nursing and health care in indonesia

HEALTH AND NURSING POLICY ISSUES

Nursing and health care in Indonesia

Linda Shields PhD RN FRCNA

Professor of Nursing, Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland

and Lucia Endang Hartati YK MN BN

Senior Lecturer, Akademi Keperawatan, Semarang, Central Java, Indonesia

Submitted for publication 9 January 2003

Accepted for publication 16 June 2003

Correspondence:

Linda Shields,

Department of Nursing and Midwifery,

University of Limerick,

Limerick,

Ireland.

E-mail: [email protected]

SHIELDS L. & HARTATI L.E. (2003)SHIELDS L. & HARTATI L.E. (2003) Journal of Advanced Nursing 44(2), 209–

216

Nursing and health care in Indonesia

Aim. Indonesia, with its population of over 220 million, has health problems

similar to those of other developing countries. In an attempt to provide nurses

throughout the world with knowledge about Indonesia, we describe the country, its

health system, and problems encountered by nurses and other health professionals.

Method. We explain the way the health system works within Indonesian culture,

discuss the effects of the international nursing shortage and outline the role of aid

agencies. The ethical dilemmas faced by health professionals who care for patients

within a poorly resourced system are examined. While the information pertains to

the whole country, we focus on the main island of Java, as that is where we have

worked and resided.

Findings. Nursing education is primarily conducted at senior high school, while

medical education is similar to the university education offered in many countries, and

allied health professionals are educated to varying standards. Indonesian health

officials recognize that the low standard of nursing education contributes to poor

health statistics, and they are working hard to improve this. There has been strong

support from the government for the implementation of university education for

nurses, and for courses within academies that bridge the gap between current

standards and the levels of education required for the delivery of optimum health care.

Discussion. We both are nurses. One of us is an Indonesian and the other has worked

for many years in Indonesia and coordinated a programme that organized exchanges

of health professionals working in large tertiary referral hospitals and health

departments in Indonesia and Australia. The information presented here is the result

of many collaborative projects and gives information not available in published

works.

Keywords: nursing, Indonesia, Java, health services, developing country,

humanitarian aid

Introduction

Indonesia is one of the world’s most heavily populated

countries. Its health system is similar to that of other

developing countries, and serves the culturally diverse pop-

ulation of the Indonesian archipelago. The aim of our paper

is to provide knowledge about nursing care, education of

nurses and other health professionals, and ethical dilemmas

encountered by Indonesian health professionals. Through this

paper, nurses in developed countries with well-resourced

health services may gain insights into working within

minimal budgets, and providing care to patients with

� 2003 Blackwell Publishing Ltd 209

conditions related to poverty, under-development and trop-

ical environments. Care delivery within Javanese culture (the

predominant culture in the Indonesian archipelago) is also

discussed. One of us (LEH) is an Indonesian, the other

Australian (LS). We have collaborated on projects in Central

Java, including an exchange programme of health profes-

sionals between Dr Kariadi Hospital, Semarang (the main

tertiary referral hospital for Central Java), community health

facilities of the Health Department of Central Java and the

Mater Misericordiae Hospitals in Brisbane, Australia.

In this paper, we provide historical and demographic

background material in order to explain contexts of nursing

in Indonesia. This is followed by descriptions of nursing,

further information about health systems and education of

health professionals, accounts of ethical dilemmas faced by

health professionals, and effects of overseas aid. While the

systems described exist throughout Indonesia, most work for

this paper was carried out in Java, the main island. Conse-

quently, specific cultural references are to Javanese people.

However, our comments are generalizable to all Indonesia.

Background

The Republic of Indonesia is situated on 13 000 islands lying

across the equator, north-west of Australia. A nation of people

from diverse cultural backgrounds, races and religions, it was

formed in 1946 after 400 years of Dutch colonization. The

population exceeds 220 million (Central Intelligence Agency

2002), and its main island, Java, is slightly larger than Ireland

and is the most densely populated island in the world, with a

population of over 100 million (Macquarie Library 1994).

Indonesia’s history is turbulent. After centuries of coloniza-

tion and several years of Japanese occupation during World

War II, Sukarno became president of the newly formed republic

in 1946, following a revolution ending Dutch domination. He

was replaced in 1967 by a military dictator, Suharto (Depart-

ment of Information, Republic of Indonesia 1980), following a

violent coup d’etat. He, in turn, was overthrown during a

comparatively peaceful event following the Asian economic

crisis of 1998 (Jenkins & Williams 1998). In 2000, Indonesia

held its first truly democratic election and a Muslim cleric,

Abdurrahman Wahid, became president. Megawati Sukarno-

putri, a highly popular politician and daughter of Sukarno has

since replaced him (McPhedran 2001).

