I recently read a disturbing report that indicates that training for nurses and doctors in Indonesia is for sale.  Admitted medical students are reportedly paying up to $2500 above tuition to gain acceptance with students with low grades paying more.  Once accepted under-performing students are paying to pass their exams.   Other reports indicate that doctors, nurses and midwifes are paying to secure scarce jobs in government clinics and hospitals.  They work in them in the mornings and retreat to their own private clinics in the afternoon where they can be paid fees.    Is it any wonder that Indonesians still mistrust their own medical institutions and doctors. They ask: have the best and brightest been educated ? Indonesia has actually created a wonderful, modern healthcare system.  Unfortunately, its just not in their own country; its in Singapore where Indonesians spend over $3 billion a year.  Those that have the means also seek medical care in Thailand, Malaysia, Japan, Europe and the US.  

It doesn’t have to be this way.  In 2010, I visited the only internationally certified hospital in Indonesia, Siloam Hospital.  The excellent private facility, established by the Riady Group, is hoping to expand to other Indonesia cities and is looking at worldwide models for cost reductions.  They have an agreement with the Mayo Clinic for tele-diagnosis as well arrangements with an Australian medical schools that supplies faculty on short term assignments. You cannot tell the income level of their patients; they are given the same rooms and hospital gowns. Their staff seeks inspiration from a book, Fortune at the Bottom of the Pyramid, by C. Prahalad, that argues that commercial success can be reached serving the overlooked market of the world’s poorest citizens.  Siloam’s cardiac department is seeking to drive the cost of open heart surgery below $3000, a level achieved by an Indian hospital.  Whereas this would still be out of reach for most Indonesians, it would be affordable to the middle class, estimated to be 30-40 million people. 

Changes to Indonesian policy have begun to make it easier for foreign investment in healthcare, but nationalistic obstacles remain.  Foreign doctors cannot practice in the country and investment rules are still too restrictive.  But, a number of Indonesian private equity funds have begun to look seriously at the sector, giving rise to hope that combined with more foreign interest some deals can be arranged.  Why not give foreign educated doctors work permits for 5 years similar to the those that were created for foreign managers in Indonesia’s oil industry.  Medical tourism would seem to be a natural for Indonesia.  A first class diabetes or cancer treatment facility in Bali or in the hills above Bandung or Bogor would be very successful. Establishing the public’s trust will require overhauling medical school curriculums and hospital management, upgrading the continuing education of the current doctor pool through certification requirements (I have met US educated Indonesian doctors who confess they have no motivation to keep up their specialty certifications) and opening the sector to foreign investment and management.

The US is uniquely qualified to assist in meeting the healthcare aspirations of Indonesians because so much of our system derives from private capital and our medical science is world renowned.  Already organizations such as Johns Hopkins and Duke University are creating medical schools in Singapore and in Duke’s case, consulting on the construction of hospitals in Dubai and India.  Indonesia should be courting them but they aren’t or at least not yet.  The right conditions would bring a tremendous amount of private capital to this sector, freeing government resources to focus on healthcare for the poor.  I am convinced its a path that is good not just for Indonesia but for the US as well. Leaving things as they are,  with medical careers for sale to unqualified students and billions spent in Singapore,  will continue a perversion the country can ill afford.