Report of Tutorial 1 Session 1 Block 4.2 Health System and Disaster Group 5 International Program

Faculty of Medicine Universitas Gadjah Mada

Date : 12 October 2015Time : 10.00 – 12.00 WIBPlace : Discussion room 5 Grha Wiyata, Faculty of Medicine UGM

Chair : Arun Kumar M. 15360Scriber : Gatri Wulandari 15339Members : Kirana Dyah Maharddika 14867Fauzan Ahmad 14870Khaerani Arista Dewi 14885Fitri Kusumastuti 15325Radenmas Wiskara J. 15327Kalsyana Rajendrah 15372

Tutorial Week 1Module Health SystemLearning Unit 1: The Concept of Health System

Title of Scenario: Physician Brain Drain and Global Emigration Step 1 - Defining Unfamiliar Terms

• Affluent community : wealthy community

• Brain Drain : loss of skilled intellectual & technical labor through movement of such lab or to move favourable geo,eco, professional environment to more promising conditions usually by developing countries

• Workforce : people engaged in work

• Global Emigration: people go to foreign countries especially to find job . Action of moving to another country to settle down one of the reason to find a job

• International Medical graduates : complete postgraduate residency / training outside country he/she intend to practice. Organisation supervising in US: American Medical Association

• Regulation : written term/guideline for process system, legal order

• Financing : the act of providing or raising funds or capital, salary & economy, budgets.

• Quality: effectiveness of things. Acknowledgement of standard. Degree of excellence.

• Equity : communities see as fair. Quality of being fair, just, impartial.

Step 2 - Formulating Problems

1. What are the cause & effect of global emigration of medical personnel?

2. Why is there inequity of physician and other health care elements in INDONESIA how does it affect the health outcome ?

3. How to improve quality of health system in INDONESIA to prevent brain drain and manage influx of foreign doctor to INDONESIA (AFTA and etc) ?

Step 3 - Brainstorming

1. What are the cause & effect of global emigration of medical personnel?

• Dimas Wiskara :

o Cause : easier access and easier opportunities to go to INDONESIA, to make new system to provide incoming doctors

o Effect : each country has different expertise

• Khaerani :

o Cause : developed countries give higher salary and incentives than developing countries

• Kirana :

o Effect : our own graduate need to compete with better educated and/or more competent medical

o Cause : ambition to go around the world

• Kalsyana :

o cause: better opportunities postgrad study with better training & med tech usually present.

o Effect : smarter & brighter doctor

• Arun :

o Cause : volunteer to enter NGOs, less racism, less appealing in amenities, social issues

o Effect : remaining workforce higher workload, health qualities can go down help other countries but not that significant

• Gatri :

o Cause : stereotype of working abroad will increase social status .

o Effect : home country will be recognised. Returning workforce will bring back more experience and knowledge

• Fitri :

o Cause : fearful for hazardous & dangerous conditions in rural area, lack of respect from locals

o Effect : centralised health care, burdening travel cost for patient transfer.

• Fauzan :

o Cause : personal issues, failure of health system to manage work force.

o Effect : government improve health system to compete

2. Why is there inequity of physician and other health care elements in ID how does it affect the health outcome ?

• Gatri : infrastructure is less developed in rural area.

• Dimas : high cost for medical education, low income, different standard of rupiah in different provinces

• Fauzan : challenges in logistics.

• Kirana : safety and security of facilities is inadequate

• Arun : mismanagement of financial resources

• Khaerani : tradition & cultural believes that hinders medical assistance.

• Fitri : need payment to develop infrastructures in eastern side of Indonesia

• Kalsyana : difference diagnostic & therapy guidelines. In health facilities

3. How to improve quality of health system in INDONESIA to prevent brain drain and manage influx of foreign doctor to INDONESIA (AFTA and etc) ?

• Arun : standardise procedure to ensure quality, based on merit.

