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Nursing and health care in Indonesia

Article in Journal of Advanced Nursing November 2003
Impact Factor: 1.74 DOI: 10.1046/j.1365-2648.2003.02785.x Source: PubMed

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HEALTH AND NURSING POLICY ISSUES

Nursing and health care in Indonesia

Linda Shields

PhD RN FRCNA

Professor of Nursing, Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland

and Lucia Endang Hartati YK MN BN

Senior Lecturer, Akademi Keperawatan, Semarang, Central Java, Indonesia

Submitted for publication 9 January 2003

Accepted for publication 16 June 2003

Correspondence:
Linda Shields,
Department of Nursing and Midwifery,
University of Limerick,
Limerick,
Ireland.
E-mail: linda.shields@ul.ie

SHIELDS L. & HARTATI L.E. (2003)

216
Nursing and health care in Indonesia
Aim. Indonesia, with its population of over 220 million, has health problems
similar to those of other developing countries. In an attempt to provide nurses
throughout the world with knowledge about Indonesia, we describe the country, its
health system, and problems encountered by nurses and other health professionals.
Method. We explain the way the health system works within Indonesian culture,
discuss the effects of the international nursing shortage and outline the role of aid
agencies. The ethical dilemmas faced by health professionals who care for patients
within a poorly resourced system are examined. While the information pertains to
the whole country, we focus on the main island of Java, as that is where we have
worked and resided.
Findings. Nursing education is primarily conducted at senior high school, while
medical education is similar to the university education offered in many countries, and
allied health professionals are educated to varying standards. Indonesian health
officials recognize that the low standard of nursing education contributes to poor
health statistics, and they are working hard to improve this. There has been strong
support from the government for the implementation of university education for
nurses, and for courses within academies that bridge the gap between current
standards and the levels of education required for the delivery of optimum health care.
Discussion. We both are nurses. One of us is an Indonesian and the other has worked
for many years in Indonesia and coordinated a programme that organized exchanges
of health professionals working in large tertiary referral hospitals and health
departments in Indonesia and Australia. The information presented here is the result
of many collaborative projects and gives information not available in published
works.
Keywords: nursing,
humanitarian aid

Introduction
Indonesia is one of the worlds most heavily populated
countries. Its health system is similar to that of other
developing countries, and serves the culturally diverse population of the Indonesian archipelago. The aim of our paper

2003 Blackwell Publishing Ltd

Journal of Advanced Nursing 44(2), 209

Indonesia,

Java,

health

services,

developing

country,

is to provide knowledge about nursing care, education of

nurses and other health professionals, and ethical dilemmas
encountered by Indonesian health professionals. Through this
paper, nurses in developed countries with well-resourced
health services may gain insights into working within
minimal budgets, and providing care to patients with
209

L. Shields and L.E. Hartati

conditions related to poverty, under-development and tropical environments. Care delivery within Javanese culture (the
predominant culture in the Indonesian archipelago) is also
discussed. One of us (LEH) is an Indonesian, the other
Australian (LS). We have collaborated on projects in Central
Java, including an exchange programme of health professionals between Dr Kariadi Hospital, Semarang (the main
tertiary referral hospital for Central Java), community health
facilities of the Health Department of Central Java and the
Mater Misericordiae Hospitals in Brisbane, Australia.
In this paper, we provide historical and demographic
background material in order to explain contexts of nursing
in Indonesia. This is followed by descriptions of nursing,
further information about health systems and education of
health professionals, accounts of ethical dilemmas faced by
health professionals, and effects of overseas aid. While the
systems described exist throughout Indonesia, most work for
this paper was carried out in Java, the main island. Consequently, specific cultural references are to Javanese people.
However, our comments are generalizable to all Indonesia.

