Introduction

As was highlighted previously, Indonesia is seemingly experiencing a surplus of nurses. Such surpluses should be a blessing for the country with the fourth largest population in the world, especially considering the global shortage of nurses. Unfortunately, the surplus of nurses is due to the limited absorption capacity of the domestic labour market. Consequently, many nurses have yet to be employed in Indonesia with the population estimated to be 250,000 in 2018. To address such high unemployment rate, the Indonesian government devised a programme to encourage nurses to work overseas since 1996. In its initial year, this programme saw only 11 Indonesian nurses out of 120 candidates (< 10% passing rate) plying their trade in the United Arab Emirates (UAE). Only in the last decade, a larger number of Indonesian nurses have successfully migrated overseas. Despite such a large population of unemployed nurses, what is preventing Indonesia from being a major exporter of nurses?

Large Excess of Nurses, Low Export Rate

Since 1996, the number of nurses successfully sent abroad has steadily increased, albeit slowly. This increase coincided with the increasing number of destination countries in the Middle East such as Kuwait and Saudi Arabia, and even into Europe such as England and Netherlands. Soon after, Indonesia initiated similar programmes for its nurses to East Asian countries. Since 2008, Indonesia and Japan have agreed on a bilateral cooperation, the Indonesia-Japan Economic Partnership Agreement (IJEPA). Part of this cooperation is the provision of Indonesian nurses and caregivers to Japan. Indonesia also routinely sends its nurses to Taiwan, thus becoming the largest exporter of nurses for this state. However, between 2013 and 2018, Indonesia only sent 3,438 nurses to numerous countries, mostly to Taiwan, Saudi Arabia, Kuwait, Japan and the UAE.

A reason for the increasing rate of migration stems from a global shortage of nurse. This global shortage has led to Indonesia receiving new requests from countries such as Australia and the United States. According to Indonesia’s Ministry of Health, the demand for both nurses and caregivers raised to 80,000 between the period of 2010 and 2020. Despite such high requests, only 5% has been fulfilled.

Despite its large excess nurses, it does not automatically equate to high export rate of Indonesian nurses. Hampering export includes the lack of desire and motivation of Indonesian nurses to do so and also their difficulties in passing the selection tests. Confounding matters is the COVID-19 pandemic which restricts overseas travel. For example, Taiwan has deferred the arrival of new Indonesian nurses because of the current situation in Indonesia. This is notable as the pandemic has further increased the global need for nurses.

Higher Income and Overseas Experiences not a Priority for Indonesian Nurses

There are several push and pull factors for nurses to work abroad. The push factors for nurses wanting to work abroad generally centres on employment issues in the donor countries. For example, the lack of job opportunities, limited career advancement, low salary and incentives, lack of job safety, and poor workplace conditions. Meanwhile, the pull factors to destination countries would address the aforementioned employment issues.

Unlike other donor countries, Indonesian nurses seem to be unaffected by such push and pull factors. There could be three reasons for this phenomenon: 1) The perception that working abroad did not commensurate with their sacrifices (this will be elaborated in the next paragraph). 2) Turning down overseas stints as they may either be employed in civil service or their families disapproved of such opportunities. Notably, in Indonesia, employment in the civil service is still regarded as an iron rice bowl. Additionally, families continue to play an important role in decision making, particularly for female family members. 3) There is still some apprehension even for nurses who desire to work overseas. Of the approximately 90% of nursing students who wished to work abroad, only about 50% had concrete plans to do so. Shedding light on this apprehension is the finding that those who were younger, lived outside of Java, spoke a foreign language, and had prior overseas experiences were more likely to have concrete plans.

