Southeast Asian countries to allow free flow of doctors

Abstract

A new common market agreement between several southeast Asian nations could transform health care in the region. But will it be for the better? Chris McCall reports.In a part of the world made famous by wars and natural disasters, bureaucratic controls to stop outsiders practising medicine are finally being prised apart. Not in the name of health, but in the name of free trade.After years of talking about it, in 2015 the ten-member Association of Southeast Asian Nations (ASEAN) will implement a common market that will, among other things, allow professionals from each member to work in the other nine countries. Among the key areas targeted is health. New agreements covering medicine, dentistry, and nursing are all due to come into effect.It promises eventually to transform the way medicine is practised throughout the bloc. For its largest member, Indonesia, it is a sea change, applauded by many and feared by some, including some Indonesian doctors.Not long ago, Indonesian law placed a blanket ban on foreign doctors. Only Indonesian citizens could practise medicine in Indonesia. Founding President Sukarno urged Indonesia to shake off three centuries of Dutch colonialism and strive for self-sufficiency in all things, including health care. This goal ultimately found its way into law.For decades, the only exceptions were a few doctors employed specifically to look after foreigners, usually by large foreign corporations such as mining companies, usually with substantial numbers of ex-patriate staff. Meanwhile, Indonesia's health system struggled; millions of poor Indonesians had little or no health care. Some small, remote islands had no doctors at all.But while ASEAN was slowly discussing liberalisation, cracks began to emerge. In 2004, the law, at least on paper, was changed to permit foreign doctors to work in Indonesia. However, implementation of that law has been slow and has met with a strong resistance. Even after natural disasters such as the 2004 Indian Ocean tsunami that devastated Aceh province in Sumatra, foreign doctors have often struggled to get permission to come to Indonesia to help.Local resistanceNevertheless, small numbers of foreign doctors are now starting to gain registration and work in Indonesia. Armyn Nurdin, head of the 1300-strong Association of Indonesian Family Physicians (PDKI), told The Lancet that the sad reality is that the quality of medical services in Indonesia is poor and the presence of foreign doctors can only help. But some Indonesian doctors, he said, are keen to protect their home market from outside competition to safeguard their own livelihoods. “The monopoly on medical services by Indonesian people means that Indonesian doctors have no competition. The quality of medical service in Indonesia is still weak, so if foreigners come in it will help improve the quality of service in Indonesia”, he said.But PDKI has often been a voice crying in the wilderness in Indonesian medicine, and Nurdin, who spent 5 years as a junior health minister, admits that the Indonesian Medical Association (IDI) has often stood in the way when others wanted to change the way medicine is practised in Indonesia. IDI was contacted by The Lancet for this article but did not respond.Brain drainASEAN has a combined population of more than 500 million. Apart from Indonesia, it includes Vietnam, Thailand, the Philippines, Myanmar, and some smaller, more developed members like Malaysia and Singapore. The moves to open up health care to foreign competition promise to have a similar effect to those in the European Union (EU) in recent years, which have permitted doctors to move throughout the EU to work. Indonesia is not the only country that will need to change its practices. The Philippines, for example, also banned foreign doctors due to a constitutional clause stating that professional posts must be held by Filipinos.Free trade works in both directions and Nurdin warned that the changes might not all be positive for Indonesia. There is every chance that Indonesia would end up losing some of its best doctors to its neighbours, precisely because of the poor conditions they work in at home. They could be head-hunted to work for better pay, particularly in Malaysia and Singapore, where the Indonesian language is widely understood. Some of the best doctors in Indonesia have had offers to work in other countries in ASEAN. “These are high quality doctors”, he says.Doctor shortagesWith 93 000 registered doctors to cover a population of more than 220 million, Indonesia has more than 2000 people to each doctor. It is not hard to see why they could be tempted by offers from overseas. Indonesia has recently implemented a form of social security, which gives family doctors some guaranteed income for treating the poor. By other countries' standards, it is still pitifully low.Even under the new scheme, Nurdin says, a doctor responsible for 3000 people may get just 9 million rupiah (under US$1000) a month from the government. From this sum that doctor may have to buy medicines and provide their own place to practise. With such difficult conditions, many people have asked why Indonesia should turn away