Background
The Republic of Indonesia is situated on 13 000 islands lying
across the equator, north-west of Australia. A nation of people
from diverse cultural backgrounds, races and religions, it was
formed in 1946 after 400 years of Dutch colonization. The
population exceeds 220 million (Central Intelligence Agency
2002), and its main island, Java, is slightly larger than Ireland
and is the most densely populated island in the world, with a
population of over 100 million (Macquarie Library 1994).
Indonesias history is turbulent. After centuries of colonization and several years of Japanese occupation during World
War II, Sukarno became president of the newly formed republic
in 1946, following a revolution ending Dutch domination. He
was replaced in 1967 by a military dictator, Suharto (Department of Information, Republic of Indonesia 1980), following a
violent coup detat. He, in turn, was overthrown during a
comparatively peaceful event following the Asian economic
crisis of 1998 (Jenkins & Williams 1998). In 2000, Indonesia
held its first truly democratic election and a Muslim cleric,
Abdurrahman Wahid, became president. Megawati Sukarnoputri, a highly popular politician and daughter of Sukarno has
since replaced him (McPhedran 2001).
Indonesia, the worlds largest Muslim country, strongly
espouses freedom of religion. Small sections of the country
are Hindu, Christian or Buddhist. Indonesias motto of
strength in diversity reflects the Republics multiculturalism
(Department of Information, Republic of Indonesia 1980).
There are many distinct cultures, but the Javanese community
210

predominates. This has caused political problems across the

archipelago, as other cultures struggle for autonomy within
their own provinces. Violent pushes for independence are
ongoing in the Sumatran province of Aceh, and in Irian Jaya.
A similar drive for autonomy came to a head in the province
of East Timor in 1999, when it was granted independence
following 20 years of civil disturbance (Dodd 1999).
Indonesian cultures are thousands of years old. Javanese
culture is characterized by strong class systems, respect for
elders, bountiful hospitality and a complex system of politeness, obligation and privilege (Koentjaraningrat 1957).
Despite the diversity of cultures, Indonesia is united by one
language, Bahasa Indonesia, and by the national philosophy
of Pancasila, based on belief in God, humanism, universal
justice, national unity and democracy (Gimon 2001).

Development
Indonesias average annual gross domestic product (GDP)
growth rate from 1980 to 1991 was 39% (World Bank 1993),
which dropped to 33% in 2001 (World Bank Group 2002).
Until the end of 1997, the economy was booming. High-rise
buildings and sophisticated shopping centres in the capital,
Jakarta, indicated that many Indonesians were financially
well-off. However, 32% lived below the poverty line [calculated on local currency and estimations of work and
consumption by poor families (World Bank 1994)]. During
the Asian economic crisis (called krismon in Indonesian) in
early 1998, the value of the rupiah fell by 84% against the US
dollar (Barclay 1998). Although the economy is recovering,
the people of Indonesia continue to face economic hardship.
After krismon, living conditions deteriorated and by 1998 an
estimated 80 million people lived below the World Bank
poverty line (McCawley 1998). By 1999, growth had declined
to
13% of GDP (World Bank Group 2001). In 2001, a
restructuring of government agencies occurred, and all government departments decentralized to the provinces, with
each provincial government responsible for raising one-third
of its income independently of the central government in
Jakarta. This has severe ramifications for all public utilities
including health care and nursing. The terrorist attacks on the
United States (US) in September 2001 resulted in a downturn
in the economies of many nations. In addition, Indonesia is
suffering further economic hardship because of the terrorist
incidents in Bali in 2002 and Jakart in August 2003.

Health parameters
Prior to the Asian economic crisis, health statistics had
improved as the economy strengthened. Average life expect-

2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(2), 209216

Health and nursing policy issues

ancy at birth increased from 41 years in 1960 to 634 years in

1995, while the infant mortality rate fell from 160 deaths per
1000 live births in 1960 to 55 in 1995 (South East Asian
Medical Information Centre 1997), and 41 in 2000 (World
Bank Group 2001). A successful family planning programme
reduced the birth rate from 56 to 31 births per woman
between 1960 and 1990 (International Development Program of Australian Universities and Colleges 1994). The
maternal mortality rate was 390 per 100 000 births in 1994
and the perinatal mortality rate was 3184 per 1000 live
births (Health Department, Central Java 1997).
After krismon, health statistics worsened. Many people lost
their jobs, families could afford only two meals a day, the
price of rice (the staple food) doubled and that of cooking oil
tripled. Maternal malnutrition increased by 5% and anaemia
in children increased from 40% to 65% (The Jakarta Post
1999 March 26). Infant formula cost five times more than
before krismon. Consequently, malnutrition in children proliferated (The Jakarta Post 1999 March 16, 1999 March 17).
Many who work in child health in developed countries assume
that in developing countries all mothers breastfeed. This is not
so in Indonesia nor, possibly, in other poor nations. When
there is no social security or benefits such as maternity leave,
mothers must work. Babies are cared for by extended family
members and carers, and breastfeeding becomes impossible.
Consequently, a rise in the cost of infant formula has a
potentially severe impact on the nutritional status of infants.
More research is needed on this topic.
Diseases endemic in Indonesia include dengue haemorrhagic fever, malaria, typhoid, cholera, tuberculosis and
other infectious diseases. Although figures are not readily
available, their incidence is increasing, as preventive measures
such as mosquito spraying have been reduced since krismon.
Conditions that are now uncommon in developed countries
are still observed; hydrocephalus is an example. In remote
villages, abnormal growth of an infants head may not be
detected early and treatment comes too late. Health department officials have described how tropical diseases such as
leptospirosis (spread by rat and cat faeces) are increasing,
particularly after major flooding in the wet season. Nurses in
Indonesia not only face problems of caring for patients with
tropical diseases and their families, but have had to become
adept at providing care in a system which is beset with
difficulties such as shortage of supplies, few disposable items
and inadequate resources.

