Expected outcomes 3. Participants (Indonesia) Resource persons (Australia) 4. Activities

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1 Health Policy and Health Finance Knowledge Hub Indonesia Non State Sector Studies Benchmarking visit by Medical Professional Associations, October 12 14, 2011 Draft report, Nossal Institute participants Date: 1 November Background, rationale and purpose Initial studies carried out by the Health Policy and Health Finance Knowledge Hub in partnership with the Centre for Health Service Management, Universitas Gadjah Mada (PMPK-UGM) of the growth of non state hospitals in Indonesia, identified the key role played by doctors, especially specialist doctors, in the distribution and function of health facilities. Current key challenges for the Indonesian health system, such as the geographical inequities in access to and distribution of health services, and poor quality of public health services particularly in rural and remote areas, are closely linked to the issues of the motivation, payment, training and support of doctors. The Indonesian government is moving towards more active regulation of the medical profession, with the establishment of the Medical Council of Indonesia (KKI) and new requirements for licensing of doctors, including participation in continuing professional development (CPD). However, the Indonesian medical professional associations, notably the Indonesian medical association (IDI), of which all doctors are required to be members, has not been actively engaged in the development or implementation of new policy, or in addressing the larger problems of the health system. The purpose of the benchmarking visit was to provide leaders from the Indonesian medical associations, the Indonesian Medical Council, and policy makers from the MoH, an opportunity to examine how medical professional associations in Australia engage in policy debate and policy development in Australia, and consider whether and how Indonesian medical professional associations could engage more actively in health system policy issues in Indonesia. The rationale behind this proposal is a recognition of the increasing complexity of the Indonesian health system, its mixed public-private nature, and the complexity of the challenges it faces. There is a need for government and policy makers to engage with other key stakeholders in both policy making and policy implementation in order to better regulate and undertake its stewardship role for the system. In a situation of relatively low regulatory capacity, co-regulation using other existing structures and organisations may offer a more effective approach. 2. Aims and objectives Overall objectives were: To identify the role of Medical Professional Associations, Australian Health Pratictioner Regulatory Agency, and Australian Medical Council within the health system To identify the potential contribution of Medical Professional Associations in addressing some of the key challenges confronting health systems Specific Objectives were: To compare current role and responsibility of Medical Professional Association in Indonesia with International experience, particularly Australia s 1

2 To describe the strategic action of Professional Association to address the issues of Physician Distribution, Retention, Dual Practice, and Incentive in Indonesia, based on current international best experience and practice Expected outcomes Workplans for follow up actions to be undertaken by each group of participants 3. Participants (Indonesia) Medical Professional Associations: - Indonesian doctors association (IDI), Indonesian medical council, Indonesian Midwives Association, Association of Specialist Obs-Gyn, Association of specialist physicians, and Association of anaesthetists Ministry of Health -Staff from personnel bureau, and from workforce planning section of the MoH health workforce development centre Reporter from the national newspaper Kompas Researchers - Centre for Health Service Management, University of Gadjah Mada; Resource persons (Australia) Medical Board of Australia / Australian Health Practitioner Registration Agency Australian Medical Association (national and Victorian state level) Commonwealth Department of Health (medical benefits section) Rural Doctors Association of Australia Royal Australian College of Physicians (Deputy chair, Victoria) Royal Australian College of Surgeons (Chair, Professional Development and Standards Board) Researchers - Prof Stephanie Short, Prof Behavioural and Social Sciences, University of Sydney - Researchers from the Nossal Institute, University of Melbourne 4. Activities Presentations and discussion on the issues and situation in Indonesia: PMPK researchers, and from participants. Presentations and questions to resource persons Discussion and interpretation of resource person inputs led by PMPK researchers 2

3 5. Results 1. Improved recognition of common interest in health system problems and of the roles / contribution the different groups can play. - Comments: why didn t we meet together in Jakarta? - The medical professional associations (MPA s) indicated their respect for the expertise and experience of the MoH participants their familiarity with the rules and regulations and attempts to use them to address the health system problems. - The MoH recognized the role MPA s could play in advocating to parliament / other ministries for changes in laws and regulations that constrain health system responses eg the regulations governing civil servants limiting age of entry to below 35 years. 2. Increased understanding of the constraints and complexities involved in addressing some of the issues such as mal-distribution of doctors - MoH clarification of the limitations imposed by civil service status; new political imperatives, such as a two year moratorium on new recruitment to the PNS. - MPA s provides clarification to the MoH on the requirements for training and the limitations that imposes on sending residents to work in rural locations 3. Confirmation of the legitimacy of doctors engagement in policy from the experience of associations and colleges in Australia - Encourage and support clinicians in Indonesia to engage in policy issues - Australian Department of Health negotiation with MPA s on setting medical benefits 4. New ideas on the role and function of medical professional associations - Linking fees to CPD to increase compliance with fee payment - Use of salaried executive / support staff to manage the organisation and provide support for training and policy activities - Specific association for rural doctors 5. New ideas on addressing services in rural areas - Use of telemedicine - Community and local government support for doctors and their families - Organisation of relief and replacement doctors (locums) 3