Indonesia, the world’s largest Muslim country, strongly

espouses freedom of religion. Small sections of the country

are Hindu, Christian or Buddhist. Indonesia’s motto of

‘strength in diversity’ reflects the Republic’s multiculturalism

(Department of Information, Republic of Indonesia 1980).

There are many distinct cultures, but the Javanese community

predominates. This has caused political problems across the

archipelago, as other cultures struggle for autonomy within

their own provinces. Violent pushes for independence are

ongoing in the Sumatran province of Aceh, and in Irian Jaya.

A similar drive for autonomy came to a head in the province

of East Timor in 1999, when it was granted independence

following 20 years of civil disturbance (Dodd 1999).

Indonesian cultures are thousands of years old. Javanese

culture is characterized by strong class systems, respect for

elders, bountiful hospitality and a complex system of polite-

ness, obligation and privilege (Koentjaraningrat 1957).

Despite the diversity of cultures, Indonesia is united by one

language, Bahasa Indonesia, and by the national philosophy

of Pancasila, based on belief in God, humanism, universal

justice, national unity and democracy (Gimon 2001).

Development

Indonesia’s average annual gross domestic product (GDP)

growth rate from 1980 to 1991 was 3Æ9% (World Bank 1993),

which dropped to 3Æ3% in 2001 (World Bank Group 2002).

Until the end of 1997, the economy was booming. High-rise

buildings and sophisticated shopping centres in the capital,

Jakarta, indicated that many Indonesians were financially

well-off. However, 32% lived below the poverty line [calcu-

lated on local currency and estimations of work and

consumption by poor families (World Bank 1994)]. During

the Asian economic crisis (called krismon in Indonesian) in

early 1998, the value of the rupiah fell by 84% against the US

dollar (Barclay 1998). Although the economy is recovering,

the people of Indonesia continue to face economic hardship.

After krismon, living conditions deteriorated and by 1998 an

estimated 80 million people lived below the World Bank

poverty line (McCawley 1998). By 1999, growth had declined

to �1Æ3% of GDP (World Bank Group 2001). In 2001, a

restructuring of government agencies occurred, and all gov-

ernment departments decentralized to the provinces, with

each provincial government responsible for raising one-third

of its income independently of the central government in

Jakarta. This has severe ramifications for all public utilities

including health care and nursing. The terrorist attacks on the

United States (US) in September 2001 resulted in a downturn

in the economies of many nations. In addition, Indonesia is

suffering further economic hardship because of the terrorist

incidents in Bali in 2002 and Jakart in August 2003.

Health parameters

Prior to the Asian economic crisis, health statistics had

improved as the economy strengthened. Average life expect-

L. Shields and L.E. Hartati

210 � 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(2), 209–216

ancy at birth increased from 41 years in 1960 to 63Æ4 years in

1995, while the infant mortality rate fell from 160 deaths per

1000 live births in 1960 to 55 in 1995 (South East Asian

Medical Information Centre 1997), and 41 in 2000 (World

Bank Group 2001). A successful family planning programme

reduced the birth rate from 5Æ6 to 3Æ1 births per woman

between 1960 and 1990 (International Development Pro-

gram of Australian Universities and Colleges 1994). The

maternal mortality rate was 390 per 100 000 births in 1994

and the perinatal mortality rate was 31Æ84 per 1000 live

births (Health Department, Central Java 1997).

After krismon, health statistics worsened. Many people lost

their jobs, families could afford only two meals a day, the

price of rice (the staple food) doubled and that of cooking oil

tripled. Maternal malnutrition increased by 5% and anaemia

in children increased from 40% to 65% (The Jakarta Post

1999 March 26). Infant formula cost five times more than

before krismon. Consequently, malnutrition in children pro-

liferated (The Jakarta Post 1999 March 16, 1999 March 17).

Many who work in child health in developed countries assume

that in developing countries all mothers breastfeed. This is not

so in Indonesia nor, possibly, in other poor nations. When

there is no social security or benefits such as maternity leave,

mothers must work. Babies are cared for by extended family

members and carers, and breastfeeding becomes impossible.

