Indonesian Journal of Health Administration Original Research (Jurnal Administrasi Kesehatan Indonesi.
p-ISSN 2303-3592, e-ISSN 2540-9301 20473/jaki.
RETENTION OF REMOTE PUBLIC HEALTH CENTER
DOCTOR IN NORTH KONAWE DISTRICT
Retensi Dokter Puskesmas Sangat Terpencil di Kabupaten Konawe Utara *Sondang Whita Kristina Tambun1.
Masyitoh Bashabih 2 1Directorate of Health Workforce Planning.
Directorate General of Health Workforce.
Ministry of Health.
Jakarta.
Indonesia 2Faculty of Public Health.
University of Indonesia.
Depok.
Indonesia Correspondence*:
Address: Jl.
Hang Jebat i Blok F3 Kebayoran Baru.
Jakarta.
Indonesia | e-mail: whita.
tambun@gmail.
Abstract Background: Remote public health centers (PHC.
have the highest proportion of PHCs without doctors, with Southeast Sulawesi Province ranking fifth in this regard.
PHCs serve as the main gateway to health services in rural and remote areas.
Despite its high fiscal capacity and provision of support for medical education and incentives.
North Konawe District has not succeeded in retaining doctors in its public health centers.
Aims: This study aims to analyze factors that influence the retention of doctors in remote PHCs in the North Konawe District.
Methods: This qualitative study employed a case study design, involving in-depth interviews with 14 informants and a review of six documents.
Results: Factors affecting doctor retention in the North Konawe District include individual factors, work factors, living environment factors, and health system factors.
Conclusion: Doctors in remote PHCs in North Konawe District are Ministry of Health placement doctors working on temporary Strategies to improve the retention of doctors in remote PHCs include improving living conditions in remote areas, supporting job opportunities for doctors' spouses, recruiting doctors early in their careers, implementing government disincentive policies, building PHCs with official housing, requiring mandatory service for recipients of medical education scholarships, and developing doctor attendance information system.
Keywords: Doctor.
PHC, remote area, retention.
Abstrak Latar Belakang: Puskesmas sangat terpencil merupakan puskesmas tanpa dokter dengan proporsi tertinggi.
Provinsi Sulawesi Tenggara merupakan tertinggi kelima.
Puskesmas merupakan pintu gerbang utama pelayanan kesehatan dasar di daerah pedesaan dan terpencil.
Kabupaten Konawe Utara Provinsi Sulawesi Tenggara merupakan daerah dengan kapasitas fiskal tinggi, memberikan bantuan biaya pendidikan dokter serta menyediakan insentif dokter tetapi dokter tidak retensi bekerja di puskesmas di kabupaten ini.
Meskipun merupakan daerah dengn kapasitas fiskal yang tinggi serta penyediaan bantuan pendidikan dan insentif bagi dokter.
Kabupaten Konawe Utara belum berhasil mempertahankan tenaga dokter di puskesmas.
Tujuan: Penelitian ini bertujuan menganalisis faktor-faktor yang mempengaruhi retensi dokter di puskesmas sangat terpencil di Kabupaten Konawe Utara.
Metode: Penelitian ini merupakan penelitian kualitatif desain studi kasus dengan wawancara mendalam 14 orang informan (Puskesmas.
Dinkes Kabupaten.
Dinkes Provinsi.
Kemenke.
dan menelaah enam dokumen.
Hasil: Faktor yang mempengaruhi retensi dokter di Kabupaten Konawe Utara adalah faktor individu, faktor pekerjaan, faktor lingkungan tempat tinggal dan faktor sistem kesehatan.
Kesimpulan: Dokter yang retensi di puskesmas sangat terpencil Kabupaten Konawe Utara merupakan dokter penempatan Kementerian Kesehatan dengan kontrak sementara.
Strategi meningkatkan retensi dokter di puskesmas kawasan sangat terpencil dengan meningkatkan kondisi kehidupan di daerah terpencil, peluang pekerjaan pasangan dokter, merekrut dokter di awal karir, kebijakan disinsentif dari pemerintah, membangun puskesmas dengan fasilitas rumah dinas, wajib pengabdian program beasiswa pendidikan dokter dan mengembangkan sistem informasi kehadiran dokter.