Nursing in Indonesia
The information on nursing presented here is the result of our
collaborative work, unless indicated otherwise. Data were

Nursing and health care in Indonesia

collected from unpublished government figures and through

communication with Indonesian health professionals, the
Indonesian Nurses Union (Persatuan Perawat Nasional
Indonesia) and the Health Department of Central Java. There
are no formal publications or published reports on this topic.
In 1994 (the latest available figures), there were 50 nurses
and 26 midwives per 100 000 people in Indonesia [World
Health Organization Statistical Information System (WHOSIS) 2002a]. Nursing, until recently, was universally considered a low-status profession, but with the introduction of
tertiary education for nurses, a major shift in attitudes is
occurring. At present, about 1% of nurses are educated at
university (Shields 1999). At some universities, nurses are
educated to the levels of S1 (sarjana satu, or bachelors
degree), S2 (sarjana dua, or masters degree) and S3 (sarjana
tiga, or doctoral degree). Faculties of nursing are politically
active, and work towards registration of nurses and standardization of curricula.
Thirty-nine per cent of nurses are educated to diploma level
at both government and private academies of nursing
Akademi Keperawatan (AKPER) (Shields 1999). Sixty per
cent of nurses are educated at senior high school, where
specialist nursing and midwifery subjects are taught in Grades
11 and 12 (Shields 1999). This is recognized by health officials
as a major contributing factor to low levels of health and high
mortality, as nurses who are high school graduates, as young
as 17 years old, care for patients with complex health
problems and deliver babies. The Indonesian government is
dedicated to improving the standard and level of nursing
education and, since 1998, many school courses have been
converted to diploma level. In 1992, 2485 nurses graduated
from nursing academies and 12 741 from high school
(International Development Program of Australian Universities and Colleges 1994).
Until recently, there was no accreditation of courses, little
standardization of curricula and no benchmarking or competency assessment to ensure a safe level of practice amongst
those who graduate as nurses. In 1984, nursing curricula
were reviewed for the first time, in 1997 a standard was set
for the whole of Indonesia, and new curricula were implemented in all AKPER by mid-1999.
No central registration for nurses exists, consequently,
there is no standardization of levels of competence and
ability, and no way of correlating education with practice
standards. The Indonesian government and Indonesian Nurses Union are working towards rectifying this. Another
major problem is the low level of basic nursing education.
Nurses with diplomas and degrees are needed to teach, and
often take up teaching positions immediately after graduation, with little clinical practice to consolidate their