For nurses and nursing students in Indonesia, salary is not the main consideration in selecting a workplace. Instead, they were found to prioritize work experiences and career development. Additionally, many are more comfortable working domestically to be close with their families. Working domestically is perceived to be less risky and challenging than working abroad. This is evident from the low passing rates of Indonesian nurses seeking overseas employment. Many failed to satisfy the requirements, particularly foreign language competencies such as English and proficiency standards such as Prometric Testing, Commission on Graduates of Foreign Nursing School (CGFNS), National Council Licensure Examination for Registered Nurses (NCLEX-RN). Despite the need for foreign nurses, destination countries will not compromise on the quality of nurses they sought.

Attempting to work in Japan and the United States aptly demonstrate the challenges Indonesian nurses faced. To gain employment in Japan, Indonesian nurses are required to sit for competency tests that are conducted in Japanese and in varying writing styles (hiragana, katakana and kanji). However, those who fail such tests can still work in Japan by taking on a lower appointment of nursing assistant. To work in the United States, candidates must pass CGFNS and NCLEX-RN. Test centres for CGFNS are available in Indonesia since 2018 but there are no test centres for NCLEX-RN. The closest NCLEX-RN test centre is in Manila, Philippines, thus, entailing additional costs. This explains why the United States is not yet a major destination country for Indonesian nurses despite repeated requests by the United States government.

Drawing Parallels to the Philippines, the Largest Global Exporter of Nurses

The current surplus of nurses in Indonesia has been experienced by the Philippines in the mid-1970s during President Ferdinand Marcos era. During that era, labour including nurses were sent abroad as a strategy to reduce socio-economic problems and domestic unemployment. This strategy continues to be implemented today. Within the three decades of its inception, more than 193,000 Filipino nurses had worked abroad while only around 30,000 worked domestically. Currently, the number of migrant Filipino nurses is estimated to be higher considering that an average of 13,000 nurses are sent overseas annually, nearly four times the total number of migrant Indonesian nurses in five years from 2013 – 2018.

Such a high migration rate has made the Philippines the largest exporter of nurses in the world. In the United States and UK, the number of Filipino nurses are estimated at 150,000 and 20,000, respectively. Currently, the Philippine government has restricted its nurses from migrating as their services are crucial to the country’s COVID-19 effort. However, Filipino nurses who have secured overseas contracts are exempted from this restriction. Notably, any attempts by the government to reduce the quota for sending its health workers abroad will also face strong resistance.

Unlike Indonesians, Filipinos are not apprehensive about working overseas. Instead, many enrol in nursing schools due to the prospect of working overseas and earning higher salaries. In fact, many Filipino doctors have pursued nursing degrees with similar motivations. In 2017, the author interviewed the senior management of the Philippine Nurses Association (PNA) in Manila, Philippines to obtain insights on their level of success in encouraging their nurses to pursue careers abroad. The PNA did not provide any encouragement but instead the nurses themselves desired to work overseas. This was unexpected as there was a high demand for them to work domestically especially in the current pandemic. Moreover, with its higher education system being oriented to export its graduates, the Philippines will face difficulties in stemming the migration of its health workers, especially nurses.

Nurse migration can be beneficial for its donor countries. Not only will it spell foreign funds entering the country, employment in destination countries is likely to be more secure. Additionally, migration to developed countries enables a brain gain for donor countries as nurses can facilitate the transfer of skills, knowledge and even technology to their home countries upon their return. The caveat is that the donor country’s government must have a strategy to facilitate such brain gain. Unfortunately, Indonesia has yet to have such a strategy. Indonesian nurses who returned from Japan experienced a loss of their learned skills and also found it difficult to re-enter the domestic market as there is no system to bridge their expertise from abroad to the domestic market needs.

The main downside of nurse migration to donor countries is the loss of skilled workers i.e. brain drain. Though sending nurses abroad entails financial gains, donor countries may themselves be in need of nurses, especially in developing countries such as Indonesia and the Philippines. This has led to the World Health Organization (WHO) to issue a Global Code of Practice on the International Recruitment of Health Personnel in 2010. This code of practice discourages the active recruitment of health workers from countries experiencing personnel shortages. Although not enforced, this code of practice sets the ethical discourse for its member countries when developing their health system.