Kata kunci: Dokter, kawasan sangat terpencil, puskesmas, retensi.
Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesi.
p-ISSN 2303-3592, e-ISSN 2540-9301.
Volume 13 No.
DOI: 10.
20473/jaki.
Received: 2024-08-07.
Revised: 2025-04-30.
Accepted: 2025-05-16.
Published: 2025-06-30.
Published by Universitas Airlangga in collaboration with Perhimpunan Sarjana dan Profesional Kesehatan Masyarakat Indonesia (Persakm.
Copyright .
2025 Sondang Whita Kristina Tambun.
Masyitoh Bashabih.
This is an Open Access (OA) article under the CC BY-SA 4.
0 International License .
ttps://creativecommons.
org/licenses/by-sa/4.
0/).
How to cite:
Tambun.
and Bashabih.
, .
Retention of Remote Public Health Center Doctor in North Konawe District.
Indonesian Journal of Health Administration, 13.
, pp.
20Ae29.
https://doi.
org/10.
20473/jaki.
Retention of Remote.
Tambun.
Bashabih Indonesian Journal of Health Administration Original Research (Jurnal Administrasi Kesehatan Indonesi.
p-ISSN 2303-3592, e-ISSN 2540-9301 20473/jaki.
Direktorat Jenderal Tenaga Kesehatan.
Optimizing the continuity is critical, given that half of the global population currenty resides in rural areas, and by 2050, it is projected that approximately one in three people will live insuch areas (WHO.
In Indonesia, only about 10% of doctors practices in rural areas, despite approximately 45% of population living in these communities (Agustina et al.
, 2.
Health service facilities in remote areas face limited accessibility due to challenging transportation infrastructure, difficulties in meeting basic living needs, and poor security conditions (SuAoudi et al.
, 2.
PHC health serve as a strategic point for delivering health services to these Southeast Sulawesi Province was the fifth-highest province for PHCs without doctors in Indonesia in 2022, even though there was a medical faculty in the province.
Based on SISDMK data in 2022.
North Konawe District had five PHCs without doctors, two of which were remote PHCs.
In 2022.
North Konawe District was a region with very high fiscal capacity, providing education tuition for students from the district, including for medicine education, and providing incentives for PHC doctors.
However, doctors were not retained to work in remote PHCs.
Data from SISDMK shows that by 2020, no remote had a doctor, and by 2023, all remote PHCs were filled by doctors 2023.
This study aims to analyze factors that influence the retention of remote PHC doctors in North Konawe District so that it can be an input in the preparation of national and local government policies in supporting the retention of remote PHC doctors.
Introduction The SDGs target aim is to strengthen health systems to achieve universal health coverage, ensuring that everyone receives the health services they need (Lee and Kim, 2.
WHO has formulated a global health system framework with six building blocks to strengthen health systems.
One of the components of this framework is the health workforces (Manyazewal, 2.
IndonesiaAos health transformation includes transforming health human resources in order to equalize the distribution of the health workforce across the country, including in DTPK (Ministry of Health.
The shortage of health workforces remains a challenge in many countries, particularly in rural and remote areas.
Australia conducts rural clinical placements for undergraduate medical students, which help improve the distribution of medical personnel (Campbell et al.
, 2.
Thailand, providing rural exposure during education for of doctors from rural backgrounds has been shown to increase their retention in these areas (Boonluksiri et , 2.
The government implemented various programs address the shortage of health workforces, including doctors (Flores et al.
, 2021.
Walton-Roberts et al.
Witthayapipopsakul et al.
, 2.
The adequacy of health workforces is the fundamental pillar of health services Law No.
17 of 2023 mandates that both the Central Government and Regional Governments must fulfill the needs formedical and health personnel in terms of distribution to ensure the sustainability of health development.
The RPJMN 20202024 targets zero percent of PHCs without The proportion of PHCs without doctors was 6.