2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(2), 209216

211

L. Shields and L.E. Hartati

education. Accordingly, nurse educators in academies may

have little understanding of the on-going education needs of
nurses working in hospitals and health centres. This causes
some anxiety for both educators and clinicians; however,
many nurses recognize these problems and work towards
solutions. Some nurses have completed a successful integrated
course, combining academic learning with clinical training,
and this is becoming standard educative practice. Senior
nurses acknowledge that removal of nursing education from
high schools will solve some of the problems.
Because the status of nursing has risen, and it offers secure
employment, approximately 25% of nurses are men. Under
Indonesian law, everyone who can work must be in employment and the government has a responsibility to ensure the
creation of jobs in its departments. Consequently, government bureaucracy is enormous. All government employees
must retire at 55 years of age to make way for younger
Indonesians. This mandate affects nursing in particular,
although medical officers, allied health professionals and
midwives continue in private practice beyond this age. Until a
nurse practitioner role in private practice is developed, nurses
will not be able to continue to work after they have retired
from government employment.
One problem besetting nurses is their lack of status
compared with medical practitioners. Nurses, in the main,
are regarded as doctors helpers. Doctors dominate health
structures, leaving nurses with little power and, hence, little
incentive to make changes or pursue higher education. Some
realize that change can only occur with education and, with
great insight, tenacity and hard work, they pursue higher
education, often leaving their families for long periods to
undertake overseas study. Many realize that doctors need to
be educated about enhanced roles for nurses. Once one nurse
achieves the position of hospital executive director, or unit
manager, a precedent will be set and others will follow.
In 1999, the Central Java Government implemented a
World Bank project to send nurses and allied health staff
overseas to attain masters degrees. They are now returning
home and educating other health professionals.

Indonesian health care system

To understand fully the position of nursing in Indonesian
society, knowledge of the overall health system is required. In
1990, Indonesia spent 12 US$ per person on health, which
was 2% of Gross National Product (GNP); only 07% of
GNP was spent on public health (World Bank 1993). By
1998, per capita spending remained the same (WHOSIS
2002b), and spending on health had increased to only 27%
of GNP. In comparison, in 1998 Australias health expendi212

ture was 86% of GNP (WHOSIS 2002b). There are two

modes of health care in Indonesia, public and private. The
state funds hospitals and primary health care clinics, and
private hospitals and clinics are run by private companies and
individuals and occasionally by Islamic and Christian organizations. Sometimes state hospitals build private wings to
generate profits to support public facilities which deliver
health care to the poor.
There are over 1000 hospitals in Indonesia and about 34%
are private. A small group of Indonesians with high incomes
can afford to travel overseas for expensive health care, while
the middle class has access to private and public health
facilities of varying quality (International Development
Program of Australian Universities and Colleges 1994). In
1993, the World Bank suggested that public provision for
health care of the poor was inadequate and maintained that
the government subsidized the health of the richest 10% up
to three times more than health services for the poor.
Following krismon, aid packages from the International
Monetary Fund (IMF) and the World Bank have included
safety net provisions for the poorest, including free health
care. Under this scheme, known as Jaring Pengaman Sosial
Bidang Kesehatan (JPSBK), hospitals and community health
facilities provide not only free medical, nursing and hospital
care, but also any supplies needed for treatment. It must be
noted, however, that this scheme is available only to the
poorest, while those who are not so poor still have to pay.
Quality of care in private hospitals varies. While some are
better resourced than public hospitals, this may not always be
the case, as small private hospitals may not be able to access
staff, including medical specialists, and may not give the same
level of care. Public hospitals are administered by the
Ministry of Health or, in some cases, by local authorities at
city or provincial level. Hospitals are classified according to
number of beds and the specialist services available. Class A
and B are major referral and teaching hospitals, and district
hospitals are either Class C (100400 beds) or D (25100
beds). Class C hospitals offer some specialist services and are
teaching hospitals, while doctors in Class D hospitals are
general practitioners (Shields 1999).
All hospitals and health care facilities operate on a user
pay system (some now provide free health care under the
JPSBK scheme). One regional hospital in Central Java has
estimated a fourfold increase in the number of free services
they provide over the next 5 years, as the country struggles to
recover economically. Usually, however, patients are charged
for admission. This entitles them to a bed, nursing care, food
and sometimes medical care (in some hospitals this is an
added charge). All equipment, drugs, dressings, intravenous
fluid, tubing, blood and other necessities have to be bought at