qualified foreigners who want to help. One foreign doctor who has fallen foul of Indonesian officialdom in the past says that Indonesia clearly needs to change. “Quality of health care in Indonesia, although improving, is not up to regional standards”, Dan Murphy told The Lancet. “Many, especially rural people, have access to only a small ill-equipped government clinic.”Before Timor-Leste's 1999 referendum on independence, Murphy—an American—went to Dili to help by setting up a clinic. But he was then forced to leave by the Indonesian authorities on the grounds that he did not have a work visa. Even after the 2004 tsunami, Murphy was still refused an Indonesian visa when he offered to go and help. Murphy now runs Bairo Pite clinic in Dili, the capital of an independent Timor-Leste.Costly careMost foreigners who come to Indonesia see it through the resort island of Bali. But one Balinese man, Gede Mangun, says that the thousands of foreign visitors mostly have no idea how hard and cruel life can be for ordinary Balinese when they fall ill. Mangun has set up an organisation to try to help address such issues: the Cempaka Putih Foundation, named after a flower with spiritual significance in the predominantly Hindu island. “In Bali, despite the development of tourism, most of the people are still poor. I live in the mountains. There are thousands of people there that don't have any health care”, he told The Lancet.In his community of Songan, people have to walk 5–10 km to reach a health centre. Once there, there may be only one or two doctors and probably not even an x-ray machine. For any serious treatment they need to go to the main city of Denpasar. There is no ambulance service. Even if they are sick, they have to pay for their own transport. For poor farmers, this can all be beyond their means. And usually, if they need an operation, they will have to pay for it. “They can die before getting to the hospital”, he says.When Mangun's father needed an appendicectomy, the operation cost around 3 million rupiah (around $300). For many Indonesians, this could be a year's earnings. To pay for it, the family had to sell their cattle.Mangun says many ordinary Indonesians are praying for more foreign doctors to be allowed into Indonesia, but he says that the reality is that many in Indonesia's notoriously bureaucratic officialdom have tried to block such moves, including some Indonesian doctors. Primarily, he feels, they are scared of competition. “Getting a doctor in Indonesia is very expensive. So if you are a doctor in Indonesia you can become very rich. They are scared of competition”, he said.Genuine contribution?Although Indonesia's law changed 10 years ago, there are still no detailed regulations about how exactly foreign doctors can apply to work in Indonesia and prominent figures in Indonesian medicine have repeatedly questioned the need for foreign doctors at all. A small trickle of foreign doctors has started to work in Indonesian hospitals, but disputes over their presence have made headlines.Budiman Sinaga, an Indonesian lawyer who specialises in health law, says that there are some legitimate concerns, but ultimately foreigners have a lot to offer Indonesia, if they help improve standards and fill gaps. It is clear, he says, that many Indonesians have little faith in their own health service. “Every day many Indonesian people go abroad to be treated or just for a checkup to various countries”, said Sinaga, adding that Malaysia, Singapore, and Thailand were all popular destinations.Sinaga says that although ASEAN's mutual recognition arrangement on medicine is supposed to come into force in 2015, it is not certain it will be implemented immediately in Indonesia. According to the Indonesian constitution, international agreements need to be incorporated into domestic laws before they are valid domestically.But will overseas doctors make a genuine contribution that is otherwise not available? Will they really want to work in the places where Indonesia really needs them? Or would they prefer to practise in more lucrative areas? And will they have a good enough grasp of the Indonesian language? As Sinaga says: “People should not be tricked into thinking that everything that comes from abroad is better.” A new common market agreement between several southeast Asian nations could transform health care in the region. But will it be for the better? Chris McCall reports. In a part of the world made famous by wars and natural disasters, bureaucratic controls to stop outsiders practising medicine are finally being prised apart. Not in the name of health, but in the name of free trade. After years of talking about it, in 2015 the ten-member Association of Southeast Asian Nations (ASEAN) will implement a common market that will, among other things, allow professionals from each member to work in the other nine countries. Among the key areas targeted is health. New agreements covering medicine, dentistry, and nursing are all due to come into effect. It promises eventually to transform the way medicine is practised throughout the bloc. For its largest member, Indonesia, it is a sea change, applauded by many and feared by some, including some Indonesian doctors. Not long