91% in 2020, which improved to 4.
91% in 2021, and further decreased to 3.
99% in 2022 (Sekretariat Direktorat Jenderal Tenaga Kesehatan.
These data indicate that recruiting doctors for PHCs has effectively reduced the number of PHCs without doctors.
However, significant disparities persist in occupancy rates between remote PHCs and those in other regions (Sekretariat Retention of Remote.
Method This research is qualitative research with a case study design that allows researchers to collect detailed and complete information to explore the dimensions of a case, focus on events that do occur, limited by space and time, and examine the interrelationships with one another (Martha and Kresno, 2.
The Tambun.
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p-ISSN 2303-3592, e-ISSN 2540-9301 20473/jaki.
research was conducted from December 2023 to April 2024 in North Konawe District in Southeast Sulawesi Province.
Kendari, and Jakarta.
The selection of informants was based on purposive sampling and snowball sampling with reference to appropriateness and adequacy.
There were 14 informants from remote PHCs in North Konawe District.
North Konawe District Health Office.
Southeast Sulawesi Provincial Health Office, and the Directorate General of Health Workforces of the Ministry of Health.
Primary data were collected through in-depth interviews using a structured list of questions (Wibowo.
Secondary data were collected from selected informants.
Researchers conducted triangulation and method triangulation to ensure the validity of the research findings (Wibowo, 2.
The data analysis process involved transcription, reading all data, coding, themes analysis within each case and cross-case, and data interpretation (Creswell, 2.
due to power outages for several hours These findings are consistent with previous studies, which found that doctors working in rural areas face many difficulties in daily life (Hou et al.
, 2016.
Mohammadiaghdam et al.
, 2.
Doctors in this study were able to retain working in remote PHCs due to their ability to adapt to these conditions (Handoyo et al.
, 2.
The remote area PHCs doctors from the findings of this study are doctors from Penugasan Khusus (Special Assignmen.
the Ministry of Health's Programme.
This program does not have guidelines for the standard of doctorsAo housing.
Improving living conditions in rural and remote areas cross-sectoral political, institutional, and financial means.
Stakeholder collaboration through the Village Fund.
Balancing Fund through the Special Allocation Fund (Noya et al.
, 2.
The Village Fund based on the Regulation of the Minister of Villages.
Development of Disadvantaged Regions, and Transmigration can be used to improve access to health services such as provision of clean water in villages and the development of transport facilities by building and maintaining roads.
Result and Discussion Individual Factors In-depth interviews with doctors and the head of the PHC remote areas in Konawe Utara District identified individual factors that influence the retention of remote PHC doctors, as shown in Table 1.
This study found that doctors working in remote PHCs live in inadequate living conditions because, for housing, they share a room with several health workforces.
This finding aligns with research in India, which reported insufficient housing for rural health workers (Rajbangshi et al.
, 2.
Previous research found that local governments have difficulty fulfilling their obligation to provide housing for health workforces.
(Tambun et al.
, 2.
The difficulty in providing housing in remote areas is due to the limited budget and the limited ability of local governments to apply for the Special Allocation Fund (DAK) (Noya et al.
, 2.
This study found that doctors experienced limitations of daily living facilities due to limited water and electricity Retention of Remote.
Work Factors Work-related factors influencing the retention of remote PHC doctors in North Konawe District are presented in Table 2.
These results are based on in-depth interviews with remote PHCs, district health office, provincial health office, and the Ministry of Health.
A document review by looking at doctorsAo training certificates found that the training frequency of doctors in remote area PHCs varies because one doctor has never attended the training.
This study found no specialized training or seminars for doctors in remote areas because it was done without considering increasing the capacity of remote area PHCs.
Educational development is required for doctors to provide safe and effective care in rural and remote communities (Abelsen et al.
, 2.
Previous research found that training affects the retention of doctors in rural areas (Honda et al.
, 2.
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Table 1.