Will Indonesia Become the Second Philippines?

The Indonesian government has chosen to adopt a policy of sending its nurses abroad in response to its perceived surplus of nurses in the country. Therefore, will the scale of Indonesian nurse migration in the near future mirror that of the Philippines?

Based on the perceived surplus of 250,000 Indonesian nurses, there seems to be a potential for Indonesia to equal or even surpass the Philippines in sending its nurses overseas. However, it is unlikely for this to occur due to two reasons:

1) Based on Indonesian legislation, there must be a balance of three factors; domestic needs, overseas opportunities, and the interest of Indonesian nurses to work abroad. This balance is ascertained from analysing the nursing labour markets and their related policies, globally. Additionally, the Human Resources for Health Information System (SISDMK) maintained by Indonesia’s Ministry of Health is expected to provide accurate, reliable, and current information for policymaking vis-à-vis the demand and supply of nurses domestically and abroad.

2) The higher education system in Indonesia is not, or not yet, export-oriented as in the Philippines. Although the curriculum in nursing courses in Indonesia bear semblance to numerous international curricula such as the ASEAN Nursing Common Core Competencies and international accreditation standards such as AUN-QA and ASIIN, interest to working abroad is still limited, as aforementioned. Additionally, Filipino nursing students have an added advantage over their Indonesian counterparts. The Filipino students generally have a higher language competency as their courses are conducted in English.

However, this may change depending on future developments in employment, education and health policies in Indonesia, and extraordinary circumstances such as the current pandemic. Such extraordinary circumstances present an opportunity for donor countries to either export its excess nurses or stockpile its excess nurses in anticipation of a worst-case scenario.

Introduction

Indonesia is experiencing both a shortage and surplus of nurses. A surplus of Indonesian nurses is created when the number of nurses far exceeds the need and demand. Consequently, there is a high rate of unemployment and low bargaining power for nursing graduates. Currently, the average salary of nurses is only slightly above the national minimum wage.

According to the Ministry of Manpower’s (MOM) 2018 report, Indonesia had 695,248 qualified nurses in the sector. However, only 446,428 are employed while the remaining 248,820 are unemployed or looking for employment. Even if the demand for domestic nurses were met, there would still be an excess of 219,257 graduate nurses that year. The demand for domestic nurses was calculated based on the ratio set by the government.

Despite the surplus in qualified nurses, Indonesia is experiencing a shortage of employed nurses. Recent data revealed that the number of employed nurses compared to Indonesia’s total population is still below the ideal. This is further confounded by the uneven distribution of nurses in several regions. This raises several questions: 1) How can there be a simultaneous surplus and shortage of nurses? 2) Why is the demand for nurses not automatically met with the surplus of nurses? 3) How is this issue being currently addressed?

The Surplus—Shortage Paradox

There are at least two reasons behind the surplus of qualified nurses. First, the continued perception that Indonesia is experiencing a critical shortage of nurses. Second, the high rate of development of nurses in Indonesia.

In 2006, WHO included Indonesia in their list of 57 countries experiencing a human resources for health (HRH) crisis. A country was deemed to be experiencing a critical shortage if it possessed less than 80% of the nursing population needed to serve the country’s needs (needs-based sufficiency). Till today, this data is often referred to when formulating health HR policies.

WHO determined that the ideal ratio of employed nurses is 1.58 nurses per 1,000 population. This is different from the Indonesian government’s standard which is 1.80 nurses per 1,000 residents. Despite the differences, both targets have yet to be met till today. The latest data from the Ministry of Health’s (MOH) HRH Information System shows that the number of employed nurses in Indonesia is 356,960 or around 1.30 per 1,000 population. Therefore, to achieve the respective ideal ratios, an additional 75,000 to 135,000 nurses have to be absorbed into the labour market. When compared with the 2018 MOM report, it must be noted that there is no decrease in the number of employed nurses. The difference in figures is primarily due to the different parameters employed by each to define nurses. MOM’s definition included nurses who were not affiliated with any healthcare facilities and were working independently (for e.g. independent home care nurses, etc) whereas MOH’s data was tabulated by nurses who were registered in their HRH information system.