• Fauzan: more incentives, more regulations

• Gatri : more scholarships that require us to return and work in Indonesia

• Khaerani : clean overall system, no KKN.

• Dimas : give more privilege to domestic doctors, increase doctor solidarities

• Kalsyana : open to suggestion & changes

• Ivit : think globally act locally

• Kiki : start from improving education, increase health care standard

Step 4

1. What are the cause & effect of global emigration of medical personnel?

The reason for medical personnels to work abroad :

• Developed countries give higher salary and incentives than developing countries.

• Better opportunities for post graduate studies as developed countries have better training & medical technologies. For examples, plastic surgeon demand is higher in South Korea than in Kenya.

• In certain countries there are systemic racism against certain minorities (i.e. African-American, Papua- Javanese) that may hinder progress in medical personnel such as disparity in wages and nepotism when it comes to promotions.

• Less appealing amenities in rural area. For example, there are less entertainment outlets (i.e shopping malls, movie theatre) to fulfil tertiary needs, it is more common in cities and developed areas.

• Stereotype among general population that working abroad will implies better education, higher standard, and more elite social status.

• Fearful for hazardous & dangerous conditions in rural area, such as unsafe drinking water, wild life, environmental hazard like volcanoes, increase chances of diseases like malaria, also danger of violence from warring tribes.

• Lack of respect from locals toward foreigner, stereotyping foreigner as colonist due to past history.

• Volunteer to enter NGOs which means personal decision made by health personnel to travel and work in less developed country. It was argued that while it would be advantageous for host country, the contribution would be insignificant.

• Easier access and easier opportunities to go to INDONESIA by making a new system that provide incentives and perks for incoming doctors. For example , doctors from Philippines who intend to work in United States of America are deterred because the standard to gain a license to practice medicine is difficult , so they instead choose Indonesia because the standards are more laxed . However this was argued to be detrimental to the local medical graduates and health care personnel as they would given less opportunities to obtain as the position were filled with foreigners. It was suggested instead that health personnel were chosen based on merit instead , reiterating the point pressed earlier in discussion.

• Failure of health system to manage work force. This point was discussed and was found to be too general and vague , as well as the inability of the group to provide a sufficient explanation of what are the components and goals of health system. This point will be researched further in the learning objectives.

Effects of global emigration of medical personnel :

• Our own graduate need to compete with better educated and/or more competent medical yet it is not always that medical personnels from developed countries are better educated and/or more competent. This is because many health personnel from developed countries lack experience in handling many patients due to low patient load as well as handling a rather narrow variety of diseases which may contribute in having difficulties coping with providing adequate health care in developing countries.

• Smarter and brighter doctor which will increase in quality of health care for the host country but simultaneously decreasing health care quality of country of origin.

• When the workforce is overly strain by excessive workload which may produce more mistakes which will decrease the overall health care qualities.

• Each country has different expertise but it was argued that this is not very common because each country is usually proficient in many aspect of health care and the example given plastic surgery in South Korea is an exceptional example.

• Home country will be recognised by internationally and improve the image of the country in the eyes of the world.

• Returning workforce will bring back more experience and knowledge but the major obstacle is that people are not returning and choose to remain in their host country

• Centralised health care in certain areas than others cause burdening travel cost to transfer patient

• Government improve health system to compete, however this was argued that because systemic corruption this form of action is challenging to execute.

2. Why is there inequity of physician and other health care elements in Indonesia and how does it affect the health outcome ?

Inequity exist because of of various reasons:

• One of them is basic infrastructure such as roads and electricity is less developed in rural areas, thus make it hard to transfer patients out to healthcare center, deliver medicines into desired places, and send medical personnel to patients in need. Without medical personnel they need, they cannot be taken care of correctly. If we are having difficulties sending the medicines, some of the healthcare center will not have enough of required drugs for the patient. If there are emergencies, mortality would be higher since it’s hard to be mobile. Therefore will decrease the health status.

