A sick system produces dumb doctors in Indonesia

“Why don’t you go to Penang/Singapore?” is the first thing most Indonesians say when they hear I don’t have kids. Obviously childlessness must be fixed, and obviously it is far too important to be left to the Indonesian health system. I usually give people short shrift when they trash the health system here. I have several smart friends who were once great doctors. Ok, they’ve mostly shifted into management jobs now, but Indonesia’s med schools are full of bright young things to take their place.

Or are they? A recent report from the World Bank wrings its hands over the quality of medical education in Indonesia. It finds that accreditation standards for health schools are wonky in the first place, are not properly applied, and are in any case not published. Not too surprising really. Another recent report from the World Bank notes politely how absolutely crap Indonesia’s education system is. In internationally standardised tests of 15 year-olds, over half of Indonesians scored less than one out of six on maths tests, and not a single Indonesian student reached the score of five or six that, according to the OECD which runs the tests, indicates decent critical thinking skills. When basic education is so poor, it would be miraculous for medical education to be much better. But the World Bank health worker report doesn’t even mention the thing that worries me most: training for doctors and jobs as nurses are for sale.

Even the best state universities, the ones that in the past gave scholarships to my smart friends, are raking in money selling places in med school. The starting price to get in, for students with exceptional grades, is 10 million rupiah, over US$ 1,000. The lower your grades, the more you have to pay to get in. Medical school is so fashionable these days that I’ve heard of people paying up to 250 million rupiah just to get in. That’s not for tuition, of course, that’s purely for the privilege of being able to say “My eldest is studying to be a doctor”. If they are either stupid or lazy or both, they will have to pay another great whack each year to pass their exams. When they graduate they’ll have had a very expensive education. But would you want them taking care of your tumour?

The sale of jobs starts at a much lower level. Nurses and even midwives now have to put out to get hired even in small town health centres. The going price in Aceh, where I’ve spent the last few weeks, is 60 million rupiah for an entry level job (assuming that you have already earned, or indeed bought, the appropriate qualifications). Sixty million rupiah, US$ 6,600 dollars, to get a job that will earn less than US$ 300 a month. Is it any surprise that most health centre staff, doctors, nurses and midwives included, go to work in the morning and run a private practice in the afternoons or evenings?

I often ask people why they pay to see the doctor in the evening when they could see exactly the same doctor for free in the morning. The universal response is that doctors keep the “strong” medicine for their private patients. At the health centre you get obat warung – “kiosk drugs”, cheap, over-the-counter stuff. Given the deterioration of standards required of people studying medicine in the first place, I would have thought the drugs they give you would be the least of your concerns.

17 Comments on "A sick system produces dumb doctors in Indonesia"

  1. yes, I’m an Indonesian, live in Indonesia, and I’m really afraid of getting sick or seeing a doctor.

  2. No basa basi. Well done.

  3. It in every aspect of live in indonesia

    Should check also on dumb engineer that indonesia produce
    These engineer build bridges that collapsed by it self

    If you have your car stolen and you report to police, they will ask some money for investigation cost, travel etc, when they eventually find your car, to take your car out from police yard you have to pay maintenance cost

    My daughter “seat fee” for just entering kindergaten class are $500 and $65 for monthly tuition fee, excluded book, and uniform that will charge later

    These corruptive habit are everywhere, there are not only dumb doctor, but also dumb engineer, dumb writter even dumb govt minister

  4. What you’re writing in these article are not the whole truth
    I have experience in buru island of maluku, there was a patient who got fever, and unconsciuss the local doctor could spot directly it was malaria and gave the right treatment and the patient get healed. While my expatriat doctor need a lot of test to determine the diagnosis, while the closes laboratory is 12 hour away with boat in normal weather condition if it windy it will take longer time. Can you imagine what will happen to the patient if he had to wait for lab result before treatment as my expatriat doctor required?