2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(2), 209216

Health and nursing policy issues

either the hospital pharmacy or from chemist shops. There

are charges for all community health services, according to
type and level of service. General practitioners and medical
specialists can be accessed privately.
Hospitals have different classes of wards, and admission
charges vary. Daily rates, for the lowest class of ward, range
from about 5000 to 8000 rupiah, while the highest class
ward costs up to 450 000 rupiah. Because exchange rates in
Asian countries are extremely labile, a comparison with other
countries currencies is not helpful. As an indication, a family
meal can cost about 8000 rupiah.
Most government employees receive private health insurance as part of their remuneration, as do many who work for
private companies and businesses. However, there is a large
proportion of the population for whom health insurance is
unavailable. They are usually from the most disadvantaged
sections of society. Many are ineligible for free health services
available for the very poor, but are unable to contribute to
health insurance schemes. Therefore, they may not be able to
afford anything but the most basic health care. Research into
costs and effects of limited services available at this level of
society is needed.
The different classes of hospitals and wards reflect class
divisions within Indonesian society. By paying the basic rate,
a poor family will be able to access a bed in a large ward
with some nursing care. Extra nursing can be paid for but,
often, family members must stay to ensure that care is given.
In the highest class of ward the patient will be accommodated in a private room with bathroom, television, refrigerator
and beds for family. Standards of nursing care vary greatly
from place to place and are dependent on the type of
hospital, nurses educational levels and the general philosophy of the institution.
In line with World Health Organization objectives for
primary health care (World Health Organization 1978),
Indonesia has an extensive primary health care system. Each
subdistrict has at least one community health centre, or Pusat
Kesehatan Masyarakat (PUSKESMAS), which is linked to a
series of sub-centres called PUSKESMAS pembantu and
community-level health stations called Pos Pelayanan Terpadu (POSYANDU). Nurses and midwives staff these centres,
providing a range of services including family planning,
immunization, maternal and child health care and preventive
services. One POSYANDU is provided for every 100 children
under 5 years of age. While the primary health care system
works well, remote areas are often disadvantaged in comparison with larger centres, although the government tries to
address this issue by making rural government service
mandatory for doctors before they can work as private
practitioners in areas of their choice.

Nursing and health care in Indonesia

Economic changes to the structure of all government

departments have affected the health system. Under a
programme called Perusahaan Jawatan, state funding for
hospitals has been decreased by over one-third, and institutions are expected to raise independent funds. While many
hospital directors seek ways to do this, the most common
stratagem is proving to be a private-public link, in which
profits from private hospitals are used to support state
organizations.

Education of health professionals other than nurses

In 1994, there were 16 doctors per 100 000 people in
Indonesia (WHOSIS 2002a). Medicine is a high-class profession, whose practitioners are highly respected. Much of this
esteem is traditional, as medicine was one of the few
professions fostered by the Dutch colonial administration
(although Indonesian-educated doctors could not work in
Holland). Doctors played key roles in the development of the
nationalist movement and were prominent in the independence wars of 19451946 (International Development Program of Australian Universities and Colleges 1994).
All doctors are educated at universities, initially at undergraduate level. They are then required to work for up to
5 years in a government position as general practitioners, and
can then choose private or public practice. Public hospital
and health care doctors have private patients. This is
considered necessary, because, as with all government
employees, salaries are kept low in the expectation that
employees will make extra money by other means. Specialist
medical training is conducted at government universities
only. A specialist diploma is conferred, and applicants must
have at least 3 years of experience prior to enrolment. Many
doctors go overseas for specialist education, and must register
their overseas qualification with the Indonesian Medical
Board before practising in that speciality (International
Development Program of Australian Universities and
Colleges 1994).
Allied health staff are educated to diploma level at
academies, or through specialist courses in the final 2 years
of high school, although, as in nursing, the current trend is to
ensure that all are educated to diploma level. This applies to
staff such as pharmacists, laboratory technicians, nutritionists, dental technicians, physiotherapists, occupational
therapists, radiographers, medical technologists, speech therapists, environmental hygienists and opticians. Allied health
staff are in short supply. In 1992, 219 physiotherapists,
52 pharmacists and 10 speech therapists graduated from
academies (International Development Program of Australian
Universities and Colleges 1994).