ago, Indonesian law placed a blanket ban on foreign doctors. Only Indonesian citizens could practise medicine in Indonesia. Founding President Sukarno urged Indonesia to shake off three centuries of Dutch colonialism and strive for self-sufficiency in all things, including health care. This goal ultimately found its way into law. For decades, the only exceptions were a few doctors employed specifically to look after foreigners, usually by large foreign corporations such as mining companies, usually with substantial numbers of ex-patriate staff. Meanwhile, Indonesia's health system struggled; millions of poor Indonesians had little or no health care. Some small, remote islands had no doctors at all. But while ASEAN was slowly discussing liberalisation, cracks began to emerge. In 2004, the law, at least on paper, was changed to permit foreign doctors to work in Indonesia. However, implementation of that law has been slow and has met with a strong resistance. Even after natural disasters such as the 2004 Indian Ocean tsunami that devastated Aceh province in Sumatra, foreign doctors have often struggled to get permission to come to Indonesia to help. Local resistanceNevertheless, small numbers of foreign doctors are now starting to gain registration and work in Indonesia. Armyn Nurdin, head of the 1300-strong Association of Indonesian Family Physicians (PDKI), told The Lancet that the sad reality is that the quality of medical services in Indonesia is poor and the presence of foreign doctors can only help. But some Indonesian doctors, he said, are keen to protect their home market from outside competition to safeguard their own livelihoods. “The monopoly on medical services by Indonesian people means that Indonesian doctors have no competition. The quality of medical service in Indonesia is still weak, so if foreigners come in it will help improve the quality of service in Indonesia”, he said.But PDKI has often been a voice crying in the wilderness in Indonesian medicine, and Nurdin, who spent 5 years as a junior health minister, admits that the Indonesian Medical Association (IDI) has often stood in the way when others wanted to change the way medicine is practised in Indonesia. IDI was contacted by The Lancet for this article but did not respond. Nevertheless, small numbers of foreign doctors are now starting to gain registration and work in Indonesia. Armyn Nurdin, head of the 1300-strong Association of Indonesian Family Physicians (PDKI), told The Lancet that the sad reality is that the quality of medical services in Indonesia is poor and the presence of foreign doctors can only help. But some Indonesian doctors, he said, are keen to protect their home market from outside competition to safeguard their own livelihoods. “The monopoly on medical services by Indonesian people means that Indonesian doctors have no competition. The quality of medical service in Indonesia is still weak, so if foreigners come in it will help improve the quality of service in Indonesia”, he said. But PDKI has often been a voice crying in the wilderness in Indonesian medicine, and Nurdin, who spent 5 years as a junior health minister, admits that the Indonesian Medical Association (IDI) has often stood in the way when others wanted to change the way medicine is practised in Indonesia. IDI was contacted by The Lancet for this article but did not respond. Brain drainASEAN has a combined population of more than 500 million. Apart from Indonesia, it includes Vietnam, Thailand, the Philippines, Myanmar, and some smaller, more developed members like Malaysia and Singapore. The moves to open up health care to foreign competition promise to have a similar effect to those in the European Union (EU) in recent years, which have permitted doctors to move throughout the EU to work. Indonesia is not the only country that will need to change its practices. The Philippines, for example, also banned foreign doctors due to a constitutional clause stating that professional posts must be held by Filipinos.Free trade works in both directions and Nurdin warned that the changes might not all be positive for Indonesia. There is every chance that Indonesia would end up losing some of its best doctors to its neighbours, precisely because of the poor conditions they work in at home. They could be head-hunted to work for better pay, particularly in Malaysia and Singapore, where the Indonesian language is widely understood. Some of the best doctors in Indonesia have had offers to work in other countries in ASEAN. “These are high quality doctors”, he says. ASEAN has a combined population of more than 500 million. Apart from Indonesia, it includes Vietnam, Thailand, the Philippines, Myanmar, and some smaller, more developed members like Malaysia and Singapore. The moves to open up health care to foreign competition promise to have a similar effect to those in the European Union (EU) in recent years, which have permitted doctors to move throughout the EU to work. Indonesia is not the only country that will need to change its practices. The Philippines, for example, also banned foreign doctors due to a constitutional clause stating that professional posts must be held by Filipinos. Free trade works in both directions and