Health Workforce Plan for Indonesia: Mitigating Critical Shortages through HRH Management

The report focuses on the importance of a health workforce essential for health services and human development in a country. Population health is of paramount importance that requires careful planning in recruiting a skilled health workforce. The report analyzes the health workforce profile and critical issues witnessed in Indonesia along with recommendations on the shortage and migration of healthcare professionals using WHO framework.

Running head: PUBLIC HEALTH
Public health
Name of the Student
Name of the University
Author note

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Executive summary
The following report focuses on the importance of a health workforce essential for health
services and human development in a country. Population health is of paramount importance that
requires careful planning in recruiting a skilled health workforce. For an efficient healthcare
delivery, HRH need to plan, recruit and select health personnel who are able to meet the health
needs of the population. However, in low and middle-income countries, the scenario is different
as they face critical shortage in healthcare providers. According to WHO, “World Health
Statistics Report, 2015” Indonesia falls under middle-income country category facing inadequate
human resource and health workers due to international migration and imbalances in demand and
supply. There are shortages of staffs ranging from doctors, nurses, midwives, clinicians and
pharmacists. The data profile showed that there is unequal distribution of health personnel, lack
of retention strategies and motivation among the health personnel. This shortage has significant
impact on the population contributing to low quality of services to the population. Therefore, this
report provides a health workforce plan that is aimed to mitigate the critical shortages witnessed
by Indonesia through HRH management and improvement of infrastructural processes.
Furthermore, this report will also provide a strategic plan on improving the health workforce in
Indonesia and enhance quality of care in meeting the needs of the population.

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Table of Contents
1. Introduction..............................................................................................................................4
2. Nature and Extent of Issue.......................................................................................................4
2.1 Environmental scan...........................................................................................................4
2.2 Health workforce data profile................................................................................................7
3. Health workforce plan............................................................................................................10
3.1 Education, Skills and training..............................................................................................10
3.2 Job creation..........................................................................................................................11
3.3 Women and gender rights....................................................................................................11
3.4 Technology..........................................................................................................................11
3.5 Healthcare service delivery..................................................................................................12
3.6 HRH utilization....................................................................................................................12
3.7 Financial space.....................................................................................................................13
3.8 Partnership and coordination...............................................................................................13
3.9 Information, data and accountability...................................................................................14
3.10 Humanitarian and crisis settings........................................................................................14
4. Conclusion..............................................................................................................................14
5. Strategic plan..........................................................................................................................15
5.1 Health and HR plan in Indonesia:........................................................................................15
5.1.1 Year 1- 2019................................................................................................................16

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5.1.2 Year 2- 2020..................................................................................................................16
5.1.3 Year 3- 2021................................................................................................................16
5.1.4 Year 4- 2022................................................................................................................16
5.1.5 Year 5- 2023................................................................................................................16
References......................................................................................................................................18

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1. Introduction
The skills, motivation, knowledge and deployment are the factors that define the ability
of a country in meeting their health goals. The number of health workers is directly linked to the
population health outcomes as outlined in literature. There is also need for formulation of
healthcare workforce plans and formulations for meeting the objectives of health development
with sound evidence and information. “World Health Statistics Report, 2015” by WHO has
segmented the low and lower middle income countries and while analyzing the report, Indonesia
face major concerns in terms of shortage of healthcare professionals with uneven distribution in
various healthcare settings and management of health workforce in a decentralized healthcare
system (Fulton et al., 2011). The rationale for choosing this country is that Indonesia is lacking
these building blocks especially in terms of good health facing a critical shortage of healthcare
professionals. Indonesia is facing challenges related to human health resources like inequitable
health workers distribution, shortage of skilled staffs, absenteeism and lack of motivation. There
is also poor supervision lack of support and unsatisfactory working environments in Indonesia.
There is need for advocating the human resource issues and situational analysis on the national
agenda. Therefore, the following report analyzes the health workforce profile and critical issues
witnessed in Indonesia along with recommendations on the shortage and migration of healthcare
professionals using WHO framework.
2. Nature and Extent of Issue
2.1 Environmental scan
Indonesia faces critical challenges in terms of human resources for health (HRH)
that is related to planning and development of HRH (Human Resource for Health) policy

