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.