Consequently, a rise in the cost of infant formula has a

potentially severe impact on the nutritional status of infants.

More research is needed on this topic.

Diseases endemic in Indonesia include dengue haemor-

rhagic fever, malaria, typhoid, cholera, tuberculosis and

other infectious diseases. Although figures are not readily

available, their incidence is increasing, as preventive measures

such as mosquito spraying have been reduced since krismon.

Conditions that are now uncommon in developed countries

are still observed; hydrocephalus is an example. In remote

villages, abnormal growth of an infant’s head may not be

detected early and treatment comes too late. Health depart-

ment officials have described how tropical diseases such as

leptospirosis (spread by rat and cat faeces) are increasing,

particularly after major flooding in the wet season. Nurses in

Indonesia not only face problems of caring for patients with

tropical diseases and their families, but have had to become

adept at providing care in a system which is beset with

difficulties such as shortage of supplies, few disposable items

and inadequate resources.

Nursing in Indonesia

The information on nursing presented here is the result of our

collaborative work, unless indicated otherwise. Data were

collected from unpublished government figures and through

communication with Indonesian health professionals, the

Indonesian Nurses’ Union (Persatuan Perawat Nasional

Indonesia) and the Health Department of Central Java. There

are no formal publications or published reports on this topic.

In 1994 (the latest available figures), there were 50 nurses

and 26 midwives per 100 000 people in Indonesia [World

Health Organization Statistical Information System (WHO-

SIS) 2002a]. Nursing, until recently, was universally consid-

ered a low-status profession, but with the introduction of

tertiary education for nurses, a major shift in attitudes is

occurring. At present, about 1% of nurses are educated at

university (Shields 1999). At some universities, nurses are

educated to the levels of S1 (sarjana satu, or bachelor’s

degree), S2 (sarjana dua, or master’s degree) and S3 (sarjana

tiga, or doctoral degree). Faculties of nursing are politically

active, and work towards registration of nurses and stan-

dardization of curricula.

Thirty-nine per cent of nurses are educated to diploma level

at both government and private academies of nursing –

Akademi Keperawatan (AKPER) (Shields 1999). Sixty per

cent of nurses are educated at senior high school, where

specialist nursing and midwifery subjects are taught in Grades

11 and 12 (Shields 1999). This is recognized by health officials

as a major contributing factor to low levels of health and high

mortality, as nurses who are high school graduates, as young

as 17 years old, care for patients with complex health

problems and deliver babies. The Indonesian government is

dedicated to improving the standard and level of nursing

education and, since 1998, many school courses have been

converted to diploma level. In 1992, 2485 nurses graduated

from nursing academies and 12 741 from high school

(International Development Program of Australian Universi-

ties and Colleges 1994).

Until recently, there was no accreditation of courses, little

standardization of curricula and no benchmarking or com-

petency assessment to ensure a safe level of practice amongst

those who graduate as nurses. In 1984, nursing curricula

were reviewed for the first time, in 1997 a standard was set

for the whole of Indonesia, and new curricula were imple-

mented in all AKPER by mid-1999.

No central registration for nurses exists, consequently,

there is no standardization of levels of competence and

ability, and no way of correlating education with practice

standards. The Indonesian government and Indonesian Nur-

ses’ Union are working towards rectifying this. Another

major problem is the low level of basic nursing education.

Nurses with diplomas and degrees are needed to teach, and

often take up teaching positions immediately after gradu-

ation, with little clinical practice to consolidate their

Health and nursing policy issues Nursing and health care in Indonesia

� 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(2), 209–216 211

education. Accordingly, nurse educators in academies may

have little understanding of the on-going education needs of

nurses working in hospitals and health centres. This causes

some anxiety for both educators and clinicians; however,

many nurses recognize these problems and work towards

solutions. Some nurses have completed a successful integrated

course, combining academic learning with clinical training,

and this is becoming standard educative practice. Senior

nurses acknowledge that removal of nursing education from

high schools will solve some of the problems.

Because the status of nursing has risen, and it offers secure

employment, approximately 25% of nurses are men. Under

Indonesian law, everyone who can work must be in employ-

ment and the government has a responsibility to ensure the

creation of jobs in its departments. Consequently, govern-

ment bureaucracy is enormous. All government employees

must retire at 55 years of age to make way for younger

Indonesians. This mandate affects nursing in particular,

although medical officers, allied health professionals and

midwives continue in private practice beyond this age. Until a

nurse practitioner role in private practice is developed, nurses

will not be able to continue to work after they have retired

from government employment.

