A Dual Hospital-University Specialist Training Reform to Address Workforce Shortage and Geographic Maldistribution in Indonesia: Integrative Qualitative Policy Process Review.

چکیده اصلی

BACKGROUND: Indonesia faces 3 interlocking medical workforce crises: an absolute specialist deficit projected to reach 70,000 by 2032 (national density of 0.18 per 1000 population vs the Ministry of National Development Planning [Bappenas] target of 0.28), severe maldistribution (with nearly 59% of specialists concentrated in Java), and a structural anomaly in which residents pay tuition while performing essential clinical work. The 2023 Health Law (Law 17/2023) authorized a transformative reform: a hospital-based residency pathway (Rumah Sakit Pendidikan Penyelenggara Utama [primary teaching hospital; RSPPU]) operating in parallel with the long-established university-based system. OBJECTIVE: This study aimed to examine the rationale, policy design, and early implementation of Indonesia's dual hospital-university specialist medical education reform, interpreted through an 8-step change management framework developed by Kotter, and to identify transferable lessons for low- and middle-income countries. METHODS: We conducted an integrative qualitative policy process review combining two evidence streams: (1) systematic documentary analysis of 19 source documents (17 primary legal, regulatory, and policy instruments plus 2 interministerial joint monitoring site-visit reports) and (2) engagement of 34 key informants through semistructured interviews and focus group discussions (45-120 min), comprising policymakers, collegium representatives, hospital leaders, and residents across all 6 pilot sites, recruited purposively until thematic saturation. Interview and focus group data were analyzed using a hybrid deductive-inductive thematic approach with an 8-step change management framework developed by Kotter as an a priori coding frame, and member checking was completed with 7 of the 34 informants. RESULTS: The reform designated 6 top-tier national referral hospitals as RSPPUs and enrolled 52 residents from 412 applicants (an acceptance rate of 12.6%) across 6 high-need specialties (ophthalmology, cardiology, pediatrics, orthopedics, neurology, and oncology). All 6 pilot sites established functional education units and designated institutional officials, adopted dual accreditation, and operationalized an integrated e-logbook for competency tracking, real-time monitoring of 80-hour duty limits, and anonymous bullying reporting. An interministerial joint monitoring team visited all 6 sites and scored each site as satisfactory or better across governance, curriculum, faculty, infrastructure, and learner support. Four cross-cutting themes emerged: financial-barrier removal, dual-governance pragmatism, accreditation strain, and equity-anchored deployment. Persistent tensions include variable educator compensation across hospitals; however, a standardized national framework remains under development. Mapping to the framework developed by Kotter demonstrated strong evidence for steps 1 to 6 and early evidence for steps 7 to 8. CONCLUSIONS: Indonesia's dual hospital-university residency model is a scalable, equity-oriented, and competency-based reform that is operationally feasible and globally aligned in its early implementation. While long-term effectiveness and sustainability await longitudinal evaluation, the design offers a transferable, not yet definitively replicable, template for low- and middle-income countries confronting parallel workforce crises.

ترجمه فارسی چکیده

اندونزی با سه بحران نیروی کار پزشکی درهم‌تنیده مواجه است: کمبود مطلق متخصصین پیش‌بینی شده تا ۷۰,۰۰۰ نفر تا سال ۲۰۳۲، توزیع شدید (نزدیک به ۵۹٪ متخصصان در جاوه متمرکز شده‌اند) و یک ناهنجاری ساختاری که در آن دستیاران پزشکی برای انجام کارهای بالینی ضروری، حق‌الزحمه می‌پردازند. قانون سلامت ۲۰۲۳ (قانون ۱۷/۲۰۲۳) اصلاحی مبتنی بر بیمارستان را مجاز کرد که در آن مسیر دستیاری در بیمارستان‌های آموزشی اصلی (RSPPU) به طور موازی با سیستم قدیمی مبتنی بر دانشگاه عمل می‌کند. این مطالعه با استفاده از چارچوب هشت‌مرحله‌ای تغییر مدیریت کاتر، به بررسی استدلال، طراحی سیاست و پیاده‌سازی اولیه این اصلاح و شناسایی درس‌های قابل انتقال برای کشورهای درآمد پایین و متوسط پرداخت.

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