The significant rise in the global life expectancy in 20th century is due to the role played by Health system. The improvement is continuing and that promoted the wellness of most of the world’s population (Constantin, 2014). The backbone of each health system is the health workforce. Health workforce is the lubricant that leads to smooth implementation of the health action for development of sustainable socioeconomic condition (Bowser et al., 2013). According to Constantin (2014) there is a positive correlation between the density of the health workforce and the positive health outcomes. The purpose of the assignment is to prepare a national health workforce plan for Indonesia. Indonesia is in the category of lower middle income countries as defined by World Health organisation (WHO). The rationale for the chosen country is the short fall of the health workers as identified in the latest report of by WHO (WHO, 2017). There is a need to address the issue of health workforce shortage as it is the health workers who save people’s life and improve their health. Increasing the health workforce will help the country gain enough coverage for important health interventions (Campbell et al., 2015). The report presents the environmental scan for health workforce of the selected country. It is followed by the data profile of the health workforce by category using the data provided by WHO. Further, the report identifies the critical issues to be addressed in the workforce plan using the literature review. Lastly, using the set of ten recommendations developed in the 2016 report of WHO as a framework, strategies will be developed to implement the five-year strategic workforce plan.
Indonesia health workforce
After the decentralization in Indonesia in 2001, the district governments have given the direct authority to the prioritizing sectors for the development. After this, the Human Resource for Health (HRH) planning was greatly in the hands of the regional governments. This decision resulted in the diverse funding and HRH challenges that are faced in the regions (Diana, Hollingworth & Marks, 2015). There is inadequate distribution of doctors and physicians with a density ranging from 10.36 per 100,000 populations to 53.89 per 100,000 populations in Lampung Province and North Sulawesi Province respectively as reported by World Health Organization (WHO) in global health workforce alliance report (Kurniati et al., 2015). Apart from the inequitable workforce distribution, there are issues regarding the HRH planning, recruitment and heath workforce retention which results in import from the neighboring countries.
According to Rokx, (2010) there is inadequate wages as the majority of the health workers in the public sector have second jobs resulting in poor quality of care that is associated with oversight lack and effective licensing in the private sector. In Indonesia, there is low number of physicians in the rural areas as the retention rate is less due to professional isolation and heavy workloads. Due to lack of proper developmental plans and concomitant efforts to deploy the healthcare personnel resulted in heavy world load and low retention pushing them to find jobs in the urban areas or out of the country. There is also lack of supplies and equipments that act as deterrent for the personnel to accept the job positions in the underserved and rural areas. The geographical location is the main reason for the scenario of poor health workforce. There are difficult terrains and its vast size put an enormous barrier and obstacle in the health system and distribution of the health professionals. The healthcare personnel are reluctant to go and relocate themselves in the forest locations and remote islands and results in poor communication, lack of professional practice and family amenities. The private practice is also done on low income and so it has led to the migration of the healthcare professionals to urban or high income-countries resulting in weak health workforce (Short, Marcus & Balasubramanian, 2016).
Data profile of the health workforce
The data profile in the Indonesia health workforce shows that there is a decline in the number of healthcare personnel during the years from 2010 to 2015. According to the 2015 census, there is a decrease in the number of dental practitioners, nursing and midwifery practitioners, pharmacy practitioners, medical and non-medical practitioners and medical technologists. There is decline in the number from 38.664 in 2010 to 32.633 in 2015 and however, there was an increase in the nurses and midwifes from 267.455 to 314.347 since 2010. In the year 2015, there were 45,445 medical practitioners, 31,590 dental practitioners, pharmacy practitioners were 20,018 and nursing and midwifery practitioners were 366,845 from 2010 onwards. Non-medical and medical health practitioners were 55,962, medical technologists were 15,662 and support staff and health management were 210,665 during the year 2015 in Indonesia. This shows that there is an increase in the total number of health workforce from 65% from 428,440 in 2010 to 688,950 in 2015. However, despite of the increase in the health workforce from the year 2010 to 2015, there is a significant decrease in the number of health workers that would support the workforce in the last two years (Dussault et al., 2016).