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with mismatches between production, demand and supply, mal-distribution and
remuneration in rural, urban and remote areas. The decentralization of health system in
Indonesia is the main reason that the country is facing challenges in terms of healthcare
system. The law was enacted in 2001 on local autonomy and that marked the beginning
of decentralization, however, its implementation was different at each level of
government (Pepinsky & Wihardja, 2011). The transferring of autonomy gave districts
more independence in terms of regulation and management of affairs in the health sector.
The line of coordination was ignored at the upper level that did not function as command
line. Although, the central line wanted to control the main line, however, the HRH
situation deteriorated due to decentralization.
As per the 2010 census, Indonesia ranked last among the ten populous countries
with respect to physicians density per 1000 population compared to Russia, United States
and China ranking first, second and fourth respectively. Similarly, Indonesia ranked fifth
in nurse and midwives density (2.04/1000) with United States, Russia, Brazil and Japan
occupying the first four positions (Rokx, 2010). During the years 2000-2012, the number
of nurses, midwives and physicians increased substantially, however, it was not
significant. The increase in health workforce was not enough to meet the needs of the
population in terms of health. Moreover, hospital beds per 1000 population were quite
low as per 2010 census on the global scale (Hoyler et al., 2014).
Decentralization in Indonesia has given the local governments to take up the
direct authority of prioritizing healthcare sectors for development. HRH planning is now
in the hands of regional governments that resulted in diverse funding and no attention
was given to these challenges in the regions. Critical shortage of HRH due to inadequate

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resources and understaffing is making Indonesia suffer at every level of healthcare
system (Heywood & Choi, 2010). There is acute shortage of health workers in low and
middle-income countries and this scenario is witnessed in Indonesia. There is
understaffing of healthcare professionals that has led to their inequitable distribution that
can be witnessed from the range 10.36 to 53.89 per 100,000 populations as per Indonesia
Heath profile, 2008 (Meliala, Hort & Trisnantoro, 2013). Moreover, HRH also face
challenges in terms of planning, recruitment and healthcare workers retention in the face
of challenging HRH from Indonesia’s neighbouring countries. The quality of care also
deteriorated during these years that are related to lack of effective licensing and oversight
in HRH. Majority of healthcare professionals in the public sector have opted for second
jobs due to lack of adequate wages in this sector.
There are also deficient information in HRH policy development that is
hampering planning and development efforts of policy makers. The average number of
HRH in Indonesia per 1000 population is quite below the threshold level that is important
to achieve the UHC and health-related MDGs. The Indonesian policy emphasizes on
production, recruitment and retention of human resources in various cadres. However,
there is less number of healthcare professionals with poor quality of quality services and
unequal distribution in rural and remote regions as there is lack of deployment policy in
terms of non-financial and financial incentives for the healthcare providers (Efendi,
2012).
These HRH critical shortages impede the progress of Indonesia that can envisage
for health system strengthening so that there is equitable access to lifesaving and essential
primary healthcare services. Furthermore, this shortage poses obstacles for health-related

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attainment of Millennium Development Goals (MDGs) and Universal Health
Coverage (UHC). Most of the health workforce in Indonesia is concentrated in Java
Island that left rural and remote areas underserved (Utomo, Sucahya & Utami, 2011).
This is the reason that there is an urgency to develop a national health workforce for
Indonesia curbing the HRH program faced by the country.
2.2 Health workforce data profile
Although, there are no appropriate norms to calculate the optimum ratio of healthcare
workers, however, WHO has identified the threshold doctors density of 2.28 per 1,000
population with nurses and midwives ranging from 2.02 to 2.54 (Short, 2016). Indonesia
falls under this threshold and there is lack of 80% coverage of skilled attendance at the
time of delivery, measles immunization and reduction of infant and maternal, mortality
rate for meeting the goals of health-related MDGs (Grewal, 2016). There is unequal
distribution of doctors in Indonesia where there is one doctor for every 3,000 people in
urban areas and one doctor for 22,000 people in rural areas as reported by World Bank
found in Java-Bali, the most populous Indonesian region (Boyle & Plummer, 2017).
According to World Bank 2009, there is only 1 doctor for every 12,000 rural people and
one doctor for every 15,000 people residing in remote areas and one doctor per 2,430
people in urban areas (Anderson et al., 2014). The situation is worse outside Bali where
nurses are less because of voluntary registration. The people in remote and rural areas
rely heavily on health services provided by nurses and were found to be critically short in
the underserved areas.
While looking into the health workforce trends in Indonesia as per 2010 data,
there is an absolute increment in the number of pharmacy practitioners, nurses, midwives,