  5. What you’ve said is not the whole truth.. Yes ours education and health system is bad but we are not that dumb.
    First, comment about the dumb Indonesian student. I’ve studied with an Americam boy at my high school and his math is the worst. He knows nothing than we are Indonesian students. We are good at math and memorizing. The study above should be investigated once more. You have to put the valid fact about the study that said we are dumb than foreign students. If it’s not valid, so you just put a rumour as well as that dumb student.

    Second, about health system. You have to study emore the differences between our insurance systems with another country’s. And also, you have to put the difference between the numbers of the civilians, islands we have, distance between two island, and our per capita incomes per year in. Their systems are not always fit for ours country.

    Third, doctors are not give a difference medicine based on their patients’ social status. We give the drugs that will help reduce patients difficulties by not give more trouble in their life to pay then. At morning shift, is not obat warung that given to them yet it is a generic or a patent drugs that listed and covered by ASKES or theirs health insurance as well which is contain the same ingredients as well as in another patent drugs that given to Private patients. For example, doctor give Mefenamic Acid for patients’ headache yet also give Mefinal (Patent drugs; that contain Mefenamic Acid as well). Imagine how the patients will pay for Mefinal (that cost 15.000/10pcs, for example) since their income just 10.000/ day (its better to give them the generic Mefenamic Acid which is cost 5.000/ 8 pcs rather their not take any drugs at all).

    The last. Most of Indonesian people thinks that foreign doctors is better than Indonesian. Its false! I did exchange at European Hospital. Th doctors do every movement by the lead of a machine to diagnosis. Here, we use less machine in oreder to press the health care cost. And the foreign doctors should do medical treatment by their tools, here we can do the medical treatment even without those things as Rudi said above.

    So, I suggest you to do some research to other country before you write this. How you write here, told me how deep is your thought.

    And also, I want to say for all Indonesian people: STOP CRITISIZING!! IT’S BETTER FOR YOU TO DO YOUR ROLE IN A GOOD WAY! OUR COUNTRY NEEDS ACTS NOT TALKS..

  6. Hi there. ACTS NOT TALKS Yeah! I am an expatriate in Indonesia. I have been to hospital many times and different hospitals. And they are all the same. Costly and with no expertise. I am better off doing a research on google myself. A German doctor can do a better diagnosis by phone. So we invited German doctors to Indonesian hospitals here on order not to just complain but get something going here. We got a neurologist from Germany and an expert for physiology. First topic was Parkinson. Indonesian doctors and professors said Parkinson is very rare in Indonesia. On the first day we identified 5 clearcut Parkinson cases they of which they did not recognized even a single one. The reason why these guys thought that there are so few Parkinson cases in Indonesia is that people get treated so badly that they do not even make it to the latter stages of this illnes but die before because of the side effects of wrong medicine and medicine that was prohibited 20 years ago in Germany and the US due to known side effects. They just dont care. And for the record, no medicine would have been better. Common occurences such as people with unproblematic G6PD are diagnosed Leucemia eventhough all they would do is stop eating green beans or taking Aspirin. And so on and so forth. They do not even check for that (though estimated 12% of the people have G6PD). And they dont look it up either. So the neurologist summarized it pretty good. All they do is quick wrong diagnosis, not sharing their thoughts with any other doctor for review purposes and then giving out the strong stuff that keeps them numb or quite. Time is money. No pain, all good principle. What happens then is that mayn people become addicted to wrong drugs. Not taking the medicine causes pain and that means … for ordinary people … the doctor must be right. The physiologist was so shocked when he saw how doctors (from reknown universities / TOP 1-5) do diagnosis here and treat people. Both agreed that they saw more patients that need to be rescued from doctors here than patients that were rescued by doctors. And sure, it stems from a stupid system. You buy yourself in. If you are too stupid and dont make it through the test, you can compensate for it by writing s short thesis putting some extra money on top. And thats it. Start treating people. In university they memorize stuff a lot without understanding any underlying principles. Its not a knowledge based culture here. No epistemic culture like in Germany for instance where people depend on creating new knowledge (due to the fact that quality and knowledge is the only primary resource there). When we invited doctors and students to discuss with the German experts, that failed. None had questions. (Translation etc. was available). Its just that they study for gelar gelar and for having money making job, its just not about the knowledge. They dont know how that works. The way young, actually capable students were raised and educated is desastrous. Its consumerism on an intelectual level. Insurance system comparison? What insurance system? You have insurances. Not an insurance system. Got some money on the shelf, be happy and go to Singapore. If not, good luck. Its even cheaper in Singapore (if you dont go there for a cough). And by the way, Indonesia has all the means to finance a good insurance system. Its just that this does not happen as ordinary people dont have anything from this countries riches. So what is the good role you are talking about Handz? We dont do it the Indonesian way Bapak senang. There has to be a clearcut evaluation in the beginning even if its hurts and then starting points are created. If the medical or education system in general is a mess, we name it. I am not racist. Indonesian people have many good habits and characters, but medical treatment and education is just as wrong as it can possibly go. And thats what Indonesia suffers from primarily. And of course … exceptions confirm the general rule. So there are some good Indonesian doctors. Its just very very rare.