2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(2), 209216

213

L. Shields and L.E. Hartati

Ethical dilemmas faced by nurses and other Indonesian

health professionals
Problems unique to developing countries beset all Indonesian
health professionals. Many describe distress and frustration
when, of necessity, their practice contradicts all they have been
taught about cross-infection and optimum patient care. Most
nurses can explain standard precautions, but have no way of
practising them, as no gloves and protective clothing are
provided. Because people must pay for all equipment used
during admission of a family member, doctors and nurses are
conscientious about minimizing costs for families. It is
common to see nurses using the same needle and syringe to
insert antibiotics into the intravenous tubing of different
patients. Although they take great care not to infect any part of
the syringe and needle, this practice contravenes all they have
been taught about cross-infection. However, they must choose
between suboptimal pratice that enables the patient to receive
available treatment or the patient being sent home untreated.
Doctors are very good at prescribing only what the patient
needs for a course of treatment, so that little waste occurs.
Patients, however, may still buy a lesser amount of the drug or
other treatment and, thus, may not complete the course. This
has far-reaching ramifications for the spread of disease and
antibiotic resistance, and provides further topics for research.
Nurses describe their distress when families (who may have
sold their homes to pay for the hospitalization of a family
member) take patients home still not cured because they can
no longer afford to pay for care; nowhere is this more
poignant than in paediatrics. Few families can afford allied
health services, so rehabilitation is often ad hoc. Health
professionals are aware that there is no unemployment relief,
and that hospitalization often involves a relative in a choice
between staying with the patient to ensure that nursing care is
adequate and keeping their job (Shields 1999). Often people
choose to jeopardise their employment rather than rely on the
health care system and, with a huge population and high
unemployment, this is a very real threat to a family (Shields
& King 2001a, 2001b).
Krismon aggravated ethical dilemmas faced by health workers, but has had some positive effects. Free health care for the
very poor is inherent in IMF and World Bank aid packages and
many hospital administrators are keen to continue this.
Currently, ways to subsidize health care for the poor are being
examined, so that free facilities can continue once the country
has recovered from krismon. However, the terrorist attacks in
Bali, Jakarta, and the US, and resultant downturn of the world
economy, will have knock-on, negative effects on such schemes.
These insoluble problems put enormous pressure on
nurses, whose aim, like their colleagues everywhere, is to
214

alleviate suffering and support patients and families. By and

large, Indonesian health professionals provide high-quality
care, within the constraints of the health system.

Effects of the international nursing shortage

All countries may feel the effects of the international nursing
shortage, but (as so often happens) poor countries are likely to
feel it the worst. Indonesia, at present, has unemployed nurses,
and nursing education is still attracting students. However, if
nurses leave the country under schemes such as those in place in
Britain, where they can take courses to upgrade their skills
which allow them to work in National Health Service hospitals
(The Independent 2001), the pool of unemployed nurses will
cease to exist. Subsequently, other nurses will leave to work
elsewhere and Indonesia will face a shortage of nurses.
Innovative schemes, in which nurses must return home to work
in nurse education once they have completed their contracts in
other countries, are laudable, as they help to create employment
and enhance the education of nurses within the country.

Overseas aid projects

There are many governments and organizations in the world
which are committed to giving aid to developing nations.
Many religious organizations, including the major Christian
churches, and governments of developed nations have
departments which distribute and administer aid. Some
overseas aid is given freely, that is, the recipient country is
able to distribute and spend the sum as it wishes. In other
cases, aid is given subject to the requirement that full
accounts of its use are sent to the donor country. Some aid
is tied to trade contracts and will not be given unless the
recipient nation agrees to purchase a certain amount of goods
from the donor country. Health care is a fertile field for aid
organizations, and in Indonesia, many health care institutions
are beneficiaries of overseas aid.
Aid is a two-edged sword, with inherent ethical dilemmas
posing problems for both donor and receiver (Fox 2001).
Indonesian health professionals often struggle with quandaries presented by aid donations. While aid provides much
needed resources and help, the industry which has grown up
around it is large and its practice can sometimes be
questioned. In many countries which are recipients of aid, a
donorreceiver dichotomy has arisen. Agents of the donor
country become patrons and display behaviour which infers
superiority over those to whom the aid is being given, while
recipients come to believe that they have a right to aid because
of their poverty. Companies which provide infrastructure and
facilitate projects for aid organizations sometimes make large

2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(2), 209216

Health and nursing policy issues

What is already known about this topic

Indonesia, the worlds largest Muslim nation, is a
developing country whose health services are reflective
of the constraints of a massive population and relatively
few resources.
Little has been written in English about nursing and
health care in Indonesia other than accounts from visitors who inevitably have limited understanding of the
surrounding complexities in this culturally diverse and
populous nation.