One problem besetting nurses is their lack of status

compared with medical practitioners. Nurses, in the main,

are regarded as ‘doctors’ helpers’. Doctors dominate health

structures, leaving nurses with little power and, hence, little

incentive to make changes or pursue higher education. Some

realize that change can only occur with education and, with

great insight, tenacity and hard work, they pursue higher

education, often leaving their families for long periods to

undertake overseas study. Many realize that doctors need to

be educated about enhanced roles for nurses. Once one nurse

achieves the position of hospital executive director, or unit

manager, a precedent will be set and others will follow.

In 1999, the Central Java Government implemented a

World Bank project to send nurses and allied health staff

overseas to attain master’s degrees. They are now returning

home and educating other health professionals.

Indonesian health care system

To understand fully the position of nursing in Indonesian

society, knowledge of the overall health system is required. In

1990, Indonesia spent 12 US$ per person on health, which

was 2% of Gross National Product (GNP); only 0Æ7% of

GNP was spent on public health (World Bank 1993). By

1998, per capita spending remained the same (WHOSIS

2002b), and spending on health had increased to only 2Æ7%

of GNP. In comparison, in 1998 Australia’s health expendi-

ture was 8Æ6% of GNP (WHOSIS 2002b). There are two

modes of health care in Indonesia, public and private. The

state funds hospitals and primary health care clinics, and

private hospitals and clinics are run by private companies and

individuals and occasionally by Islamic and Christian organ-

izations. Sometimes state hospitals build private wings to

generate profits to support public facilities which deliver

health care to the poor.

There are over 1000 hospitals in Indonesia and about 34%

are private. A small group of Indonesians with high incomes

can afford to travel overseas for expensive health care, while

the middle class has access to private and public health

facilities of varying quality (International Development

Program of Australian Universities and Colleges 1994). In

1993, the World Bank suggested that public provision for

health care of the poor was inadequate and maintained that

the government subsidized the health of the richest 10% up

to three times more than health services for the poor.

Following krismon, aid packages from the International

Monetary Fund (IMF) and the World Bank have included

safety net provisions for the poorest, including free health

care. Under this scheme, known as Jaring Pengaman Sosial

Bidang Kesehatan (JPSBK), hospitals and community health

facilities provide not only free medical, nursing and hospital

care, but also any supplies needed for treatment. It must be

noted, however, that this scheme is available only to the

poorest, while those who are not so poor still have to pay.

Quality of care in private hospitals varies. While some are

better resourced than public hospitals, this may not always be

the case, as small private hospitals may not be able to access

staff, including medical specialists, and may not give the same

level of care. Public hospitals are administered by the

Ministry of Health or, in some cases, by local authorities at

city or provincial level. Hospitals are classified according to

number of beds and the specialist services available. Class A

and B are major referral and teaching hospitals, and district

hospitals are either Class C (100–400 beds) or D (25–100

beds). Class C hospitals offer some specialist services and are

teaching hospitals, while doctors in Class D hospitals are

general practitioners (Shields 1999).

All hospitals and health care facilities operate on a ‘user

pay’ system (some now provide free health care under the

JPSBK scheme). One regional hospital in Central Java has

estimated a fourfold increase in the number of free services

they provide over the next 5 years, as the country struggles to

recover economically. Usually, however, patients are charged

for admission. This entitles them to a bed, nursing care, food

and sometimes medical care (in some hospitals this is an

added charge). All equipment, drugs, dressings, intravenous

fluid, tubing, blood and other necessities have to be bought at



either the hospital pharmacy or from chemist shops. There

are charges for all community health services, according to

type and level of service. General practitioners and medical

specialists can be accessed privately.

Hospitals have different classes of wards, and admission

charges vary. Daily rates, for the lowest class of ward, range

from about 5000 to 8000 rupiah, while the highest class

ward costs up to 450 000 rupiah. Because exchange rates in

Asian countries are extremely labile, a comparison with other

countries’ currencies is not helpful. As an indication, a family

meal can cost about 8000 rupiah.