Critical issues in health workforce
There are many critical issues that are pertaining in Indonesia’s health workforce. The underlying issue is the human resource for health (HRH) related to policy, quality, imbalance between production and demand, planning, mal-distribution and renumeration. There is a critical level of shortage in the HRHs that would address the underlying issues that follows in the Indonesian health workforce (Rumsey et al., 2016). There is a high shortage and mal-distribution of healthcare professionals with the rural areas being understaffed. There is a highly underfunded and fragmented health system that is limited with respect to technical and allocative health system and insurance system. This results in low productivity, major shortages in the nurses, physicians and specialists and human resources that pose a challenge to the weak health workforce. The geographical imbalance is also a major issue where there is a great disparity between the urban and rural areas and the healthcare personnel are unable to meet the specific needs of the population and resulting weak workforce. In Indonesia, there is a geographical imbalance due to the vast geography that is making difficult for the doctors to be placed in deserted areas, no scope for practice and poor communication (Becker, 2017).
There is mal-distribution of human resources and the primary concern is the nurse and physician workforce as they are likely to settle in the inner suburbs due to employment opportunities, education, professional development and other amenities. There is also lack of professionalism where the healthcare personnel have non-compliance with the good healthcare protocols and practices and resulting absenteeism (Reich et al., 2016). There is uneven deployment, low motivation among the health workforce and lack of planning that is focused on the needs of the private-public capacity building. Nurses’ shortage is also a major issue where there is imbalance between the doctors to nurse ratio. In the intensive care units, there is a sharp decline in the registered nurses and in the operating rooms which reflect that the nurses who are working in this particular setting are retiring or have reduced shift hours. There is less per capita population of the healthcare workers in the Indonesian workforce who are employed across the country. The skill mix of nurse to doctor ratio has many consequences as it is a low income country. There are also services and institutional imbalances where in some places, there are too many staffs and some places are understaffed (Meliala, Hort & Trisnantoro, 2013). These issues illustrates that the Indonesian health workforce is poor due to these obstacles that have an impact on the health and well-being of the service users and also the health workforce and system as a whole. Therefore, there is a need for the proper HRH planning, implementation and maintenance and retention of the workforce in Indonesia.
Strategies relevant to implement the workplace plan
The proposed strategies for the health workforce plan is based on the recommendations of the “High-Level Commission on Health Employment and Economic Growth” published by WHO in its 2016 report “Working for health and growth: investing in the health workforce”. These recommendations by the commission were developed to minimise the projected shortfall of the health workforce in low and lower middle income countries by 2030 (Bangdiwala et al., 2017). The WHO strategic framework relates to the changes, in the delivery of the health service, health employment, health education, and maximisation of future investment returns. The WHO recommendations to transform the health workforce cover job creation, humanitarian setting, health service organisation, financing, technology, partnership and cooperation, education and training, gender equality and rights, data information and accountability, and international migration (WHO, 2017).
The first strategy is to introduce a new program for the health care graduates which mandate a six month of service in the rural and remote areas. This strategy will help increase the number of the health care professionals in the remote areas which is the short term outcome. The long term outcome of this strategy is elimination of gap in the distribution of health employees between rural and urban areas. This strategy includes facilitation of easy accessibility to specialist education. The compulsory contract should be supported with lucrative offers such as performance pay incentive in addition to free clothing, and accommodation. It may limit the workers leaving rural areas soon after completion of the contract (Ghimire et al., 2013). To increase the workforce in the rural areas for long term other programmes such as the rural recruitment training can be initiated for increasing the distribution of midwives and nurses (Dickson et al., 2014).
The second strategy is to strengthen collaboration between public and private sectors and different agencies to meet the increasing demand for human resources for health. It will not create opportunities for the health workers in professional development but also increase mobilisation of resources to HRH (Kurniati et al., 2015).
