Background: Doctor shortages in remote areas of Indonesia are amongst challenges to provide equitable healthcare access. Understanding factors associated with doctors' work location is essential to overcome geographic maldistribution. Focused analyses of doctors' early-career years can provide evidence to strengthen home-grown remote workforce development. Method: This is a cross-sectional study of early-career (post-internship years 1–5) Indonesian doctors, involving an online self-administered survey on demographic characteristics, and; locations of upbringing, medical clerkship (placement during medical school), internship, and current work. Multivariate logistic regression was used to test factors associated with current work in remote districts. Results: Of 3,176 doctors actively working as clinicians, 8.9% were practicing in remote districts. Compared with their non-remote counterparts, doctors working in remote districts were more likely to be male (OR 1.5,CI 1.1–2.1) or unmarried (OR 1.9,CI 1.3–3.0), have spent more than half of their childhood in a remote district (OR 19.9,CI 12.3–32.3), have completed a remote clerkship (OR 2.2,CI 1.1–4.4) or internship (OR 2.0,CI 1.3–3.0), currently participate in rural incentive programs (OR 18.6,CI 12.8–26.8) or have previously participated in these (OR 2.0,CI 1.3–3.0), be a government employee (OR 3.2,CI 2.1–4.9), or have worked rurally or remotely post-internship but prior to current position (OR 1.9,CI 1.2–3.0). Conclusion: Our results indicate that building the Indonesian medical workforce in remote regions could be facilitated by investing in strategies to select medical students with a remote background, delivering more remote clerkships during the medical course, deploying more doctors in remote internships and providing financial incentives. Additional considerations include expanding government employment opportunities in rural areas to achieve a more equitable geographic distribution of doctors in Indonesia.
Bibliographical noteFunding Information:
The authors thank dr. Maxi Rein Rondonewu, DHSM, MARS, dr. Mawari Edy, M. Epid, Tumpal Pardomuan Hendriyanto, S. Kom, M.Sc (PH), and Ananta Dwi Saputra, S. Kom from BPPSDM MoH and Dr. dr. Andreasta Meliala, DPH, M. Kes, MAS from Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada for support in conducting this survey. We also thank the survey participants for their time and sharing their experiences. Funding. The research was funded by LPDP (Endowment Fund for Education) Indonesia and the Monash University Student Support Fund. The first author received a PhD scholarship from LPDP Indonesia.
aUrban districts are non-remote districts that have 50% or less of population living in rural villages, according to Head of Central Bureau of Statistics Regulation 37/2010. bRural districts are non-remote districts that have more than 50% of population living in rural villages, according to Head of Central Bureau of Statistics Regulation 37/2010. cRemote districts are those defined as isolated, border or island districts according to Presidential Regulation 131/2015. dPrivate medical schools are those funded by a private or non-government organization. ePublic medical schools are those funded by the government. fClerkship or clinical rotation is a phase in the undergraduate medical course, usually in the final year(s) of study, in which students are under supervision and do not have full authority to treat patients. In Indonesia, clerkships take 1.5–2 years. During the clerkship, medical students are placed in teaching hospitals or affiliation hospitals, in accordance with their medical school’s regulations. For example, one medical school may allocate the entire clerkship to one hospital’s pediatrics department, while another may distribute the clerkship across more than one hospital. gIn Indonesia, internship completion is required for medical graduates to obtain registration as a doctor. Interns have full authority to treat patients. hGovernment employment of doctors with a long-term (lifetime) contract, whether during candidature or at the official stage (Calon Pegawai Negeri Sipil [CPNS] or Pegawai Negeri Sipil [PNS]). iRural incentive programs include Nusantara Sehat and PTT. Incentive amounts may vary. jRefers to any work experience in rural or remote locations outside the Nusantara Sehat and PTT programs. The participants may or may not have received additional financial incentives.
© Copyright © 2021 Putri, Russell, O'Sullivan and Kippen.
- career choice
- health workforce maldistribution
- low- and middle-income countries
- physician practice
- professional practice location
- rural health services