Most government employees receive private health insur-

ance as part of their remuneration, as do many who work for

private companies and businesses. However, there is a large

proportion of the population for whom health insurance is

unavailable. They are usually from the most disadvantaged

sections of society. Many are ineligible for free health services

available for the very poor, but are unable to contribute to

health insurance schemes. Therefore, they may not be able to

afford anything but the most basic health care. Research into

costs and effects of limited services available at this level of

society is needed.

The different classes of hospitals and wards reflect class

divisions within Indonesian society. By paying the basic rate,

a poor family will be able to access a bed in a large ward

with some nursing care. Extra nursing can be paid for but,

often, family members must stay to ensure that care is given.

In the highest class of ward the patient will be accommoda-

ted in a private room with bathroom, television, refrigerator

and beds for family. Standards of nursing care vary greatly

from place to place and are dependent on the type of

hospital, nurses’ educational levels and the general philoso-

phy of the institution.

In line with World Health Organization objectives for

primary health care (World Health Organization 1978),

Indonesia has an extensive primary health care system. Each

subdistrict has at least one community health centre, or Pusat

Kesehatan Masyarakat (PUSKESMAS), which is linked to a

series of sub-centres called PUSKESMAS pembantu and

community-level health stations called Pos Pelayanan Terp-

adu (POSYANDU). Nurses and midwives staff these centres,

providing a range of services including family planning,

immunization, maternal and child health care and preventive

services. One POSYANDU is provided for every 100 children

under 5 years of age. While the primary health care system

works well, remote areas are often disadvantaged in com-

parison with larger centres, although the government tries to

address this issue by making rural government service

mandatory for doctors before they can work as private

practitioners in areas of their choice.

Economic changes to the structure of all government

departments have affected the health system. Under a

programme called Perusahaan Jawatan, state funding for

hospitals has been decreased by over one-third, and institu-

tions are expected to raise independent funds. While many

hospital directors seek ways to do this, the most common

stratagem is proving to be a private-public link, in which

profits from private hospitals are used to support state

organizations.

Education of health professionals other than nurses

In 1994, there were 16 doctors per 100 000 people in

Indonesia (WHOSIS 2002a). Medicine is a high-class profes-

sion, whose practitioners are highly respected. Much of this

esteem is traditional, as medicine was one of the few

professions fostered by the Dutch colonial administration

(although Indonesian-educated doctors could not work in

Holland). Doctors played key roles in the development of the

nationalist movement and were prominent in the independ-

ence wars of 1945–1946 (International Development Pro-

gram of Australian Universities and Colleges 1994).

All doctors are educated at universities, initially at under-

graduate level. They are then required to work for up to

5 years in a government position as general practitioners, and

can then choose private or public practice. Public hospital

and health care doctors have private patients. This is

considered necessary, because, as with all government

employees, salaries are kept low in the expectation that

employees will make extra money by other means. Specialist

medical training is conducted at government universities

only. A specialist diploma is conferred, and applicants must

have at least 3 years of experience prior to enrolment. Many

doctors go overseas for specialist education, and must register

their overseas qualification with the Indonesian Medical

Board before practising in that speciality (International

Development Program of Australian Universities and

Colleges 1994).

Allied health staff are educated to diploma level at

academies, or through specialist courses in the final 2 years

of high school, although, as in nursing, the current trend is to

ensure that all are educated to diploma level. This applies to

staff such as pharmacists, laboratory technicians, nutrition-

ists, dental technicians, physiotherapists, occupational

therapists, radiographers, medical technologists, speech ther-

apists, environmental hygienists and opticians. Allied health

staff are in short supply. In 1992, 219 physiotherapists,

52 pharmacists and 10 speech therapists graduated from

academies (International Development Program of Australian

Universities and Colleges 1994).



Ethical dilemmas faced by nurses and other Indonesian

health professionals

Problems unique to developing countries beset all Indonesian

health professionals. Many describe distress and frustration

when, of necessity, their practice contradicts all they have been

taught about cross-infection and optimum patient care. Most

nurses can explain standard precautions, but have no way of

practising them, as no gloves and protective clothing are

provided. Because people must pay for all equipment used

during admission of a family member, doctors and nurses are

conscientious about minimizing costs for families. It is

common to see nurses using the same needle and syringe to

insert antibiotics into the intravenous tubing of different

patients. Although they take great care not to infect any part of

the syringe and needle, this practice contravenes all they have

been taught about cross-infection. However, they must choose

between suboptimal pratice that enables the patient to receive

available treatment or the patient being sent home untreated.