Unfortunately, this demand cannot be immediately be met despite the high number of nursing job seekers. The main issue stems from the suboptimal capability of the domestic market to absorb available nurses. According to the MOM, Indonesia needs an additional 584 hospitals to achieve the recruitment of nurses as set by the government’s 2024 target. The number of new hospitals would have to be revised to 1,958 to absorb all available nurses. However, achieving the 2024 target is already hampered by the government’s and private sector’s limited budget. Though the COVID-19 pandemic has forced large-scale recruitment of nurses, it would still not satisfy the ideal ratio set out by the government nor is sufficient to absorb the entire surplus of nurses.

It is common practice to use nurse-per-population ratio to formulate health HR policies, especially in low- and middle-income countries. This needs-based approach can indeed reveal the number of health workers needed for a population. However, this approach cannot provide a comprehensive picture of the dynamic nature of labour markets.

In the past, there was a tendency for any shortage to be perceived as a result of insufficient supply.  It was the result of overreliance towards nurse-per-population which had been widely used in many countries as well as by the WHO. Consequently, in response to the lack of supply, the government increased the production capacity and to train more health workers. In 2008, Indonesia was able to produce 34,000 nurses annually. A decade later, in 2019, the production capacity increased to 138,206 nurses per year (roughly a four-fold increase). However, the increased capacity was unexpectedly unaligned with the absorption capacity of the labour market, resulting in an oversupply, high number of unemployment and loss of competent nurses.

Inadequate Policy Implementation Perpetuates Overproduction

As the policy to train nurses is closely linked to the tertiary education policy, the government implemented several policies to reduce the overproduction. This included closing non-accredited nursing programmes, reducing the quota for new student admissions, and imposing a moratorium on the establishment of new nursing programmes.

In 2019, the government revoked the permits of 130 private universities because of not meeting accreditation standard, ostensibly in an attempt to reducing the number of nursing programmes. Additionally, the moratorium on new nursing programmes has continued since 2011. This moratorium, however, can be waived for regions experiencing a shortage of nurses. Moreover, the establishment of undergraduate and professional nursing programmes is still permitted so long as the applying college has a vocational nursing programme (D3) that is minimally B-accredited.

Unlike these two policies, there has not been any concrete implementation to reduce the quota for new nursing students. Conversely, there has been a tendency to increase this quota annually as the colleges themselves continue to determine it independently. In fact, the Nursing Act regulates the national quota for new admissions of nursing students, as has been implemented for medical and dentistry programmes. However, to this day, the derivative rules regarding this quota have not been promulgated.

Nurse Migration as a Means to Address Surplus

Despite these policies, the production capacity of nurses cannot be drastically reduced immediately. Similarly, the absorption capacity of the labour market cannot be increased in a short period of time. Therefore, to manage the increasing number of nurses graduating annually while the job market remains limited, the Indonesian government has adopted a policy to encourage nurses to migrate. This policy was feasible as there was a global shortage of nurses. In 2014, it was estimated that there was a shortage of 9 million nurses globally.

Between 2013 and 2018, 3.838 Indonesian nurses found employment overseas. The top five destinations were Taiwan (1,446), Saudi Arabia (932), Kuwait (495), Japan (307) and the United Arab Emirates (112). Despite this, migration is still insignificant to impact the existing surplus of nurses. There are several challenges preventing this from being a viable solution. One challenge is that Indonesia is still a “new player” when compared to neighbouring Philippines which has been a top exporter of nurses globally for more than seven decades.

Need for Accurate Data to Drive Policy Changes

The Indonesian government has relied on nurse migration to address the surplus issue. However, there is a need to improve the health HR data management through an integrated information system.