Individual Factors PHC Individual Factors Tapunggaya Langgikima Pesisir Personal life Inadequate housing.
limited water Inadequate housing.
limited water and electricity.
unstable phone and electricity.
unstable phone weak internet signal.
weak internet signal.
access the city once a month access the city once a month Character Adventurous character Adventurous character Family Unmarried doctors living Married doctor living separately separately with their parents from spouse, but living with children not yet of school age Background Urban origin has never been Urban origin has never been exposed to the countryside exposed to the countryside Demographics Female, young .
nder 35 years Female, young .
nder 35 years ol.
, married doctor with a ol.
, married doctor with a husband who is a local resident husband who is a local resident Table 2.
Works Factors Work Factors Professional and PHC Tapunggaya Langgikima Pesisir There is no special training for There is no special training for doctors at remote PHCs.
doctors at remote PHCs.
There are no career development There are no career development offers for continuing education offers for continuing education Receive training quite often.
Never attended training.
Equipment is incomplete, medicine is lacking, clean water is available, ambulances are available to refer patients, and buildings are adequate.
Being placed in a team supports a good work culture.
Incentives from the Ministry of Health are received according the work contract agreement, regular, and the amount of incentives received is adequate.
Equipment is incomplete, medicine is lacking, clean water is available, ambulances are available to refer patients, and buildings are adequate.
Good relations with superiors and Incentives from the Ministry of Health are received according the work contract agreement, regular, and the amount of incentives received is adequate.
No local government incentives.
No local government incentives.
Employment Non-ASNs, do not want register in CASN selection during the work In the work contract the doctor cannot transfer between PHCs.
Work support No need for a mentor Non-ASNs, do not want register in CASN selection during the work In the work contract the doctor cannot transfer between PHCs.
Have utilized paid WhatsApp groups for patient consultations Physical working Coworker Incentives Can make patient referrals Retention of Remote.
Can make patient referrals Tambun.
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A review of North Konawe Regent Regulation No.
97 of 2022, concerning Guidelines for the Implementation of the Regional Budget of North Konawe District for Fiscal Year 2023, found that education tuition fee is provided to ASN and the community, health workforce incentives are only provided to ASN doctors.
This study found that there is no offer of education tuition fee from the district government, but the Ministry of Health provides specialist education tuition fees for doctors after Penugasan Khusus Programme.
The opportunity to obtain specialized education fees makes doctors satisfied working in remote areas (Mohammadiaghdam et al.
The facilitation of continuing education is one of the interventions that can improve retention (WHO, 2.
A review was also conducted by the Minister of Health Regulation No.
33/2018
on Penugasan Khusus Programme requiring district governments to provide regional incentives for health workforces deployed but the North Konawe District Government did not provide additional incentives for doctors.
Previous research found that doctors in rural and remote areas argued that they deserve higher financial incentives due to higher workloads and missed opportunities for additional income (Darkwa et al.
, 2.
Research in Vietnam found that the appointment of rural health workforces who have worked more than three years in civil service with greater incentives can improve retention (Zhu et , 2.
This study found that physical working conditions with limited drugs and equipment did not affect doctor retention because the doctors had tried to treat patients with limitations.
If patients could not be treated at the PHC, doctors could still refer patients to the hospital.
This contrasts with previous research which found that doctors in rural and remote areas face constraints in referring patients, leading to decreased motivation of doctors to work in rural and remote areas (Noya et , 2.
This study also found that doctors who are placed in teams can support doctor retention because it allows doctors to maintain work discipline.
This aligns with previous research showing that a team of professionals socializing and learning together supports retention in rural and remote despite the high demands and frustration caused by the inability to change the system (Abelsen et al.
, 2.
Environmental Factors The results of in-depth interviews with doctors and heads of remote PHCs are presented in Table 3:
Table 3.
Environmental Factors PHC Environmental Factors Tapunggaya Langgikima Pesisir Geographical Located on land that is not Located on land that is not separated from the province, separated from the province, lives close to a PHC, has public lives close to a PHC, has public transport once a day to the transport once a day to the district and province or private district and province or private motorbikes, road conditions are motorbikes, road conditions are damaged making it difficult to damaged making it difficult to pass after rain.