Doctors are very good at prescribing only what the patient

needs for a course of treatment, so that little waste occurs.

Patients, however, may still buy a lesser amount of the drug or

other treatment and, thus, may not complete the course. This

has far-reaching ramifications for the spread of disease and

antibiotic resistance, and provides further topics for research.

Nurses describe their distress when families (who may have

sold their homes to pay for the hospitalization of a family

member) take patients home still not cured because they can

no longer afford to pay for care; nowhere is this more

poignant than in paediatrics. Few families can afford allied

health services, so rehabilitation is often ad hoc. Health

professionals are aware that there is no unemployment relief,

and that hospitalization often involves a relative in a choice

between staying with the patient to ensure that nursing care is

adequate and keeping their job (Shields 1999). Often people

choose to jeopardise their employment rather than rely on the

health care system and, with a huge population and high

unemployment, this is a very real threat to a family (Shields

& King 2001a, 2001b).

Krismon aggravated ethical dilemmas faced by health work-

ers, but has had some positive effects. Free health care for the

very poor is inherent in IMF and World Bank aid packages and

many hospital administrators are keen to continue this.

Currently, ways to subsidize health care for the poor are being

examined, so that free facilities can continue once the country

has recovered from krismon. However, the terrorist attacks in

Bali, Jakarta, and the US, and resultant downturn of the world

economy, will have knock-on, negative effects on such schemes.

These insoluble problems put enormous pressure on

nurses, whose aim, like their colleagues everywhere, is to

alleviate suffering and support patients and families. By and

large, Indonesian health professionals provide high-quality

care, within the constraints of the health system.

Effects of the international nursing shortage

All countries may feel the effects of the international nursing

shortage, but (as so often happens) poor countries are likely to

feel it the worst. Indonesia, at present, has unemployed nurses,

and nursing education is still attracting students. However, if

nurses leave the country under schemes such as those in place in

Britain, where they can take courses to upgrade their skills

which allow them to work in National Health Service hospitals

(The Independent 2001), the pool of unemployed nurses will

cease to exist. Subsequently, other nurses will leave to work

elsewhere and Indonesia will face a shortage of nurses.

Innovative schemes, in which nurses must return home to work

in nurse education once they have completed their contracts in

other countries, are laudable, as they help to create employment

and enhance the education of nurses within the country.

Overseas aid projects

There are many governments and organizations in the world

which are committed to giving aid to developing nations.

Many religious organizations, including the major Christian

churches, and governments of developed nations have

departments which distribute and administer aid. Some

overseas aid is given freely, that is, the recipient country is

able to distribute and spend the sum as it wishes. In other

cases, aid is given subject to the requirement that full

accounts of its use are sent to the donor country. Some aid

is tied to trade contracts and will not be given unless the

recipient nation agrees to purchase a certain amount of goods

from the donor country. Health care is a fertile field for aid

organizations, and in Indonesia, many health care institutions

are beneficiaries of overseas aid.

Aid is a two-edged sword, with inherent ethical dilemmas

posing problems for both donor and receiver (Fox 2001).

Indonesian health professionals often struggle with quanda-

ries presented by aid donations. While aid provides much

needed resources and help, the industry which has grown up

around it is large and its practice can sometimes be

questioned. In many countries which are recipients of aid, a

donor–receiver dichotomy has arisen. Agents of the donor

country become ‘patrons’ and display behaviour which infers

superiority over those to whom the aid is being given, while

recipients come to believe that they have a right to aid because

of their poverty. Companies which provide infrastructure and

facilitate projects for aid organizations sometimes make large



profits. While all companies must make money to survive, the

ethics of the intent and management of aid becomes ques-

tionable if involvement in aid projects is motived only by the

chance to make large profits. Sometimes employees of aid

projects have little knowledge of and sensitivity about the

culture, customs and mores of the country in which they are

working, and offend the local population.

The Indonesian health care system benefits from overseas aid

from countries such as Holland, Australia, America, Germany

and other European nations. Some of this aid is freely given,

well spent and benefits the Indonesian population. Other aid

projects within health care may be funded by countries who

insist that their donation is used to purchase large pieces of

medical equipment that incorporate disposable items which

must be purchased from a company based in the donor nation.