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dental practitioners, medical technologists and public health practitioners. 2010 figures
show that there is a major decline in the number from 34,554 to 33, 7336 during the year
2009 to 2010 and during this period, the number of nurses and midwives increased from
194.399 to 266,348 (Anderson et al., 2014).
Considering the distribution of Indonesian health workforce over the region,
recruitment was done using the formation of medical doctors, nurses, midwives and civil
servants. During the year 2010, there was a significant increase in the number of health
providers from 328,044 to 498,590 from 2009 to 2010 with 52% (Anderson et al., 2014).
However, despite the increase, there was significant decrease in the supporting staff over
these years. Nurse shortages in the rural and remote areas were due to international
migration across the country where they are moving from rural to urban areas. The recent
data on health workforce showed that international migration remains an issue where they
move to urban lands in order to sought employment due to high unemployment in labour
market migrating to countries like Japan. Indonesia has become a potential market for
migration of international nurses where thousands of them are moving to neighbouring
countries for better opportunities.
No. Type Indicator/ 100,000
population (2010)
Need for health
workers (2010)
A Medics
1 General practitioners 30 70,782
2 Specialists 9 21,234
3 Dentist 11 25,953

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B Nursing
4 Nurse 158 372,783
5 Midwife 75 176,954
6 Dental nurse 16 37,750
C Pharmaceutical
7 Assistant pharmacist 18 42,469
8 Pharmacist 9 21,234
D Public health
9 Sanitarian 10 23,594
10 Graduate of public health 8 18,875
E 11 Nutrition 18 42,469
F 12 Medical technicians 6 14,156
13 Physical therapy 4 9,438
Figure: Indonesian health workforce (Anderson et al., 2014)
The above statistics illustrates that there is limited workforce management, low
production with adequate number of healthcare providers being prevalent in Indonesia.
These figures suggests that there is inadequate motivation and retention mechanisms by
HRH due to geographical imbalances, inadequate skill mix and mismatches between
education and training services results in limited nursing students enrolment, limited
medical schools and critical medical educator shortages. Therefore, HRH needs to
employ strategies that ensure responsive and competent division of labour with optimum
output. Moreover, they should also implement HRH plans that ensure adequate supply of

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labour with proper balance between production, demand and supply in order to improve
distribution and performance of the existing health workforce in Indonesia.
3. Health workforce plan
The health workforce plan in Indonesia is aimed challenging the decentralization as it has
hindered human resources development in the health workforce. There is improvement
needed for dividing tasks and for the sound functioning between central and local
government. This health workforce plan is aimed at improving the HRH condition, rural
services through community approach that focuses on offering quality healthcare services
and extension of healthcare workers to outreach to the rural and remote areas. This HRH
plan would be beneficial in scaling up healthcare providers in offering clinical services to
the regional and zonal levels. Most importantly, this plan is aimed at increasing the health
workforce as the current statistics shows that there is a rising demand for them in the
health services. Concisely, this plan aims to improve the healthcare staffs including,
physicians, nurses, midwives and other medical officials. Therefore, the following
recommendations would be helpful in curbing the problem of international migration
entailing a road map for the avenues in a way where the Indonesian health workforce can
address the problems.
3.1 Education, Skills and training
Indonesia is at risk for international migration especially to Japan and they need to do
more in prioritizing investments in education and training. Education models need to shift away
from specializations and move towards building of lifelong relevant competencies at the local
level. Geographical inequalities need to be addressed and provide opportunities for strengthening

