The Paradox of Surplus and Shortage: A Policy Analysis of Nursing Labor Markets in Indonesia

Figures & data

Table 1 Participants at Focus Group discussion

Ministry or Agency	Number of Representatives
Ministry of Health (MoH)	8
Ministry of Education and Culture (MoEC)	1
Ministry of Manpower (MoM)	5
The Independent Accreditation Boards for Indonesian Health Higher Education (LAM-PTKes)	1
The Association of Vocational Nursing Education Institution of Indonesia (AIPVIKI)	1
The Association of Indonesian Nurse Education Center (AIPNI)	1
Indonesian National Nurses Association (INNA)	1
Indonesian Private Hospitals Association (ARSSI)	1
Indonesian Hospitals Association (PERSI)	1
The Indonesian Regional Hospitals Association (ARSADA)	1
The National Board for the Placement and Protection of Indonesian Overseas Workers (BP2MI)	6
The Association of Indonesian Workers Deployment Company (ASPATAKI)	1
The Indonesian Manpower Service Association (APJATI)	1

Table 2 Selected Health Workforce Indicators Related to the Health Labor Market Based on MoH Indonesia’s Reports

Indicators	Description	2018
Stock and density	Number of nursing graduates (a year)	138,206
	Density of certified nurses	2.46 (n=639,356)
	Density of certified health workers (physician, nurses, midwives)	5.25 (n=1,403,4017)
Employment (in-country)	Density and number of all types actively employed health workers	4.25 (n = 1,072,598)
	Number and percentage of employed nurses from the total certified nurses	320,772 (50.17%)
	Number and percentage of employed midwives from the total certified midwives	214,687 (36, 33%)
	Density of employed physician	0.43 (n = 76,807)
Skill mix	Distributions of health workers by category	7.2% physicians; 49.9% nurses and midwives 42.9% others.
Age distribution	Percentage over 40 years old	34.2%
Gender distribution	Percentage female (all health workers)	70.9%
Distribution by institutional sector	Percentage of health workers based on type of employer	80.1% public 10.8% private 4.9% faith based organisation 4.2% private not-for-profit
Geographical distribution	Percentage by region	Highest: Java (47.29%) Lowest: Maluku-Papua (3.47%)
	Urban/rural distribution	Urban = 54.1% Rural = 45.9%
Migration (2013–2018)	Number of migrant Indonesian nurses	3438
	Number by main destination countries	Taiwan (n = 1446) Saudi Arabia (n = 932) Kuwait (n = 495) Japan (n = 307)
Annual projected needs-based shortage	Calculated based on the national minimum standard staffing requirement in 2019)	25,073 nurses
Remuneration	Median monthly salary of nurses	IDR 4,185,000 (± USD 300)
	Average Indonesian minimum wages as the benchmark	1.52 times higher

Notes: Data from.^8,9,60

Table 3 Summary of the Focus Group discussion on Policies Related to the Labor Market Analysis