This often incurs large costs for the recipient facility. Some aid

projects in Indonesia provide managerial support for hospital

administrators who are, in reality, well-versed in management

theory and practices and have a much better understanding of

the needs of their health service than people from outside.

Working in Indonesia

There is much discussion about corruption in Indonesia

(Muhammad 2002) and the health service is not immune.

While corruption does occur in Indonesia, it is important that

such practises are understood in their proper context. For

thousands of years, Indonesian society has run on a system of

privilege and patronage within a culture structured along

strong class divisions (Koentjaraningrat 1957). Within this

system, it is acceptable practice to pay for privileges. The

Indonesian government has a commendable policy of provi-

ding employment for as much of its vast population as

possible, and the cost of paying employees who work in

public service is taken from the national budget. Conse-

quently, government employees, although securely employed,

earn little and are expected to supplement their incomes. It is

a common and accepted custom for companies operating in

Indonesia to pay for the privilege of doing business. This may

range from a small payment to a government clerk to

facilitate the passage of a document through a department, to

subsidizing large social events for families of senior employ-

ees in organizations with whom the agent is conducting

business. The same holds true for health services. People from

other nations find this system difficult and, subsequently,

misunderstandings arise. These practices are a normal part of

the fabric of Indonesian life, and while stamping out true

corruption is an aim of the government of Megawati

Sukarnoputri (Maher 2001), an understanding of how the

system works may afford foreign nurses and other health

professionals a more rewarding and interesting experience.

Conclusion

Indonesia, the largest South East Asian nation, is beset by

problems resulting from its immense population, recent

economic downturns and, in particular, the local effects of

the recent bombings. These problems are reflected in its

health statistics. Nursing, while traditionally perceived as a

low-status occupation, with the introduction of tertiary

education, is developing as a profession. However, it is

plagued by problems found in all developing countries.

These include patients who are poverty-stricken, a system

which lacks resources, the need for patients to pay for

health care, a dearth of disposable items and a network of

factors that increase the illness acuity of patients presenting

for care. Nurses (and other health professionals) face ethical

dilemmas which are not encountered by health professionals

in wealthier nations. The Indonesian government is working

towards standardized accreditation of nursing education

across the archipelago. Also, it is attempting to implement a

registration system for nurses and is committed to improv-

ing the standard of nursing education throughout the

country and, by so doing, improving the health of the

population.

What is already known about this topic

• Indonesia, the world’s largest Muslim nation, is a

developing country whose health services are reflective

of the constraints of a massive population and relatively

few resources.

• Little has been written in English about nursing and

health care in Indonesia other than accounts from vis-

itors who inevitably have limited understanding of the

surrounding complexities in this culturally diverse and

populous nation.

What this paper adds

• It provides a first hand account, written collaboratively

by an Indonesian nurse and a colleague who has lived

and worked in Indonesia over many years.

• It uses previously unpublished information from health

and nursing sources in Indonesia and gives an accurate

picture of how nursing fits with the health services and

other health professions.

• It will provide useful and correct information for nurses

interested in Indonesia.



Humanitarian aid can help with such problems, but its

ethics must be discussed and limitations to its benefits

examined. Nursing education should include courses on the

ethics of aid, so that nurses can be circumspect about its use

and ensure that nursing and the health of the Indonesian

people benefit.

This paper has provided insights about nursing and health

care in Indonesia. It is hoped that knowledge of the culture, how

the health system works within it and the role of nurses will

enhance the relationship between nurses from Indonesia and the

rest of the world. We hope that the adverse publicity which

Indonesia received after the bombings in Bali and Jakarta may,

in some small way, be offset by the information given here.

Acknowledgements

This work was supported by a National Health and Medical

Research Council of Australia Public Health Postdoctoral

Fellowship, a National Health and Medical Research Council

of Australia Dora Lush Memorial Scholarship, Queensland

Nursing Council, Mater Children’s Hospital, Brisbane, Cen-

taur Memorial Fund for Nurses, and University of Queens-

land Alumni. Special thanks to Dr Krishnajaya (Head of the

Department) and Dr H. Hartanto from the Health Depart-

ment of Central Java, and to Dr H. Gatot Suharto, Director

of Dr Kariadi Hospital, Semarang for their help in compiling

this work.

References

Barclay G.stJ. (1998) Not too late to avert doomsday. The Courier

Mail (March 8), 4.

Central Intelligence Agency (2002) Indonesia. The World Fact-

book 2002. http://www.odci.gov/cia/publications/factbook/geos/

id.html#People, last accessed 17/12/02.

