Indonesian universities’ residency fees are driving doctors abroad

In most countries around the world, doctors tend to come from relatively privileged backgrounds. The prestige, salary and inherent interest of a career in medicine are such that competition for places on medical degree courses is fierce, placing a premium on the private schooling and tutoring that can help secure the necessary grades.

But it is fair to say that Indonesia has a particular problem when it comes to widening participation in medicine.

After their basic medical training, those who do not want to go into general practice complete what is called a residency: a four- or five-year programme of focusing on a particular branch of medicine, after which they are recognised as specialist doctors. This is common around the world – as are the massive workloads associated with being a junior doctor.

However, what (as far as I know) is unique to Indonesia is that residency programmes are run not by hospitals but by universities. This makes little sense conceptually because almost all learning during the residency occurs in hospitals rather than in a university classroom or laboratory. But the worst consequence of this system is that resident doctors are considered university students, instead of qualified medical professionals.

This means that unlike the general medical degree common around the world, Indonesian students leave with a degree in a particular specialism. The snag is that, rather than being paid, they are required to continue paying tuition fees throughout their residencies. Moreover, these fees are not cheap; they can amount to tens of millions of rupiah per semester (10,000,000 rupiah is about $700) in a country where the average annual wage is about $4,000. And students can’t even do any paid medical work on the side: they are expressly prohibited from working as medical professionals before finishing their studies.

Hence, unless Indonesian students have large savings, family financial backing or one of the very limited number of scholarships available, they can’t undertake medical specialty education in Indonesia. Moreover, there is something of a vicious circle in operation because the more opportunity is confined to the very rich, the more potential opportunity there is for universities to increase residency tuition fees further; there is no regulation in place to properly monitor them.

As well as the inherent inequity of this situation, it also no doubt helps explain why there is a significant shortage of medical specialists in Indonesia – and an uneven distribution of those that there are. Where they can, increasing numbers of Indonesian doctors are going abroad to carry out their residencies – and, inevitably, not all return.

The Covid-19 pandemic has underlined just how unfairly Indonesia’s resident doctors are treated. Like everyone else, resident doctors have been affected financially – by, for instance, the loss of non-medical second jobs or their parents’ jobs, on which they rely to pay the cost of their tuition and accommodation. At the same time, they have been society’s first line of defence against the disease, some of them contracting Covid-19 themselves.

Demonstrations demanding tuition fee waivers at universities such as Sam Ratulangi University, in the North Sulawesi capital, Manado, did not prompt a response from university authorities. Fortunately, the Indonesian Health Ministry stepped in, providing monthly “incentives” of 12.5 million rupiah for each resident involved in Covid treatment – but only until this month.

A hospital-based residency system would not only bring more inclusive and affordable medical specialty training. It would also permit a more merit-based selection of medical students since the candidates’ financial position would be less of an issue. The need for this has never been more evident than it is now.

Until such reforms can be implemented, many brilliant Indonesian doctors will have to continue going abroad to pursue their dreams of being the best doctors in their field. And Indonesia’s loss will be other countries’ gain.

Fistra Janrio Tandirerung is a general practitioner at Inco Sorowako Awal Bros Hospital, Indonesia. He is part of the 2021 intake for the MSc in cardiovascular science at UCL.