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youth education for successful employment in the health sector. For this, the government needs
to scale up high quality, transformative and lifelong learning for skilled workers who match the
needs of the population and work to their best potential (Kurniati et al., 2015).
3.2 Job creation
There is an urgency to develop the current Indonesian labor market for fostering the
demand for a sustainable and population-centered health workforce. There is need for
government policies that address the issues in labor market. The right mix of skills is required for
fulfilling the health needs of the population. The government should stimulate investments for
the creation of decent jobs in the health sector especially for women and youth with right skills at
right places in right numbers.
3.3 Women and gender rights
The health sector is a growing platform for women employment and gender equality. In
the healthcare sector, women are the main care providers including conflict settings and
humanitarian crises. However, there are prevailing gender biases in this sector that remains a big
challenge that need to be addressed. To curb the problem of gender inequality, there should be
maximization of women participation in the economy and fostering empowerment. This can be
achieved through leadership that addressed education inequalities, gender biases in the health
labor market, and tackle concerns regarding gender in the reform processes.
3.4 Technology
The rapidly changing phase of technology is already changing the nature of healthcare
services. Information and communication technology (ICT) is changing and there is emergence
of new cadres of healthcare providers. In such cases, digital technologies can offer opportunities

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for enhancing the access to healthcare services and in improving the responsiveness of system
towards health needs of the communities and populations. The delivery of healthcare can be
improved and therefore, there should be harnessing of cost-effective ICT that enhances health
education, offer client-centered care and health-related information systems (Agarwal et al.,
2015).
3.5 Healthcare service delivery
The healthcare systems are organized around hospitals and clinical specialties and
therefore, there is a need for shifting towards primary care and prevention. There is lack of
perfect mix of private and public healthcare professionals and so, the government should adopt
healthcare policies that cover overall performance of the health sector. For serving the
underserved, social business, models in private sector can be socially oriented solution where
regulatory bodies and public policies should protect the public interests ensuring that there is no
domination from professional interests (Carruth & Valle, 2013). Therefore, service models need
to be reformed that concentrates on hospital care and focus on prevention with efficient-
provision of affordable, high-quality, community-based, integrated and patient-centered
ambulatory and primary care especially offering services to the underserved and remote areas.
3.6 HRH utilization
The recruitment and selection of healthcare personnel should be fair and conducted in
each central units and local government levels coordinated and selected by a single body. The
deployment and distribution mechanisms should be based on available staff and recruitment
plans. Unequal distribution and placement of health personnel can be tackled through contractual
employee and civil servant scheme. To attract interest for health providers towards working in
underserved and remote areas, financial incentives through national budget can be helpful and

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encouraging local governments to pay for additional incentives. The shortening of service period
with scholarship for higher education and workplace safety can also attract more health workers.
Foreign investment in health sector can help to increase the private health workers in the future.
Development of HRH plans and policies is an important task that comprises of main functions
like HR policy and strategy, HR planning and distribution, coordination of in-service and pre-
service training with proper evaluation and training that can produce equitable distribution of
medical staffs, HR personnel and service quality improvement (World Health Organization,
2016).
3.7 Financial space
There is a need to have a sustainable health financing to assume continuous growth in
public revenue and necessary prioritization in the health workforce. Political commitment and
societal dialogue are the critical factors that drive health finance policies and macroeconomic
reforms. However, there is insufficient market demand to create jobs and in fulfilling the
Sustainable Developmental Goals (SDG) in fragile and middle-income countries like Indonesia.
Collective action is demanded on financing by raising adequate funds from national and
international sources, appropriate privatization and health financing. Health financing reforms
can be undertaken through investment in right skills, proper working conditions and having an
appropriate number of healthcare professionals.
3.8 Partnership and coordination
In Indonesia, there is an urgency to achieve fit-for-purpose healthcare workforce across
all health sectors in the labor market. Inter-sectoral collaboration promotion at regional, national
and international levels can help in supporting effective partnership in health sector. There is also
requirement of aligning with international bodies that can be helpful in supporting health