Department of Information, Republic of Indonesia (1980) Indonesia

1980: An Official Handbook. Department of Information, Direc-

torate for Foreign Information Services, Jakarta.

Dodd M. (1999) Independence day: thousands greet their future.

Sydney Morning Herald (August 16), 9.

Fox F. (2001) New humanitarianism: does it provide a moral banner

for the 21st Century? Disasters 25, 257–289.

Gimon C.A. (2001) Notes on Pancasila. http://www.gimonca.com/

sejarah/pancasila.html, last accessed 17/12/02.

Health Department, Central Java (1997) Health System Research on

Decreasing Maternal and Perinatal Mortality in Wonosobo

District, Central Java. PDA Proposal, Health Department, Central

Java, Semarang.

International Development Program of Australian Universities and

Colleges (1994) The Indonesian Health Care System: Opportun-

ities for Overseas Education and Training Services. Department of

Premier, Economic and Trade Development Division, Government

of Queensland, Brisbane.

Jenkins D. & Williams L. (1998) The handover: how Soeharto fell on

his sword, News Review. Sydney Morning Herald (May 23), 29,

32, 33.

Koentjaraningrat R.M. (1957) Yale University Southeast Asia Studies

Cultural Report Series: A Preliminary Description of the Javanese

Kinship System. Yale University, New Haven.

McCawley P. (1998) Human dimensions of Indonesia’s economic

crisis and foreign assistance. Paper presented at Indonesia Now

Symposium, 14 October 1998, Brisbane.

Macquarie Library (1994) The Macquarie World Atlas. McMahons

Point, N.S.W.: Macquarie Library in Association with Australian

Surveying & Land Information Group and Department of Survey

& Land Information, Wellington.

Maher M. (2001) A big ask. Bulletin with Newsweek 119, 25.

Muhammad N. (2002) Money politics lurks behind corruption cases.

The Jakarta Post (On Line). http://www.thejakartapost.com/

detailreview2001.asp?category¼national&fileid¼20011226.K03,

last accessed 27/03/02.

Shields L. (1999) A comparative study of the care of hospitalized

children in developed and developing countries. PhD Thesis, Uni-

versity of Queensland, Brisbane.

Shields L. & King S.J. (2001a) Qualitative analysis of the care of

children in hospital in four countries – Part 1. Journal of Pediatric

Nursing 16, 137–145.

Shields L. & King S.J. (2001b) Qualitative analysis of the care of

children in hospital in four countries – Part 2. Journal of Pediatric

Nursing 16, 206–213.

South East Asian Medical Information Center (1997) SEAMIC

Health Statistics 1996. International Medical Foundation of Japan,

Tokyo.

The Independent (2001) Foreign nurses registered in the UK up by

41%. Nursing Review (September), 15.

The Jakarta Post (1999) Baby found suffering from chronic under-

nourishment. The Jakarta Post (March 17), 4.

The Jakarta Post (1999) RI trying to cut maternal mortality rate. The

Jakarta Post (March 26), 8.

The Jakarta Post (1999) 3,000 under-fives suffering from malnutri-

tion in Jakarta. The Jakarta Post (March 16), 2.

World Bank (1993) World Development Report: Investing in Health.

Oxford University Press, Oxford.

World Bank (1994) Social Indicators of Development. The Johns

Hopkins University Press, Baltimore.

World Bank Group (2001) World Development Indicators 2001.

http://www.worldbank.org/data/wdi2001/worldview.htm, last

accessed 27/03/02.

World Bank Group (2002) Indonesia Data Profile. http://www.

worldbank.org, last accessed 17/12/02.

World Health Organization (1978) Primary Health Care. Report of

the International Conference on Primary Health Care, Alma-Ata,

USSR, 6–12 September 1978, Geneva.

World Health Organization Statistical Information System

(WHOSIS) (2002a) WHO Estimates of Health Personnel. http://

www.who.int/whosis, last accessed 18/12/02.

World Health Organization Statistical Information System (WHO-

SIS) (2002b) The World Health Report 2001. Annex Table 5

Selected National Health Accounts Indicators for all Member

States, Estimates for 1997 and 1998. http://www.who.int/

whr2001/2001/main/en/annex/annex5.htm, last accessed 17/12/02.



nursing and health care in indonesia

Documents