The third strategy is to convert the most eligible health workers on the local and state contracts to permanent civil service status. It must also include offering a lucrative payment, so that the health workers can be retained and motivated. In addition financial and non-financial incentives should be adequately monitored and evaluated. It will assist in maintaining balance of the health workers in the public and the private sectors. This will be the long term outcome because economic factors play a vital role in the health worker’s decision to remain in the sector (Ghimire et al., 2013). According to the study executed by Araujo et al., (2016) financial incentives lead to increase in the health worker productivity, better quality health services and decreased the informal fees of the users.
The fourth strategy is to improve the quality of care by developing stringent licensing in the private sector. It will help prevent the health workers in the public sector from undertaking second job in the private sector. Eliminating the lack of oversight will facilitate improvement of quality of care delivered by health workers in the public sector (Beers, 2015). Increasing the quality of care will consequently increase the life expectancy of people (Constantin, 2014).
Fifth strategy- Indonesia must urgently implement the global code of practice for recruiting the health professional for planning and managing the human resource for heath (HRH). Together with the personnel the country must develop guidelines for health workers working abroad and for recruiting highly qualified workers to Indonesia. The long term outcome of this strategy is the mobilisation of additional resources for HRH. In addition it will also facilitate multi-stakeholder coordination for HRH (Campbell et al., 2015). This strategy is aimed at increasing the number of migrant and local health workers (Kurniati et al., 2015). The sixth strategy for Indonesia health workforce improvement is to increase the budget of HRH. Particularly in rural areas the service provision is becoming difficult due to the limited budget. Therefore, for this areas there is a need of increasing the allowances from the state budget (Bowser et al., 2013).
The seventh strategy is to facilitate continuing professional development of the health care workers through education and training. According to the study executed by Lee, et al., (2016) education and training has been found to motivate the health workers to reduce attrition. The training and education programme must focus on cultural competency of the health workers. It includes training on skills and local languages to meet the needs of migrant workers. Training the workers to meet the regional standards may aid in the distribution of the workers. By developing open online courses updated knowledge can be provided to the health care professionals. Consequently, it will eliminate the need for the physicians to travel overseas and eliminate the risk of losing potential candidate (Bangdiwala et al., 2017). According to Davis & Rayburn (2016) continuing professional development in any sector act as a tool for job satisfaction. Further, it was found that ongoing learning increases professionalism and retention of the midwives.
The eighth strategy is to improve supervision and management to enhance job satisfaction. It must include recognition of achievements, provision of adequate technical support, delegation, effective communication, and clear roles and responsibilities. Adherence to the code of conduct must be monitored (Piette et al., 2016). These elements are critical to care quality and performance of the health system.
It is evident from the literature review that Indonesia is currently facing severe shortage of the health care workforce due to inequitable distribution of physicians and challenges related to the retention of the health workers, and quality of care due to effective licensing in the private sector. The critical challenges for HRH in Indonesia are related to policy, planning and production. The effect of the health workforce crisis is certainly worse with increased morbidity, mortality and health care cost. The backbone of each health system is the health workforce. This backbone must be strengthened by increasing the density of the health workforce. Recognising these challenges to HRH and critical issues related to health workforce several strategies have been developed to strengthen the health system of Indonesia. It includes innovative incentive strategies, improved education and training opportunities, mitigating gap in distribution of health worker between public and private sector and between rural and urban areas. The strategy of multi-stakeholder engagement will assist the country’s efforts to achieve the Universal Health Coverage. The expected outcome of the overall strategic planning is ensuring optimal quality care in Indonesia by smooth implementation of the health action. However, there is a paucity of evidence on exact factors that contribute to health workers’ motivation, satisfaction and retention. This information is critical for development of effective workforce planning and policy in the health sector. Other than that there is a need of continued research and evaluation to strengthen the knowledge base of country specific strategies to mitigate the shortage of health workforce and decrease the inequalities in accession of health care services.
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