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workforce investments as a part of educational strategies and national health plans. The
processes must engage private and public sectors, trade unions, civil society, workers
associations and non-governmental organizations, training organizations and regulatory bodies
(World Health Organization, 2014).
3.9 Information, data and accountability
Analysis of data through institutional capacity is much need for health labor market. The
strengthening of health workforce depends on the active engagement of health workers,
communities, training institutions, employers and regulatory bodies. Organizations like WHO
and OECD play a key role in the establishment of harmonized metrics for monitoring trends in
the Indonesian health labor market.
3.10 Humanitarian and crisis settings
Every country should have health system and workforce that has the capacity to identify
and respond to the health risks prevailing in the population and emergencies. Public health crisis
in conflict and fragile settings can exacerbate existing shortcomings of the countries for
providing health care to their populations. To achieve this, ensure investment in places with right
mix of skills including domestic and international workers in humanitarian aid and emergencies.
The country should also ensure security and protection of all health workers in all settings.
4. Conclusion
Health workforce is one of the important pillars and interacting blocks in the healthcare
system that has an impact on the strengthening of the systems. However, many countries face
lack of human resources that is required to fulfill the healthcare needs and deliver healthcare
interventions due to shortage of healthcare professionals, migration, and poor mix of skills,

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limited capacity and demographic imbalances. The current health personnel shortages in service
delivery greatly affect the quality of care including diagnosis and treatment provided to the
people of the country. In low-middle income country like Indonesia, health workforce is
experiencing critical staff shortages with imbalances in production, demand and supply
especially in underserved and remote areas. Quality of healthcare is also deteriorated that
depend on the policies where the healthcare providers are capable of delivering care as per the
demand. There are loopholes in the HRH strategies and its implementation in terms of planning
recruitment and selection that is resulting in international migration experiencing shortage of
nurses and midwives in the underserved and remote areas. As a result, there is urgency for a
health workforce plan that ensures to fulfill the challenges in Indonesian health sector. Therefore,
the above report mentioned recommendations that are aimed at curbing the critical shortage and
addressing health workforce issues faced by the country.
5. Strategic plan
The plan comprises of HRH development as one of the main priorities in
Indonesian health workforce that includes planning, management, registration, training,
certification and technical support.
5.1 Health and HR plan in Indonesia:
The five-year plan can act as a catalytic support for Indonesia to report a well
functioning HRH information system through stakeholders’ engagement. By
implementing this strategy, the country can make a substantial move towards
strengthening health workforce and foreign investment. Moreover, the country can
mobilize additional resources for the HRH development.

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5.1.1 Year 1- 2019
Stakeholder analysis will be done for identifying constituencies with
development of close links. The HR committee should have adequate
representation and inclusive having defined roles and responsibilities.
5.1.2 Year 2- 2020
HRH situational analysis includes pre and during service training and
professional development, current utilization of existing healthcare workforce and
determinants, health trends and analysis of retention strategies, responsiveness
and migration trends with respect to population health needs.
5.1.3 Year 3- 2021
HRH planning should be comprehensive, evidence-based and cost-effective that
engages all stakeholders from every health sector aligning with the national
strategy, aims and objectives that are measurable, achievable, realistic and time-
bound.
5.1.4 Year 4- 2022
Resource mobilization for HRH investments will happen in the fourth year that
requires resource mobilization plan and advocates for additional resources from
national budget and exploring funds from bilateral and multilateral partners.
5.1.5 Year 5- 2023
Implementation, monitoring and evaluation of the HRH plan at the committee
can be implemented through stakeholders’ collaboration employing in framework

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of indicators in a unified manner with dissemination of transparent and accurate
information.
Strategic plan 2019 2020 2021 2022 2023
Stakeholder
analysis
HRH situational
analysis
HRH planning
Resource
mobilization for
HRH
investments
Implementation,
monitoring and
evaluation
Figure: Gantt chart

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