4 6. Action plans Five action plans were developed as follows: Organisation Priority areas Activities Indonesian medical association Association of Obs-Gyn specialists (POGI) Associations of anaesthetists Advocacy to progress the social welfare system (SJSN) Advocacy to increase budget allocation to health Capacity building, institutional strengthening Increase focus on professionalism and ethics Define standard competencies of Obs-Gyn specs Institutional reforms Address inequitable distribution of Obs-Gyn specialists Address shortage of anaesthetists in NTT 4 Workshops, meetings with DPR Engage in setting fees with regulator Meetings with Bappenas Improve fee collection Organisational changes such as appointment of non clinical CEO, clarification of board role in governance, improve services for members Taskforce; socialisation thru organisation Standardisation of competencies; re-training Review structure & finances Improve accountability Regionalised program to provide 1 year rotating trainees to districts with no Obs-Gyn Ministry of Health Workforce planning Coordinate needs assessment and planning with KKI & other involved ministries PMPK - UGM Examine potential for specific rural stream in specialist training Distribution of doctors Technical support / facilitation to MPAs in implementing action plans Support MPA s in improving organisation and procedures Define competencies with KKI Request feedback from professions on issues faced by resident / new specialists Involve MPAs in provision of support and communication with doctors in rural locations Documentation of progress as case studies Assist MPA s in survey of members to understand their

5 Assist structures & mechanisms to improve communication MoH and MPAs issues Provide guidance and support in engaging in policy making Provide further information to MPA leaders on policy issues 7. Assessment Extent to which objectives achieved and lessons learnt from the process (1) Compare role and responsibilities of MPAs in Australia and Indonesia. Achieved. A table was prepared collectively comparing the role and function of medical professional associations in Australia and Indonesia, and this stimulated identification of the implications for Indonesia. The action plans incorporated the implications identified for the associations. Key implications identified were: engagement in policy making; stronger financial basis with higher fees and greater compliance with fee paying; and a professional salaried workforce to support volunteer board positions. Lessons in achieving this objective: Personal presentations by Australian resource persons were very effective in conveying information not only because of the verbal communication and opportunity for questions and clarifications but also because the personal presentation conveyed something of the attitudes and values of the presenters. This is much more effective than discussion of papers and documents. There is an important role in the researchers in translating and interpreting this information for the participants both researchers familiar with the Australian context, and those familiar with the Indonesian context. The combination of Nossal and UGM researchers was effective in this regard. The study team needs to be given time to digest and consider information imparted by the resource persons, so should have plenty of time to discuss internally. (2) To describe the strategic action of Professional Association to address the issues of Physician Distribution, Retention, Dual Practice, and Incentive in Indonesia. Partly achieved. Action plans identified a variety of initiatives which might address the issues of maldistribution of doctors, and made some reference to the role of other stakeholders. But the visit did not have sufficient time or resources to explore in depth the policy issues, their causes, and potential policy strategies. Thus the initiatives proposed are rather ad hoc. The MOH representatives commented that some of the proposals could conflict with strategies currently being undertaken by the MoH. While there was increased commitment to the need for better communication between the MoH and the MPAs, the structures and mechanisms for such communication have not been identified. It is unclear how much senior policy maker support there will be for this relationship, given that the MoH representatives were not in senior positions. Lessons in achieving this objective It may be that the study visit was overly optimistic in considering that the 3 days would be sufficient to also identify appropriate policy strategies. Objectives should be kept focused. There is a need for more understanding and capacity building about the process of developing policy, particularly for the MPAs. There is a tendency to move quickly to implementation without considering the rationale for believing the strategy will be effective. In particular, the MPAs need to 5

6 consider how to engage their members in policy input, and to ensure that their policy inputs reflect the views of their members, rather than just that of the leaders. Future visits need to include more senior representatives from the MoH. (3) What have we learnt about the potential role of professional stakeholders in health system policy making in Indonesia? Currently most policy making is made in house within the Ministry, with limited consultation or engagement of relevant stakeholders or implementers such as the MPAs. Equally MPAs have little capacity to engage in policy making, or mechanisms to provide policy inputs representing or drawing on the views of their members. The discussions have identified potential benefits to both parties from greater communication and dialogue, but the capacities and mechanisms to facilitate and support this will need to be developed. There appears to be willingness on both parties to better coordinate and engage, but this will need to be confirmed by leadership within MoH and MPAs, and appropriate structures and mechanisms for dialogue developed. The development of MPAs and their engagement in policy making may support the development of structures and mechanisms in Indonesia to better identify and manage contesting viewpoints and interests. 8. Next steps (1) Summary report and thanks to be provided to Australian resource persons, together with request for feedback (2) Provide summary report to AusAID representatives and request any feedback (3) Review with UGM researchers follow up to the study visit in particular documentation of policy engagement / policy processes / changes that might occur. Consider how this might be framed as participatory action research and how key members from the MPA might be involved eg as a reference group. Identify potential outcomes and document changes that may be related to these outcomes both in terms of policy content (changes, strategies, initiatives, implementation); and process (engagement, communication, dialogue) 6