Commenting on the Health Minister's Podcast with Akbar Faizal Uncensored

Recently, there’s been buzz about the Ministry of Health planning to allow foreign doctors to practice in Indonesia. I happened to come across a podcast/interview with Budi Gunadi Sadikin (BGS) on Akbar Faisal Uncensored.

The foreign doctors being allowed in are specialists. The reason is that specialist doctors are severely lacking. The output of specialist medical education is very limited. The Health Minister ran into the authority of Minister Nadiem (Higher Education), as medical faculties had been placed under a moratorium despite output being unable to meet Indonesia’s needs. According to the Minister, he had already addressed the shortage of equipment and facilities, only to find there were no doctors. This is an issue I also discussed when writing about COVID.

Look at the chart below from Our World in Data. It’s true – the number of doctors in Indonesia is extremely low, and for specialists, it’s probably even worse.

The shortage of doctors has been a problem for a very long time. Friends who focus on development research, especially health economics, always discuss this. And the problems are many – not just equipment-to-patient ratios but also health-worker-to-patient ratios! Hospital investment is needed, but ultimately…

The conversation moved to infrastructure: equitable distribution of medical equipment. Of 3,200 hospitals in districts and cities, only 300 have mammography equipment, he said. He also discussed shortages of other equipment, like stroke screening devices. Watch it yourself for the details.

When discussing infrastructure, the procurement governance of medical equipment naturally comes up. The e-catalogue was mentioned – that e-catalogue prices are higher than medical equipment elsewhere. Unfortunately, BGS didn’t mention TKDN (local content requirements), the fact that the e-catalogue must meet TKDN thresholds. And he’s an economist.

But then he talked about drug prices in general, not just government purchases through the APBN via the e-catalogue. Drug prices in Indonesia, he said, can be 2-3 times higher. Taxes alone can’t explain that gap. There must be a problem in the industry, which unfortunately wasn’t elaborated further.

The conversation shifted to priorities. Priority should go to community health centers (puskesmas). Interesting. Puskesmas aren’t getting attention, but foreign doctors are headline news because they affect the elites. Only about 20% of puskesmas have ultrasound machines. Stunting screening can be as simple as distributing scales to all puskesmas. According to BGS, his focus has been on puskesmas, what matters most for the public. But what gets attention is foreign doctors – something in the interest of the “elites,” by which he seemingly means the Indonesian Medical Association (IDI) and some doctors.

He also said we don’t need new regulations. The current legislative infrastructure is already capable of many things. For example, does BPOM (the drug and food authority) need new regulations to increase accountability? Not really. What we have should be strengthened in execution, because BPOM is already relatively autonomous and auditable by BPK.

Not needing new regulations (just fix the execution) and starting prevention from puskesmas are two things I also believe in, so at least on these two points he’s saying things I agree with.

The Minister could answer in detail, such as addressing the midwife appointment issue raised by Rieke Pitaloka on the same show previously. He could also explain problems in pharmaceuticals – which drugs are free for which diseases – bearing in mind he’s not a doctor, which is already impressive. I’ve seen far worse. Such detailed answers usually indicate he’s actually doing the work, at least when discussing problems, he’s genuinely listening and understanding.

BGS’s tone throughout this podcast was very similar to several issues in the US as well: elites vs. the general public. BGS seems to position the doctors’ consortium / IDI / subsets of doctors (Twitter doctors? haha) as the elite group. This elite group prefers to defend its own interests, and ultimately limiting and controlling who can join their club is clearly in their interest. This is similar to the “guild” problem in 14th-century Europe, and today’s American elite discussed in the book “Six Faces of Globalization” by Roberts and Lamp. Is IDI or similar organizations really like that in practice?

Next up was a tease for Azwar Anas, the minister in charge of civil servants. This would be interesting if he comes on – I’d definitely watch that episode because it affects all civil service professions, including teachers, lecturers, and health workers.

Overall, I thought BGS’s explanation was quite solid. I also liked Akbar Faizal’s build-up. I haven’t covered everything from the podcast in this post, and please note I’m not a health practitioner, so I might have missed something. If you’re interested in health issues like preventive care at puskesmas, foreign doctors, and the like, it’s best to watch the full episode here.

Thoughts? Did I miss anything? Comment on my Twitter and we can chat.