Nurdin warned that the changes might not all be positive for Indonesia. There is every chance that Indonesia would end up losing some of its best doctors to its neighbours, precisely because of the poor conditions they work in at home. They could be head-hunted to work for better pay, particularly in Malaysia and Singapore, where the Indonesian language is widely understood. Some of the best doctors in Indonesia have had offers to work in other countries in ASEAN. “These are high quality doctors”, he says. Doctor shortagesWith 93 000 registered doctors to cover a population of more than 220 million, Indonesia has more than 2000 people to each doctor. It is not hard to see why they could be tempted by offers from overseas. Indonesia has recently implemented a form of social security, which gives family doctors some guaranteed income for treating the poor. By other countries' standards, it is still pitifully low.Even under the new scheme, Nurdin says, a doctor responsible for 3000 people may get just 9 million rupiah (under US$1000) a month from the government. From this sum that doctor may have to buy medicines and provide their own place to practise. With such difficult conditions, many people have asked why Indonesia should turn away qualified foreigners who want to help. One foreign doctor who has fallen foul of Indonesian officialdom in the past says that Indonesia clearly needs to change. “Quality of health care in Indonesia, although improving, is not up to regional standards”, Dan Murphy told The Lancet. “Many, especially rural people, have access to only a small ill-equipped government clinic.”Before Timor-Leste's 1999 referendum on independence, Murphy—an American—went to Dili to help by setting up a clinic. But he was then forced to leave by the Indonesian authorities on the grounds that he did not have a work visa. Even after the 2004 tsunami, Murphy was still refused an Indonesian visa when he offered to go and help. Murphy now runs Bairo Pite clinic in Dili, the capital of an independent Timor-Leste. With 93 000 registered doctors to cover a population of more than 220 million, Indonesia has more than 2000 people to each doctor. It is not hard to see why they could be tempted by offers from overseas. Indonesia has recently implemented a form of social security, which gives family doctors some guaranteed income for treating the poor. By other countries' standards, it is still pitifully low. Even under the new scheme, Nurdin says, a doctor responsible for 3000 people may get just 9 million rupiah (under US$1000) a month from the government. From this sum that doctor may have to buy medicines and provide their own place to practise. With such difficult conditions, many people have asked why Indonesia should turn away qualified foreigners who want to help. One foreign doctor who has fallen foul of Indonesian officialdom in the past says that Indonesia clearly needs to change. “Quality of health care in Indonesia, although improving, is not up to regional standards”, Dan Murphy told The Lancet. “Many, especially rural people, have access to only a small ill-equipped government clinic.” Before Timor-Leste's 1999 referendum on independence, Murphy—an American—went to Dili to help by setting up a clinic. But he was then forced to leave by the Indonesian authorities on the grounds that he did not have a work visa. Even after the 2004 tsunami, Murphy was still refused an Indonesian visa when he offered to go and help. Murphy now runs Bairo Pite clinic in Dili, the capital of an independent Timor-Leste. Costly careMost foreigners who come to Indonesia see it through the resort island of Bali. But one Balinese man, Gede Mangun, says that the thousands of foreign visitors mostly have no idea how hard and cruel life can be for ordinary Balinese when they fall ill. Mangun has set up an organisation to try to help address such issues: the Cempaka Putih Foundation, named after a flower with spiritual significance in the predominantly Hindu island. “In Bali, despite the development of tourism, most of the people are still poor. I live in the mountains. There are thousands of people there that don't have any health care”, he told The Lancet.In his community of Songan, people have to walk 5–10 km to reach a health centre. Once there, there may be only one or two doctors and probably not even an x-ray machine. For any serious treatment they need to go to the main city of Denpasar. There is no ambulance service. Even if they are sick, they have to pay for their own transport. For poor farmers, this can all be beyond their means. And usually, if they need an operation, they will have to pay for it. “They can die before getting to the hospital”, he says.When Mangun's father needed an appendicectomy, the operation cost around 3 million rupiah (around $300). For many Indonesians, this could be a year's earnings. To pay for it, the family had to sell their cattle.Mangun says many ordinary Indonesians are praying for more foreign doctors to be allowed into Indonesia, but he says that the reality is that many in Indonesia's notoriously bureaucratic officialdom have tried to block such moves, including some Indonesian doctors. Primarily, he feels, they are scared of competition. “Getting