• Health instrument for diagnostic and therapy sometimes outdated and different in rural areas therefore challenging for medical personnel who work there, so only those who are trained well who might work there.

• This is compounded by the difficulty of the government and contractors to build the needed infrastructure and public facilities as the local people often demand payment to allow the development to be carried out.

• This in turn will endanger the security and safety of health care personnel, especially if the facilities lack the required security features. Such was discussed in previous question that sometimes there are war tribes or even there is none, the medical personnel are afraid and hesitating to go to work there. When only little who wants to work there to take care of many locals, the health services would be ineffective.

• There are a lot of mismanagement of finances happening in Indonesia, such as corruptions and bribery, that disrupt what supposed to be solution for rural areas healthcare problems and improvement for development.

• There are also traditional believes and culture as our challenge because in Indonesia, locals believe in alternative solution. They tend to go to in witch doctor to solve their problems and tend to think that their diseases are caused by curses. These alternative solutions are not evidence based and may not be save for patients. There are some rituals that also medically dangerous to be done.

• Lack of trust for doctor is also one of the reason, adding to previous answer, some locals might reject the doctor’s practice because they believe more to witch doctor or even just dislike the practice of medicine.

• Indonesia is country with many islands and highly populated country. The economy and education status of its population has many spectrums. There are people who are professors with many degrees and there are people who cannot read and write. Their comprehension to medical information and their ability to afford medical care is different. Those who understand and comply to medical information also can afford medical care will probably have better health outcome than those who are unable to do so.

3. How to improve quality of health system in INDONESIA to prevent brain drain and manage influx of foreign doctor to INDONESIA (AFTA and etc) ?

• Create some guideline of standardisation to ensure quality and to give incentives and promotions based on merit, means that giving appropriate rewards based on their qualities when they are doing their job.

• Give more incentives such as added facilities and increase salary to those working in their home country. But it was argued that even though it would be great for doctors, it is not that simple with our country economics conditions right now.

• Produce more regulations to filter illegal and/ or incompetent doctor who are coming from other countries

• There are a lot of scholarship available for student to study abroad and from the exposure to probable better opportunities, brain drain might happen. Indonesia now, has more scholarship than it was before but it would be better if most of the scholarships required the obtainers to return and work in Indonesia. We can also took example from India who start to give deadlines to Indian workers in US to eventually return and work in their home country.

• Build a clean system, free of corruption, collusion and nepotism by strengthening our law enforcement and choosing good policy maker.

• Give more privilege to domestic doctor rather than foreigner doctor who work in Indonesia, so there will be low problem on competition. Yet this was argued because it would be unfair, some domestic doctor can be as good as foreigner and as incompetent as them. So any rewards should be based on how they work regardless.

• Increase Indonesian doctor solidarity by strengthening the organisation, building inner pride and motivation to improve home nation.

• We need to start improving education level of people in Indonesia and create standardise regulation for medical personnel qualities worldwide so they all can work anywhere without borders and still be qualified since our basic purpose as medical personnel is the same. But the challenges would be a lot since we have different languages and different type of diseases in different countries.

• Start to think globally and act locally, means we need to increase our standard as well as those abroad and utilised our ability in our own country so we can improve and be as good as others.

• Basically to solve problems is to be open to suggestion and changes, we need to learn from past mistakes what are our obstacles in the past that are significant and then we can do system evaluation. From that we can improve our health system quality. Yet we need to know what are really the obstacle in improving our health system and how to overcome it systematically, therefore it will be discussed further on the next meeting.

MIND MAP

LO :

1.What are the component and goals of health system ? Compare Health system in Indonesia compare to an ideal health system and how to improve it? ( financing, education & regulation)

2. What are the obstacles to achieve the goals?

3. Example of strategies to overcome these obstacles?

Health System

ComponentBrain Drain

Inequity

Reason

Effect

Objectives Improvement

Problems

?

?

?

Strategies ?