Currently, conflicting data between institutions is a chronic issue in Indonesia. For example, there is a difference of around 50,000 nursing graduates between the data issued by the Ministry of Health (MOH) and the Higher Education Database (PD DIKTI) in 2019. Additionally, the data on employed nurses in 2018 from the MOH and the MOM also differed significantly (around 36,000 difference). In fact, the author found inconsistencies in the number of nurses from documents released by the MOH.

Such inconsistencies have led the Minister of Health himself to be reluctant in using his ministry’s data to facilitate the COVID-19 vaccination programme. Currently, there is a Health Human Resources Information System which includes data of nurses entering and leaving the labour market, as well as active nurses at the national, provincial, and district / city levels. However, this system requires vast improvements such as integrating data on nursing graduates with PD DIKTI and data on vacancies available in the job market. By ensuring the accuracy of such data, more effective policies on the development and employment of nurses can be formulated.

Introduction

While struggling to contain COVID-19 infections, Indonesia like many in the world is facing a “second pandemic.” As a consequence of the pandemic, many Indonesians are suffering from various forms of psychological issues such as anxiety, depression and trauma. Confounding this is the implementation of social distancing measures, a response to the virus’ quick transmission, that impacts access to health services. It is, thus, important to evaluate the impacts of the COVID-19 pandemic on mental health services in Indonesia and measures to address this issue.

Limited Mental Health Services in Indonesia even Prior to COVID-19

Indonesia possesses 9,831 community health centres, locally known as Puskesmas, spread across 34 provinces. Of which, 92.4% administer mental health programmes. This indicates the Indonesian government’s reliance on them to provide mental health services to the community. Though some form of assistance are rendered to them by the Ministry of Health such as service guidelines and Mental Health and Psychological Support (MHPSS) during the pandemic, it is uncertain how many of these programmes are still running and how effective they are to reach the community. Unfortunately, there is also a lack of in-depth research that evaluates the sustainability of these mental health programmes, especially in areas that are remote and with limited resources.

Key to ensuring the sustainability of such programmes in these community health centres is the availability of resources, namely financial and health personnel. When conducting research in Lombok after it encountered a disaster in 2019, the author found that mental health programmes were not administered in several community health centres because of limited funds. To confound matters, available funds were also redirected to other programmes as mental health was not deemed to be an urgent issue. This was despite the discovery that around 60% of the elderly had developed PTSD; none were treated.

At the national level, the budget for mental health is also insignificant. However, from this meagre sum, 90% of it is allocated for psychiatric hospitals. Additionally, the human resources for mental healthcare are still far from ideal. For every 100,000 citizens, Indonesia only has 0.31 psychiatrists, 0.17 clinical psychologists, and 2.52 trained mental health nurses. Similarly, these numbers are insufficient to serve more than 260 million Indonesians. Furthermore, these specialists are not evenly distributed; most are largely concentrated in Java. With such limited resources, mental health programmes may only be present in name at these community health centres as they lack impactful activities.

With the onset of COVID-19, Indonesia was reported to have experienced a disruption in its mental health services. Globally, disruptions occurred due to reasons including 1) outpatients could not come for their appointments, 2) social restrictions, and 3) a decrease in the number of inpatients due to the cancellation of elective services. Although the types of services that were disrupted and the scale of disruption were not specified, any disruptions could further burden Indonesia’s already fragile mental healthcare system, potentially leading to its breakdown. As an example, the author discovered a psychiatric hospital in a major city in Indonesia was forced to discharge their inpatients earlier due to disruptions. Unfortunately, such disruptions can lead to a knock-on effect of overwhelming Indonesia’s primary healthcare due to a surge in patients. If the primary healthcare was to fail, patients can be left untreated, thus widening the mental health treatment gap in the community.