Dimension	Content	Implication
Policies on Production
Nursing education and enrolment	Nursing student admission is done through a national joint selection or independent selection schemes.	There are many ways to recruit nursing students, which is likely to increase the production of the nursing workforce.
	The national quota for nursing student admission mandated by Nursing Laws has not been operationalized; currently, the quota depends on each higher education institution (HEI).	The absence of a national quota standard can hinder efforts to regulate the number of recruits each year, especially those recruited through private selection.
	The government has discontinued the establishment of new nursing programs, except in some underserved areas.	This policy was intended to prevent over-production of nursing workforce. However, it cannot reduce the current production rate, unless the national quota is implemented.
Nursing education quality assurance system	Each nursing program is obliged to hold internal and external quality assurance; the external quality assurance is done through accreditation.	This policy can maintain the quality of nursing education provided in each HEI. Most nursing programs got a B rank (58.6%).
	Accreditation based on National Standard of Higher Education (NSHE). National Standard for Nursing Education (NSNE) mandated by Nursing Laws has not been operationalized.	The accreditation standard still follows the general guideline, not specific for nursing education.
	The ASEAN Nursing Common Core Competencies (NCCC) have been adopted as a nurse profession standard.	This policy can support the international deployment of the nursing workforce, especially preparing Indonesian nurses to enter the regional nursing labor market in the era of the ASEAN Economic Community.
	National standard of the nursing curriculum.	The national curriculum standards were established for different levels of the educational system (vocational, academic, and profession).
Policies to Address Inflows and Outflows
Policies on inflows	Competency examination to get competency certificate (vocational) and profession certificate (bachelor + profession).	The competency examination tests the quality of nursing graduates before entering the labor market. The competency and profession certificates are requirement for obtaining registration certificate (STRP) and license to practice certificate (SIPP).
Policies on outflows	Deployment of Indonesian nurses to work abroad by both government and private parties.	Indonesia sent 3438 nurses overseas between 2013 and 2018. This number is still relatively small compared to available nursing supply.
	The deployment has to consider the balance between domestic needs and opportunities abroad.	Nursing production is not aggressively oriented “for export” despite the oversupply situation.
Health information system (HIS) on HRH	Indonesia has HIS on HRH which reports the inflows and outflows as well as active stocks.	This system can inform the situation of the nursing labor market in Indonesia, but it does not inform the availability of health workers or vacant labor market as well as on production.
Policies to address maldistribution and inefficiencies
Nurses deployment	The government deploys nurses to underserved areas through special assignment and Nusantara Sehat programs.	Between 2011 and 2014, around 1000 diploma nurses were deployed through special assignment programs. Between 2015 and 2019, 1319 individual-based and 762 team-based nurses were deployed to 30 provinces through Nusantara Sehat.
	Budget allocation and special deployment of health workforce in underserved areas through Nusantara Sehat.	Around 15.5 billion rupiah was allocated for HRH agendas between 2020 and 2025, and the target to establish nursing program in the frontier, outermost and underdeveloped regions, specifically mentioned Papua and West Papua.
Skill mix and task-shifting	Health Workers Laws allows task-shifting in extraordinary circumstances	Task-shifting is implemented in 90.2% public health centers and 74.6% hospitals in Indonesia, which can help to tackle treatment gap in case of unavailable particular health providers.
Nurse career development	The implementation of nurses’ career path; there are various versions, including professional level development for clinical nurse; functional roles of nurses based on skills; functional roles of nurses based on expertise.	Despite its benefits to develop professionalism of nurses, the implementation of the nurses’ career path is often not consistent. It depends on policies applied in each healthcare facility.
Employment characteristics and working conditions	The Manpower Laws regulates the working duration for all labor: 7–8 hours per day, 40 hours per week.	The proportion of nurses working more than 40 hours per week increased from around 65% in 2013 to 75% in 2018. The extra hours are deemed overtime work.
Health workforce spending and remuneration	The salary for civil servant nurses is based on the government standard, while non-civil servant nurses depend on the employment agreement.	In 2018, the average basic salary of nurses was around 3 million rupiahs, 1.36 higher than Indonesian standard salary, it excludes other incentives. The standard salary for special deployment is ranged from 4.5 to 7 million rupiah per month, depending on the qualification, employment status, and rank.
Policies to regulate the private sectors
	Private HEIs can be carried out in their private selection.	It can contribute to the over-production of nursing workforce unless the standard quota is implemented.
	Nurses are allowed to have maximum two SIPP (dual practice)	Dual practice can increase the number of working hours and patients treated per week, but in some cases can reduce the quality of services in the public sector and inducing conflict of interest between public and private practices.
	Private agencies are allowed to deploy Indonesian nurses abroad.	Private agencies alongside the government agencies deployed 3438 nurses overseas between 2013 and 2018. The involvement of private agencies can help to reduce nursing unemployment.

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