  7. Of course Indonesian are not dumb. Its a matter of education and structure of education systems. Incentives to develop deep understanding of things. Students are not to be blamed either. Its an issue on grassroot level.

  8. Im a Malaysian doctor who was trained in Indonesia and currently practising in Malaysia – which gives me a unique qualification and objectivity to speak on this subject.
    The problem beleaguing Indonesian healthcare is multifactorial. For simplicity im going to list them down.
    1. Standards for admission is becoming too lax. Now with the Mandiri classes, students with poor academic results but with deep pockets are able to study to become doctors. They often struggle to pass exams or to catch up.
    2. Academic standards are not safeguarded. Exams are not conducted properly – rampant cheating, recycled questions, leaked questions, no limits on no of times of failing, etc
    3. Students and even lecturers lack English proficiency ad thus find enormous difficulty to stay up to date with current medical best practice and evidence. Instead of perusing internationally recognised guidelines and protocols, many choose to rely on so called National Consensus which are often outdated and not evidence-based.
    4. Programs to train specialist doctors are known to be corrupt and inefficient. It is an open secret that applicants have to fork out a small fortune just to get in the program, unless u have the right connections. Little wonder that medical care is so “dynastic” in Indonesia.
    Residents are not sufficiently supervised and instructed. Many are left to their own devices esp during call hours, resulting in many unnecessary deaths. It is more like an apprenticeship because unlike other systems in the world, passing a rigorous board exam is seen as of secondary importance. The standard is put too low.
    5. Poor training begets poor quality doctors. I can attest to u of specialist not knowing a lot of knowledge expected of them. Specialists very often relegate clinical n ward work to residents, prefering to sit n have tea in their offices, or just to see selected outpatients. Patient care is compromised.

    However the greatest problem is denial. To set things right, first u must recognise that theres a problem in the first place. The fact that patients even very ill ones are going overseas by the planeloads DAILY speaks for itself. Put your pride aside and see for yourself what are the real problems and work to correct them. Blaming others, dismissing the problem, accusing people of ignorance wont help a thing, except to enrich doctors of neighbouring countries.
    Don’t get me wrong. I hold Indonesians in the highest regards. I know for a fact that they are NOT stupid. In fact I’ve seen very brilliant Indonesian classmates. What needs to be changed is the system and the working culture. Im sure if these are done, Indonesian patients need not come to Penang or Singapore. Who knows one day the reverse may even happen!

  9. your article was written in 2012. i’ve just come across it. Things haven’t changed, from the little that i’ve seen. i’m a doctor in Singapore and about 1/5 of my patients are from Indonesia. I also know my colleagues from Jakarta, Surabaya, Medan, Jogya, Semarang, Manado etc. Yes, the system is rotten. I do wish Indonesia the best, and hope that the system will change over time, and patients don’t have to come to Sg any more.

