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.

9 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.

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