonesia. On the other hand, there are opportunities for Indonesia to send nurses abroad due to high needs of nurses from neighboring countries (i.e. Malaysia, Singapore, Australia), middle-east countries (i.e. Saudi Arabia, Abu Dhabi etc.), European countries (the Netherlands, Germany etc.) and USA. The Government of Indonesia has also encouraged for placement of Indonesian manpower especially for nurses to work abroad for improving countries foreign reserves and reducing jobless in Indonesia.
HEALTH SYSTEM AND HRH IN INDONESIA
The policy of health development in Indonesia is based on the Health Law no. 23/1992 and several regulations or decrees based on this law as well as other health related laws. The Minister of Health Decree to the 2003 New National Health System in Indonesia (NNHSI), the concept of Healthy Indonesia 2010, and some ratification documents made by the Government of Indonesia (GOI) to the global health commitments such as roll back malaria, 3 by 5, millennium development goals and so forth have directed the health policy in Indonesia to be more specific strategies or programs of health development in Indonesia.
It is clearly stated in all of those stewardships direction, particularly by the Minister of Health Decree to the 2003 NNHSI that HRH is one of the most important subsystems of NNHSI framework in Indonesia. The other subsystems of NNHSI are health services, health financing, health management, drugs and health equipments, and community empowerment. NNHSI is a stewardship document covered all of the Indonesian integrated efforts to guarantee the achievement of the health status of Indonesian to the highest possible degree. The NNHSI objective is to ensure the implementation of health development by all nation potentials, public, private and community, in synergizing optimally, efficiently and effectively in order to achieve the highest possible degree of Indonesian health status. The basic principles of NNHSI are humanity, human right, equity and fairness, community empowerment and self-sufficient, partnership, priority and efficiency, and effectiveness.
The subsystem of health services is a NNHSI subsystem directed all of public and private health care services integratedly and to support each other in achieving the highest possible degree of Indonesian health status. The objective of this sub-system is the implementation of accessible, affordable and high quality of health care services in Indonesia as a part of overall health development in Indonesia. The basic principles are: 1. The public health care services should be carried out by the GOI with community involvement and 2. The private health care services should be implemented by GOI, community and private sectors. The implementation of public and private health care services should be comprehensive, integrated, retain sustainability, affordability, high quality and gradually. The public and private health care services should be professional, based on nation morale, ethics and follow on the development of health knowledge and technologies.
The subsystem of health financing is a NNHSI sub-system directed all of efforts in collecting, alocating and spending of health budget integratedly and to support each other in achieving the highest possible degree of Indonesian health status. The objective of this sub-system is the availability of sufficient health budget, the fairness of health budget allocation and the efficiency as well as effectiveness of health budget spending for health care services in Indonesia as a part of overall health development in Indonesia. The basic principles are: 1. Health budget should be sufficiently available and it should be managed transparently, 2. The GOI budget should be used particularly in increasing the public and private health care services for disadvantaged communities; 3. The community budget for private health care services should be organized effectively and efficiently for compulsory health insurance system with additional benefit as needed voluntarily, 4. The compulsory health insurance for private health care services is a part of overall scheme of compulsory social insurance in Indonesia, and 5. The application of health financing in Indonesia should be based on the public-private mix partnership.
The subsystem of human resources on health (HRH) is a NNHSI subsystem covered all of integrated planning, training, education and utilization of HRH in Indonesia and to support each other in achieving the highest possible degree of Indonesian health status. The objective of this sub-system is the availability of high quality of HRH, the fairness distribution of HRH, and the effectiveness and efficiency HRH utilization to realize the highest achievement of health development in Indonesia. The basic principles are: 1. Production of HRH covering number, types and qualification based on the need and demand of the local and international markets, 2. Appropriate utilization of HRH concerning particular attention to the equity, welfare and fairness aspects of HRH, 3. Improvement of the HRH quality which are focused at the advancement of health knowledge and technologies, moral and performance based on the religion and professional ethics, and 4. Career development should be carried out objectively and transparency based on their working performances and national The subsystem of drugs and health equipments is a NNHSI subsystem directed all of integrated efforts to ensure the availability, equity and quality of drugs and health equipments in Indonesia and to support each other in achieving the highest possible degree of Indonesian health status. The objective of this sub-system is the availability of safe, effective, affordable and high quality of drugs and health equipments to realize the highest achievement of health development in Indonesia. The basic principles are: 1. Drugs and health equipments as one of the human basic needs cannot only be treated as economic commodities, 2. Basic drugs and health equipments as public needs should be ensured their availability and affordability, 3. Drugs and health equipments should not be promoted improperly and exaggeratedly, 4. The circulation and utilization of drugs and health equipments should be in line with laws, ethics and morale of Indonesian, 5. Optimizing of national drugs and health equipment industries should concern with their variability and competitiveness, 6. Hospital and other health care services should be standardized based on the standard list of national essential drugs, 7. Drugs and health equipments should be managed nationally with high concern in quality, usefulness, price, accessibility and safety, 8. High quality, safe, scientific tested and effective effects of traditional drugs should be developed and improved, 9. Drugs and health equipments safety should be carried out since their production, distribution and utilization, and 10. Further policy of national drugs and health equipments should be decided by GOI and other related components.
The subsystem of community empowerment is a NNHSI subsystem covered all of integrated health efforts of personals, groups and communities in Indonesia and to support each other in achieving the highest possible degree of Indonesian health status. The objective of this sub-system is the availability of effective and efficient health care services, health and social advocated, health and social monitoring by personals, groups and communities to realize the highest achievement of health development in Indonesia. The basic principles are: 1. Promotion of personals, groups and communities based health care services, 2. Empowerment of community voices and choices, 3. Improvement of community awareness, willingness and abilities in health development, 4. Improvement of openness, responsiveness and responsibility of GOI to empower the community, 5. Improvement of partnership and mutual self-help.
The subsystem of health management is a NNHSI subsystem covered all of integrated health data and information system, health knowledge and technology application, law enforcement and health administration in Indonesia and to support each other in achieving the highest possible degree of Indonesian health status. The objective of this sub-system is the availability of high quality of health information system, health knowledge and technology support, law and health administration application to realize the highest achievement of health development in Indonesia. The basic principles are: 1. Empowerment of evidence based health development supported by high quality of health information system, health knowledge and technology, morale and professional ethics, 2. Certainty of health law and health administration discipline, 3. Anticipation to the global health development and enforcement of decentralization and local autonomy policy, 4. Development of self sufficient, inter-sector coordination and involvement of community as well as private sectors, 5. Application and coordination of all subsystems within the Indonesian health system.

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