  10. I agree with Thomas, Indonesian system is still corrupt. I graduated from Indonesia and I was taking my residency training program outside of my country.
    I finished the training on 2013, but to be able practice in Indonesia again, I need to take a process called adaptation program for 1-2 years. Everything just the same with my residency training outside, such as: daily rounds, morning report, etc.. Plus, here I required to pay them almost 200 millions IDR to be able to enter the process..
    I’m not joking.. This is very true about Indonesia medical residency training program, while at other country I’ve being paid, here I need to pay them for nothing..
    This IS serious problem..
    I need help from other country to fix this situation..
    Any solution? Maybe someone must report this to WHO, medical residency training is NOT for SALE..
    Please help us! Thank you in advance..

  11. Thank you for bringing this up. We do have a standardized test for doctors now. We are trying to improve our medical graduates. So, let’s see if we can publish something about our medical education system. Hopefully next time it can be included in your future article, instead of anecdotal cases.

  12. Rings a bell. On a recent trip to Papua, a friend asked why the ambulance siren is heard roughly every 2-3 hours. Maybe it was just a one-off day, or maybe that it is the real senerio. Citizens of Indonesia must seriously address it.

  13. Hei,

    I think youre right. DENIAL is our number one mistake.

    First we have to be sure, that we are in bad condition
    Second. We take Royal college or american college curriculum

  14. As a physician graduated and currently working in Indonesia I couldn’t say anything except this: you’re absolutely correct. The medical education system is rigged by nepotism and corruption (both in state and private university), the universal health coverage is strangling physician’s neck (would you work for 5000 rupiah for a patient?), people’s lack of education makes it harder for us to promote healthy life style, the scarcity of diagnostic tools and drugs availability, etc. So many problems and to be honest I myself have lost my hope for this country’s health system.

  15. More than one year after the last comment, and sadly, nothing have changed for the better. Medschool is still a hellscape filled with mentally ill underperformed students, professors with ego problems who openly insult a patient(especially if the pt is one of their former pupil) in lecture. The moment you got on a doctor’s bad side, your wish for a residency is squashed forever, leaving you and your excricating cancer pain with people talented in licking the balls of higher ups professors back in school instead of people who are empathetic or smart enough to treat your suffering. No, they will be stuck in primary care to be choked to death by BPJS. An internist at a certain state medschool info was leaked to be diagnosed with narcissitic personality disorder and still allowed to teach your fuure doctor, honestly, just what on eath do you expect?

    • Exasperated Pseudoexpat | October 21, 2020 at 5:04 am | Reply

      I can attest to most of the things written there being true. It actually pointed out a major issue I also notice with the professional fields in this country. So many years have passed since the date of the published article, and in the most unfortunate ways possible, things haven’t exactly improved by much in 2020. Maybe this is one of those things you can’t just rush, I do not know. But there is still a very nuanced distrust among a great number of people of the credibility of healthcare professionals in this nation and a great deal of the reason for that explained briefly throughout the article as well as the comment section.

      Regarding the issue of ego problems, this is in my opinion such an overwhelmingly huge problem which is surprisingly rarely ever mentioned anywhere in the public discourse. There is certainly some deep, partly nurtured ego issues with some of the ‘field veterans’ in many professional fields, not just in healthcare. This is what some people had dubbed as the “Little Duke syndrome” or “sindrom radja ketjil” where as a great number of people here have very unhealthy interest in being a self-proclaimed ruler(s) over pockets of communities, whether it’s on the street in form of premans, at university in form of mean bossy seniors or in the professional field as long-time workers with seniority complex, which not coincidentally, also a parallel to the above anecdote of professors with ego issues.