a doctor in Indonesia is very expensive. So if you are a doctor in Indonesia you can become very rich. They are scared of competition”, he said. Most foreigners who come to Indonesia see it through the resort island of Bali. But one Balinese man, Gede Mangun, says that the thousands of foreign visitors mostly have no idea how hard and cruel life can be for ordinary Balinese when they fall ill. Mangun has set up an organisation to try to help address such issues: the Cempaka Putih Foundation, named after a flower with spiritual significance in the predominantly Hindu island. “In Bali, despite the development of tourism, most of the people are still poor. I live in the mountains. There are thousands of people there that don't have any health care”, he told The Lancet. In his community of Songan, people have to walk 5–10 km to reach a health centre. Once there, there may be only one or two doctors and probably not even an x-ray machine. For any serious treatment they need to go to the main city of Denpasar. There is no ambulance service. Even if they are sick, they have to pay for their own transport. For poor farmers, this can all be beyond their means. And usually, if they need an operation, they will have to pay for it. “They can die before getting to the hospital”, he says. When Mangun's father needed an appendicectomy, the operation cost around 3 million rupiah (around $300). For many Indonesians, this could be a year's earnings. To pay for it, the family had to sell their cattle. Mangun says many ordinary Indonesians are praying for more foreign doctors to be allowed into Indonesia, but he says that the reality is that many in Indonesia's notoriously bureaucratic officialdom have tried to block such moves, including some Indonesian doctors. Primarily, he feels, they are scared of competition. “Getting a doctor in Indonesia is very expensive. So if you are a doctor in Indonesia you can become very rich. They are scared of competition”, he said. Genuine contribution?Although Indonesia's law changed 10 years ago, there are still no detailed regulations about how exactly foreign doctors can apply to work in Indonesia and prominent figures in Indonesian medicine have repeatedly questioned the need for foreign doctors at all. A small trickle of foreign doctors has started to work in Indonesian hospitals, but disputes over their presence have made headlines.Budiman Sinaga, an Indonesian lawyer who specialises in health law, says that there are some legitimate concerns, but ultimately foreigners have a lot to offer Indonesia, if they help improve standards and fill gaps. It is clear, he says, that many Indonesians have little faith in their own health service. “Every day many Indonesian people go abroad to be treated or just for a checkup to various countries”, said Sinaga, adding that Malaysia, Singapore, and Thailand were all popular destinations.Sinaga says that although ASEAN's mutual recognition arrangement on medicine is supposed to come into force in 2015, it is not certain it will be implemented immediately in Indonesia. According to the Indonesian constitution, international agreements need to be incorporated into domestic laws before they are valid domestically.But will overseas doctors make a genuine contribution that is otherwise not available? Will they really want to work in the places where Indonesia really needs them? Or would they prefer to practise in more lucrative areas? And will they have a good enough grasp of the Indonesian language? As Sinaga says: “People should not be tricked into thinking that everything that comes from abroad is better.” Although Indonesia's law changed 10 years ago, there are still no detailed regulations about how exactly foreign doctors can apply to work in Indonesia and prominent figures in Indonesian medicine have repeatedly questioned the need for foreign doctors at all. A small trickle of foreign doctors has started to work in Indonesian hospitals, but disputes over their presence have made headlines. Budiman Sinaga, an Indonesian lawyer who specialises in health law, says that there are some legitimate concerns, but ultimately foreigners have a lot to offer Indonesia, if they help improve standards and fill gaps. It is clear, he says, that many Indonesians have little faith in their own health service. “Every day many Indonesian people go abroad to be treated or just for a checkup to various countries”, said Sinaga, adding that Malaysia, Singapore, and Thailand were all popular destinations. Sinaga says that although ASEAN's mutual recognition arrangement on medicine is supposed to come into force in 2015, it is not certain it will be implemented immediately in Indonesia. According to the Indonesian constitution, international agreements need to be incorporated into domestic laws before they are valid domestically. But will overseas doctors make a genuine contribution that is otherwise not available? Will they really want to work in the places where Indonesia really needs them? Or would they prefer to practise in more lucrative areas? And will they have a good enough grasp of the Indonesian language? As Sinaga says: “People should not be tricked into thinking that everything that comes from abroad is better.”