Indonesian Rural Medical Internship: The Impact on Health Service and the Future Workforce

Abstract

Background: Studies have shown a shortage of medical practitioners in rural areas, and that graduate doctors are reluctant to practice in the rural areas. To address this shortage and reluctance, the Government of Indonesia implemented a rural medical internship program with the aims of preparing medical graduates for primary medical practice, and attracting them to rural areas. The purpose of this study was to understand the experience of medical interns in the rural medical internship program, and to identify the barriers and enablers to achieving the program aims. Method: A purposive sample of 38 medical interns (70.4%) from five districts of West Sumatera Province, participated in focus group interviews. The interviews were recorded and transcribed verbatim. Data was coded and categorized before thematic analysis for experiences in rural setting specifically to identify factors important for retention of the doctors. Results: The medical interns indicated that their exposure to rural practice did not influence their decision to practice in rural area in the future, with most interns reporting that they did not intend to undertake clinical practice as rural doctors. The main reasons expressed were due to interpersonal issues with senior clinicians, nurses and hospital staff, which resulted in their autonomy and decision making processes being undermined; and a perceived lack of professional and financial reward for practicing as rural doctors. Overall, the study found that the program improved access to medical services in the five districts, but may not improve the shortage of medical practitioners in rural areas on a long term basis Conclusion: A rural medical internship program improves rural medical services. However, the program alone will not address the long term goal of improving rural workforce shortage. Providing incentives for rural doctors and structural change are needed in order to make rural practice more attractive.

Factors associated with increasing rural doctor supply in Asia-Pacific LMICs: a scoping review

“…Better financial incentives were desired by doctors [ 52 , 54 , 56 , 58 , 60 , 73 , 74 , 85 – 87 ] and medical students to address rural doctor shortages [ 36 , 40 , 47 , 59 , 75 – 80 , 88 , 89 ] b) Opportunity to earn additional income ‡ Opportunity to additional income refers to income-generating activities related to clinical service, usually in private sector, hence the term ‘private practice’ Government doctors working in rural areas have a more limited opportunity for private practice [ 32 , 50 , 73 , 90 ]. While a study in Pakistan revealed that private practice was one of reasons of willingness to work in rural areas in Pakistan [ 45 ], a study in India discovered that aversion to private practice was among reasons of doctors chose to work in rural location [ 53 ] Lacking private practice opportunity in rural areas has discouraged interns to continue working in rural locations [ 80 ] D. Personal and professional support a) Better living conditions † Better living conditions refers to any environmental aspects related to personal amenity such as housing, transportation, electricity, water and communication, education and business facility Any general aspects of poor living conditions [ 45 , 50 , 52 , 57 , 72 , 83 ], schooling facilities [ 50 , 53 ], spouse employment [ 53 ], access to electricity and water supply [ 36 ], transportation [ 49 ], were among the key reasons for unwillingness to work rurally …”

“…Females regarded housing provision higher than males [ 58 , 74 ] b) Safe and supportive working environment† Working environment comprising both human and non-human resource such as: other health or non-health professionals, facility infrastructure, drugs and medical equipment Despite the same average working hours in their main job, doctors in rural areas had longer working hours in dual practice compared to urban doctors [ 46 ]. Higher rural doctors’ workloads, owing to inadequate supply of health professionals in rural location or difficult geographical access, was another reason doctors were unwilling to work or remain in rural posts [ 50 , 52 , 57 , 70 , 93 ] Other important attributes for rural doctor recruitment was lack of drugs, equipment and facility infrastructure [ 52 , 57 , 66 , 83 ], while for retention was good relationships with peer and manager [ 53 , 72 ] One study found that higher satisfaction score to work environment were associated with intention to stay working in rural area [ 91 ] Other attributes important to improve intention to work or staying in rural areas were: adequate number of health professional [ 73 , 85 ], relationship with colleagues or seniors [ 80 ], lack of drugs, equipment and poor facility infrastructure [ 40 , 59 , 60 , 73 , 79 , 81 , 88 , 92 , 94 ] Of those studies applying discrete choice experiment methods, 2 studies found that an adequate health facility was less important to medical students than salary [ 75 , 76 ], while 2 studies found the opposite among doctors [ 56 , 58 ] c) Foster interaction between urban and rural health workers† Interaction between urban and rural health workers comprising communication or consultation of docto...…”

“…Other attributes important to improve intention to work or staying in rural areas were: adequate number of health professional [ 73 , 85 ], relationship with colleagues or seniors [ 80 ], lack of drugs, equipment and poor facility infrastructure [ 40 , 59 , 60 , 73 , 79 , 81 , 88 , 92 , 94 ]…”

“…However, in other studies, associations were not found between rural preference and: housing allowance or support [58,75], access to a vehicle [58] and spouse and child education [34] Overall better living conditions [6,10,11,35,45,65,70,71], housings [76,92], basic infrastructure (i.e., electricity, water, communications connectivity) [52,57,59,88], transportation [57,72,74,76], access to nearest town [41], and children schooling facilities [73], were also important attributes to rural preference. Females regarded housing provision higher than males [58,74] [53,72] One study found that higher satisfaction score to work environment were associated with intention to stay working in rural area [91] Other attributes important to improve intention to work or staying in rural areas were: adequate number of health professional [73,85], relationship with colleagues or seniors [80], lack of drugs, equipment and poor facility infrastructure [40,59,60,73,79,81,88,92,94] Of those studies applying discrete choice experiment methods, 2 studies found that an adequate health facility...…”

“…Connection and the absence of language barrier with community [83], or community appreciation, growth and support [72], was important attributes in attracting doctors to work or remain in rural locations Community appreciation, literacy, attitude to western medicine have been mentioned as one of factors motivated doctors and students to work in rural locations [39,41,79,89] i) Career stages ‡ Although the definition is unclear, support from local government was among the most selected attributes influencing rural work preferences of medical students [75] and intention for rural retention among doctors [80,85] k) Gender ‡ There is evidence that male are more likely to working in rural areas [27,29] Half of the studies investigating gender (n = 16) found no difference in rural preference between male and female [33, 34, 36, 39-42, 44-46, 48, 49, 55, 56, 91, 93]. While some studies found that, after adjusting for other variables, being male was strongly associated with preference to work in rural areas [43,47,77], several other studies found the opposite [35,37].…”