Geographical pass after rain.
Geographical conditions and access conditions and access limitations can be adapted.
limitations can be adapted.
Community support Doctors feel their presence is The community responds well to more useful when they are in the presence of doctors remote areas Security conditions are Security conditions are Cultural or customs No communication barriers No communication barriers Retention of Remote.
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doctors in North Konawe District.
The number of doctors graduating is considered sufficient to fill the vacancies.
This study found that to meet the need for doctors, the district government recruited doctors, including doctors in remote areas, through pK recruitment, but no one was interested because during the contract period, they could not continue their education.
Document analysis of Konawe Utara District's pK recruitment for 2023 found 11 formations for PHC The Konawe Utara District pK recruitment lists the pK income range according to the professional education But, it does not include doctor incentives in the pK PHCs doctor's Previous research found that recruitment of PHC health workforces was carried out through civil servants and noncivil servants .
entral and regional contracts.
Penugasan Khusus for remote areas, contract workforces of the Regional Public Service Agency (BLUD)), which then after 2014 through Law Number 5 of 2014 with the recruitment of civil servants and pK (Nugraha et al.
, 2.
pK doctor formations were not filled due to formations (Amin.
Maldistribution of health workforces causes rural, remote areas always lack health workforces (WHO, 2.
This study found that the Penugasan Khusus Programme the Ministry of Health has a doctor placement program for remote PHCs, which provides incentives, voluntary and temporary.
Previous research found 1% of PHCs fulfilled their (Nurlinawati and Putranto, 2.
WHO
recommends providing interconnected, combined, and local interventions related to education, regulation, incentives, and support from employers, governments, health workforce associations, international stakeholders, and other stakeholders to improve recruitment and retention in rural and remote areas (WHO, 2.
The information system used to monitor the presence of doctors in this study is not optimal because it is still Previous research in Bangladesh found that the lack of supervision of doctor attendance can lead to high doctor absence The in-depth geographical conditions in remote PHCs are as follows:
"When it rains, the road is slippery.
After the rain, it's really sticky, and you can't go anywhere, so when the schedule goes to the village.
I wait for it to dry first.
if not, wait for the next day, but even though the place is isolated when it rains, it doesn't get any worse because the electricity is still there even though it sometimes power outages, the water is still available, you don't have to wait for it to rain .
" (I-.
This geographical conditions of remote areas of PHC are difficult to access during the rainy season, limiting the mobilization of doctors in and out of the PHC areas.
Previous studies have also found that the geographical conditions and infrastructure of PHC areas in remote areas are poor, making them difficult to access (SuAoudi et , 2022.
Tambun et al.
, 2.
Regulation of the Minister of Villages.
Development of Disadvantaged Regions Transmigration No.
7 of 2023 states that road construction in rural areas supports access to basic services can be supported through the Village Fund.
Health System Factors The results of in-depth interviews with district health offices, provincial health offices, and the Ministry of Health.
The disctrict goverment recruited doctors through pK, however, there were no applicants in 2023.
Additionally, contract doctors in remote areas PHC resigned, and the goverment did not recommended mutations to urban PHCs.
The provincial government does not have a policy to fulfill PHC doctors.
The Ministry of Health distributes doctors, including to remote areas, under the Penugasan Khusus Programme.
However, the presence of non-ASN doctors is not recorded in the district government information system.
The district governmentAos policy of providing tuition fee for medical education is not intended to directly fulfill the need for Retention of Remote.
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rates in rural areas (Sadiq and Ahmed.
Supervision of doctors in rural Bangladesh service with information system technology using biometric fingerprinting, online systems, and random monitoring under the supervision of sub-district and district-level bureaucrats can support retention in rural areas (Joarder et al.
, 2.
This study found that the presence of doctors is recorded in SISDMK, which the Ministry of Health uses for mapping health workforce planning, while provincial health offices and district health offices use it for recruitment This study found that the Affirmation Programme of the Ministry of Health provides tuition fees for medical school to DTPK students who completed their education and will be required mandatory service (Ministry of Health, 2.