      Say, for example, you are a freshman at university or newcomer at work demonstrating a lot of potential and somehow earned a certain fame within the institutio. It is then to be expected that some people on the higher end of the hierarchy might feel you’re trying to steal the limelight from them, and will go out of their way to guarantee you “know your place” in the system and try to screw you over almost without mercy, just to make sure you get the message. The result is often times disastrous not only for the individuals targeted by such attitude, but also for the overall morale of the institution, because people would pick up there is an unwritten rule that says you can’t be too far ahead from the rest of the people, else you’ll get what’s coming at you. This of course results in lowered standards for expertise, because showing off your skills could actually be considered a TABOO here, because of the said ego issues among some people.

      Where as in other places, to strive for excellence and earn credibility in a given field you have to reach the highest standards possible through merit, hardwork and possibly talent, here in Indonesia the surest and fastest way possible to obtain a so-called “credibility” is to have deep pockets for bribe, or to suck on as many reproductive organs as possible to expand your connection thus leveraging you at a better chance of getting promotions and what not. Such another product of the high ego on the higher end and a recipe for disaster in any kind of field in need of any skilled experts, and ESPECIALLY on healthcare. So with this system in place where people can just bribe their way through the system or put as many testicles as possible in one’s mouth to ensure you progress, it takes no genius to predict that most if not all the people at the top of hierarchy in any institution would only be these good-for-nothin’, insecure individuals who clearly have not earned their position in the face of anything resembling a global standard.

      On the other hand, if you are a very talented, morally upright, smart individual but have a certain disdain for petty politics, the system in place is clearly NOT doing you or people like you any favor AT ALL. This is why morale at work is so low in many professions, because the much needed appreciation ought to be given for excellence is almost non-existent and many people spend more time lobbying for better positions, paychecks or even fame instead of pushing their own standards upwards to compete with each other in fair game, let alone with the rest of the world. And they do that because that is what works in Indonesia.

      What’s also frightening, when the time comes some of these Indonesian field experts have to go face to face with the global leading experts, they will find themselves feeling totally unarmed to tackle complex issues with the standards set by the rest of the world, because so little have been expected of them throughout their career and it has been all about putting bollocks in their mouths, so you are safe to expect this is seemingly the only kind of crucial skills they seem to all have in common.

      To add insult to the injury, it is also a surprisingly difficult thing to give “experts” in Indonesia a much needed criticism to improve, because there also seem to be an almost dangerous, national-level knee jerk reactionary anger to anything remotely resembling any kind of constructive input let alone criticism. So to those of us who feel that Indonesia could do better if they’re to do this or that instead of what they’re doing now, it is almost commonplace to see most people would find themselves being surrounded by people on the offensive, lecturing you back about how everything is relative, or that you have to look at it from 100s different perspective, or the choice of words you use or that you are rude and so many unbelievably dim-witted responses you would never expect to come from a certified, skilled “expert”.

      With that being said, it is no wonder the brain drain in Indonesia is as real as it can be. As many really talented, smart individuals in Indonesia have to eventually abandoned their idealism about the country or even the country itself if they are to reach greater heights in their respective fields. Not because they’re unpatriotic or not a good citizen to begin with, but because many have felt the system isn’t doing them any favor and have realized the hard way that their hardwork and expertise will NOT be recognized the way they thought it should. Whereas in other places, they knew people like them are in high demand to compete with the ever-changing global world.

      This is why I have argued over and over again that the whole system in place is doing everyone, I mean literally EVERYONE in the nation a huge disfavor, even to those who think they’re so high and mighty and thought they’re benefiting from it on the short term. While also simultaneously lambasting anyone that dared to threaten the system in the process. The overall image is not looking good for Indonesia.

  16. Yes you are absolutely right about how crap medical education in Indonesia is, especially the residency program. Until now, there is no sign that the corruption and nepotism will be ended.
    The worst part is some faculties (and even professors!) have rascism towards christian or chinese descent doctors, thus they couldn’t get into the residency/specialist program. Check this video https://youtu.be/vyBU4nGrAn8

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