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Healthcare Within Borders


JAKARTA, May 3 (Reporting ASEAN) – Aria Mangunkusumo, 38, has been an ophthalmologist at National University Hospital (NUH) in Singapore for more than 10 years. “I went to the National University of Singapore (NUS) to further my medical education and be an eye specialist, not long after I finished medical school at the University of Indonesia in Jakarta,” he said. After Aria finished his course in 2004, NUH offered him a position as a physician.

Aria admitted he went through a rigorous process to obtain his medical license because he is not a Singaporean citizen. “If I was a local, right after I graduated I could have easily gotten my license to practice but that’s not the case with foreigners,” he said.

Three kinds of licenses are issued to practice medicine in Singapore: full, conditional and temporary registration. Foreign doctors can practice medicine and get a conditional registration only if they complete their postgraduate degree in universities approved by the Singaporean government. “The list covers only around 70 universities worldwide and Indonesian universities are not included,” said Aria.

The only way for an Indonesian graduate to get a medical license in Singapore is to go for one of the licensing tests taken in that country. Two of them are the UK Royal College of Physician tests, or the American Board of Internal Medicine tests. They also have to be fluent in English with a minimum 7.0 IELTS score. This takes a great amount of time and money because taking board tests overseas is not cheap.

The Singaporean government however, is willing to issue a temporary registration that is valid for one year to foreign doctors who are specialists and whose skills are highly needed. Furthermore, doctors who study in Singapore as a clinical observer can also obtain temporary license, under the strict condition that they will be there only for educational purposes.

Indonesia also has regulations concerning foreign doctors. According to Health Minister Regulation No. 317/2010, foreign medical professionals are only allowed to practice medicine in Indonesia temporarily if the country does not have his or her area of expertise. This also comes with a clause that says doctors must transfer his or her knowledge to their Indonesian counterparts.

According to a study conducted by the ASEAN Studies Center in 2013, there are 180 specialists in Singapore for every 100,000 people. Meanwhile, in Indonesia the number is no more than eight, the lowest among the 10 Association of Southeast Asian Nations (ASEAN) member states. Moreover, the Indonesian Medical Council listed 73,585 general practitioners in 2010. That means Indonesia only meets 77.43 percent out of the demand for medical professionals. According to the Indonesian Health Indicator, the ideal ratio is 40 doctors per 100,000 citizens.

This fact alone raises concern among the medical community in Indonesia, especially as the launch of the ASEAN Economic Community (AEC) will happen in December this year. The Mutual Recognition Agreement (MRA) which covers eight professionals, including doctors, was signed in Bangkok on February 26, 2009, by representatives from the 10 member states. The aim is to facilitate doctors’ mobility in ASEAN, exchange cooperation, promote adoption of best services and provide opportunity for capacity building. Tan Tai Hiong, head of Services and Investment Division of the AEC department at the ASEAN Secretariat said that member states could learn from each other on the rules and regulations of the different health sectors. “It will allow member states to strengthen their healthcare services through better regulations. However each member state should have the authority to control the flow of foreign doctors into the country,” he said.

Zaenal Abidin, chairman of the Indonesian Doctors Association (IDI), said that the MRA would not benefit doctors in Indonesia because there were more demands for foreign doctors in the country compared to those in other countries. “Medical professionals should be excluded from the MRA, because this field is supposed to serve national interests,” he said. Zaenal is worried that Indonesia will become a market for foreign doctors, while Indonesian doctors will have difficulty practicing overseas.

Clearly, the continuing barriers indicate that an integrated system of medical services in ASEAN will not happen anytime soon, not only because of the protective laws of each country preventing foreign workers from entering the market, but also the language barrier. Countries in the region that share the common Malay basic language are Indonesia, Malaysia, Singapore and Brunei. Other ASEAN member states speak different languages.

Tan said that there was also no requirement to take the language proficiency tests at the ASEAN level. However, Ina Hagniningtyas Krisnamurthi, director for ASEAN economic cooperation at the foreign ministry in Indonesia said that the language problem would be easy to solve because at all ASEAN meetings, English is the language spoken. “So it will again depend on the domestic policy of each country,” she added.

Ina also said that it would be difficult to stop the movement of professionals in all member states because globalization has happened long before the MRA was signed. “The MRA is merely a recognition of common qualification and levels competency for ASEAN professionals,” she said. But she warned that each country can still hold on to their respective laws and that other member states should respect that.


BESIDES the medical professionals, the patients will also be affected by the MRA. The lack of studies and discussions on the impact of the agreement on patients will place them as the most vulnerable group, even more than the doctors.

According to the Indonesian health ministry, there were 600,000 Indonesians in 2014 who went overseas—mostly to Singapore—to seek medical services. But Aria said that it was not because Indonesian doctors were inferior. “I still consult with my Indonesian colleagues on many difficult cases; it’s more because of the available technology and the quality of service,” he added.

Zaenal said that the medical field would become more of an economic commodity in a capitalist society. “In our (Indonesian) constitution and according to the doctors’ code of ethics, providing health care is a social service,” he opined. “So I’m confused, because medical professionals have a different ideology and should work towards the welfare of the Indonesian people, not make this into a business.”

Rosalia Sciortino, a medical anthropologist from Mahidol University in Thailand said that competition could be good to increase the standard of healthcare, which would benefit the patients. “We need to focus on how we can improve the healthcare in all member states,” she explained.

There is a danger that healthcare will become more segmented once the AEC kicks off and the gap widens between those who can afford the best private healthcare and those who cannot. “There is already discrimination between those who can pay. They often get better service,” she said.

Hasbullah Thabrany, a public healthcare expert from University of Indonesia, said that instead of worrying, all member states should focus on learning from each other and embrace the AEC. “It is not a problem if the law protects the patients,” he said. Hasbullah said that in the future there might be opportunities for the poor in Indonesia to get the same standard of healthcare like the rich who often go to Singapore.

He said Indonesia had nothing to worry about. “If the Singaporeans or Malaysians take a portion of the market here, we can go to the other markets, like Cambodia or Myanmar. That’s what integration is all about,” he said, adding that the patients’ interest is all that mattered. “With medical liberalization, the people, including the poor will have more options.”

The way to do that is by integrating the more open medical system with the national health insurance program (JKN). “If the government can do that, our standard of healthcare will improve tremendously,” Hasbullah said. “With more professionals available, instead of queuing for hours to see a specialist, we will have 10 more so we wouldn’t have to queue up for so long.” (END/Reporting ASEAN)


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