What this paper adds

It provides a first hand account, written collaboratively
by an Indonesian nurse and a colleague who has lived
and worked in Indonesia over many years.
It uses previously unpublished information from health
and nursing sources in Indonesia and gives an accurate
picture of how nursing fits with the health services and
other health professions.
It will provide useful and correct information for nurses
interested in Indonesia.

profits. While all companies must make money to survive, the

ethics of the intent and management of aid becomes questionable if involvement in aid projects is motived only by the
chance to make large profits. Sometimes employees of aid
projects have little knowledge of and sensitivity about the
culture, customs and mores of the country in which they are
working, and offend the local population.
The Indonesian health care system benefits from overseas aid
from countries such as Holland, Australia, America, Germany
and other European nations. Some of this aid is freely given,
well spent and benefits the Indonesian population. Other aid
projects within health care may be funded by countries who
insist that their donation is used to purchase large pieces of
medical equipment that incorporate disposable items which
must be purchased from a company based in the donor nation.
This often incurs large costs for the recipient facility. Some aid
projects in Indonesia provide managerial support for hospital
administrators who are, in reality, well-versed in management
theory and practices and have a much better understanding of
the needs of their health service than people from outside.

Working in Indonesia
There is much discussion about corruption in Indonesia
(Muhammad 2002) and the health service is not immune.

Nursing and health care in Indonesia

While corruption does occur in Indonesia, it is important that

such practises are understood in their proper context. For
thousands of years, Indonesian society has run on a system of
privilege and patronage within a culture structured along
strong class divisions (Koentjaraningrat 1957). Within this
system, it is acceptable practice to pay for privileges. The
Indonesian government has a commendable policy of providing employment for as much of its vast population as
possible, and the cost of paying employees who work in
public service is taken from the national budget. Consequently, government employees, although securely employed,
earn little and are expected to supplement their incomes. It is
a common and accepted custom for companies operating in
Indonesia to pay for the privilege of doing business. This may
range from a small payment to a government clerk to
facilitate the passage of a document through a department, to
subsidizing large social events for families of senior employees in organizations with whom the agent is conducting
business. The same holds true for health services. People from
other nations find this system difficult and, subsequently,
misunderstandings arise. These practices are a normal part of
the fabric of Indonesian life, and while stamping out true
corruption is an aim of the government of Megawati
Sukarnoputri (Maher 2001), an understanding of how the
system works may afford foreign nurses and other health
professionals a more rewarding and interesting experience.

Conclusion
Indonesia, the largest South East Asian nation, is beset by
problems resulting from its immense population, recent
economic downturns and, in particular, the local effects of
the recent bombings. These problems are reflected in its
health statistics. Nursing, while traditionally perceived as a
low-status occupation, with the introduction of tertiary
education, is developing as a profession. However, it is
plagued by problems found in all developing countries.
These include patients who are poverty-stricken, a system
which lacks resources, the need for patients to pay for
health care, a dearth of disposable items and a network of
factors that increase the illness acuity of patients presenting
for care. Nurses (and other health professionals) face ethical
dilemmas which are not encountered by health professionals
in wealthier nations. The Indonesian government is working
towards standardized accreditation of nursing education
across the archipelago. Also, it is attempting to implement a
registration system for nurses and is committed to improving the standard of nursing education throughout the
country and, by so doing, improving the health of the
population.

2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(2), 209216

215

L. Shields and L.E. Hartati

Humanitarian aid can help with such problems, but its

ethics must be discussed and limitations to its benefits
examined. Nursing education should include courses on the
ethics of aid, so that nurses can be circumspect about its use
and ensure that nursing and the health of the Indonesian
people benefit.
This paper has provided insights about nursing and health
care in Indonesia. It is hoped that knowledge of the culture, how
the health system works within it and the role of nurses will
enhance the relationship between nurses from Indonesia and the
rest of the world. We hope that the adverse publicity which
Indonesia received after the bombings in Bali and Jakarta may,
in some small way, be offset by the information given here.

Acknowledgements
This work was supported by a National Health and Medical
Research Council of Australia Public Health Postdoctoral
Fellowship, a National Health and Medical Research Council
of Australia Dora Lush Memorial Scholarship, Queensland
Nursing Council, Mater Childrens Hospital, Brisbane, Centaur Memorial Fund for Nurses, and University of Queensland Alumni. Special thanks to Dr Krishnajaya (Head of the
Department) and Dr H. Hartanto from the Health Department of Central Java, and to Dr H. Gatot Suharto, Director
of Dr Kariadi Hospital, Semarang for their help in compiling
this work.

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2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(2), 209216