Tele-psychiatry: An Ideal Replacement of Conventional Mental Health Services Model

Despite the grim mental healthcare situation in Indonesia, there were several innovative strategies to respond to the people’s mental health needs during the pandemic.  First, the Indonesian government launched a psychological service programme called Sejiwa, abbreviated from Sehat Jiwa (literally Mentally Healthy) at the end of April 2020, in collaboration with the Indonesian Psychological Association (HIMPSI). This service entails providing psychological assistance via the telephone, thus improving accessibility. A month into its launch, this programme has received nearly 15,000 calls from all over Indonesia, or an average of about 500 callers per day. Some local governments have also provided online-based mental health services. For example in Jakarta through a programme called Mental Health Friend (Sahabat Jiwa) and in West Java with Online Mental Health Consultation (KJOL).

Second, many mental health practitioners have themselves taken the initiative to provide their services via online communication platforms such as WhatsApp, Zoom, and Meets. These individual initiatives help overcome the absence of such services that are supposed to be integrated into healthcare facilities. The community also benefits from the presence of various psychological consulting applications, for example: Getbetter.Id, Riliv, Kalm, Klee and Kariib. These proliferation of online-based service innovations can further reduce the gap in mental health services.

Demonstrating the potential of such innovations, tele- medicine as well as mental and psychosocial helplines were the two most widely used strategies to manage psychiatric issues during the COVID-19 pandemic. Tele-medicine (or tele-psychiatry specifically for mental health) and the helplines were used in about 70% and 67.7% of respondent countries, respectively. This approach is beneficial for the continued provision of healthcare services in this pandemic, considering the highly-contagious nature of the virus. The conventional mental health services model which emphasizes three factors (i.e. providing face-to-face consultations between therapists and patients, conducting consultations in a healthcare faculty, and is provided by specialists) is, thus, becoming less relevant. Continued emphasis on these three factors will only widen the service gap.

Innovations such as tele-psychiatry that were developed in the midst of the COVID-19 pandemic were found to possess  three characteristics: 1) offering spatial flexibility, 2) entailing health and social aspects, and 3) leveraging on technology. Therefore, it can be argued that this pandemic is a catalyst for the development of tele-psychiatry in Indonesia. In just one year, many have switched from conventional services to adopting this innovation; a feat difficult to achieve under normal conditions.

Towards Sustainability and Scaling up of Tele-psychiatry

However, it should be noted that this innovation is only at its infancy because of the current pandemic. Also known as imposed service innovation, such innovations are not triggered due to the strength or development of services, otherwise known as extant service innovation. Unfortunately, such innovations can end abruptly if the compelling circumstances no longer exists and / or if there is no further effort for development. Moreover, many tele-psychiatric services are currently provided as a private initiative with minimal facilities. Even though such services are beneficial, they will encounter issues in sustainability and scaling up.

Sustainability and scaling up are important due to two reasons. First, regardless of the pandemic, tele-psychiatry is considered a strategy that has the potential to reduce inequalities in mental health services. It is important to highlight that while developing countries such as Indonesia require such innovations, many have yet to implement it on a large-scale. Second, sustainability would be dependent on factors such as relevance of the innovation. Tele-psychiatry’s relevance can be ensured by using the behaviour of current users during the pandemic as a reference to envision the future market. Such massive developments would thus require political will from the government and support by its stakeholders.

Noteworthily, tele-psychiatry is not a strategy that can be applied in all situations, considering the socio-demographics of Indonesia. However, it is an effective stopgap measure to reduce the gap in mental health services that have been disrupted due to the pandemic. Moreover, with the limitations of mental health specialists, tele-psychiatry can be used to reduce spatial and temporal needs of service delivery. What the provincial governments of Jakarta and West Java are implementing should be adopted by other regions, although ideally this service should be meted out in every district / city while working closely with the community health centres to reach the community at the grassroots. Investment in this field will greatly impact everyone as they can access mental health services wherever they are, even after the pandemic.