This is in line with previous research that specialized rural pipeline programs support applicants from rural backgrounds being accepted into medical education (Beck Dallaghan et al.
Physicians who are placed in rural areas and have a rural background may increase the likelihood of subsequently working in rural areas (George et al.
, 2.
family via mobile phones.
and having access the city at least once a month.
Individual inadequate housing.
limited acces to water and electricity.
and living separately from spouses for extend periods.
Individual factors that do not affect retention: history of exposure to rural areas and female Regarding job-related factors:
factor that promote retention include good superiors, having supportive team, and receiving very adequate financial incentive.
factors that led to non-retention include long working hours.
factors that do not influence retention include opportunities for further education, chances to become permanent employees, and absence of As for living environment factors, those that support retention are adaptable community responses, and conducive security conditions.
Regarding health system: factors that directly influence doctor retention include doctor distribution related to Penugasan Khusus Programme.
factors that indirectly influence retention include information systems related to SISDMK.
factors that do not influence retention include information systems related to doctor attendance, coordination between the education and health sectors, and rural-oriented higher education.
The North Konawe District Government needs to formulate a policies that provide employment opportunities for the spouses of doctor working inremote area PHCs, including the salary and incentive components as outline in the pK Additionally, the goverment should develop a doctor attendance information system and offer tuition fee support for medical school with mandatory service commitment at PHCs.
The Southeast Sulawesi Provincial Health Office developed a training curriculum to supports doctors in delivering health services in remote PHCs.
The Ministry of Health should map the distribution of doctors at PHCs iat remote areas PHCs across districts and cities based on maps of regional fiscal capacity maps and formulate national policies that support the retention of doctors in these Study Limitations The limitation of this study is that one PHC was not involved as an informant due to access difficulties.
The researcher's work background could potentially bias the interview results, but triangulation of sources and methods was conducted to validate the findings of this study.
This study did not involve district government in the fields of education and did not involve communities in remote PHC areas.
Conclusion The retention of doctors in remote areas PHC is a systematic, interconnected effort aime at encouraging doctor to continue working in these location.
Factors affecting retention of doctors at remote area PHCs in North Konawe District include individual factors that suport retention:
having an adventurous character.
able to bring children who are not yet of school age.
being able to communicate with Retention of Remote.
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We would like to thank the North Konawe District Health Office.
Southeast Sulawesi Health Office.
Ministry of Health for their technical support and all the contributors who helped in this study.
Furhermore, it should advocate for the central government to assist district and city governments that have been unable to fulfill doctors staffing at remote PHCs due to limited regional fiscal capacity.
Policies should also ne made to build PHCs with official housing in remote areas.
Lastly, an Affirmation Programme implemented to recruit students from rural backgrounds through special pathways that prepare them to enter the medical education and serve their communities.
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Creswell.
Research Design (Qualitative.
Quantitative, and Mixed Abbreviations ASN: Aparatur Sipil Negara .
ivil DTPK: Daerah Tertinggal.
Perbatasan dan Kepulauan .
emote are.
PHC: Public Health Center.
Pegawai Pemerintah dengan Perjanjian Kerja (Government Employees with Work Agreemen.
RPJMN:
Rencana Pembangunan Jangka Menengah Nasional (National Medium-Term Development Pla.
SDGAos: Sustainable Development Goals.
SISDMK: Sistem Informasi Sumber Daya Manusia Kesehatan (Health Human Resources Information Syste.
WHO:
World Health Organization.
Ethics Approval and Consent Participant This research has received approval from the Ethics Committee for Public Health Research and Service.
Faculty of Public Health.
University of Indonesia with Ethical Approval Letter Number:
Ket807/ UN2.
F10.
D11/PPM.
02/2023
Conflict of Interest The authors declare that there is no conflict of interest in this study.
Availability of Data and Materials Not applicable.
AuthorsAo Contribution SWKT and MB conceptualized the study.
SWKT handled the manuscript and data collection, and MB reviewed and improved.
Funding Source Ministry of Health Republic of Indonesia
Acknowledgment